Aaron Shergis - Maroondah Hospital - TPOT: The Productive Operating Theatre

Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,

Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health



Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards

TPOT : The Productive Operating Theatre.

Aaron Shergis





Surgery 2015


1. Preparation : Surgery 2015 Project.

2. Journey of TPOT for Eastern Health.

3. Theatre Dashboard : Developing useable data on efficiency, Safety and Patient experience.

4. How Data has changed us.

Eastern Health

Box Hill

7 OT

Maroondah

5 OT

Angliss

3 OT

Yarra

Ranges

2 OT

Healesville

1 OT

Includes Endoscopy





Background Surgery Services

• Clinical Services – Site Based across all areas • Differing Medical Payment Models • Lack of organisational structure (All site based) • Efficiency issues

Project Surgery 2015 Aims : 1. Create Eastern Health Clinical Streams -April 2012 2. Create Eastern Health structures and committees (unlock the

Silos) April 2012. 3. Implement Standard medical Payment Model - Feb 13 - May

13 4. Theatre schedule reform. 5. Work through modules of The Productive Operating Theatre.

Cage Brawl





•Creation of EH clinical streams per Surgical Specialty.


Project Surgery 2015

Easter Health Unit director.

Site based lead (Associate director)

Staff Surgeons/Anaesthetists





•Align Eastern Health


EH Surgery Program Director

Site based APD (Associate Program Directors)

Perioperative services managers

Ward NUMS Admission/ward NUMS Theatre NUMS

Eastern Health Surgery aspires to provide excellent surgical care to patients by excellent staff in an

efficient and frustration free environment.

• Excellent surgical care means delivery of safe, high quality outcomes for

patients from their surgical care that results in an excellent patient experience.

• Efficient environment means decisions for care are based on clinical need and best use of available resources.

• Excellent staff means supported and supportive teams created from the best people.

• Frustration free environment means a motivated surgical team being able to deliver excellence of care.





•Creation of EH standard payment model



Sessional payment for in hour’s surgery.

Sessional payments for in hours trauma (including emergency additions)

FFS/RVG for out of hours surgery (for plastics and ortho)

General Surgery Paid : On call/recall payment model for emergency surgery out of hours.

Surgery 2015 : Theatre Schedule Review.

• Historical

• Site Specific

• Not based on capacity or demand

• Cultural

Emergency Contact Hours

Elective Contact Hours

Elective O/N Beds

Emergency O/N Beds

ICU Hours Surgeon Contact Hours

After Hours and Weekend Work

Waiting List Data

Same Day Admissions

Multi Day Admissions

Aspects to Consider for Template Build.

Session Allocation Principles

• To maximise emergency surgery to within hours

• To separate emergency from elective procedures

• Ensure sessions are fully booked and usage of surgical beds is

optimised.

• Speciality and General sub-speciality elective lists will be identified

and planned in consideration of existing resources i.e. radiology.

Intensive care, to ensure optimal patient care and avoid clash of

resources.

• Endeavour to separate Same-Day from Multiday Elective &

Emergency by specialty.

• Best use of available resources required template build up from clean

sheet – reference to existing occurred after clinical stream

discussions

From this Speciality Aggregated

Wide variation week to week

This – February 14

Angliss – Box Hill – Maroondah - Sites ESIS Reportable

Decreased Variation

Procedures Week

Angliss – Box Hill - Maroondah ESIS Reportable

Week

0

100

200

300

400

500

600

700 Ja

n-1

3

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

Dec

-13

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

2013 2014

MAR

MAR

Stabilisation of electives (Small dip in April for Easter.)

No Cases.

Angliss – Box Hill - Maroondah ESIS Reportable

Decreased Variation Increasing

Contact Hours

Contact Hours Week

Achievements Surgery 2015

• Network focused Organisational structure that allows for escalation, reporting and review.

• Creation of Eastern Health task forces and committees to oversee the surgical service.

• Fair and equitable payment models. • A theatre schedule built on Data that matched more

closely our demand for theatre and our capacity. • Decreased variation in lists from day to day, week to

week, making best use of available resources.






TPOT : The Productive Operating Theatre. • NHS : Institute for Innovation and Improvement : Productive series

A modular improvement programme, co-produced with NHS organisations. A systematic way to deliver significant improvements in safety, efficiency and patient care. A method of involving and enabling front line theatre teams to transform the way they work.






TPOT : Modules

Key areas of focus • Session Start-up.

• Patient Preparation.

• Consumables and Equipment.

• Well Organised Theatre

• Knowing how we are doing

• Operational Status at a Glance.



Confirmation of Theatre List

Order

- 120 mins

-90 mins

-70 mins

-60 mins

-50 mins

-40 mins

-30 mins

-20 mins

-10 mins

Registration & Admission process commences. Anaesthetic review of all patients except 1st patient on each list

1st Patient on AM List On-Time Starts

Patient transferred to anaesthetic room/theatre. Anaesthetic team begin anaesthetic interventions

Surgical team arrive in Theatre

Handover to the Surgical Team

Time Out

Fixed Point

1st Patient on PM List On-Time Starts

1st Patient of each list arrive in holding bay for

anaesthetic review

13:30

08:30

Session Start-up.

Clerical

Admission

5 minutes

Nursing

Admission

15 minutes

HMO

Anaesthetics

Surg. Registrar

Surgeon

Theatre –

Ring to

say they

are

Ready

Day of Surgery Patient Preparation.

Session start up improvements • 1st patients for AM and PM lists are seen in theatre not admission ward.

• Theatre order decided day before and not changed.

• Surgical Admission done when waitlisted

(Remove need for medical admission on Day)

• Anaesthetic assessment done to check fit for surgery.

• All 1st patients arrive to theatre at 0730 and no need for theatre to call (unless something out of ordinary)

• Staggered start times for PM admissions.

• Patient phone calls day prior to ensure patients are going to come and then are advised their arrival time and position on list (Main focal point of patient experience.)

Equipment and Consumables

Imprest

Barcoded

Items put

away by

Supply

Can be

direct entry

from

Company –

may sit

there for a

few days

before it is

looked at.

Ordered by

Supply – but

not barcoded

or over load

barcoded

item

One EFT from

Supply

Supply Entry

Processes

Inventory manager

– 2 days a week

Quick wins..

Overstocking EH = $ 19000+ Stock isolated and returned or not re ordered until stock used.

Stock spread through network.

Stock consolidation : All items reviewed and many line items deleted, Par levels dropped according to 12 month use.

Out of date stock removed (loss) = $5000

Process requiring NUM/APD/HOU sign off put in place for new or additional supplies required single time or ongoing.

Network consolidation of inventory (Ports, Hernia Mesh, Laparoscopic equipment, orthopaedic Joints, consumables) (HOU

and inventory coordinator lead)

Decrease in holding stock / returned overstock / product consolidation / Product changes to

cheaper alternatives

Saving = $194641 PA

Ongoing 6 monthly/as required stock review put in place. Inventory coordinator across sites is now employed to monitor and review holding stock and find cheaper comparable alternatives.

HTRAK

Real Time Data Acquisition, Prosthesis, Rebate, Coding and

Prosthesis Costing System

Well Organised Theatre (WOT)

Aim : •Increase patient touch time

•Make the theatres look and feel better. •Make the work environment easier to work in.

•Decrease mistakes and errors •Reduce risk.

Sort Set

Shine Standardise

Sustain

Apply 5S’s Principal

ADUIT

•Video walks •Activity follows of Nurses Support staff Anaesthetics Surgeons •Spaghetti diagrams •Waste walks

Nurse movement for Drugs New safes fitted

100.0%

53.3%

5.0%

5.0%

1.7%

3.3%

31.7%

0.0% 0.0% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total Motion Paperwork / Administration Discussion Other Pateint Care Pre Op Phase Intra Op Phase Post Op

% o

f ti

me

Activity

Waterfall Chart for Nurse Activity Follow

Evaluation of Change

Team performance and staff wellbeing. Patients Experience

and Outcomes.

Value and Efficiency.

Safety and reliability of

care.

WOT : Everything now has a place and is easy to identify if/when something is missing.

Prosthesis/Loans Area

Unsafe storage, Cant use box lifter in a

corridor/Clutter

Wall to be removed

New Prosthesis Area

after Redesign

Creation of Safe operating practice (With Work safe Victoria) and

enforcement of minimum delivery standards for loan kits.

Measures for Success

Knowing how we are doing..

Developing useable data on Efficiency, Safety and

Patient experience.

• Deciding on what to display that is relevant to the

team • Daily, Weekly, Monthly and Yearly measures. • Focus on measures that clearly show if we are getting

better or worse. • Keep it simple. • Extract our own data for smaller improvement

projects.



Weekly Start Time Report KHWAD : Efficiency

Operation Date

Theatre Spec

Arrival at

Theatre time

Anaesthesia Start Time

Surgery Start Time

Delay Reason

25/07/2014

Fri

1 ORTH 7:35 8:10 8:28

2 SUR2 7:35 8:25 8:50 Surgeon Late Arriving

3 PLAS 7:40 8:10 8:40

4 SUR1 7:50 8:10 8:45 Surgeon Late Arriving

DPA GAST 9:00 9:10 9:15

PACA PSY1 8:15 8:20 8:22

24/07/2014

Thu

1 SUR4 7:45 8:20 9:35 EQUIP/SUPPLIES NOT READY/AVAILABL

2 ORTH 7:50 8:00 8:30

3 PLAS 7:45 8:15 8:30

4 UROL 7:45 8:20 8:30 LIST ORDER CHANGED

DPA AMM1 7:55 8:05 8:12

23/07/2014

Wed

1 ORTH 7:40 7:55 8:35 Surgeon Late Arriving

1 VASC 7:40 8:05 8:36

2 SUR3 7:55 8:20 8:42 COMPLEX ANAESTHETIC

3 PLAS 7:35 8:15 8:37 SURGEON UNAVAILABLE

4 SUR1 7:55 8:20 8:30

DPA GAST 8:20 8:30 8:36

PACA PSY1 8:07 8:10 8:14

22/07/2014

Tue

1 ORTH 7:45 8:05 8:50 EQUIP/SUPPLIES NOT READY/AVAILABL

2 SUR4 7:50 8:05 8:40

3 PLAS 7:30 8:05 8:30 LIST ORDER CHANGED

4 UROL 7:45 8:00 8:30

DPA RESP 9:35 9:45 9:50

21/07/2014

Mon

1 SUR3 8:05 8:20 8:25

2 SURC 7:50 8:10 8:36

2 SUR4 7:50 8:25 8:45

3 PLAS 7:40 8:10 8:30

DPA GAST 9:00 9:10 9:15

Like most Health Services our Start on Time Initiative is Hard Work with gradual improvement

Small improvement to date

New template

KHWAD : Maroondah Session – Delay Reasons

28 Apr 14 to 04 May 14

05 May 14 to 11 May 14

12 May 14 to 18 May 14

19 May 14 to 25 May 14

26 May 14 to 01

Jun 14

02 Jun 14 to 08

Jun 14

09 Jun 14 to 15

Jun 14

16 Jun 14 to 22

Jun 14

23 Jun 14 to 29

Jun 14

30 Jun 14 to 06

Jul 14

Cases 59 55 55 55 49 61 57 60 54 58 Increase

Elective Cases 47 45 46 44 42 49 50 49 49 46 Decrease

Emergency Cases 12 10 9 11 7 12 7 11 5 12 Increase

Total Surgery Time(hrs)

48.85 47.93 49.73 49.42 62.08 57.93 54.37 54.30 50.83 43.82 Decrease

Average Surgery Time per Case

49.68 52.29 54.25 53.91 76.02 56.98 57.23 54.30 56.48 45.33 Decrease

Number of Sessions Starting On Time

4 5 4 7 5 1 9 7 6 8 Increase

Percentage of Sessions Starting On Time

20.0% 31.3% 20.0% 35.0% 26.3% 5.0% 45.0% 35.0% 30.0% 42.1% Increase

Late Start Hours Lost

3.77 5.70 7.77 4.07 5.63 9.03 2.88 3.83 4.45 5.50 Increase

Average Minutes Lost per Late Start

14.13 31.09 29.13 18.77 24.14 28.53 15.73 17.69 19.07 30.00 Increase

Number of Sessions Starting > 15 Mins Late

7 7 10 6 8 13 4 7 9 6 Decrease

KHWAD : Theatre AM weekly summary

KHWAD : Patient Experience



Small Improvements in patient waiting time for surgery

Notes: Time to first surgery is calculated from admission time to first anaesthetic time. Excluded records where no anaesthetic time has been entered.

KHWAD : Safety



Gradual Improvement.

We are seeing some

reductions

KHWAD : Generating your own data : Small improvements



15:36:00

16:48:00

18:00:00

19:12:00

20:24:00

21:36:00

1/0

4/2

01

4

8/0

4/2

01

4

15

/04

/20

14

22

/04

/20

14

29

/04

/20

14

6/0

5/2

01

4

13

/05

/20

14

20

/05

/20

14

27

/05

/20

14

3/0

6/2

01

4

10

/06

/20

14

After Hours Start Time

start time

Linear (start time)

1830 Target

Start time trend after

hours is increasing to later at night.

How we use what the dash board is telling us?



Measurement for diagnosis Measurement for judgement Measurement for improvement or Measurement for sustainability.

Critical Success Requirements

• Executive level support • Aligned strategic direction. • Governance • Good measurements/ Correct Data • Maintaining momentum • Perseverance and resilience • Quick wins



Key Success Factors to Date for EH • Data – in a form the clinicians

understand • Craft group meetings. • Meetings with Clinical Leads • Support from Directors of Anaesthesia &

Surgery • Weekly Session Meeting • Establish usable dashboards.



Future priorities of TPOT •Continue to develop the theatre dashboard. •Recovery module of TPOT •Handover and patient turnaround. •Ongoing schedule review •Implementation of brief and debrief in theatres under team-working modules. •Theatre behaviours.








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Aaron Shergis - Maroondah Hospital - TPOT: The Productive Operating Theatre