… An Innovation Clearinghouse

1. Improving Operating Theatre Management and Production PlanningSummary Presentation for <our hospital>

2. … An Innovation Clearinghouse • Share problems • Share solutions • Avoid reinventing wheels • “Seed” large scale projects • Provide CEO network Health Roundtable UHC IHI

3. 34 Organisational Members –over 50 Hospital facilities Plus: Regional Health Improvement Network

4. Agenda – Thursday Morning

5. Elective Data Summary: • Elective surgical volume constrained by: • bed availability • shift to same day • competition with private sector • Should elective surgical capacity shrink, or should overall hospital capacity increase?

6. Elective capacity & demand volume

7. Issues Discussed – Elective Surgery Cancellations • Understanding current rates and causes of cancellations • How to adjust capacity to meet demand; number of patients to put on the lists • How to assess patient readiness and suitability for surgery (including proper patient consents) • How to ensure staff and facilities are available

8. Our Key Elective Surgery Issue(s) • (List your key issue here with feedback from your discussion sessions)

9. Agenda – Thursday Afternoon

10. Emergency Surgery Issues Discussed • How to set and communicate emergency surgery priorities • How to integrate emergency with elective caseloads • How to reduce after hours surgery requirements • Improving operating speed for unsupervised registrars • Ensuring emergency patients fit for surgery • Appropriate staff / patients / theatres available at the right time

11. Key observation: Emergency volume can be predicted

12. Our Key Emergency Surgery Issue(s) • (List your key issue here with feedback from your discussion sessions)

13. Agenda – Friday Morning

14. Maximising utilisation – Issues Discussed • How to ensure patients and staff are ready on time? • How many patients to schedule in a given session? • How to adjust patient numbers and staffing when necessary • How to provide an efficient and effective service?

15. Utilisation Analysisonly tellshow muchof sessionused

16. Operating Time analysis designed to show relative procedural efficiency

17. Our Key Utilisation Issue(s) • (List your key issue here with feedback from your discussion sessions)

18. Agenda – Friday Afternoon

19. Feasibility Screening

20. Facilitating Change • Create the right guiding coalition • Spend as long as you must to create a burning platform • Involve as many people as possible at all stages • Give people all the information • Measure, measure, measure

21. Our recommended project • Aim: To increase/reduce X by Y% in this area by this date • Project Sponsor: • Key Stakeholders: • First steps: • See “aims statements.doc” - attached

22. Meeting Materials

23. Reducing cancellation rates for elective surgery Topic 1 – Group discussions

24. Group 1 – Understanding Causes and Rates of Cancellations

25. Priority issues • Cancellations because of substitution of emergency for elective • Overruns due to late starts • Variability because of registrars competence and speed • Multiple avenues to the booking list • Who books • Who cancels • Competing priorities • Anaesthetic assessments done be different people to the ones doing the procedure • Surgeons cancelling at short notice

26. Process solution • Case manager as link between surgeons and booking officers (Vulcan) • Response of readiness of surgery • Booking the patient • First draft of list • Navigates individual path for patient • Ranking system out of 100 by specialty – with a target waiting time for each level (NZ) • Monthly data to surgeons, manager oversees process • Active waiting list audit • Summary data to surgeons • Monitor cancellations

27. Process solution (cont) • List locking – only one person to change list • No changes following prior Thursday for the whole next week (Dionysis) • Reduces changes on a whim e.g interesting case works in conjunction with speciality liaison nurses • Map patient journey • Close link between periopoerate process and booking clerks – surgeons trust the process

28. Surgeons cancelling at short notice • Include cancelled list in theatre utilisation statistics which go to the unit heads (Rigel) • Publish data of wasted time • 6 weeks notice for surgeon leave • Use unit based lists so that registrars so that registrars and other consultants can use scheduled time

29. Substituting urgent for elective • Dedicated emergency lists (Regulus) • Reducing out of hours surgery • VMO’s are rostered to staff emergency lists • Ortho team meets at 07.30 and plans the day ahead – goes to theatre and CSSD so workflow can be planned (?)

30. Late starts • Data is an issue with dobbing and finger pointing • Definition of starting time (Regulus) • Anaesthetist start? • Cut to stitch (KTS) • Time out • Map the journey to identify the real issues and address issue • E.g. consent (Regulus) • Automatic delivery of 1st patient to theatre for commencement (Cougar) • Clinical unit “service agreement” on commitment to change identified problems

31. Variability of registrars • Surgeon takes responsibility for list finishing on time so obliged to step in if list is running over • Make last patient stand by in case list overruns during the day (Vega) • Apply a cost to late overruns which is then applied to the clinical units to reduce scheduled sessions (Achilles)

32. Group 2A – Adjusting Capacity to Meet Demand

33. Priority Issues • Bed capacity • Elective / emergency mix • Seasonal variation • Unscheduled leave

34. Bed capacity • Quarantined patients for long wait patients • Through special purpose funding • Admit from operating suite – no bed no ICU allocation (Achilles) • Hold in recovery until bed available • ICU bed in recovery • Start first case without a ward bed • Meet day before ICU beds – query adverse outcomes (NZ) • Change to ICU case mix model (Achilles)

35. Bed capacity (cont) • Shift ICU / HDU near recovery (Achilles) • Discharge policy of hospital is 1800 hours • Do people employ rewards for early discharge? (query) • Asklepios – admission and planning unit • Discharge time of 1100 hours • Late discharge into evening • Do hospitals do 23 hour day cases? (query)

36. Elective / emergency mix • Bed substitution model of emergency to elective in orthopaedics / plastics (Vulcan) • Improved patient satisfaction • Classification of OR list management • Dedicated emergency list • All day list to meet surgeon expectations • Flexible session length • Panther – unit based lists – 12 hours of operating time a week lost due to understaffing of anaesthetists XXXX

37. Seasonal template • Seasonal template takes into account • School holidays • Christmas closure • Surgical leave management • Self initiated or hospital initiated • Feedback provided to surgeons • Asklepios – audits list • GP liaison • More funding for elective capacity

38. Leave • VMO  cases allocated to same unit first, then to urgent cases • List filled with whatever is under XXXX • Link to bed management (allows day cases) • Payment to surgeons for additional work

39. Other issues • Defining flow / processes • Cancellations / Bed capacity? • Recovery Block Delaying Lists (Vulcan) • Colonoscopy not counted in published waiting lists • Operating Room Capacity • Bed Capacity – Winter  Medical • No quarantine beds  Surgery

40. Other issues (cont) • Inflexible award structures and professional boundaries • Surgeon based rather than unit based sessions • Session length • Spare time belongs to manager • Surgeon availability for emergency theatre • Public / private mix • Classification scales

41. Group 2B – Adjusting Capacity to Meet Demand

42. Athene’s approach • Challenge: • Small bed base • Bed availability for elective admissions • Centralised bookings – outside of theatre • Confirmation of operating theatre booking • Regular meeting • Plan 14 days in advance • Ration lists to fit demand • On the 2 elective lists, one emergency assigned per list

43. Other approaches • Separate emergency operating session • Quarantine beds (Fury, Demeter, Hawk) • Geographically separate acute emergency theatre • DOSA unit (Hawk, Demeter) • First come first serve (Demeter) • Flexible list length (Demeter) • Unit based sessions (Panther, Demeter)

44. Other approaches (cont) • Decision by a team of stakeholders (Hawk) • Remove ownership of elective surgery wait list (Athene) • 23 hr unit (Panther, Vega, Athene) • Reduces hours in recover room • Patient discharge coordinator and planned discharge date (Athene) • Patient transport and bus to airport (Vega)

45. Group 3 – Patient Readiness

46. Priority issues • Anaesthetic consistency / surgeon consistency • Follow up of investigations • Preadmission • Complex patients • Short notice patients • Informed consent • Booking info?

47. Anaesthetic consistency • Team streaming • Dionysis • Clear procedure / intranet • Dionysis • Consultant pre-anaesthetic assessment • Preadmission clinic run by anaesthetics

48. Follow up of investigations • Case management with single point accountability • Panther, Achilles • Pathways • Computerised patient records • Streamlining coagulation blood tests

49. Preadmission issue • Outreach clinic • Dionysis • Health questionnaires • Define criteria for: • Preadmission • Anaesthetic preadmission • Quarantine sessions for investigation • Rigel • Triage process • Achilles • Allow adequate time for preadmission assessment

50. Informed consent • At time of placement on the waiting list by the consultant • Procedure specific consent forms • No consent, no transport to operating theatre • Athene