Darling Downs Hospital and

Health Services

Improving Operating Theatre

Efficiency:

Implementing and Refining Target Time Procedures

Improving theatre throughput by focusing on target times for the patient’s journey, particularly start times

Preventing theatre delays due to recovery issues

Darling Downs Health Service District

Catchment Area for Acute

Elective & Emergency Surgery

Stats in Brief

• We intend to perform 4800 Elective Surgeries in 2013

• We currently have:

– 0 Category 1 long Waits

– 0 Category 2 long waits

– 130 Category 3 long waits remaining and intend to

have all treated by end December 2013.

• We treat 78% in turn across all categories

Theatre Target Times

Identifying Target Times to achieve better theatre

utilisation

• Assuming that there is always room for improvement.

• Controversy over theatre times and time wasting

practises e.g. lists starting or finishing late –change over

time between cases. More important tasks.

• End the Blame Game

Someone else's fault

Anaesthetists

Nurses

Theatre Assistants

Wards

Surgeons

Domino effect

Procedure start 0830hrs( locally defined rules)

• Nurses check OT : Patient not there- disappear

• Anaesthetist arrive: no patient – disappear

• Nurses come back: still no patient – no

Anaesthetist– disappear

• Surgeon arrive: no Anaesthetist, no Nurse, no Patient -

Disappear

History

Historically everyone has their own work to do.

We’re only hear for the shift, let me know when your ready to start.

Meet you in the tea room for a quick cuppa until the patient arrives.

The Patient

Where does the patient come into the equation??

Patient care is paramount.

How do we move from it being about me! to being about the patient, efficient time frames and quality outcomes for all.

Realistic Targets

In Suite time -0745 hours.

Is this realistic?

Staff availability?

Is there impact on other ward areas?

Determine Realistic Targets and agree on what these times mean.

Realistic Targets

In Anaesthetic Bay time - 0800 hours.

Whose role is it bring the patient down?

Is the anaesthetist available to start?

Is the surgeon present to facilitate commencement of anaesthesia?

Determine Realistic Targets and agree on what these times mean.

Realistic Targets

In Theatre Time - 0815 hours.

Who does this?

Is the team available?

What happens now?

Determine Realistic Targets and agree on what these times mean.

Realistic Targets

Procedure start time - 0830 hours.

Is this knife to skin?

Is this prepping?

Is this patient positioning?

Determine Realistic Targets and agree on what these times mean.

Continue to collect the data and Advertise the

results

Variation

Create Local Rules

Communication

Competing interests

May involve roster changes

Difficulties can arise.

Who will take the Lead.

Sell it to Everyone

Convince staff that this is about ensuring we are utilising our time in the best possible manner – reinforce targets.

Namely that we avoid cancellations through lack of theatre time and that staff overtime is reduced

Not about spying on people - Not targeting individuals

Our Experience - People were genuinely concerned that this information would or could be used against them.

The aim is to look for ways to improve.

This will involve

System or Cultural Changes

Some of the barriers

• Theatre runners didn’t start until 0800

• Day Surgery staff needed to have ownership of their part in the process, to have the first cases in theatre by 0745 – what are their rostering and staff arrangements?

• I’ll anaesthetise when I see the “whites of his eyes” (DR W)

• What are the competing interests?

• List order preferences and changes.

Keep the interest going

Communicate and display the information to encourage staff to get on board

Posters AM / PM

Email containing report

Report on Daily Targets and Delays

Impact of Delays 501 individual delays entered for a 6 month period

1st April 2012 to 30 September 2012

Total delays = 381 hrs

Some examples

Surgeon unavailable 104 delays -1955 minutes (32.58 hours)

Anaesthetist unavailable - ECT 30 delays of which 288 minutes (4.8 hours)

Anaesthetic complication 29 delays - 939 minutes (15.65 hours)

Complex Anaes. Reversal 9 delays - 305 minutes (5.08 hours)

Radiology unavailable 22 delays -589 minutes ( 9.82 hours)

Recovery room full bed unavailable 10 delays 375 minutes (6.25 hours)

Understand your Data

2012 –Elective only 0600-1600 only

What’s

Happening here

Effect on Utilisation 158.1 hours lost

126.2 hours lost

Other Impacts

What is good practice?

What’s our target?

What’s considered inefficient?

Acceptable variations

Expect some late starts in your data as a result of commencing surgery in blank session spaces.

Note – some private sessions start times don’t necessarily mean cases will be cancelled or overtime will be incurred – Rostering

Complex anaesthesia will show as later start for first case. What’ the policy for these situations?

All day lists compared to AM / PM.

Rostering methods.

Where to next

SCALPEL PROJECTNational Elective Surgery TargetImproving patient access to elective surgery

• Scalpel is an initiative which aims to improve patient access to elective surgery (in line with NEST targets), by identifying and addressing barriers to process efficiency.

SCALPEL PROJECTNational Elective Surgery TargetImproving patient access to elective surgery

SCALPEL Project is funded under the Clinical Services Redesign Program (CSRP), Clinical Access Redesign Unit (CARU), and

Department of Health.

As a Queensland Health multi site project, Toowoomba Hospital (THS), CARU and PricewaterhouseCoopers (PwC) will work

collaboratively to conduct the redesign project commencing in May 2013 for 26 weeks. It is envisioned that this project will be

the beginning of a process of redesign work at Toowoomba Hospital.

The National Elective Surgery Targets have been assigned to progressively improve Hospital and Health Service (HHS)

performance, until the target of 100% across all categories 1, 2 and 3 is reached in 2015.

PART 1: Targets for HHS improvements in patients treated within the clinically recommended time

2012 2013 2014 2015

Category 1 89 100 100 100

Category 2 81 87 94 100

Category 3 91 94 97 100

2012 2013 2014 2015

Category 1 0 0 0 0

Category 2 67 45 22 0

Category 3 61 41 20 0

Source: CARU SCALPEL DATA PACK 2013. CALENDER YEAR 2012

PART 2: Targets for HHS improvements for reduction in average overdue days

*Source: CARU SCALPEL DATA PACK, 2013. CALENDER YEAR 2012

HOW?

• Mobilise project

team

• Establish

governance

• Conduct

stakeholder

analysis

• Data requests

made

• Plan key project

activities

Phase 1

Project Launch

Can be 1-4

weeks

• Diagnostics

showcase

• Data analysis

• ‘Voice of the

Patient’

activities

• Process

mapping

• Issues

prioritisation

• Data driven

hypothesis

testing

Phase 2

Diagnostics

Can be 2– 6

weeks

• Solutions

design

workshops

• Detail plans of

how the

solutions will be

implemented

• Solutions Fair

• Implementation

planning

Phase 3

Solutions

Design

Can be 1-4

weeks

• Implementation

planning and

preparation

• Allocation of

timelines

• Teams

assignment and

mobilisation

• Transition to

business as

usual

Phase 4

Implementation

Can be 6-12

weeks

• Continue

implementation

• Measure

progress

• Implement

corrective

responses

• Identify

learning's

• Share

knowledge and

outcomes

• Tollgate reviews

Phase 5

Sustain

Can be 6-

12mths

Clinical Access Redesign Unit Methodology

Project approach

16 issues

identified

across the

surgical patient

journey

191 Stakeholders

engaged in

SCALPEL

Process Mapping

Interviews with THS

Staff.

Quantitative Data

Focusing on what

barriers there are

to meeting &

sustaining NEST

Workshops &

Prioritisation

Mapping

Sessions

Data Analysis

Voice of the

Patient Forum

Mapping the processes and Identifying Issues

Key Issues A combination of interviews, observations, focus groups and process

mapping identified several key issues. These 4 issues where identified by

the steering committee to pursue during the solutions phase:

– Unplanned DOS cancellations often result in decreased theatre

utilisation. HIC and PIC

– There is no clearly defined process for patients to be optimised for DOS

following PAC. This results in poorly prepared patients on DOS

– There is not an agreed hospital approach to backfilling leave within

surgical specialties.

– The current elective surgery booking form presents issues in relation to

theatre bookings as the form is often difficult to read, and surgeons omit

important information.

Issue Prioritisation

1.Unplanned

DOS

cancellations

4.Elective

Surgery

Booking

Form

2.Poorly defined

process for pts

to be optimised

for DOS

3. Backfilling

leave within

surgical

specialities

Reasons for Cancellations

3

5

What are the major

contributing factors?

Can they be reduced or

avoided and how?

All cancellations July 2012 to 18 November 2012

What is the data telling us?

Within 24hours

What are the contributing

factors?

Cnx within

24 hours

0 10 20 30 40 50 60

Doctor unavailable - Insufficient Staff

Insufficient staff - Nursing

Doctor unavailable - Urgent case

Anaesthetist unavailable - On leave

Anaesthetist unavailable - Insufficient staff

No ICU beds

List Rearranged - Priority case

No beds

Doctor unavailable - On leave

Case cancelled by Surgeon

Equipment failure/unavailable

No OT time

Hospital Initiated Cancellations 2012 (<= 24hrs)

0 20 40 60 80 100 120

List Rearranged - Case brought forward

Patient Did Not Wait

Natural Disaster

Treated elsewhere

Pt requested to be removed

No longer requires treatment

Unfit for surgery - Preparation

Failed to attend - Pre-admission appt

Failed to attend - Day of surgery

Patient cancelled booking

Unfit for surgery - Condition

Patient initiated Cancellations 2012 (<= 24hrs)

What is the

relationship

to utilisation

What is the

relationship to

patient cond.

Unplanned DOS cancellations often result in decreased theatre utilisation.

BACKGROUND:

• Insufficient operating theatre time

• Insufficient beds/ ICU beds

• Priority cases such as emergency cases displacing elective admissions

• Patient presents unwell/ unfit for surgery

• PAC anaesthetist express a different opinion to the DOS anaesthetist

• Pre-operative tests/ investigations incomplete

• Incomplete Consent

• Consultant/ Surgeon unavailable due to priority case

• At times, teaching out weighs the need to complete complex cases quicker, impacting on

finish times.

• Late starts due to late arrival of surgeons

• Perception that last case will not finish within the session therefore is cancelled.

• Backlog of patients in PACU can stall theatres. Need to get patients to ward areas quicker

once clinically stable.

• Turnaround times extended due to complexity of patient and or teaching

• Often theatre lists order is rearranged on DOS impacting on time frames.

“Once we have a theatre

cancellation, there is no way we

can fill that space”

THS Staff

“We’re here on time, why can’t the

surgeon by here on time?”

THS Staff

The current elective surgery booking form presents issues in relation to theatre bookings; the form is

difficult to read and surgeons omit important information.

BACKGROUND:

• The current elective surgery booking form is difficult to read

and surgeons omit important information.

• The form should indicate the following important information:

– Category

– Special equipment

– Relevant investigations

– Medical conditions

– Type of admission and duration

– Omission of any of this information requires follow up by the

bookings clerk, if missed they may lead to DOS

cancellation.

• Consents are often ‘out of date’

• Booking forms can be misplaced in patients files, and not

reach their intended destination i.e. theatre bookings

• The estimated case times vary, are open to interpretation, and

are often not completed due to lack of standardised processes

.

“We often spend hours of rework chasing

Doctors to identify important omitted information.”

THS Staff

An ideal day for THS staff involves

‘good communication’.

The current elective surgery booking form presents issues in relation to theatre bookings; the form is

difficult to read and surgeons omit important information.

Critical

information

missing

Duration of

procedure

omitted

2 incomplete forms per

day, requiring 20 minutes

follow-up each.

Admission type

omitted

Moving to Solutions

Identify the reason

• What did the mapping tell us?

• Does the data support this?

There could be multiple reasons.

• In theatre issues

• Patient preparation and optimization.

• Outdated or poorly defined processes.

Overview of Solutions Design

Week 1

• Identify solutions working parties and book times (1-2hours)

• Meet with dedicated working parties

• Begin research & collect ideas

Week 2

• Meet with working parties

• Discuss ideas and decide on best options

• Script the critical moves

Week 3

• Meet with working parties

• Discuss ideas and decide on best options

• Outline the process changes

Week 4, 5, 6

• Meet with working parties

• Consider risks, benefits, KPIs

• Test solutions where possible (other staff, trial runs)

Week 7

• Submit proposed solutions to Steering Committee

• Determine solutions that will implemented

• Prepare for Implementation

Creating Awareness

Diagnostics EPXO • Sharing information

and creating

awareness

• Seeking further input

around solutions

from all staff.

Diagnostics EPXO

What Solutions do we Envisage

will be Identified

Target Times - Ramp up and continue

Organisational awareness of NEST – continue the EXPO’s

Identify processes to better prepare patients and /or implement measures to avoid cancellations on DOS

Electronic Booking Form

Bringing it all together

• Yes – Its about NEST.

• Yes – Cancellation rates will continue to effect

our ability to maximise theatre throughput.

• Yes – Target Times and monitoring Data and

delays form part of the solution.

• Yes – Establishing Local Guidelines and

maintaining communication is essential.

WHY?

Its about our patients

Its our duty as health professionals to make

it about our patients.

Voice of the Patient • Mary

• 65 years of age

• Lives 2.5 hours drive from Toowoomba

• Relies on the support and care of family

• Category 1

• Arrival 0630 to Day Surgery fasted from 2100 previous day

• Booked Last on AM list for mastectomy (all others Cat 1)

• Suffered anxiety and depression resulting from the news about the need for a

mastectomy.

• Communication was limited by staff due to uncertainty of theatre times and pressure

of not wanting to alert Mary of her pending cancellation.

• At 1430 hours Mary’s surgery was cancelled with the view to rebook for the next

week.

• The devastation on her face was unbelievable. Due to her anxiety and the thought of

having to prepare herself a second time she stated she wouldn’t be back.

• Her Husband was waiting in the waiting room throughout this time and had not been

communicated to in relation to the possibility of Mary’s cancelled.

• Mary was nauseated on her return trip home. Her family was also devastated.

• Incidentally the theatre started late on this occasion as the surgeon was late.

• http://www.youtube.com/watch?v=QI1go72c5H8