Breakthroughs in Operating Room Efficiency

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Breakthroughs in Operating Room Efficiency
Presented by Dr Terry Loughnan Director of
Anaesthesia
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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)

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Why?

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

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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

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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

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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

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Project Plan

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

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Methodology

• Six Sigma Improvement Process
• Define
• Measure
• Analyse
• Improve
• Control
• Structured approach with emphasis on appropriate
  quality tools.

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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.

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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

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Affinity Diagram
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Value Chain
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Data Collection

• Issues Identified by Site

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Cause Effect Diagram Cancellations on the Day
Processes/Procedures
Equipment
Staff/People
Fasting guidelines/usednot understood by
patients (use nil by mouth)
Illness - Sick staff
Bed unavailability- ICU/general beds
Unavailability
Overruns

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

Breakdown
Staff unavailablebetween 4.30pm and
6.00pm/safe hours
Scheduling to fill the time emergency cases
intervene
Rostering(safe hours)
Poor planning for/booking of appropriate
equipment
Lack of an emergency theatre
Non-worked up patients
Surgeons/staff on holiday and PH not notified
Effect
Delayed starts
Poor bed availability
Causes
Cancellations on the day
Inappropriate health questionnaire screening (for
day theatre) through PAC, eg. Anaesthetists miss
pieces of information (patient completed
questionnaire)
Poor bed availability data
Pathology equipment/staff unavailable/inappropri
ate on the day
Undiagnosed, sickpatient (acute illnessafter
preparation)
Poor predictive data re length of operations
equipment required
We dont know whether beds available
Emergencies - management semi- urgent cases
No real time data rein-patients for theatrewho
are fasting/nil bymouth
Equipment breakdown
Overruns
Environment
Technology
Data
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Cause Effect Diagram Delays in Theatre
Staff/People
Processes/Procedures

• Late culture
• Everything runs a little late
• - No expectation to start on time

• Surgeons bookings from other hospitals

Processes reliant on surgeon (who didnt start on
time)
How do we know when surgeons due?
Surgeons dont want to wait around/be kept
waiting with patients not ready
Poor patient discharge
Medical, education teaching- scheduled deferred
starts - skills mix
Start times do not relate to surgeons

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

Poor booking of eg. Pacemaker technician
Staff availability/absenceseg. Monday
technician(sick leave)
No team driver- surgeons are key in the process
Effect
Causes
Unplanned delays, late starts
Poor forecasting ofequipment required
Poor CSSD capacity logistics need a quicker
cycle
Poor knowledge of accurate list
Arthroscopy need digital equipment increasingly
Theatre staff have to wait for surgeons
People work on other things are legitimately
late
Machines being sent between sites, eg Endoscopy
equipment not available until 9.00am
On time theatre not a priority
Poor data re wards/ ICU status ( beds), post
9.30am meeting
Overrun of other lists earlier in the day
causes delays
Impact of emergencies
Poor predicted times of length of operation-
compounds as the day goes on
Poor parking for staff
Morning/night theatre overruns
Environment
Technology
Data
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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.

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Successes

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

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Communication
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Communication

• Letters to all
• surgeons
• endoscopists
• other proceduralists
• Regular contact with VMO representative

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Current Activities

• Data Collection
• Rosebud Operating Suite
• Frankston Operating Suite
• Frankston Endoscopy
• Frankston Day Surgery
• Surgeon Interviews
• Focus Groups

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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

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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

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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

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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

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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.

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Questions?