Healthy Communities – Mauriora! Lakes District Health Board Surgical Services Improvement Journey...

Healthy Communities – Mauriora!

Lakes District Health BoardSurgical Services

Improvement Journey

Improving the System - Meeting the Challenge – April 2012Greg Vandergoot – Service Manager, Surgical & Elective ServicesMartin Thomas – Clinical Director Surgical & Elective Services


Lakes District Health Board Background Project Outcomes Ongoing Work

Overview


Lakes District Health Board

Population base (incorporating Lakes District) 108,000 Operates from two sites, Rotorua and Taupo Rotorua theatre capacity three elective, one acute and endoscopy unit Taupo day-case theatre with an endoscopy facility

Ageing facilities

Surgical & Elective Services covers the following specialties: Ear, Nose, and Throat (ENT) General Surgery Orthopaedics Ophthalmology (Provided through Lakes Ophthalmic Services Ltd (LOSL) Plastic Surgery (outpatients provided though Health Waikato) Urology (Provided through Venturo Subcontract) Vascular Surgery as part of General Surgery Audiology


Background Issues regarding theatre throughput and utilisation

raised by medical and clinical staff 2005

Some work done historically to address issues but found that it was too complex and required sound project methodology

Recognised the need to set up as a project to ensure a sustainable outcome. Project Team established 2006

Service Improvement Project


Over-arching Issues

Improvement in Theatre Utilisation identified Reactive vs Proactive system Recruitment and Retention (Anaesthetics and Nursing) Patient complaints High hospital driven day of surgery cancellations Negative view of service and service performance Data rich, information poor Staff frustrated and felt disempowered Rationing of services


Project Principles

Patients at the Centre

Sustainability long term

Staff buy in and involvement

Short term and long terms


A Good Place to Work - For Our PeopleA Good Place to Work - For Our People• Environment that supports effective service delivery

Clearly defined roles with KPI’s

Staff Satisfaction

Business Focus - For Our StakeholdersBusiness Focus - For Our Stakeholders• Achieve contract volumes within budget

Meet benchmarks

Increase theatre throughput

Provision of meaningful and useful reporting

Ministry compliance

Patient Experience – For Our CustomersPatient Experience – For Our Customers

• Timeliness and equity of access Reduce DOS cancellations and DNA’s

• End to end coherent process Patient Satisfaction

• Well coordinated services

Patient informed/responsible

Easy to engage with/participate in serviceOutpatient

Booking Process

Pre-assessment

Process

Acute Booking Process

Elective Booking Process

Through Theatre Process

Our Approach


Cultural Lifebelt

To work in partnership with

patients/ clients ensuring they are the

f ocus of eff ective care

4. Provide evidence based care

2. Create an effective culture

1. Improve the patient experience

3. Develop new ways of working

Org

anisa

tion

Clinical areasGovernance


Goals and Objectives

Quality care for patients

Improve efficiency and productivity within Surgical Service

Support Clinical Leadership

Redefine scheduling, reporting and rostering processes

Improve theatre roster co-ordination and communciation

Development of tools to ensure ongoing service improvement and decision making

To create an environment that supported and promoted staff involvement in service improvement


Project Framework

•Radical change – quantum improvement• Long term (18-36 months)• Addresses strategic end to end processes

• Streamline existing process, best practice• Medium term (1-18 months)• Addresses segments of operational

processes within a defined area

•Quick hits – day to day activity• Short tem - immediate improvement opportunities (days – weeks)Quick Hits

Focused Improvement

StrategicChange


Six Stages of the Improvement Process

Investigate – Gather evidence to explore the initial hypothesis

Evaluate – Assess validity of the concept in light of evidence

Determine Options – what are the courses of action open to us?

Communications– Who needs to know? How will they be informed?

Buy-in/approvals – Who’s approval or support will be necessary?

Report back to TMG– Who is accountable for reporting back? When will the report be made?


Improvement Portfolio

Initiative Number

QH no.

Matrix Quadrant Initiative Name Hot List Area Status

4 1 Quick Hits Large whiteboard in theatre showing full week’s bookings Acute Booking Process Implemented5 5 Quick Hits ED whiteboard to improve 'Pts ready for theatre' communication Acute Booking Process Implemented9 Focused Improvement Direct Access GP bookings – currently trialling Elective Booking Process Implemented

10 Focused Improvement Review Admin Support for bookings and waitlist management for SMOs Elective Booking Process Implemented12 2 Quick Hits Define Peri-op Unit hours of operation Peri-Operative Assessment Implemented13 8 Quick Hits No changes accepted from Units without approval from Surgeon and Anaesthetist Elective Booking Process

Implemented

14 3 Quick Hits Review internal procedure and communications for exiting pts from Peri-op Unit Peri-Operative Assessment Implemented15 4 Quick Hits Update patient information outlining Peri-Op Unit procedures (pick-up from where, etc) Peri-Operative Assessment Implemented16 Focused Improvement Review who needs what info re Elective bookings/pts, i.e. Surgeon, Reg, HO, Units, Admin, etc Elective Booking Process Implemented

17 Focused Improvement Implement single point of contact for elective list co-ordination in theatre Elective Booking Process Implemented18 Focused Improvement Implement Central Scheduling Process Staff Scheduling Process Implemented22 7 Quick Hits Weekly Theatre Roster / Scheduling meeting Staff Scheduling Process Implemented23 9 Quick Hits Nominate a single contact person for roster changes Staff Scheduling Process Implemented36 6 Quick Hits Update expectations of patient readiness for Acute Surgery Acute Booking Process Implemented38 Focused Improvement Implement feedback loop to booking clerks on actual list utilisation by consultant Utilisation / Patient Flow Implemented39 Focused Improvement Theatre staff data entry of patient flow times saving 0.25 admin FTE duplicate data entry Data for Performance Monitoring Implemented

40 12 Quick Hits Expand TUG Membership Theatre User Group Implemented41 13 Quick Hits Redraft TUG Terms of Reference in line with NHS TMG model Theatre User Group Implemented42 Focused Improvement Roster H/S to PAC clinic - each H/S dedicated session to see their specialty patients Pre-Admission Process Implemented43 Focused Improvement Health questionnaire to be filled out by patients prior to seeing surgeon Pre-Admission Process Implemented44 Focused Improvement Health questionnaire: identify big ticket items on questionnaire for clarity Pre-Admission Process Implemented47 16 Quick Hits Set aside dedicated area in each unit to display pirinted PAC/Surgical Lists for following week Pre-Admission Process

Implemented

48 Focused Improvement Special Requirements Form re Task List for H/S prior to surgery for each patient Pre-Admission Process Implemented49 Focused Improvement Design process to ensure PAC tests followed up for patients who miss/fail surgery Pre-Admission Process Implemented50 17 Quick Hits Review and implement process for patient notes to be on ward prior to admission Pre-Admission Process Implemented53 18 Quick Hits Define and communicate responsibility for patient readiness for theatre - children Elective Booking Process Implemented


BusinessImpact

LOW

HIGH

LOW HIGHImplementation Challenge

FOCUSED IMPROVEMENT

QUICK HITS BOTTLENECK

2

20

17

1 11

18 24,26-34

38

7

16

6

39

8

35

27

25

3

19

1023

374

22

12

36 13

1514

5 21

40

41

42 4344

45 4647

4849

50

52

53

54

56

57

58

59

60

61 62

64

65

66

67

68

70

71

72

73

74

75 76

77

79

80

81

82

83 84

STRATEGIC CHANGE

Prioritising Our ImprovementsPeri-operative Assessment

Staff Scheduling

Elective Booking Process Theatre Staffing Model

Acute Booking Process Utilisation / Patient Flow

Data for Performance Monitoring


Understanding our Theatre Utilisation


Project Focus

Structure

Resourcing

Reporting

Theatre Roster & Schedule Analysis

Patient Journey Mapping & Detailed Process Mapping


What did we achieve?

Quick Hits – staff innovation and involvement

Establishment of a clinically led Theatre Management Group (TMG) – driver behind our improvement

Six weekly rolling theatre and anaesthetist roster sustained

Master Theatre Schedule Review

Introduction of flexible scheduling - sharing of lists within and across specialties

Re-designed theatre list formation and confirmation process – team focus


What did we achieve?

A sustainable increase in elective theatre utilisation and productivity

Theatre Dashboard Report

Specialty Procedure Times Report

Culture change – no cancellation of elective surgery

A better understanding of our business

Motivation to drive service improvement


General Surgery

The Challenge Unmanageable waitlist ESPI non compliance High cancellation of elective surgery High number of patient complaints Duplication of effort and rework Clinician and staff dissatisfaction - couldn’t see the wood for the

trees

Addressing the Challenges Validation of waitlist Collaboration with private provider Access criteria and thresholds Business rules - clinic volumes and FSA:Follow up ratios Pooling of patients MDT fortnightly Scheduling Meeting


Monitoring and Improving our Performance

General Surgery Elective Procedure Trends

0

50

100

150

200

250

300

350

400

450

Jul-09

Aug-0

9

Sep-0

9

Oct-

09

Nov-0

9

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10

Apr-

10

May-1

0

Jun-1

0

Jul-10

Aug-1

0

Sep-1

0

Oct-

10

Nov-1

0

Dec-1

0

Jan-1

1

Feb-1

1

Mar-

11

Apr-

11

May-1

1

Jun-1

1

Jul-11

Aug-1

1

Sep-1

1

Oct-

11

Nov-1

1

Dec-1

1

Jan-1

2

Feb-1

2

Mar-

12

Total Waiting with Certainty New referrals Number treated Exited untreated

Jun-04 Jun-05 Jun-06 Jun-07 Jun-08 Jun-09 Jun-10 Jun-11 Apr-12

2. Patients waiting longer than six months for their First Specialist Assessment (FSA)

J J J

5. Patients given a commitment to treatment but not treated in six months

J J J J

General Surgery - Patient Flow Indicator Results



Cholecystectomy and Hernia - Patients Waiting

170

189

100

77

51

0

50

100

150

200

Jan-09 May-09 Sep-09 Jan-10 Current0

20

40

60

80

100

120

140

160

180

200

Total Number Patients Waiting Cholecystectomy Hernia Patients Waiting >6 months



Elective Theatre Utilisation

72

74

76

78

80

82

84

2006/2007 2007/2008 2008/2009 2010/2011 2011/2012

% U

tili

sati

on

Elective Utilisation

Day of Surgery Cancellations

150

200

250

300

350

400

450

500

550

2002 2003 2004 2005 2006 2007 2008 2009 2011 2012

Nu

mb

er

of

Pati

en

ts C

an

cell

ed

DOS Cancellations



Day of Surgery Cancellations

0

20

40

60

80

100

120

140

160

2002 2003 2004 2005 2006 2007 2008 2009 2011 2012

Nu

mb

er o

f P

atie

nts

DNA Unfit No Bed


Service Changes

Strategic Planning

Service Improvement

Clinical Governance Model

Quality Focus

Balance Scorecard


Integration into Service Improvement

Embedded within Service Strategic Plan

TMG is fundamental to ongoing success of a Theatre Improvement Project

Needs buy in from Surgeons and other staff (clinical)

Maintaining engagement• Ownership• Delivery• Evidence

Concentrate on improvements but always reflect on successes


Surgical Strategic & Operational Plan


Key Learnings

The Service Improvement Process is ownership and accountability

Staff engagement

Leadership is key

Change is a difficult process

Perseverance and persistence can and does change culture

No quick fixes but a lack of action is not an option

Complex problems require a framework to address

Change is not a one time effort!


Making it Happen!

Enough need – a burning deck, a reason to change

Enough time – like a chronic disease, it’s a long journey

Enough money – waste reduction = resource gain

Enough knowledge / methodology

Enough support – at the right levels

Enough willingness, stamina and vision


Current Challenges

Ministry of Health Targets – Strategic Direction

Regional collaboration for Elective Surgery

Theatre Management Group maintaining impetus

Adherence to specialty business rules – eg entry and access criteria

Ongoing development of the Clinical Governance Framework

Facility redevelopment and co-location of service staff – management, administrators, clinicians

Resource efficiency vs funding constraints

30

We are moving in the same direction

We have strong

Leadership

We work in partnership as a team

We share common

goals and vision

We communicate

with each other

We are confident in our ability together

We have the knowledge, skills and

tools we need to do our job

We respect

and support

each other

We are flexible and

open to change

We are focused on

service improvemen

t

Healthy Communities – Mauriora! Lakes District Health Board Surgical Services Improvement Journey...

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