Surgical Services 2020 and

Beyond. Kenneth Mealy

National Clinical Programme in Surgery

Charter Day Meeting February 9th 2017

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Demographic changes

2031 1m > 65 yrs, 86% increase 136,000 > 85 yrs, 133% increase

Demographic Implications for Surgery

Operation >65 >65 (2031) Total (2031) # neck of femur 2741 5098 5490 Cataract 7697 14,316 16,127 Cystoscopy 8074 15,017 23,168 TURP 550 1023 1191 Lap choley 774 1440 5375 Unilat hernia 597 1110 3060

Challenges for Surgery • Hospital groups

o Effective administrative

structures

• Capacity groups o Beds

o Theatres

• Manpower o Consultant numbers

o Non-consultant staff

o Nursing

• Funding

• Measuring

Individual/Institutional

Performance

• Governance and

Quality Improvement

• Leadership

5

NCPS use HIPE data for reports

Inpat # 69,391 DC # 121,053 Total # 190,444 % DC 63.6%

Dublin North East % of Nat 17.0%

West & NW % of Nat 18.1% Inpat 10,187 AvLOS 6.10

Inpat 13,596 AvLOS 5.13 DC 22,182 %DC 68.5%

DC 20,798 %DC 60.5% All 32,369

All 34,394

Dublin Midlands % of Nat 15.3%

Inpat 11,027 AvLOS 6.88

DC 18,194 %DC 62.3%

All 29,221

Mid West % of Nat 6.7%

Inpat 4,908 AvLOS 5.69 Dublin East % of Nat 21.5%

DC 7,912 %DC 61.7% Inpat 15,460 AvLOS 5.97

All 12,820 DC 25,437 %DC 62.2%

All 40,897

South & SW % of Nat 20.1%

Inpat 13,098 AvLOS 5.66

DC 25,185 %DC 65.8% Peadiatric Group % of Nat 1.3%

All 38,283 Inpat 1,115 AvLOS 6.14

DC 1,345 %DC 54.7%

All 2,460

(All)Nationally

General Surgeon discharged from All Model types in 2015 (Both those who had surgery & did not have surgery) HIPE 2015 – Clinician specialty 2600 - General Surgery, 2602 - Gastro Intestinal Surgery, 2603 - Hepatobiliary Surgery, 2604 - Vascular Surgery, 2605 -

Breast Surgery

Pop: 745,379

Pop: 330,315

Pop: 911,381

Pop: 974,514

Pop: 737,527

Pop: 889,126

Pop: 4,588,252

Surgical Hospital metrics performance notes – recent example month end data M4 : Highest AvLOS (10.4), Lowest DoSA (25.3%), ReAdmit of Target (3.1%) - off target 5th highest IP/DC WL (4,027) & 11th highest OP WL (9,000) LapChole DC % much improved (59.1%),

M4 : 3rd Highest AvLOS (7.9), 6th Lowest DoSA (63.5%), ReAdmit of Target (3.4%) – off target 16th highest IP/DC WL (1,531) & 4th highest OP WL (14,522)

LapChole DC % (32.2%),

M4 : 2nd Highest AvLOS (8.2), DoSA (75%), ReAdmit on Target (2.3%) – near target 2nd highest IP/DC WL (4,493) & 3rd highest OP WL (15,094) LapChole DC % (32.9%),

M4 : 4th Highest AvLOS (7.8), DoSA (80.1%), ReAdmit on Target (2.0%) – near target! 18th highest IP/DC WL (1,427) & 13th highest OP WL (7,962) LapChole DC % (62.4%),

M4: : Waiting list issue (OP: 18,580 / IPDC:9,785) , Off target AvLOS (6.6 days) M3: : Highest Readmission rate (4.6%) … AvLOS ahead of target (4.9 days) M3 : Off target AvLOS (6.4 days) M4 : Waiting list issue (OP: 21,200 / IPDC: 4,251) , AvLOS just over Target (5.1 days) M4 : Wait list issue (OP: 13,762) , AvLOS off Target (5.1 days) M4 : AvLOS near to Target (5.9 days) , Wait list (IPDC: 3,961)

M4 : 5th Highest AvLOS (6.5), DoSA (58.4%), ReAdmit on Target (2.2%) – off target 3rd highest IP/DC WL (4,408) & 7th highest OP WL (12,835) Low LapChole DC % (11.4%),

NQAIS – Cholecystectomy Data

NQAIS – Acute colorectal Surgery

##### #####

Greater Precision: More cases (more reliable)

Lower Precision: Fewer cases (not as reliable)

FUNNEL PLOT: Precision (no. of cases)

Your hospital

All hospitals

Hospital Mortality

Challenges for Surgery

• Measuring Individual/Institutional

Performance

• Governance and Quality Improvement

• Leadership

Models of Care

Improving Elective Practice • Pre-admission Assessment • Day Surgery • Day of Surgery admissions • Discharge planning

2010

17

Improving Acute Practice • Separate stream • Early access to Senior

Decision Makers • Acute Surgical

Assessment Units/Diagnostics

• Emergency theatres

2013

Healthcare Transformation

• Top-management

structural change

• Local operational

design o Clinical and administrative

leadership

o Data and measurement

systems

o QI/process design

o Empowerment

o Standards

IP/DC waiting list for all Surgery Specialties – 16% increase in 1 year (as at 31 Jan’17) Day Case &

Inpat Wait 0-3

Months

3-6

Months

6-8

Months

8-12

Months

12-15

Months

15-18

Months

18-24

Months

24-36

Months

36-48

Months

48+

Months

Grand

Total

2017-01-31 25,724 16,469 7,516 11,425 5,819 4,202 1,992 589 19 3 73,758

2016-02-04 24,510 15,124 7,442 10,128 4,238 1,273 685 236 46 5 63,687

% 1 Yr change 5% 9% 1% 13% 37% 230% 191% 150% -59% -40% 16%

Galway UH ( 10,016 )

UH Waterford ( 4,827 )

Beaumont ( 4,363 )

Mater ( 4,323 )

Tallaght Adult ( 3,951 )

St James's ( 3,912 )

Sligo ( 3,190 )

UH Limerick ( 3,057 )

Royal Vic ( 2,821 )

Tullamore ( 2,796 )

Roscommon ( 2,710 )

SIVUH ( 2,310 )

Letterkenny ( 2,084 )

Cappagh ( 2,009 )

Crumlin ( 1,955 )

St Vincent's ( 1,673 )

Cork UH ( 1,512 )

Connolly ( 1,406 )

Drogheda ( 1,133 )

Louth ( 1,122 )

31/1/2017

Galway UH ( 8,947 )

Beaumont ( 4,941 )

UH Waterford ( 4,449 )

Mater ( 3,995 )

St James's ( 3,805 )

Tallaght Adult ( 3,141 )

UH Limerick ( 2,608 )

Tullamore ( 2,440 )

Royal Vic ( 2,412 )

Sligo ( 2,376 )

Cappagh ( 2,221 )

Crumlin ( 1,980 )

Letterkenny ( 1,728 )

SIVUH ( 1,648 )

Roscommon ( 1,634 )

St Vincent's ( 1,392 )

Cork UH ( 1,159 )

Kilkenny ( 1,102 )

Drogheda ( 991 )

Louth ( 975 )

04/02/2016

Waiting list reduction • Waiting list validation

• Demand/capacity analysis and planning

• Subspecialty engagement

• Performance metrics and analysis

(TPOT/TQIP)

• Sustainable infrastructural and operational

investment.

Theatre Utilisation

Surgery Discharges in 2015 (including Acute and Elective admissions for surgery or surgical care)

Surgical Specialty split in 2015

NCPS use HIPE data for reports -

Confidential 23

Acute

Elective

Total

AvLOS

9.75

4.53

6.93

AvLOS

5.17

6.43

5.33

Had Surgery

Not Had Surgery

Acute Surgery • Individual

o Model 4 Hospitals

• Emergency care

o Sub-specialty

interests

o No incentive to

contribute

o Model 3 Hospitals

• Staffing issues

• Rotas

• Institutional o 26 acute units

o Acute Model of Care –

not implemented

• ASAUs

• Emergency theatres

• Senior Decision

Makers

o Model 3 Hospitals – better metrics

Appendicectomy

Model 3 Model 4 No. 2499/757 2247/416 AvLOS 2.3/3.0 3.0/4.0 DOSA 61/62% 52/56% PreAvLOS 0.5/0.5 0.7/0.6 PreAvLOS 0.3 – 1.2 spread nationally

HIPE 2015

Acute General and Colorectal

Surgery - Mortality

Operation Model 3 Model 4 No Mortality (%) No Mortality (%) Hartmanns 74 9.5 61 9.8 Right Hemi 72 9.7 96 6.3 Total Colorectal 366 9.2 622 8.3 Laparatomy 38 7.9 44 6.8 SB resection 86 10.5 129 9.3 Perf DU 52 3.9 72 9.7 Total General 6189 0.8 6216 1.4

2015 HIPE

Acute Surgical Assessment Units

• Business case

• Design

• Governance/Leadership

• Sustainable staffing

oConsultant

oNon-Consultant

• Integration with the ‘acute floor’

• Metrics and outcome analysis

Surgical Performance – what does good look like?

• Good outcomes • Good process

o What governance structures do you have?

o Are the Models of Care functioning and monitored?

o Does your hospital have a QI office?

o Do you regularly review surgical metrics, KPI’s and waiting list data, NQAIS, NOCA audits?

o Do you regularly review all complaints and adverse events?

o Do you carry out patient and staff satisfaction surveys and exit surveys for trainees?

o What QI initiatives do you monitor? o What is on your risk register?

• Hospital admin engagement and clear institutional strategic goals • Sound governance structures • Deep institutional penetrance of sustainable performance improvement • Greater oversight of internal professional and operational standards (appraisal) • Greater consultant engagement, corporate responsibility and alignment • More senior decision making early in the patient journey • Better defined and co-ordinated flow optimisation SOPs between and within:

EDs, AMAUs, SSU, ASAU and Admissions • Better ambulatory care pathways and appropriate procedure settings • Better older person pathways • Greater in-patient ward cohorting, rounding, and discharge rigor • Greater use of effective continuous information management hubs and

dashboards • Greater weekend working • More patient experience metrics • Better staff management to meet declining resilience – staff/resource shortages • Greater HSE drive on integration and process improvement at the coal face*

DEFINING PERFORMANCE

Challenges for Surgery

• Measuring Individual/Institutional

Performance

• Governance and Quality

Improvement

• Leadership

Institutional Leadership

Mayo Clinic

• All major committes

chaired by a Medical

graduate

• Audit Committee

• Compensation Committee • Conflict of Interest and

Managing Innovations Committee

• Development Committee

• Finance Committee • Governance Committee

• Government and Community Relations Committee

• Research and Education Committee

• Quality, Safety and Patient Experience

Medical Leadership • Reasons

o Peer to peer credibility

o Continued focus on

patient care

o Employee satisfaction

o Know what ‘good looks

like’

• Healthcare balance:

o Quality vs cost

o Technology vs humanity

• US NWR o Medical CEO led hospitals

show 25% increase in

quality scores

• % of managers with a

clinical degree

• Size, private ownership

and competition

Bloom N, Sadum R, Van Reman J 2014 dmn.health.pdf

Medical Leadership • Cleveland Clinic

o Management Training

• Emotional

intelligence

• 360 feedback

• Team building,

executive coaching,

conflict resolution

and situational

leadership

• Yale Medical

o Two tier approach

• Training in the

principles of

healthcare delivery

• Emergency leaders

selected for MBA

training

Surgical Services 2020 and Beyond

• Process Measurement

o Individual and Institutional outcome reporting

• Quality Improvement Initiatives

o Models of Care

o Value added care

• Leadership

o Training in Management and Health Care

Economics

38 NCPS use HIPE data for reports -

Confidential

Surgery Discharges between 2010 and 2015 (including Acute and Elective admissions for surgery or surgical care

excludes obstetrics, maternity hospitals, hospices and rehab units)

National Acute & Elective surgical volumes comparing 2010 to 2015

Surgical volume ↑ X 12.4%

Bed day usage ↓ X 10.9%

Bed day savings 87,561 242,372

Marginal cost saving of €16,549,029 €197,048,221

Day Cases rate ↑ X 12.4%

Based on HIPE discharges in 2010 & 2014 for model 4, 3 & 2 Hospitals

excluding maternity & neonates discharges.

Marginal saving in direct costs is € 189 per BDU.

Fully loaded cost is € 813 per BDU.

Without improvments

Extra BDUs at

a cost of

Note: New 2015 surgical procedure map table reapplied to all yearly analysis 2010 … 2015

Without the improvements would have required

2 fully staffed Model 3 Hospitals (738 beds)

to cope with increase surgical workload

NOCA Audit Portfolio

# Audit National Report Since

Total Hospita

ls Live 2016 2017 2018 TBC

1 National Audit of Hospital

Mortality (NAHM) 2016 44 44

2 Major Trauma Audit (MTA) 2016 26 26

3 Irish Hip Fracture Database

(IHFD) 2013 16 16

4 NPEC Severe Maternal Morbidity 2011 19 19

5 NPEC Perinatal Mortality 2008 19 19

6 NPEC Planned Home Births 2013 20 20

7 Intensive Care Unit Audit (ICU) TBC 22 5 4 7 6

8 Irish National Orthopedic

Register (INOR) TBC 27 1 1 4 7 15*

*Private Hospitals

Emergency General Surgery

• Measured Standards o Organisational change

o Consultant involvement

o Risk assessment

o Emergency theatre capacity

o Post-operative critical care

o Data collection and audit

• Mortality o 30 day – 11.1%

o 90 day – 15.5%

Acute Colorectal Surgery

Model 3 and 4 Hospitals

Model 3 Model 4 Total Colostomy 29 67 96 Ileostomy 14 65 79 Resection and anastomosis 122 148 270 Total colectomy 18 60 78 Anterior Resection 4 39 43 Hartmanns 74 69 143 TOTAL 261 448 709

HIPE 2015