Rapid change in Orthopaedics

ACC Friday 30 April 2010

Seabridge House

Robert MiddletonThe Royal Bournemouth Hospital

NHS Institute for Innovation and Improvement

What were the issues?

Waiting times Balancing demand with capacity Reduce costs Competition Outcomes

Why do our solutions fail?

We treat the symptoms of the problem The end result doesn’t change because

we don’t change the whole system

Every system is perfectly designed to get the results it gets (Deming)

Variability

Operating times

Variability

There was huge variability in outcomes. Mean length of stay = 7.8 days and St Dev = 5.5 days

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Deming

Understanding variation is the most important aspect when trying to understand a system

How do we go about this in healthcare when so many factors vary from patient to patient?

What were the issues?

Approx 6000 procedures per year 10 procedures = approx 70% of the workload

Hip and knee replacement Approx 25% of the workload 7.8 day average length of stay Many pathways

What did we do?

We analysed the issues Assessed the variability Recognised what we could change and

what we couldn’t Provided a framework which accounted for

variability Kept it patient centred

Focused on what we could change

Non-confrontational SDSA (standardise-do-study-act) Single pathway Introduced daily and weekly outcome

measures Ongoing audit/performance

management

Framework

Freedom and responsibility to work within a framework

Manage the system and not the people

Patient-centred

The reason we are here Galvanises professional groups Evidence base for orthopaedics isn’t

controversial NHS Institute for Innovation and

Improvement There is no single magic bullet

Results – First 1200 patients

100% of operation dates are mutually agreed Over 90% attendance at pre-op education

class 100% of patients admitted on day of surgery 99% of patients waited less than 4 hours

between admission and operation (Mean = 2hrs 43mins)

100% of patients received physiotherapy within 18 hours of surgery

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Length of Stay Before Change

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Length of Stay After Change

Average length of stay by NHS trust

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TKR(H04) July 2007/08 – June 2008/09

THR(H80) July 2007/08 – June 2008/09

TKR(H04) July 2006/07 – June 2007/08

THR(H80) July 2006/07 – June 2007/08

Data from Dr Foster Intelligence – October 2008

Performance against case-mix adjusted expected length of stay by NHS trust

TKR(H04) July 2007/08 – June 2008/09

THR(H80) July 2007/08 – June 2008/09

TKR(H04) July 2006/07 – June 2007/08

THR(H80) July 2006/07 – June 2007/08

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Data from Dr Foster Intelligence – October 2008

Results – First 1200 patients

No cases of deep infection Complications rates below 1%. Re-admission rate decreased by 50% Patient satisfaction is extremely high Length of stay dramatically decreased

Results - Length of stay

Mean LOS = 4.1 days St Dev LOS = 1.7

48% decrease on previous mean LOS (7.8 days)

Approx 4000 extra bed days

DIFFERENCE IN LENGTH OF STAY

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PREVIOUS LOS

DERWENT LOS

Results – Operative times

Results - Variability

Example - Operative times

Using knowledge of variability to plan ahead

We have developed a forward looking model

Informed by real data and consistent with principles from other industries and leading thought leaders

Predicting variability

Sequential vs staggered operating lists

Same distributions Sequential compounds

error (difference from mean) through all cases

Staggered softens errors through all cases

Operative Time

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00:28

00:57

01:26

01:55

02:24

02:52

03:21

03:50

04:19

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Benefiting the NHS

DOH 18 week workshops Dorset Gold Award 2009 Redesign of Orthopaedic services in Scotland National and International Presentations and Papers to

Orthopaedic and Health Management meetings

NHS Institute for Innovation and Improvement

The 6 key characteristics of organisations providing high quality care and value for money in patients with hip and knee replacement

Patients’ expectations are consistently Patients’ expectations are consistently managedmanaged Patients are admitted on the day of Patients are admitted on the day of surgerysurgery

Patients’ planned procedures are not Patients’ planned procedures are not cancelledcancelled

Patients are mobilised within 12–18 Patients are mobilised within 12–18 hours of surgeryhours of surgery

Patients are discharged using a criteria-Patients are discharged using a criteria-based processbased process

The decision to change your serviceThe decision to change your service

NHS Institute for Innovation and Improvement

Focus on seriesRapid Improvement ProgrammeRegional MeetingsNational Meetings

Summary

Change the system Standardise Stream Variability is predictable and

controllable

Thank you