Transcript Challenging and Changing Every Step of the Surgical

Challenging and Changing
Every Step of the Surgical
Pathway in an NHS Hospital
EHMA Annual Conference, Athens, June 2008
M. HEMADRI
MBBS (Madras) FRCS (Edinburgh) MBA (Leicester)
In this presentation
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Conventional surgical pathway
Challenge each step
Single Visit pathway & results
People versus structure
Leadership from the ground and
Feed-forward techniques
Problems
Lessons
Present/Traditional Model
GP REFERS PATIENT
Up to 13 weeks
Specialist Consultation
1
2
Radiology Endoscopy
+/- 13 Weeks
3
2 Bloods & review 6 weeks
Review and place on waiting list
Up to 6 months
5
2
Other specialists,
anaesthetic assessment
+/- 2 to 8 weeks
4
Nurse pre-assessment
Surgical operation
2 to 12 weeks
31/62 Impact
6
Routine post operative visit/visits
18 WDP Impact
Business Process Re-engineering
"... the fundamental rethinking and radical redesign of
business processes to achieve dramatic improvements in
critical contemporary measures of performance, such as
cost, quality, service, and speed.“
Hammer & Champy (1993)
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Time compression
Process re-design
The shortest distance between two points is a straight line
Time compression of Traditional Model
GP REFERS PATIENT
6 weeks
Specialist Consultation
1
2
Radiology Endoscopy 6
Weeks
3
2 Bloods & review 6 weeks
Review and place on waiting list
6 Weeks
5
2
Other specialists,
anaesthetic assessment
6 weeks
4
Nurse pre-assessment
Surgical operation
6 weeks
6
Routine post operative visit/visits
18 WDP Impact
How useful is a post-operative follow up visit?
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70% of patients felt that they would
not benefit from a routine outpatient
appointment.
Re-engineering of Traditional Model
GP REFERS PATIENT
6 weeks
Specialist Consultation
1
2
Radiology Endoscopy 6
Weeks
3
2 Bloods & review 6 weeks
Review and place on waiting list
6 Weeks
5
Surgical operation
2
Other specialists,
anaesthetic assessment
6 weeks
4
Nurse pre-assessment
Strong and abundant
evidence for effectiveness of
telephone pre-assessment
Especially for day case surgery
Re-engineering of Model
GP REFERS PATIENT
6 weeks
Specialist Consultation
1
2
Radiology Endoscopy 6
Weeks
3
2 Bloods & review 6 weeks
Other specialists,
anaesthetic assessment
6 weeks
Review and place on waiting list
Telephone pre-assessment
6 Weeks
4
Lets look at
Visit 2 & 3
2
Surgical operation
Re-design: Emerging new model
GP REFERS PATIENT
6 weeks
Specialist Consultation
1
1
Radiology Endoscopy
1
Other specialists,
anaesthetic assessment
1 Bloods
6 weeks
2
Telephone pre-assessment
Surgical operation
Lets look at
Visit 1 & 2
Dissatisfaction was due to waiting times
between admission operation and discharge.
Single Visit Model
Structured GP Referral
Unsuitable
Standard pathway
Suitable
Communication – Negotiation with patient
1
Telephone Pre-assessment
Surgical Consultation, Investigations, Nurse Assessment,
Anaesthetist Assessment, Admission and Operative Surgery
ALL ON THE SAME DAY
NO ROUTINE FOLLOW UP
Discharge when stable
Guarantee to see in 48 hours at request
New model performance
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Age range 20 to 83 years (M:F 2:1)
Minor (small lesions, vasectomy): Intermediate (hernia,
varicose veins): Major (gall bladder, incisional hernia):
LA:GA=1:1
No mortality, one unplanned admission, no 30 day
readmissions.
Reduced DNA rates.
No cancellation due to hospital reasons.
20 declined due to lack of indication/complexity/fit with
exclusion criteria)
Referral to treatment time: Average 4 weeks
No major complications
No significant complaints
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COST
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Patient Feedback
‘BETTER THAN PRIVATE’
Why are we different?
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Conventional Projects
18 WDP
Hospital at night
2/52 & 31/62
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Unconventional project
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Spontaneously emerging, self
selected teams
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No hierarchical structure
No titles
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Self-monitoring
Conventional Teams
Chairman, Vice Chairman,
Project Manager,
Appointed/deputed multidiscipline members
Modernisation/Service
Development
sponsorship/supervision
Regular formal meetings,
reports
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Recipe books
‘‘Assured success’’
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No budget
Very rare formal meetings
Continuous informal contact
Never produced a formal
report
Action first – discussion and
documentation later.
Rigid infrastructure
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Flex/alter structure to get people in line
Use people to get around rigid structure
Example our patient admin IT system
Emotional appeal one at a time builds up
to a change
Sharing the glory is an investment
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Financial – forget it?
Co-authoring
Award applications
Exclusive day outs
Appreciation letters
Press exposure
Some of our team enjoying at the
racecourse with a Brazilian
theme!!
FEED FORWARD TECHNIQUES
The Rewards Network
Pay
Rise
Promotion
CV improvement
Better Appraisals
Authorship
Awards
Press citing
Letters of appreciation
Other
Prestige
Self worth
Emotional satisfaction
Soft skills enhancement
ACTIVITY
FEED FORWARD TECHNIQUES
Losers
Resistors
Turkeys will not vote for Christmas
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Doctors
Hospital
OPD
Ward
Back office staff
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Busy surgeons
have long waiting
lists
Genuine belief in
the old linear
sequential process
Not invented here
LEADERSHIP FROM THE GROUND
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Goole District Hospital
Accepting fluidity
Accepting asymmetrical progress
Saying ‘Yes’ more often than ‘no’
Using the power of non-agenda
Short term micro feedback
Long term macro feed forward
Current Status
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Radiology/Ultrasound and out patient
predictive synchronisation
Radiology/USS + OPD + PreAssessment synchronised
Radiology/USS + OPD + PreAssessment + Anaesthetist
Assessment synchronised
NATURAL EXPANSION OF THE CONCEPT
AND
GENERIC GROWTH OF THE TEAM
So what is the problem?
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Transformational change but……………
Small scale
Roll out
WHAT IS THE SOLUTION?
Optimism.
Strength of the model.
Getting more political?
Conclusions
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Change programmes not centrally defined
can be done with equal or better success
People can be used to overcome rigid
infrastructure
Loose alliance of normal employees can
achieve the same effects as formal teams
The impact of small informal teams & their
projects could be local and limited but…..
Lessons learnt
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Feed-forward is a useful tool not only
for hard and soft career progression
but also a good political tool for
enabling change.
Leadership from the ground is
definitely possible and perhaps
should be used more often
THANK YOU
Acknowledgement to our small core team which apart
from myself includes
Peter Moore, Consultant Surgeon
Jeanette Heaven-Terry, Surgical Secretary
Jane Hopkins, Sister Day Surgery Unit
Theatre floor in-charge of the day
Anaesthetist of the day (usually Dr. M Thant, Associate
Specialist or Dr S Jha, Staff Grade)
AND
An increasing band of extended team members and
supporters