Post on 19-May-2015
description
Operating Theatre Efficiency Models of Care, Measures and
Sustainability
Jenny Abernethy
Operations Director
Surgery, Anaesthetic Services, Intensive Care Unit
Peninsula Health
About Peninsula Health
• Provides a full range of services across 14 major sites
• Operating revenue of $450 million
• 820 beds and growing
• 9 operating theatres
• Building a new ED and 3 new wards
• Serves a population of 295,000 plus visitors
• 4,900 staff, and over 800 volunteers
• Changing Culture Creating Certainty • Create certainty for the patient and staff • No patient cancellations on the day of surgery • Patients who require emergency surgery will be
clinically prioritised and operated upon in a timely manner
• Surgery and interventional procedures will occur in a safe and effective manner
• Create the perfect list
Aspirational Goals
Service
Arrive on time
Be available as rostered/scheduled
Be here for the patients
Open to the new challenges
Open to change
Work within Scope of Practice
Seek teaching/learning opportunities
Excellence
Honest
Openness
Transparent
Takes responsibility for own actions]
Does not blame others
Integrity
Arrive on time
Equality of all staff
Consider the situation when making requests
Put yourself in their position
Interact with colleagues as you would like to be interacted with
Acknowledgement of others actions
Respect
Be aware of colleagues situation
Take holistic view of patient
Communicate
Be approachable
Work together
Staff enjoy their role & workplace
Positive attendance
Take responsibility
Help others
Compassion
Professionalism
Staff Behaviour
Surgery & Anaesthesia – Team Working - Behaviour
Team Dynamics Workshop
Principles
• Themed Operating Theatres
• Move to 4 week schedule
• Dedicated emergency Theatre 24hrs / 7 days
• Separate Emergency Orthopaedic Surgery from the Emergency Theatre
• Additional Elective Surgery Time for Orthopaedic & Vascular Surgery
• Additional capacity for targeted initiatives in Plastics, Urology &
ENT
• Increase Rosebud Theatre Utilisation
Balancing Elective & Emergency Surgery – Peninsula Health’s Journey
Emergency
Elective
Challenges faced
• Theatre Capacity • Emergency Surgery • Staff availability • Funding • Elective Surgery Targets • Emergency Dept. Targets • Equipment • Bed access
Waiting times!
This page is intended to help you think about how you feel at different stages in your journey through the Surgical Pathway.
Put a circle around the words that best describes your feeling at each stage, or write your own words at the bottom.
How did you feel ?
If you’ve got time, we’d like to know why you felt like this. Was it friendly staff, a nice conversation, a long wait or an uncomfortable chair... whatever it is we’d like to know...
Arriving/Checking In Waiting Going to Theatre Post Op. Phase Check Ups (Physio,
OT, Nurse, Doctor) Leaving Information
Happy
Supported
Safe
Good
Comfortable
In pain
Worried
Lonely
Sad
Why ?
Peninsula Health – Surgery Patient Survey
Happy
Supported
Safe
Good
Comfortable
In pain
Worried
Lonely
Sad
Happy
Supported
Safe
Good
Comfortable
In pain
Worried
Lonely
Sad
Happy
Supported
Safe
Good
Comfortable
In pain
Worried
Lonely
Sad
Happy
Supported
Safe
Good
Comfortable
In pain
Worried
Lonely
Sad
Happy
Supported
Safe
Good
Comfortable
In pain
Worried
Lonely
Sad
Happy
Supported
Safe
Good
Comfortable
In pain
Worried
Lonely
Sad
Happy
Supported
Safe
Good
Worried
In Pain
Lonely
Sad
Comfortable
Patient Experience
Emotional Experience
Clarity about what happens to me
Informed about procedures & risks
Awareness of course of treatment
“Certainty”
Understanding aftercare/self-care
Compliance assured
Lifestyle changes
Where to get help
Worried
Lonely
In Pain
Sad
Supported
Safe
Good
Comfortable
Happy
Patient Experience Emotional Experience Out of comfort zone Looking for answers
“Uncertainty” Distressed/Waiting
Clarity about what/when will happen
Informed about procedures & risks
Awareness of course of treatment
“Certainty” Understanding
aftercare/self-care Compliance assured
Lifestyle changes Where to get help
Elective Patient Emergency Patient
Patient Story – Emergency Patient • Admitted on the 12/7 with Cholecystitis and discharged on the 21/7
• Her emergency surgery was cancelled 6 times
Her issues:
• Casual worker who will lose up to 3 weeks work
• Told she should be grateful as another lady upstairs was waiting one day longer
• Staff were afraid to tell her she had been cancelled
• When told she was cancelled, she just wanted a hug to release emotions
• Angry at being pumped full of drugs for best part of 8 days
• When going to surgery finally, paperwork not completed correctly and she was scared she would be cancelled
• First happy face she saw was the surgeon who said he was going to operate on her
“Patients and families will bring ideas to the table that expand the horizons of health care professionals”
Patient Centred Care
Tom Delbanco, M.D., and Sigall K. Bell, M.D.
N Engl J Med 2007; 357:1682-1683
Impact of the Emergency Model
• Reduces twilight and after hours surgery
• Decreases tension through increased resource allocation within hours
• Creates certainty by focusing on standard operating procedures
• Decreases on-the-day cancellations for elective surgery patients
• Decreases cancellations of unplanned surgical cases
• Creates certainty o for emergency surgery o for the elective patient o for staff
Balancing Elective & Emergency Surgery
vs
It is not just about chipping away but rather shaping and
transforming the future
Why start operating sessions on time?
• We should respect our patients • We should respect our fellow team members • Starting the day on time means we have a better chance of
finishing the day on time • We may be able to do additional minor procedures in the session • Risk of patients being cancelled is reduced • Create certainty for patients and staff
“I have noticed that the people who are late are often so much jollier than the people who have to wait for them.” E.V Lucas (1868-1938)
Surgery Start Time Project
• Patient arrival was defined as 6.45 am • Results showed 23% late • Patient tracking (arrival to surgery start) • Admission process was time consuming on
day of surgery (up to 30 min) • Nursing and medical staff wanting to access
the patient on day of surgery – multiple interruptions, staff coming and going
• Patients waiting in the Admission consulting rooms – unclear why they were delayed
Patient perspective Patient comments: “lost in the dark” “poor signage and lighting - arrived in wrong area” “confused with instructions” “slept in!”
Defines patient steps and staff responsibilities Working towards common goal Shared understanding of ‘start time’ Staff rosters re-aligned to support agreement
Surgical ‘Team Agreement’
First Case Surgical Start Time Author: Lauren Manning, Peninsula Health, VIC
Co-Authors: Karen Barker, LEAN This Way, VIC and Ally O’Dell, Nurse Manager Surgical Services
Problem: Delayed surgery start time impacted on the ability to finish on time. Goal: To have reliable first case surgery start time.
Background: Multiple problems associated with delays to first case surgery start time • Extended wait times for
patients to access surgery even despite being the first case
• Frustrations for staff as the co-ordination of timely and safe care was problematic at the start of the day and some staff were waiting for the patient be processed in Admissions
• Staff downtime, high staffing costs
• Affected the ability to provide additional surgical cases
VSM surgical services.igx
Patient
Clerical
Total C/T = 1 minutes
Value Add: 1 minutes
NVA = 0 minutes
2
OR timeout
Total C/T = 24 minutes
Value Add: 24 minutes
NVA = 0 minutes
Central W/L
1 minutes
6 minutes
11.3 minutes
36.3 minutes 12 minutes
8 minutes 1 minutes 11 minutes
28 minutes 22 minutes
24 minutes
Lead Time = 138 minutes
VA / T = 56.3 minutes
NVA = 72 minutes0 minutes 6 minutes 15 minutes 12 minutes 0 minutes 0 minutes 17 minutes 22 minutes 0 minutes
Consulting Rooms
Total C/T = 36.3 minutes
Value Add: 11.3 minutes
NVA = 15 minutes
3
Pre Op Area
Total C/T = 8 minutes
Value Add: 8 minutes
NVA = 0 minutes
2Total C/T = 12 minutes
Value Add: 0 minutes
NVA = 12 minutes
Total C/T = 6 minutes
Value Add: 0 seconds
NVA = 6 minutes
Distance Traveled: 5 m
Anaesthetic
Total C/T = 28 minutes
Value Add: 11 minutes
NVA = 17 minutes
Total C/T = 22 minutes
Value Add: 0 minutes
NVA = 22 minutes
Pre Admission
Total C/T = 4 hours
Uptime = 35%
admissions
desk - IPM
Total C/T = 1 minutes
Value Add: 1 minutes
NVA = 0 minutes
Pink Hat
Coordinator
improve add on
notification
Standardise pt
processing by
nursing
Improve patient arrival times
Defect = 65%
Visual Mgt &
Signalling b/w
disciplines
Introduce pull
systems into Pre Op
Shared understandng of
time out and subsequent
processing times by all staff
Introduce Early Warining System to
escalate first case delays
Day prior processing ?
telephone assessments
and EWS for issues
Review staffing and balance to
meet timeout aims
Key performance measures
avaliable visually on a daily
basis for all staff
Value Stream Mapping - First Case Surgical Start Time
Patient's information packs -
opportunities to improve
Aims with Interventions: Improve patient arrival time delays by: • Consistent and streamlined information • Improved signage for day of arrival • Introduction of day prior phone call and
admission checklist Reducing patient processing time on day: • Dedicated patient processing time with a Time Out agreement • Revised scheduling and staggered admission times • Standard consulting rooms layout
Achievements: We have achieved average
start time delay from 16 min to 9 min (37% reduction in delays to first case surgery start time)
Patient arrival times have improved by at least 11%
Patients happier with clear written and verbal instructions
Reduced processing times through the admissions area
Staff aligned in their definition of surgery start time
Staff morale has significantly improved
Stakeholder Engagement: Regular staff workshops Staff surveys across all disciplines Process mapping and Value Stream
mapping Clerical staff audits - patient arrival
times Regular meetings with management
Visual patient tracking board in Admissions to • Identify patients steps from arrival
to pre-op hold • Reduce interruptions • Improve flow of patient by moving
in one direction
Key Learning's: Define the problem, engage all staff, strong leadership , executive support and continuously improve
ARRIVED PRE-OP
07:30 07:30 07:30 08:00 07:30
07:45 07:45 07:45 08:15 07:45
08:00 08:00 08:00 08:30 08:00
WITHIN 15 MINUTES
Green Starts 6 5 7 8 7
Red/Amber 3 4 2 1 2
% On Time 66.67% 55.56% 77.78% 88.89% 77.78%
Mon Tue Wed Thu Fri
F Theatre 1 07:38 07:35 07:45 07:54 07:32
F Theatre 2 07:44 07:30 07:37 07:36 07:27
F Theatre 3 07:25 07:47 07:23 07:27 07:50
F Theatre 4 07:35 07:21 07:27 07:59 07:34
F Theatre 5 07:28 07:26 07:33 07:45 07:25
F Theatre 6 07:41 07:45 07:32 07:55 07:25
F Theatre 7 07:55 08:19 07:42 08:27 08:02
F Theatre 8 07:47 07:50 07:29 08:10 07:20
R Theatre 1 08:10 07:50 07:58 08:22 07:45
TIME OUT – AM – SESSION START TIME
WITHIN 10 MINUTES
Green Starts 4 4 5 7 6
Red/Amber 5 5 4 2 3
% On Time 44.44% 44.44% 55.56% 77.78% 66.67%
08:15 08:15 08:15 08:50 08:15
08:25 08:25 08:25 09:00 08:25
08:35 08:35 08:35 09:10 08:35
Mon Tue Wed Thu Fri
F Theatre 1 08:28 08:30 09:00 08:53 08:08
F Theatre 2 09:12 08:21 08:32 09:05 08:26
F Theatre 3 08:15 08:35 08:20 08:45 08:21
F Theatre 4 08:24 08:25 08:18 09:04 08:20
F Theatre 5 08:36 08:26 09:10 08:50 08:27
F Theatre 6 08:30 08:27 08:25 08:40 08:34
F Theatre 7 08:39 09:00 08:15 09:20 08:40
F Theatre 8 08:18 08:15 08:10 08:30 08:16
R Theatre 1 08:18 08:23 08:07 08:27 08:18
FINISH TIMES OF LAST CASES FOR THE DAY
16:30 16:30 16:30 16:30 16:30
16:45 16:45 16:45 16:45 16:45
17:00 17:00 17:00 17:00 17:00
WITHIN 15 MINUTES
Green Finish 2 2 5 2 3
Red/Amber 6 6 3 6 5
% On Time 25.00% 25.00% 62.50% 25.00% 37.50%
Mon Tue Wed Thu Fri
F Theatre 1 16:45 15:00 16:40 15:30 16:20
F Theatre 2 16:25 15:59 16:35 17:15 16:32
F Theatre 3 15:50 17:05 16:45 15:43 19:45
F Theatre 4 16:50 16:00 15:20 16:42 16:10
F Theatre 5 17:03 16:30 16:10 16:30 15:50
F Theatre 6 16:52 18:00 16:30 16:50 14:30
F Theatre 7 22:24 22:45 21:50 15:45 22:41
F Theatre 8 09:35 16:45 12:00 15:32 16:00
R Theatre 1 11:05 14:30 16:27 14:40 16:25
Start Time Improvement - Frankston
Patient comments…
“Love that the same nurse who calls the night
before sees me the next morning for my admission”
Senior Anaesthetist’s comments…
"This project has resulted in one of the most successful change management processes in Surgery and Anaesthesia Services at
Peninsula Health...“
Surgeon’s comments …
“ its great, patients are arriving on time
and are ready - there is now a reason for us to be on time”
Surgery Start Time Project - Feedback
Redesigning Stock & Inventory
• Define the Problem
• Create a functioning stock area for receiving and distributing
of consumables
• Ordering system to gain inventory control and improve
efficiency
• Provide support to Theatre Staff and improve Theatre
function
• Decrease costs
• Provide accurate financial reporting
Changing Culture Creating Certainty
Defining the Problems
• Clutter in hall due to lack of delivery space • Risk of stock being lost or damaged • Excess stock on shelves • Staff coming out between procedures for stock • Patients and visitors having access to this non secure area
• Barcoding system implemented • Reduced Inventory Holding • Documenting Freight Charges • Product Analysis • Consumable Agreements
Receiving and Distributing of Consumables
Savings Opportunities
• Product analysis – Usage and cost
– Not relying on companies to provide analysis
– Gowns savings disposable vs. linen
– Review pricing agreements
• Freight costs – Ensure correct cost centre charged
– Identifies suppliers who charge incorrect costs
– Product costs vs. freight costs analysis
• Theatre recycling – Identified opportunities
– Recycling PVC and segregating waste items
Measures of Efficiency and Theatre Optimisation
• Start Times • Contact hours • Number of Procedures • Theatre Utilisation • Anaesthesia RVG’s • Pre-operative time to surgery • Elective Cancellations for emergencies • Elective cancellations on day of surgery • Length of stay • Elective Surgery Waiting List impact
Frankston - Procedures & Contact hours
Contact Hours Mon - Fri
Contact Hours Mon - Fri
Contact Hours - Weekend
Contact Hours - Session
CONTACT HOURS PER WEEK
Time Period Mon Tue Wed Thu Fri Sat Sun Grand Total
07:00 - 12:00 32.33 36.82 32.52 32.02 27.75 9.87 9.82 181.12
12:00 - 17:00 21.43 25.65 20.77 21.97 52.18 6.83 7.23 156.07
17:00 - 22:00 3.00 3.42 3.38 0.00 5.97 4.57 6.58 26.92
22:00 - 07:00 2.00 0.75 1.25 0.00 1.08 2.80 1.43 9.32
Grand Total 58.77 66.63 57.92 53.98 86.98 24.07 25.07 373.42
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Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15
Ho
urs
Total Contact Hours Per Week
Previous Year 2014 - 2015
NUMBER OF PROCEDURES BY SESSION AND DAY OF WEEK
Time Period Mon Tue Wed Thu Fri Sat Sun Grand Total
07:00 - 12:00 27 30 28 28 34 5 5 157
12:00 - 17:00 16 20 21 27 26 3 6 119
17:00 - 22:00 3 2 4 0 3 2 3 17
22:00 - 07:00 1 4 1 0 1 2 1 10
Grand Total 47 56 54 55 64 12 15 303
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Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15
Pro
ced
ure
s
Total Procedures Per Week
Previous Year 2014 - 2015
THEATRE UTILISATION
Theatre Minutes Available Minutes Used % Used Number of Ops
Emergency Theatre 10066 1814 52% 66
FH Theatre (Excluding Emerg) 16796 11060 93% 207
Rosebud Theatre 2250 2160 61% 33
0%
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120%
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Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15
Per
cen
tage
% Used of Available
Emergency Theatre FH Total (Excluding Emerg) Rosebud Theatre
Anaesthesia
Unplanned Surgery
Cancellations for Emergency Patients
Cancellations on Day of Surgery
Length of Stay – Appendicectomy & Lap Chole
YEAR 2010 2011 2012 2013 2014
G07A 6.52 4.98 5.23 3.71 3.35
G07B 2.55 2.48 2.27 2.03 1.92
H08A 7.92 6.9 5.62 4.21 3.61
H08B 1.83 2.12 1.72 1.69 1.5
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2010 2011 2012 2013 2014
Average of LOS
G07A
G07B
H08A
H08B
G07A = Appendicectomy with Complication G07B = Appendicectomy without
H08A = Laparoscopic Cholecystectomy with Complication
H08B = Laparascopic Cholecystectomy without
Length of Stay – Hip Fractures
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4
6
8
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12
14
16
18
2010 2011 2012 2013 2014
Average of LOS
I08A
I08B
I08A = Other Hip and Femur Procedures W Catastrophic CC I08B = Other Hip and Femur Procedures W/O Catastrophic CC
YEAR 2010 2011 2012 2013 2014
I08A 17.01 14.53 13.73 10.93 8.45
I08B 8.98 6.65 7.63 6.42 5.14
Elective Surgery Activity 2013 to 2014
Elective Surgery Activity 2013 to 2014 Total Elective Surgery Waitlist 2013 to 2014
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Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
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Actual Activity Target 2013-14 Previous Year
2013-14 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
Actual Activity 555 549 549 635 490 462 534 560 536 540 604 585
Target 2013-14 552 530 528 616 550 460 532 558 590 532 540 590
Previous Year 600 584 484 594 589 387 371 482 490 506 500 506
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Actual Waitlist Target 2013-14 Previous Year
2013-14 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
Actual Waitlist 1801 1872 1800 1718 1678 1588 1637 1616 1594 1543 1445 1379
Target 2013-14 1816 1875 1850 1830 1810 1790 1700 1650 1600 1550 1500 1435
Previous Year 1664 1724 1737 1742 1740 1778 1896 1914 1862 1861 1901 1765
Elective Surgery Long Waits 2013 to 2014
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800
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Actual Long Waits Target 2013-14 Previous Year
2013-14 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
Actual Long Waits 607 611 531 535 481 500 515 469 457 456 435 385
Target 2013-14 610 630 610 590 565 540 520 495 470 440 410 380
Previous Year 467 475 495 489 514 598 675 683 639 607 639 585
Elective Surgery Long Waits 2013 to 2014
Elective Surgery Cat 2 Long Waits 2013 to 2014 Elective Surgery Cat 3 Long Waits 2013 to 2014
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700
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No
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Actual Long Waits Target 2013-14 Previous Year
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120
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Actual Long Waits Target 2013-14 Previous Year
2013-14 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
Actual Long Waits 91 101 72 75 61 55 52 44 42 40 36 32
Target 2013-14 91 100 95 90 85 82 80 75 70 65 60 55
Previous Year 43 46 46 56 71 72 85 88 90 84 82 85
2013-14 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
Actual Long Waits 516 510 460 460 420 445 463 425 415 416 399 353
Target 2013-14 519 530 515 500 480 458 440 420 400 375 350 325
Previous Year 424 429 449 433 443 526 590 595 549 523 557 500
General Surgery Long Waits 2013 to 2014
Category 2 Category 3
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General Cat 2 - '13 to '14
All Patients Long Waitetrs
2013 to 2014 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
All Patients 353 318 284 256 247 218 210 215 214 176 152 178
Long Waitetrs 142 129 116 90 67 70 71 61 49 37 30 28
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45
50
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
No
. of
Pat
ien
ts
General Cat 3 - '13 to '14
All Patients Long Waitetrs
2013 to 2014 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
All Patients 40 44 37 30 23 22 26 20 23 19 18 17
Long Waitetrs 7 9 3 4 2 1 2 1 1 0 1 0
Sustainability
• Daily operating suite meetings x 3
• Weekly report to Surgical Executive to monitor performance
• Early identification and escalation of issues
• Review outliers
• Weekly review of theatre lists
• Monitor Elective KPI’s
• Celebrate the successes
• Create certainty for the patient and staff • Cancellations reduced • Patients prioritised • Safe and timely surgery and interventional
procedures • Length of stay improved • Activity optimised • The perfect list!
Summary
“Care is constantly reviewed and opportunities for improvement identified”