Goals of the

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Introduction
Introduction
What are the aims of the toolkit? The patient
flow collaborative aims to remove unnecessary
constraints or delays in the patient process. It
is recognised that operating theatre utilisation
will deliver effective and efficient service to
aid patient flow.   How should the concepts be
implemented from this toolkit? Local theatre
innovation teams should discuss tools and
concepts adapting these to their local context.
What is the operating theatre toolkit for? The
operating theatre toolkit has been designed to
develop organisation wide strategic management of
current operating theatre services and promote
best practice.   Who should use the toolkit? The
toolkit will promote discussion and innovate
solutions around possible present constraints.
Anyone with responsibility for effective theatre
utilisation will benefit from this tool.  
Goals of the toolkit
Overview and strategy
Health service team
Processes
Data
Resources
Diagnostics and tools
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Goals of the toolkit
Introduction

• Introduction
• The operating theatre toolkit is based on whole
  system thinking and includes a whole of hospital
  perspective on effective and efficient theatre
  utilisation.
•  
• Goals
• Key elements to efficient use of operating
  theatres are
• Effective management
• Good communication
• Well trained staff
• Appropriate facilities and equipment
• Operational layout that allows flow of patients.
•  

• Support services play a large part in maximising
  efficiency by providing
• Pre-operative preparation and assessment
• Available beds
• Sterile theatre equipment
• Portering, cleaning and maintenance staff.
• Effective planning and scheduling systems will
  enable smooth patient flow thus increasing
  capacity, improving patient and carer experience,
  improved employee satisfaction and morale.
•  
• Your feedback
• Feedback on this first version of the operating
  theatre toolkit is welcome and will be used to
  update subsequent versions.

Goals of the toolkit
Overview and strategy
Health service team
Processes
Data
Resources
Diagnostics and tools
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Overview and strategy
Planning patient pathways
Introduction
Key elements
Theatre Management structure
Goals of the toolkit
Overview and strategy
Staffing
Postponements
Health service team
Processes
Operating list management
Data
Trauma and emergencies
Effective use of theatre time
Resources
Diagnostics and tools
Theatre design
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Overview and strategy
Introduction
Theatre Management structure

• Theatre management structure
• Theatre management structure should be clearly
  defined with accountability for
• Full budgetary authority
• Adequate sessional allowance
• Information systems
• Utilisation
• Administrative, medical and nursing staff.

Goals of the toolkit
Overview and strategy
Health service team
Day to day management should be provided by an
experienced trained and skilled theatre manager,
who is responsible for clear communication,
ensuring competent staffing and suitable
equipping of all theatres.   Suitable systems for
planning activity should be available to allow
allocation of staff, and to respond safely and
flexibly when changes take place to routines.
  Policies should be developed to deal
effectively with changes to operating lists.
Operating lists should be clearly posted well in
advance and in suitable locations.   Theatre
management team should regularly review
utilisation, cancellations, list overruns, late
starts and waiting lists.
Processes
Data
Resources
Diagnostics and tools
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Overview and strategy
Introduction
Planning patient pathways
Goals of the toolkit
Overview and strategy
Health service team
Planning patients pathways Patients pathways
should take into account ways to maximise use of
theatres and bed availability. Patients
admitted to pre-operative units can be
transferred to wards following surgery allowing
time for discharge of previous patients. Integrat
ion of pre-operative assessment and day case
recovery area located adjacent to theatres
provides an efficient use of space, skilled staff
and may aid patient transport to and from
theatres. This scheme also reduces time on ward
rounds for surgeons and anaesthetist as patients
are in one place.
Processes
Data
Resources
Diagnostics and tools
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Overview and strategy
Introduction
Staffing
Goals of the toolkit
Overview and strategy
Health service team

• Staffing
• Anaesthetic departments should provide a system
  of staffing that works locally and is acceptable
  to staff
• Department staffing should match clinical
  activity, with sufficient cover for elective and
  emergencies
• Robust systems for booking leave must be in place
  and owned by all, with an advertised leave policy
• A lead anaesthetic consultant should be
  identified to support the theatre management team
  and trainees
• Adequate orientation of new or locum staff should
  be made a priority
• Adequate staffing should be available to cover
  governance tasks of note recording and data
  entry.

Processes
Data
Resources
Diagnostics and tools
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Overview and strategy
Introduction
Goals of the toolkit
Operating list management
Overview and strategy
Health service team

• Operating list management
• Close communication and coordination between
  pre-op area and theatre using agreed procedures
  is essential
• A nominated person should liaise with wards and
  transport staff from theatres
• A suitable holding area staffed and equipped will
  assist with smooth flow
• Agreement should be made for preparation and
  transport of patients to and from theatres
• Policies on fasting, anticoagulation, shaving,
  dentures, jewellery, appropriate underwear and
  removal of make-up should be developed
• Units should agree the level of training needed
  to escort patients to and from theatres
• A documented system of handover and
  identification of patient should be in place
• A system to book critical care beds for elective
  admissions should be in place
  and booking confirmed before anaesthesia for
  surgery.

Processes
Data
Resources
Diagnostics and tools
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Overview and strategy
Introduction
Goals of the toolkit
Overview and strategy
Effective use of theatre time
Health service team

• Effective use of theatre time
• It is important that all theatre lists start and
  finish at the agreed time. Agreement should be
  made to make this possible.
•  
• Realistic scheduling of theatres will prevent
  cancellations
• All day theatre lists have proven efficient,
  within the synchronising of surgical and
  anaesthetic time and staffing
• Good time keeping principles should be adopted
  and monitored by the theatre management team
• Pro-active re-allocation of cancelled theatre
  lists.

Processes
Data
Resources
Diagnostics and tools
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Overview and strategy
Introduction
Goals of the toolkit
Overview and strategy
Theatre design
Health service team

• Theatre design and operational layout
• Design of operating theatres is essential for
  maximising patient flow, consideration needs to
  be made for
• Large multi-purpose accommodation to enable
  increase in complexity and equipment
• Transport routes that flow through stages of
  theatre care
• Internal communication IT systems that facilitate
  appropriate communication and supervision.

Processes
Data
Resources
Diagnostics and tools
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Overview and strategy
Introduction
Goals of the toolkit
Trauma and emergencies
Overview and strategy
Trauma and emergency surgery Effective planning
for emergency and trauma surgery is needed to
prevent cancellation of elective
surgery. Provision of exclusive emergency list
will assist in preventing cancelled elective
surgery.
Health service team
Processes
  Good communication enables clinical decisions
to be made rapidly, increasing the number of
surgical procedures carried out in a safe time
and environment. Time should be allowed for the
Anaesthetist to assess emergency patients to
their satisfaction.   Experienced surgical staff
should prepare patients who have multiple and
complex medical problems, this can prevent
cancellation at anaesthetic assessment.   Pre-oper
ative assessment for patients who are elderly,
have multiple and complex medical problems can
benefit from a team approach between
anaesthetist, surgeon and physician.  
Data
Resources
Diagnostics and tools
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Overview and strategy
Introduction
Postponements
Goals of the toolkit
Overview and strategy
Health service team

• Cancellations of surgery
• It is extremely distressing and stressful to
  patients who are postponed surgery, many
  cancellations can be prevented by assisting
  patient flow with good planning in
• Bed management
• Pre-operative assessment
• Increased communication
• Regular review of cancellation can assist with
  target areas for redesign and innovation.
• Cancellation data should be collected and
  reviewed weekly with agreed action plans.

Processes
Data
Resources
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Health service team
Introduction
Goals of the toolkit
Overview and strategy
Health service team
It is essential for operating theatre innovation
to have a skilled, trained and committed
innovation team. The team should consist of
representatives of all theatre staff
groups.   Management clinical/non
clinical Nursing Pre op and theatres, including
operating department practitioners Clinical
Anaesthetist/Surgeons Administration Admin and
Portering
Processes
Data
Resources
Diagnostics and tools
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Processes
Introduction
Goals of the toolkit
Initial recording of overall patient processes
should be made covering
Admission
Receive patient to ward following operation
Overview and strategy
Health service team
Processes
   Administration Processes will also need to map
demonstrating process from
Data
Allocation to theatre list
Theatre reception on day of operation
Resources
Diagnostics and tools
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Processes
Introduction
Process map groups
Goals of the toolkit
Theatre
Theatre
Bed
ICU
Theatre
Overview and strategy
Recovery
Recovery
Theatre
Theatre
ICU
Health service team
Home
Bed
HDU/ITU
ICU
Bed
Processes
Data
Home
Bed
Bed
Home
Resources
Home
Home
Mapping tip Map high level group first
Diagnostics and tools
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Processes
Introduction
Scheduling The realistic building of theatre
lists start in processes outside of theatre
environment, essential validation of how lists
are made needs to be undertaken to maintain
effective and efficient operating
theatres.   Agreement can be made on average time
per procedure to enable effective booking of
theatre lists.   Average time per operation can
be agreed and used to assist building theatre
templates.
Goals of the toolkit
Overview and strategy
Health service team
Processes
Data
Resources
Diagnostics and tools
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Processes
Introduction
Process steps examples
Goals of the toolkit
Overview and strategy
Health service team
Processes
Data
Resources
Diagnostics and tools
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Processes
Introduction
Process steps examples
Goals of the toolkit
Overview and strategy
Health service team
Processes
Data
Resources
Diagnostics and tools
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Processes
Introduction
Build your schedule
Goals of the toolkit
Use graph paper with one square per minute to
sequence time scales per procedure.
Overview and strategy
Health service team
1 MINUTE
102 MINUTES
Processes
Data
Resources
Diagnostics and tools
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Processes
Introduction
Build your schedule
Goals of the toolkit
Transfer graph sequence timescales to chart
clinic time.
Overview and strategy
9.00 am start
1.30 pm end
Health service team
Processes
Data
Resources
Diagnostics and tools
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Data
Introduction

• Core data set
•  
• Suggested Measures
• Late Starts (e.g. gt15mins) / Early Finishes (e.g.
  gt60mins) / Overruns (e.g. gt30mins)
• Example For ten Orthopaedic sessions with a
  scheduled start time of 830am the sample showed
  four (or 40) started gt15mins late.
• Number of Major Procedures (gt1hr) v Minor
  Procedures (lt1hr) by Specialty
• Average time in theatre by specialty / procedure
• Lost time due by Cancellation reasons e.g. no
  beds, patient unfit
• Number of patients arriving in theatre with
  consents not completed by week
• Delays
• Monitor theatre delays for one week to agree on
  the top 10 reasons for delays. When this is
  agreed, 4 weeks data will be collected against
  the top 10 delays. Once 4 weeks of 10 delays
  have been gathered SPC charts will need to be
  produced. Time needs to be collected against each
  reason(s) per day, as the top ten offenders may
  not amount to the longest waste in time.

Goals of the toolkit
Overview and strategy
Health service team
Processes
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Resources
Introduction

• Aim To increase the utilisation and quality of
  care within operating theatres.
•  
• Change Concepts
•  
• Review operating theatre utilisation (see tool
  kit)
• Scheduling
• Identify system to report delays daily via agreed
  criteria
• Remove delays, complexity and hand offs within
  administration process
• Smooth process from Emergency Department /
  Inpatient wards to Operating Room and back to
  ward
• Review stages of Transfer from ward /Emergency
  Department, recovery to ward
• Review capacity and demand for emergency and
  elective theatre

Goals of the toolkit
Overview and strategy
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Processes
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Diagnostics and tools
Introduction

• Operating theatre checklist
• Delay proforma

Goals of the toolkit
Overview and strategy
Health service team
Processes
Data
Resources
Diagnostics and tools
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