Transcript Document
Breakthroughs in Operating Room Efficiency Presented by Dr Terry Loughnan Director of Anaesthesia Department of Human Services 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? • Emerged from specialist survey in June 2004 that operating room efficiency was the highest priority improvement opportunity. 40 35 30 25 20 15 10 5 0 Issues Identified by Specialists (2004) Th eat re Ou t pa ti en Ag ed ts Ca re Em erg Issue enc Ac ad y em ic Ob s tet ric s Our 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 Scope 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 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 Plan • • • • • • • Establish Structure of Team Define Project Measure Current Situation Complete Analysis Plan and Trial Improvements Control/Redesign Process Evaluate and Review Project Methodology Six Sigma Improvement Process • Define • Measure • Analyse • Improve • Control • Structured approach with emphasis on appropriate quality tools. Meetings • 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 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 Diagram Value Chain Data Collection Issues Identified by Site ROSEBUD THEATRE 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 Diagram: Cancellations on the Day Processes/Procedures Staff/People Illness - Sick staff Bed unavailability: - ICU/general beds Staff attitude -not working out of hours - safe working hours required Staff unavailable between 4.30pm and 6.00pm /safe hours Unavailability Overruns Breakdown Scheduling to fill the time & emergency cases intervene Rostering (safe hours) Lack of an emergency theatre Surgeons/staff on holiday and PH not notified Equipment ‘Fasting’ guidelines/used not understood by patients (use ‘nil by mouth’) Non-worked up patients Delayed starts Poor bed availability Causes Poor bed availability data Poor predictive data re length of operations & equipment required We don’t know whether beds available Data Pathology equipment/ staff unavailable/ inappropriate on the day Undiagnosed, sick patient (acute illness after preparation) Emergencies - management & semiurgent cases Equipment breakdown Overruns Technology Effect Cancellations on the day Inappropriate health questionnaire screening (for day theatre) through PAC, eg. Anaesthetists miss pieces of information (patient completed questionnaire) No real time data re in-patients for theatre who are fasting/nil by mouth Poor planning for/booking of appropriate equipment Environment Cause & Effect Diagram: Delays in Theatre Staff/People Processes/Procedures “Late culture” -Everything runs a little late - No expectation to start ‘on time’ How do we know when surgeons due? Medical, education teaching - scheduled deferred starts - skills mix Start times do not relate to surgeons -Surgeons bookings from other hospitals Processes reliant on surgeon (who didn’t start on time) Surgeons don’t want to wait around/be kept waiting with patients not ready Poor patient discharge Poor booking of eg. Pacemaker technician Staff availability/absences eg. Monday technician (sick leave) No “team driver” - surgeons are key in the process Causes Poor data re wards/ ICU status (& beds), post 9.30am meeting Data Effect Unplanned delays, late starts Poor forecasting of equipment required Arthroscopy need digital equipment increasingly Are we scheduling to give surgeons enough time? - lists are too full - all day lists at Rosebud/one site? Poor knowledge of accurate list Poor CSSD capacity & logistics: need a quicker cycle Machines being sent between sites, eg Endoscopy equipment not available until 9.00am Poor predicted times of length of operation - compounds as the day goes on Theatre staff have to wait for surgeons Overrun of other lists earlier in the day causes delays Poor parking for staff Technology Environment People work on other things & are legitimately late On time theatre not a priority Impact of emergencies Morning/night theatre overruns Challenges • 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”. Successes • Discovering the true functions of our procedural areas. eg Admission and Discharge Lounge Communication Communication Letters to all • surgeons • endoscopists • other proceduralists Regular contact with VMO representative Current Activities • Data Collection Rosebud Operating Suite Frankston Operating Suite Frankston Endoscopy Frankston Day Surgery • Surgeon Interviews • Focus Groups Data Collection Simple forms specific to each area Compatible with NHS Definitions Common 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 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 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 Groups • • • • Patients Anaesthetists/Registrars Surgeons/Registrars Theatre Nursing Staff (both day and evening groups) • Theatre technicians/PSAs/Reception Ideally 8-9 participants for 40-50 minutes Letter to staff to explaining process and inviting them to participate Planned 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?