Benchmarking in Day Surgery Skues.pdf · Post-op Recovery Day Unit ... Effect of Pathway Redesign Post-discharge support Documentation ... Benchmarking in Day Surgery Mark Skues

British Association of Day Surgery www.bads.co.uk

Benchmarking in Day Surgery

Mark Skues President, British Association of Day Surgery


Across the Irish Sea...

Issues with

• Financing

• Demographics

• Morale


Making Day Surgery count…

An opportunity for care that is:

• Better quality

• More patient focussed

• More cost efficient

Getting started…


•Circumcision

•Excision of breast lump

•Varicose veins

•Dupuytren’s contracture

•Ganglion excision

•Cataract removal

•Myringotomy

•MUA # Nose

•D&C

•Termination of Pregnancy

The Audit Commission Basket of Procedures 1990

•Orchidopexy

•Inguinal hernia repair

•Anal Fissure excision

•Cystoscopy

•Carpal Tunnel Decompression

•Arthroscopy of Knee

•Squint correction

•Sub Mucous Resection

•Pinnaplasty

•Laparoscopy + Sterilisation


BADS Trolley of Procedures (1999)

• Laparoscopic cholecystectomy

• Thorascopic sympathectomy

• Partial thyroidectomy

• Wide excision of breast lump

• Urethrotomy

• Laser prostatectomy

• Eyelid surgery

• Arthroscopic meniscectomy

• Dentoalveolar surgery

• Haemorrhoidectomy

• Tonsillectomy

• Submandibular gland excision

• Bladder neck incision

• TCRE

• Hallux valgus ops

• Arthroscopic shoulder ops

• Tympanoplasty

• Rhinoplasty


•Orchidopexy

•Inguinal hernia repair

•Anal Fissure

•Lap Cholecystectomy

•TURBT

•Carpal Tunnel Release

•Arthroscopy of Knee

•Removal of metalware

•Squint correction

•Tonsillectomy

•MUA # Nose

•D&C, Hysteroscopy

•(Termination of pregnancy)

Audit Commission Basket of 24 Procedures (2000)

•Circumcision

•Excision of breast lump

•Haemorrhoidectomy

•Varicose veins

•Dupuytren’s contracture

•Ganglion excision

•Bunion operations

•Cataract removal

•Myringotomy + Grommet

•Sub Mucous Resection

•Pinnaplasty

•Diagnostic Laparoscopy


‘Watch Wayne Littlejohn have his kidney removed and return home the same day.’

"It's a challenge and a brave decision, but our patients are driving it," says Anurag Golash,

Consultant Urologist at the University of North Staffordshire Hospital.

"I was given the choice - I chose going home," said Mr Littlejohn, just arrived home after having a kidney removed.

"I get bored in hospital,

Nothing is better than being in your own bed.” "I have my sport on TV and my family around to help me."


Time to move away from the “Basket”

• Gives the impression that these procedures are the only ones to concentrate on

• Advances in surgical and anaesthetic techniques

mean much more can be managed as day surgery

• Non comparable across all Trusts


The BADS Procedure Directory

2006 2007 2009 2012


The Directory 2012


Procedure Directory Use


BADS Procedure Directory

Breast Surgery ENT General Surgery Gynaecology Head and Neck Ophthalmology Orthopaedic Surgery Urology Vascular Surgery

Paediatric Surgery Emergency Surgery Medical Procedures

170 Procedures


BADS Procedure Directory

•Therefore, achievement of these goals may require: •Reconfiguration of day surgery lists •Redesign of the clinical pathway •Investment in appropriate technology

•Some procedures may need longer recovery or observation times

•Others may required specialised equipment or training for Clinicians to achieve their full potential



Laparoscopic Cholecystectomy


National Dataset


Laparoscopic Cholecystectomy


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Day Case Laparoscopic cholecystectomy

2000

2010

English Hospitals


NHS Atlas of Variation


Day case Laparoscopic Cholecystectomy


Why the variability?

• Clinician “resistance”?

• Suboptimal anaesthesia?

• Pathway and process


Day Surgery Pathway

• “Intention to treat”

• Outpatient review

• Preoperative assessment

• Information provision

• Admission management

• Nurse led discharge

• Discharge information

• “Help line” backup


Unified Day Surgery Pathway

GP Surgical OPD Preop assessment

Diagnostics Day Surgery Waiting List

Admission and Surgery

Inpatient Waiting List

Surgical OPD

Post-op Recovery

Day Unit

Inpatient / Short Stay Unit

Unanticipated overnight admission

Discharge

Immediate Post-

operative support


Illustration

2008–9


Rapid Improvement Sites

All English Trusts invited

– 10 chosen

– 1 per SHA

Low day case rates

– 1 “high performer”


0

25

50

75

100

Start Oct 2008

Applying Basic Principles

Day surgery

rate (%)

Trusts

A B C D E F G H I

Smith et al. J One-Day Surgery 2010;20:80-4.


Effect of Pathway Redesign

Post-discharge support

Documentation

Patient discharge

Recovery facilities

Operating lists

Admission

Booking

Selection criteria

Preoperative assessment

Surgical outpatients

Patient referral


0

25

50

75

100

Start Oct 2008

Applying Basic Principles

Day surgery

rate (%)

Trusts Smith et al. J One-Day Surgery 2010;20:80-4.

End Nov 2009 (Self-reported data)

A B C D E F G H I


0

25

50

75

100

Start Oct 2008

Sustainable?

Day surgery

rate (%)

Trusts

End Nov 2009 National Data, Mid 2012

A B C D E F G H I


0

25

50

75

100

Start Oct 2008

Sustainable?

Day surgery

rate (%)

National

Trusts

End Nov 2009 National Data, Mid 2012

A B C D E F G H I


Back to Benchmarks...


How do we update the Procedure Directory?

Collaboration with external organisations:

• Audit Commission

• “Payment by Results” Tariff Team

• NHS Information Centre (HES data)

• NHS Institute “Better Care” indices


How do we update benchmarks?

Collaboration with

Individuals and Professional Organisations;

• Gynaecology and the RCO&G

• Paediatric Surgery and APA

Trusts:

• BADS Efficiency Assessment Tool



BADS Efficiency Assessment Tool


Comparative benchmarking

Basket of “25” Scores: 73% 89% 82%


NHS Better Care website www.productivity.nhs.uk


Individual hospital performance


Other Benchmarks / Outcome Indicators

• Individual

• Departmental

• Hospital

• National

• What the patient thinks?

• Environment efficiency

Clinical

Organisational

Social

Economic


Clinical Indicators: Individual Anaesthetists

• Audit for appraisal

• Unplanned overnight admission rates

• Pain scores in recovery

• PONV rates

• Regional anaesthesia “success” rates

• Patient (MSF) feedback


Unanticipated Overnight Admission Rate

• A useful outcome marker?

• “...Should be less than 2%.....”?


How to reduce this rate to zero..

Ultra-conservative selection criteria


Reasons for overnight admission Predictable Unpredictable

Medical • Pre-operative co-morbidity

• Complications • Cardiovascular • Respiratory

Surgical • A challenging individual patient for day care

• Pain • More complex

operation • Misadventure • Bleeding

Anaesthetic • Staff roster – skill mix • PONV • Somnolence

Social • No home support

Administrative • Wrong time of day for day case operation

• Wrong environment


Reasons for overnight admission Predictable Unpredictable Outcome

Medical • Pre-operative co-morbidity

Complications • Cardiovascular • Respiratory

17.2%

Surgical • A challenging individual patient for day care

• Pain • More complex

operation • Misadventure • Bleeding

38.1%

Anaesthetic • Staff roster – skill mix • PONV • Somnolence

25.1%

Social • No home support 19.5%

Administrative • Wrong time of day for day case operation

• Wrong environment • Capacity pressures

Can J. Anaesthesia 1998;45.7:612

Pre-Operative

Assessment


0%

1%

2%

3%

4%

5%

6%

7%

8%

9%A

ug

-02

No

v-0

2

Fe

b-0

3

Ma

y-0

3

Au

g-0

3

No

v-0

3

Fe

b-0

4

Ma

y-0

4

Au

g-0

4

No

v-0

4

Fe

b-0

5

Ma

y-0

5

Au

g-0

5

No

v-0

5

Fe

b-0

6

Ma

y-0

6

Au

g-0

6

No

v-0

6

Fe

b-0

7

Ma

y-0

7

Au

g-0

7

No

v-0

7

Fe

b-0

8

Ma

y-0

8

Au

g-0

8

No

v-0

8

In-Patient Admission after Day Surgery

Mean

UPL/LPL



• Individual

• Departmental

• Trust

• National



Clinical

Organisational

Social

Economic


Patient Satisfaction

• Effective postoperative analgesia

• Minimal emetic sequelae

• Staff courtesy and privacy in the unit

• Short waiting times on the day of surgery

• No perception of being rushed

• Post-operative telephone contact

• Good surgical outcome

Smith I, Skues MA, Philip B. Miller’s Anaesthesiology, 8th Edn: in Press



• Individual

• Departmental

• Trust

• National



Clinical

Organisational

Social

Economic


Economic benchmarks


Economic Efficiency

• Cancelled lists

• Substitution?

• Timely notification of leave

• Late starts / early finishes

• Patient booking remits

• DNAs

• ‘Gap times’ in theatre


Avoidable?



Theatre Utilisation


“In Theatre” Delays


Other benchmarks or “barriers”...

National facilities?


Barriers to Day Surgery?


Selection criteria

BADS Guidelines (2012)

•Dedicated day surgery lists provide the best model of care. •Lists with a mix of day and short stay surgery can be efficient and provide flexibility. •Lists that have a mix of inpatient and day case patients cause tension between the needs of major cases and the day cases.

Operating lists

•A 24 hr telephone support number should be provided to each patient and their carer. •This support service should be provided by nursing staff with knowledge of the potential complications following surgery.

Post discharge support

•Guidelines have been published by the British Association of Day Surgery and the Association of Anaesthetists of Great Britain and Ireland. •There is no set maximum travelling time from hospital to home. •Carer support after discharge - usually 24 hrs but may be shorter or longer depending on the procedure. •BMI should not be used as an arbitrary contraindication to day surgery. •Co-morbidities should be assessed and optimised for day surgery. •Hypertension should not be used as a contraindication to day surgery.


Resources: From www.bads.co.uk



Benchmarking in Day Surgery

Mark Skues President, British Association of Day Surgery

Benchmarking in Day Surgery Skues.pdf · Post-op Recovery Day Unit ... Effect of Pathway Redesign Post-discharge support Documentation ... Benchmarking in Day Surgery Mark Skues

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