Kerry Leaver, Flinders Medical Centre: Improvement is a Continuous Process
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Transcript of Kerry Leaver, Flinders Medical Centre: Improvement is a Continuous Process
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Elective surgery management at FMC 2004-2013:
Improvement is a continuous process
Kerry Leaver Operations Manager Flinders Medical Centre
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Outline
> Information management > Waiting list management > Service changes > Policy changes
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Flinders Medical Centre
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Flinders Medical Centre > 588-bed tertiary public teaching hospital
> Major referral centre in southern Adelaide
> Only hospital in SA offering services for people of all ages
> 62,000 ED presentations each year
> 55,000 admissions (45% emergency) each year
> 5, 500 emergency theatre procedures annually
Let’s go back, way back to 2004
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Elective Surgery Strategy 2004-2008
Department of Health funding to:
> Appoint two Elective Surgery Coordinators
> Improve waiting list management
> Increase activity
> Reduce waiting times to national targets by 2008
> Use Checklist tool to assist
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Where did we start?
> No admissions for category 3 overnight patients for 2 years
> No management of the patients whilst waiting for surgery
> No systems to monitor and report on waiting list management
> 576 overdue patients
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Information management
> Data quality management (Ongoing)
> Weekly and monthly monitoring (2007- ongoing)
> Theatre utilisation reporting (2006-ongoing)
> Annual strategy (2007 – ongoing)
> Checklist reporting (2004-07)
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Case study: Plastic Surgery scenario modelling
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Case study: Plastic Surgery scenario modelling
> Checklist used to model resources required to admit 60 major plastics patients
> 27 theatre hours per week, 4 quarantined beds
> Head of Plastic Surgery devised a 3 month work plan
> Patient clinical review process
> Education sessions
> Management protocol introduced
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> Phone call to patient to obtain information to determine their ready for care status • Collected health information that could impact on
surgical outcomes
• Included Body Mass Index, smoking history, diabetes, heart disease, sleep apnoea, mobility issues
• General discussion about family support, child care, activities of daily living and driving restrictions
• Estimated time in hospital and follow up care
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> Senior registrar discussed the surgery, risks and surgical outcomes eg smoking - effect on wound healing
> Preadmission & Ward Nurses discussed hospital care and expectations
> Outpatient clinic nurses discussed wound care and dressings and the estimated time to be spent in clinics
> Occupational therapist commenced the collection of life style data using the Short Form (SF36) and Multidimensional Body-Self Relations Questionnaire (MBSRQ)
> Patients were given health information
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Plastic Surgery Waiting List June 2005 to November 2006
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> Routine provision of written patient information required
> Health assessment at 1st Outpatient visit necessary
> Point of contact to assist with patient’s health concerns while on the waiting list valuable
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Waiting list management
> Patient information folder (2006)
> Health questionnaire at outpatients (2006)
> Case management for not ready for care patients (2007)
> Cat 1 bookings for ENT and Plastics undertaken by ES coordinator (2011)
> Reallocating resources within a unit
> Treat in turn
> Pooled list
> Urgency categorisation
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Plastic surgeon
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Transfer of care
> FPH > Mount Barker Hospital > Noarlunga Hospital > Blackwood Hospital > Repatriation General Hospital
> Critical success factors • Senior nursing co-ordination • Health questionnaire introduction to OPD • Health service structure • Co-location
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FMC Transfer of care
Hospital 05/06 06/07 07/08 08/09 09/10 10/11 11/12
NHS 247 368 410 384 305 192 187
FPH 55 48 184 180 228 253 312
RGH 525
Mount Barker 52 19
CNAHS 61
Blackwood 5
TOTAL 354 416 613 625 533 450 1024
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The challenges
> Treat in turn principle set aside
> First time quality - right patient, right hospital – set aside
> There is a lot of waste in the process
• Additional visits pre op
• Communication with many departments
• Patient understanding of processes
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Transfer of care
Hospital 05/06 06/07 07/08 08/09 09/10 10/11 11/12
NHS 247 368 410 387 305 192 187
FPH 55 48 184 242 228 253 312
RGH
Mount Barker 52 19
CNAHS 61
Blackwood 5
TOTAL 302 416 613 690 533
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Service changes
> ENT and Plastics theatre time (2005)
> Ortho and Vascular service changes (2010)
> Theatres redevelopment (2011-2012) > DOSA unit co-location > Bariatric surgery service move (2013)
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Theatre redevelopment
> Emergency and elective theatres had been defined
> Theatres all ran on an 8 hour roster
> Redevelopment for 1 year had displaced theatre session times and locations
> New theatre suite provided opportunity
• to right size emergency capacity
• review theatres governance
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Average time waited for emergency theatre
0
100
200
300
400
500
600
700
800
900
Tim
e (M
inut
es)
Average wait time (mins) historical mean
Improved data collection
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Right sizing
> Reduce Muda (waste) • Waiting - time spent by patient waiting for a
theatre • Inventory – surgeon availability • Patient cancellations caused by lack of theatre
time • Queue jumping - caused by c-sections
> Reduce Muri (unevenness or overburden) • out of hours operating
“See today’s patients today”
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See today’s patients today
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Methodology
> How much emergency theatre capacity do we have?
> How much emergency demand do we have?
> Should we define capacity for specific services and create streams? • Obs and gynae • Surgical division
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Emergency theatre configurations
Requests made by the Clinical Director of Surgery and Clinical Director of Women’s and Children’s
1 2 3 4
Option 1: 24/7 Ortho trauma Surgical division Emerg gynae & obstetrics
Option 2: 24/7 Ortho trauma Emerg gynae & obstetrics
Option 3: 24/7 Ortho trauma Surgical division
Option 4: 24/7 Ortho trauma Undifferentiated Emerg theatre
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How much theatre capacity do we have? > Calculate theatre capacity in minutes per
theatre
> Adjust to 85% capacity
> Allow for 10 minute changeover
> Adjust capacity to exclude 2200-0800 operating hours, assuming this is life and limb surgery only
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How many theatres does the demand fit into?
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Orthopaedic Trauma
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Emergency gynaecology and all obstetrics
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Surgical division
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Emergency theatre configurations
Requests made by the Clinical Director of Surgery and Clinical Director of Women’s and Children’s
1 2 3 4
Option 1: 24/7 Ortho trauma Surgical division Emerg gynae & obstetrics
Option 2: 24/7 Ortho trauma Emerg gynae & obstetrics
Option 3: 24/7 Ortho trauma Surgical division
Option 4: 24/7 Ortho trauma Undifferentiated Emerg theatre
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Results summary
> 3 theatres meets demand most of the time
> Two theatres need to run until 10pm to deal with the daily patient demand
> Increased capacity for sections must be created in elective theatres
> The third theatre should be undifferentiated
> Another proposal…..
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General surgical specialties theatre
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General emergency theatre proposal > Consultant led emergency theatre service
> Emergency theatre roster created
> Commitments for the day cancelled
> Responsible for managing the queue and doing the work
> First patient identified day before and ready for a 1000 start time
> Other specialties have access during the day if required
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Elective theatre changes
> Request for additional sessions, any timetable changes
> Long standing complaint from surgeons that elective theatres finished at 3.30
> 10 hour rosters introduced for elective theatres
> Flexible start time for theatres > All theatres finish at 5pm, allow for a 30
minute overrun
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Elective theatre changes
> Reduce known subspecialty demand gaps > Principle to schedule all day theatre lists > Accommodate multiple theatres for clinical
units with VMO staffing > Principle to remove ‘transfer of care’ as a
strategy for managing elective demand > Create capacity for c-sections to avoid
delays to elective theatres > 191 additional hours
• 30 hours c-section lists
• 90 hours plastic surgery
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Theatres governance
> Elective and emergency value streams completely separated
> Manager for each value stream (Theatre coordinators)
> Management policies created > Rostering changed to meet needs of each
stream • 8 hour rosters in emergency • 10 hours in elective
> Huddles – match demand and capacity daily
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Number of patients waiting longer than 24 hours
0
10
20
30
40
50
60
70
80
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Average time waited for emergency theatre
0
100
200
300
400
500
600
700
800
900
Tim
e (M
inut
es)
Average wait time (mins) historical mean LCL UCL
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0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13
Added
Treated
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0%
5%
10%
15%
20%
25%
30%
35%
40%
0
500
1000
1500
2000
2500
Jul-99 Jul-00 Jul-01 Jul-02 Jul-03 Jul-04 Jul-05 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jul-11 Jul-12 Jul-13
waiting list
overdues
% overdues
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0
20
40
60
80
100
120
140
Total FMC Overdues
New emerg model New elective model
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Can we get to zero overdues?
Yes –
> restructure consultant workforce > insist on treat in turn > remove sub specialisation > remove patient choice for admission
date
What does it mean for the patient and the quality of the service?
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Policy changes
2004: Payment to remove patients from the waiting list
2013: Unfunded activity ($6m in 2012-13)
2004-2012: increased elective admissions targets year on year. (2009-10 incentive payments for exceeding target)
2013: “commissioned” activity targets and planned reductions in activity
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Where to next
> Network wide load levelling from point of referral
> Subspecialisation demand gaps remain > Impact of New RAH > EPAS > MATES
> Commissioning
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What did we learn?
> Strength in the individual members’ different skill mix
> Understand the business, know the facts
> There is no such thing as the magic pill
> Improvement is a continuous process
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Thank you