Department of Human Services Breakthroughs in Operating Room Efficiency Presented by Dr Terry Loughnan Director of Anaesthesia.

Department of Human Services

Breakthroughs in Operating Room

Efficiency

Presented by Dr Terry Loughnan

Director of Anaesthesia

Why?Why?

• Internally recognised that improving the performance of operating theatres is a key to improving services for patients.

• Independent Review in 2003 concluded that there were gains to be made within existing resources. (Giffney Report)

Why?Why?

• Emerged from specialist survey in June 2004 that operating room efficiency was the highest priority improvement opportunity.

Issues Identified by Specialists (2004)

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Issue

Our ObjectivesOur Objectives

• Maximise utilisation of current theatre resources• Reduce time lost due to late starts and changeover• Reduce Cancellations • Increase patient throughput• Improve Satisfaction of Patients, Specialists, OR

Staff

ScopeScope

Four Procedural Areas across 2 sites Rosebud• 1 Theatre for Low risk patients undergoing

elective surgery excluding joint replacements and laparotomies

Frankston• Day Surgery Unit (free standing)• Endoscopy Unit (separate to Main Theatre)• Theatre Suite of four operating rooms

Our TeamOur Team• Director of Anaesthesia (Project Manager)• Executive Director Medical Services• Director of Surgery• Orthopaedic Surgeon (VMO representative)• Consumer Representative• Operations Director Surgery and Inpatient Services• Nurse Managers of the 4 Procedural Areas and

Admission/Discharge Lounge• Consultants and Six Sigma Facilitator • Manager Admissions/Discharges• Project Officer• ESAC Coordinator

Project PlanProject Plan

• Establish Structure of Team• Define Project• Measure Current Situation• Complete Analysis• Plan and Trial Improvements• Control/Redesign Process• Evaluate and Review Project

MethodologyMethodology

Six Sigma Improvement Process• Define • Measure• Analyse • Improve • Control• Structured approach with emphasis on

appropriate quality tools.

MeetingsMeetings

• Initially every second Monday morning at 0800 – 0930.

• Located away from Operating Suite.

• Activities have generated free flowing discussion and far greater understanding of the challenges faced in other areas.

Quality ToolsQuality Tools

• Affinity Diagram (brainstorming session of relevant issues)

• Value Chain/Process Mapping

• Critical to Quality Analysis

• Survey of Issues by Site

• Cause and Effect Diagrams

Affinity DiagramAffinity Diagram

Value ChainValue Chain

Data CollectionData CollectionIssues Identified by Site

ROSEBUDTHEATRE

FRANKSTON MAIN

THEATRES

FRANKSTON DAY SURGERY

FRANKSTON ENDOSCOPY

FRANKSTON A/D

LOUNGE

Start Times Start Times Start Times Start Times Patient Arrival Times

Equipment Issues

Emergency Patients v

Elective Patients

Equipment Issues Surgeon Leave Replacement

Patient not Worked-Up Adequately

Surgeon Leave Replacement

Changes to OR Lists

Surgeon Leave Replacement

Changes to Lists

Multiple Staff Members

Needing Patient Access

Available v Used OR Time

Multiple Cancellations of

One Patient

Available v Used OR Time

Changeover Times

Admitting Day Medical Patients

Lack of Surgeon Leave

Notification

Access to Critical Care Beds

Surgeon Committed to Other Areas of

Hospital

Lists Running Over Time

Cause & Effect Cause & Effect Diagram: Cancellations Diagram: Cancellations on the Dayon the Day

Causes

EnvironmentTechnologyData

Effect

Cancellations on the day

Poor bed availability data

Poor predictive data re length of operations

& equipment required

No real time data rein-patients for theatrewho are fasting/nil bymouth

We don’t know whether beds available

Undiagnosed, sickpatient (acute illnessafter preparation)

Emergencies- management & semi- urgent cases

Overruns

Inappropriate health questionnaire

screening (for day theatre) through

PAC, eg. Anaesthetists miss

pieces of information (patient completed

questionnaire)

Staff/People Illness

- Sick staff

Staff unavailablebetween

4.30pm and 6.00pm/safe hours

Staff attitude-not working out of hours- safe working hoursrequired

Surgeons/staff on holiday and PH

not notified

Pathology equipment/staff unavailable/inappropriate on the day

Equipmentbreakdown

Poor planning for/booking of appropriate equipment

Processes/Procedures

Bed unavailability:- ICU/general beds

Delayed starts

Overruns

Lack of an emergency theatre

‘Fasting’ guidelines/usednot understood by patients

(use ‘nil by mouth’)

Scheduling to fill the time &emergency cases intervene

Non-worked up patients

Rostering(safe hours)

Poor bed availability

Equipment

Unavailability

Breakdown

Cause & Effect Cause & Effect Diagram: Delays in Diagram: Delays in TheatreTheatre

Causes

Staff/People Processes/Procedures

EnvironmentTechnologyData

Effect

Unplanned delays, late starts

“Late culture”-Everything runs a little late- No expectation to start ‘on time’

Medical, education teaching

- scheduled deferred starts

- skills mix

-Surgeons bookings from other hospitals

Poor forecasting ofequipment required

How do we know when surgeons

due?

Arthroscopy need digital equipment increasingly

Start times do not relate to surgeons

Poor predicted times of length of operation- compounds as the day goes on

Poor knowledge of accurate list

Poor data re wards/ ICU status (& beds), post 9.30am meeting

No “team driver”- surgeons are key in the

process

Poor patient discharge

Poor booking of eg. Pacemaker technician

Staff availability/absences

eg. Monday technician(sick leave)

Processes reliant on surgeon (who didn’t start on time)

Surgeons don’t want to wait around/be kept waiting with patients not ready

Are we scheduling to give surgeons enough time?- lists are too full- all day lists at Rosebud/one site?

Theatre staff have to wait for surgeons

Overrun of other lists earlier in the day

causes delays

Poor parking for staff

People work on other things & are legitimately late

On time theatre not a priority

Impact of emergencies

Morning/night theatre overruns

Poor CSSD capacity & logistics: need a

quicker cycle

Machines being sent between sites, eg

Endoscopy equipment not available until

9.00am

ChallengesChallenges

• Christmas break and Public Holidays.

• Availability of Visiting Medical Officers (VMOs). Everyone is willing to be involved but no-one can attend a meeting.

• Shortened time-lines and need to start .

• Avoiding use of the word “Efficiency”.

SuccessesSuccesses

• Discovering the true functions of our procedural areas. eg Admission and Discharge Lounge

CommunicationCommunication

CommunicationCommunication

Letters to all

• surgeons

• endoscopists

• other proceduralists

Regular contact with VMO representative

Current ActivitiesCurrent Activities

• Data CollectionRosebud Operating SuiteFrankston Operating SuiteFrankston EndoscopyFrankston Day Surgery

• Surgeon Interviews• Focus Groups

Data CollectionData Collection

Simple forms specific to each area Compatible with NHS DefinitionsCommon Data Items: examples• Times of arrival of Surgeon • Times of arrival of Anaesthetist• Time patient called for by OR• Time patient sent to OR from preparation area• Time induction commenced• Time “knife to skin”• Time transferred to recovery• Time ward called to collect patient• Time patient left recovery

Surgeon InterviewsSurgeon Interviews

• Surgeons from each specialty were nominated by Director of Surgery

• Letter sent to all surgeons with list of suggested interviewees

• Those not on the list were invited to make contact if they wished to be interviewed.

• Appointment times and locations scheduled to suit surgeon

Surgeon InterviewsSurgeon Interviews

• Quantify expectations of the surgeons regarding issues such as Knife to skin time,

• Perceptions of current performance of the Theatre

• Suggested improvements within current resources

Focus GroupsFocus Groups

• Patients• Anaesthetists/Registrars• Surgeons/Registrars• Theatre Nursing Staff (both day and evening

groups)• Theatre technicians/PSAs/ReceptionIdeally 8-9 participants for 40-50 minutesLetter to staff to explaining process and inviting

them to participate

Planned Future ActivityPlanned Future Activity

• Process re-design workshop. To be held in the evening with interested stakeholders to review the data collected and address issues raised, to improve theatre utilisation.

Aim is to have stakeholders re-design the process to meet the customers expectations.

Questions?Questions?