National Theatres Project Report

Transcription

1 National Theatres Project Report November 2006 Technical Appendix

2 National Theatres Project Report November 2006 Technical Appendix Scottish Executive, Edinburgh 2007

3 ii National Theatres Project Crown copyright 2007 ISBN: Scottish Executive St Andrew s House Edinburgh EH1 3DG Produced for the Scottish Executive by Astron B Published by the Scottish Executive, January 2007 Further copies are available from Blackwell s Bookshop 53 South Bridge Edinburgh EH1 1YS The text pages of this document are printed on recycled paper and are 100% recyclable

4 Contents 1 Contents INTRODUCTION 2 APPENDIX A: Glossary and Definitions 4 APPENDIX B: Balanced Scorecard 19 APPENDIX C: Mandatory Scorecard 22 APPENDIX D: Measure Definitions 23 APPENDIX E: Reporting Framework 25 APPENDIX F: Pilot Management Reports 26 APPENDIX G: Pilot Scorecard 29 APPENDIX H: Pilot Analysis - Hours Breakdown 30 APPENDIX I: Pilot Analysis - Session Duration 31 APPENDIX J: Pilot Analysis - Patient Pathway 32 APPENDIX K: Pilot Analysis - Surgical & Anaesthetic Times 33 APPENDIX L: Capability Scoping 35 APPENDIX M: Capability Template 45

5 2 National Theatres Project Introduction The objective of the National Theatres Project (NTP) is to achieve Best Value for theatre services by appropriately increasing patient throughput, thereby using resources more productively and efficiently. The purpose of this Technical Appendix is to provide further detail to the main report on the project work undertaken and to give examples of analysis and investigation of findings from the use of the balanced scorecard approach to comparative performance. Summary of Supporting Information In June 2005 the National Theatres Project agreed the following activities with the National Benchmarking Project Board: a national theatres glossary with agreed definitions to be drawn up and implemented a minimum standard dataset to be agreed across Scotland development of routes for ensuring local accountability evaluation of existing/available theatre systems. Glossary and Definitions A draft Glossary and Definitions was produced in conjunction with the Service. Where there was already agreement from existing national bodies on specific definitions, these were incorporated. Where no such agreement existed, definitions were agreed by a wide group of theatre users and where necessary amended following consultation (national events and Board visits). This draft was progressed through the National Clinical Dataset Development Programme Board and has been subject to a full formal consultation process with a view to implementation in A summary of terms and definitions appears as Appendix A. Minimum Dataset A National Data Points Day was held in August 2005 with stakeholders from across the Service to determine the information required in order to manage theatres effectively. A theatre services balanced scorecard which covers strategic and operational indicators was produced from the output of the day. This scorecard has been subsequently refined and further developed with a focus on patient outcomes and clinical governance matters with a wide range of Service input from across Scotland. The latest draft balanced scorecard, and some notes on the potential application of the balanced scorecard in a theatres context can be found in Appendix B. A subset of these indicators have been proposed as mandatory national indicators to be collected by Boards from 2007/08 onwards. These are shown in Appendix C, while Appendix D provides more detailed definitions of the measures. Scorecard Pilots Following development of the balanced scorecard, two pilot implementations tested: the use of the balanced scorecard to monitor and manage continuous improvement in theatres accountability and responsibility structures to achieve ownership and control of the theatre capacity and improvement in theatre services. Appendix E shows an outline reporting framework, and examples of the management reports developed during the pilots can be found in Appendix F. Data from the pilots was used to populate the balanced scorecard as far as possible. This populated scorecard forms Appendix G. Where data could be extracted from an existing theatre system, much of the scorecard could be populated with

6 Introduction 3 relative ease. Where a manual system was in place it was not possible to populate as much of the scorecard. Accordingly two full pilot site scorecard comparisons were not able to be generated as only one site had a comprehensive electronic theatre system with the other pilot site providing manual returns for pilot reporting. Following completion of the pilots, the data collected was analysed and effective ways of representing this information were explored. Appendices H to K illustrate these. Capability Scoping During March to July 2006 visits were made to all mainland Health Boards. The purpose of these was to: carry out a detailed assessment of currently available local theatres information evaluate existing theatres system implementations validate and assess nationally collected theatres data seek Board input to the National Theatres Project and balanced scorecard development communicate the purpose and objectives of the National Theatres Project to Health Boards and interested staff. The detailed findings from the capability scoping are contained in Appendix L and the template used to structure the visits can be found in Appendix M.

7 4 National Theatres Project APPENDIX A: Glossary and Definitions Operating Theatres Data Standards GENERIC DATA ITEMS CHI Number Person Birth Date Associated Professionals Associated Professional Group Health Record Identifier The Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate. Associated Professionals are those individuals who are involved with the client/patient in a professional capacity, e.g. consultant, social worker, occupational therapist, etc. The recognised professional group to which the care professional belongs and in which they are employed. A Patient Health Record Identifier is a code (set of characters) used to uniquely identify a patient within a health register or a health records system, e.g. PAS. PATIENT DETAILS ASA status The ASA PS classification globally assesses the degree of sickness or physical state prior to selecting the anaesthetic or prior to performing surgery. Code P1: A normal healthy patient. Code P2: A patient with mild systemic disease. Code P3: A patient with severe systemic disease. Code P4: A patient with severe systemic disease that is a constant threat to life. Code P5: A moribund patient who is not expected to survive without the operation. Code P6: A declared brain-dead patient whose organs are being removed for donor purposes.

8 Appendix A: Glossary and Definitions 5 PATIENT DETAILS (Contd) NCEPOD category NCEPOD classification categorizes the urgency of the patient s intervention. Code 01: Immediate: Life, limb or organ saving intervention. Resuscitation simultaneous with surgical treatment. The target time to theatre is within minutes of decision taken to operate. E.g. Rupture aortic aneurysm, major trauma to abdomen or thorax, fracture with major neurovascular deficit, etc. Code 02: Urgent: Acute onset or deterioration of conditions that threaten life, limb or organ survival. Sub code A: Intervention within 6 hours: the target time to theatre is within 6 hours of decision to operate and normally once resuscitation is complete. Sub code B: Intervention within 24 hours: the target time to theatre is within 24 hours of decision to operate and normally once resuscitation is complete. Code 03: Expedited: Stable patient requiring early intervention for a condition that is not an immediate threat to life, limb or organ survival. Target time to theatre is within days of decision to operate. Code 04: Elective: Surgical procedure planned or booked in advance of routine admission to hospital. Target time to theatre is planned. Encompasses all conditions not classified as immediate, urgent or expedited.

9 6 National Theatres Project OPERATING ENVIRONMENT Operating room type The type and setting of the room in a hospital where an interventional procedure codeable in OPCS4 takes place. Code 01: Category 1: Main theatre suite Code 02: Category 2: Code 03: Category 3: Code 04: Category 4: Sub code A: Operating theatre Sub code B: Anaesthetic room Sub code C: Recovery room Sub code D: Procedure room Sub code A: Satellite or isolated theatre Sub code B: Day theatres Sub code A: Endoscopy Suite Sub code B: Radiology Sub code C: Cardiac Catheterisation Lab Sub code D: Procedure room Sub code E: Pain clinic Sub code A: ICU Sub code B: A & E Sub code C: Wards Code 98: Other: Any other location not included in the above. Operating session type The type of period of operating time allocated to a consultant. Code 01: Scheduled: Sub code A: Planned: Periods of theatre time allocated to a consultant, usually on a regular basis, in which the consultant or a member of the firm can perform operations, the majority of which have been arranged beforehand. The maximum duration of a scheduled session is a notional half-day. Sub code B: Emergency: Periods of time allocated to a consultant on a regular basis for patients whose visit to the operating theatre were not foreseen but take place as a result of illness or a complication requiring an urgent operation. The maximum duration of a scheduled session is a notional half-day, e.g. trauma sessions/sessions sometimes locally known as CEPOD sessions. Code 02: Unscheduled: Periods of time allocated to one or more consultants outside scheduled sessions allocated to a consultant and used by that consultant or one of the same main specialty, for specific Theatre Case, usually at short notice. Operating list type The type of published list, which consists of a set of patients who are to be operated on in a session. The list documents the patients and the details of their impending operation. Code 01: Elective: An operating list that comprises solely elective cases. Code 02: Emergency: An operating list that comprises solely emergency cases.

10 Appendix A: Glossary and Definitions 7 OPERATING ENVIRONMENT (Contd.) Specialty of session The specialty of the consultant to whom the operating session has been allocated. A specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties. Code A1: Code A2: Code A7: Code A9: Code AA: Code AM: Code AQ: Code C1: Code C12: Code C3: Code C4: Code C41: Code C42: Code C5: Code C6: Code C7: Code C8: Code C9: Code CA: Code CB: Code D3: Code F2: Code F3: Code G1: Code H1: Code R11: Code 98: General Medicine Cardiology Dermatology Gastroenterology Genitourinary Medicine Palliative Medicine Respiratory Medicine General Surgery Vascular Surgery Anaesthetics Cardiothoracic Surgery Cardiac Surgery Thoracic Surgery Ear, Nose & Throat Neurosurgery Ophthalmology Trauma and Orthopaedics Plastic Surgery Paediatric Surgery Urology Oral Surgery Gynaecology Obstetrics General Psychiatry Clinical Radiology Surgical Podiatry Other, specify To be determined, no existing codes at present: Dental Surgery Maxillofacial Interventional Radiology

11 8 National Theatres Project OPERATING ENVIRONMENT (Contd.) Operating hours The hours during which the procedure was performed. Code 01: Office hours: 08:00 hrs to 17:59 hrs Monday to Friday. Code 02: Out of hours: 18:00 hrs to 07:59 hrs Monday to Friday and all day Saturday and Sunday. Time of day/night The period during which the procedure was carried out. Code 01: Daytime: Code 02: Evening: Code 03: Night: 08:00 17:59 hours. 18:00 23:59 hours. 00:00 07:59 hours. Operating times The combined date and time of an event. Allocated start time of list/session: Time when the anaesthetist is scheduled to take charge of the (first) patient in preparation for anaesthesia. Actual start time of list/session: Time when the anaesthetist actually takes charge of the (first) patient in preparation for anaesthesia. Allocated finish time of list/session: The time when the anaesthetist is scheduled to hand over the care of the last patient to recovery staff. Actual finish time of list/session: The time when the anaesthetist actually hands over the care of the last patient to recovery staff. Sub-data items - adapted from the National Theatres Project: Planned hours of list/session: The difference between the allocated start time of list/session and allocated finish time of list/session. List run time: The time difference between the actual list/session start time and the actual list/session finish time. List under run: When the list run time is less than the planned hours of list/session. The term, as used in the Acute Hospital Portfolio, does not necessarily mean the list finished early, as it might have started late. List over run: When the list run time exceeds the planned hours of list/session. The term, as used in the Acute Hospital Portfolio, does not necessarily mean the list finished late, as it might have started early.

12 Appendix A: Glossary and Definitions 9 OPERATING ENVIRONMENT (Contd.) Reason for cancellation of list/session An explanation of why an operating list or session did not take place as planned. Code 01: Public holiday Code 02: Cancelled by surgeon/main operator: Sub code A: Planned leave Sub code B: Sick leave Sub code C: On call Sub code Z: Other reason Code 03: Cancelled by anaesthetic department: Sub code A: Planned leave Sub code B: Sick leave Sub code C: Skill mix Sub code Z: Other reason Code 04: Theatre Staff: Sub code A: Sick leave Sub code B: Skill mix Sub code Z: Other Code 05: Training/Continuing Professional Development Code 06: Maintenance Code 07: Equipment failure/unavailable Code 08: Administrative error Code 09: No ward beds Code 10: No High Dependency Unit beds available Code 11: No Intensive Care Unit beds available Code 98: Other reason for cancellation Code 99: Not known Reason for late start of list/session An explanation for the theatre list/session starting later than its allocated start. Late start: When the actual start time of list/session is later than the allocated start time of list/session. Code 01: Porter not available Code 02: Patient arrived late to hospital Code 03: Patient not fasted Code 04: Patient not ready in ward Code 05: Patient not consented Code 06: Staff not available to accompany the patient Code 07: Investigations or x-rays missing Code 08: Blood not available Code 09: Intrusion of other specialty or emergency Code 10: Anaesthetist delayed

13 10 National Theatres Project OPERATING ENVIRONMENT (Contd.) Reason for late start of list/session (Contd.) Reason for late finish of list/session Code 11: Surgeon/main operator delayed Code 12: Theatre staff delayed Code 13: Anaesthetic assistant delayed Code 14: Theatre not adequately staffed Code 15: Theatre not ready Code 16: Equipment failure/unavailable Code 98: Other Code 99: Not known An explanation for the list finishing later than its allocated finish time. Late finish: When the actual finish time of list/session is later than the allocated finish time of list/session. Code 01: Late start of list/session Code 02: Unexpectedly difficult procedure Code 03: Difficult or unexpected anaesthetic problem Code 04: Intrusion of other specialty Code 05: Intrusion of other emergency Code 06: Delayed availability of recovery facilities Code 07: Delayed availability of High Dependency Unit facilities Code 08: Delayed availability of Intensive Care Unit facilities Code 09: List overbooked Code 10: Equipment failure/unavailable Code 98: Other Code 99: Not known

14 Appendix A: Glossary and Definitions 11 THEATRE PROCESSES AND OPERATIVE PROCEDURES Specialty of procedure The specialty of the consultant who is responsible for the patient s care. A specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties. Code A1: Code A2: Code A7: Code A9: Code AA: Code AM: Code AQ: Code C1: Code C12: Code C3: Code C4: Code C41: Code C42: Code C5: Code C6: Code C7: Code C8: Code C9: Code CA: Code CB: Code D3: Code F2: Code F3: Code G1: Code H1: Code R11: Code 98: General Medicine Cardiology Dermatology Gastroenterology Genitourinary Medicine Palliative Medicine Respiratory Medicine General Surgery Vascular Surgery Anaesthetics Cardiothoracic Surgery Cardiac Surgery Thoracic Surgery Ear, Nose & Throat Neurosurgery Ophthalmology Trauma and Orthopaedics Plastic Surgery Paediatric Surgery Urology Oral Surgery Gynaecology Obstetrics General Psychiatry Clinical Radiology Surgical Podiatry Other, specify To be determined, no existing codes at present: Dental Surgery Maxillofacial Interventional Radiology

15 12 National Theatres Project THEATRE PROCESSES AND OPERATIVE PROCEDURES (Contd.) Type of theatre case An indication of the type of patient visit to the operating theatre to undergo one or more operative procedures. Code 01: Scheduled: Includes scheduled or elective cases where the operation was planned in advance. Code 02: Unscheduled: Where the operation was unexpected or could not be planned in advance. Sub code A: Emergency Sub code B: Revisit to theatre: When it was necessary for the patient to be referred to theatre for a further operation/procedure as a result of complication(s) related to a previous operation/procedure undertaken during the same episode of care. Management intent Whether or not the patient's attending clinician expects, at the time of booking, that the patient will be admitted and discharged on the same calendar day, or discharged on a subsequent date. Code 00: None: Where no decision has been taken. Code 01: Inpatient: Where the patient is expected to be discharged on a subsequent date following the procedure. Code 02: Day case: Where the patient is expected to be discharged on the same calendar day after the procedure. Code 03: Extended recovery: Where patients are admitted, operated on and stay for one night post-operatively in a hospital facility (overall stay up to 23 hours). (International Association for Ambulatory Surgery.) Code 99: Not known. Dates and times of theatre processes and operative procedures The combined date and time of an event. Date and time of booking: The combined date and time at which the theatre team were notified that the patient required a procedure in theatre. Time patient sent for: The time that the theatre team sent the request for the patient to be brought to the operating theatre department. Time patient arrived in theatre premises: The time that the patient actually arrived in the operating theatre premises. Time into anaesthetic room: The time at which the patient was brought into the anaesthetic room. Start time of anaesthesia: The time of start of the anaesthetic procedure where this takes place either in the operating theatre or in the anaesthetic room. Time into theatre: The time at which the patient is transferred from the anaesthetic room into theatre. Start time of procedure: The time of commencement of the procedure regardless of whether an anaesthetic is given or not. This should be knife to skin or equivalent. It does not include positioning, with the exception of manipulation of fractures.

16 Appendix A: Glossary and Definitions 13 THEATRE PROCESSES AND OPERATIVE PROCEDURES (Contd.) Dates and times of theatre processes and operative procedures (Contd.) Finish time of procedure: The time at which the procedure was finished and any dressings applied. Time patient entered recovery: The time at which the patient was transferred into the recovery area. Time patient ready to leave recovery: The time at which the patient was assessed as meeting the discharge criteria of the recovery room. Time patient actually left recovery: The time at which the patient actually left the recovery room. Operative procedure performed indicator Reason operative procedure not performed An indication of whether or not the intended operative procedure was performed. Code 01: Procedure performed. Code 02: Patient anaesthetised but procedure not performed. Code 03: Procedure cancelled. Code 99: Not known. An explanation for an operative procedure not having taken place as planned. Code 01: Secretarial error. Code 02: Cancelled by patient: Sub code A: Unable to attend Sub code B: No longer wishes procedure Sub code C: Did not attend reason not known Sub code Z: Other Code 03: Cancelled by surgeon/main operator: Sub code A: procedure not required Sub code B: Patient not prepared Sub code C: Surgeon/main operator not available Sub code Z: Other Code 04: Cancelled by anaesthetist: Sub code A: Patient not fit Sub code B: Patient not prepared Sub code C: Anaesthetist not available (Sickness) Sub code D: Anaesthetist not available (Skill mix) Sub code Z: Other

17 14 National Theatres Project THEATRE PROCESSES AND OPERATIVE PROCEDURES (Contd.) Reason operative procedure not performed (Contd.) Code 05: Cancelled by theatre management: Sub code A: Staff not available (Sickness) Sub code B: Staff not available (Skill mix) Sub code C: Equipment not available Sub code D: Intervention by emergency case Sub code E: Intervention by priority case Sub code F: Lack of theatre time Sub code Z: Other Code 06: Cancelled by hospital: Sub code A: No ward bed bed available Sub code C: No Intensive Care Unit bed available Sub code D: Administrative error Sub code Z: Other Code 07: Preoperative guidance not followed. Code 98: Other reason for cancellation. Code 99: Not known.

18 Appendix A: Glossary and Definitions 15 HEALTHCARE PROFESSIONALS Associated Professional Role (Operating theatres) An indication of the role carried out by each professional. Professionals are those individuals who are involved with the client/patient in a professional capacity. Code 01: Consultant responsible for care: Consultant who carries clinical responsibility for a patient s healthcare during an episode. Code 02: Code 03: Code 04: Code 05: Code 06: Code 07: Code 08: Code 09: Code 10: Code 11: Code 12: Code 13: Code 98: Operating surgeon/main operator (Main operating clinician): Clinician performing the procedure. Surgical first assistant (First operating assistant): An individual who assists the operating surgeon in performing the procedure. Assistant surgeon (Additional operating assistant): Any other individual (in addition to the first assistant) who assists the operating surgeon/clinician in performing the procedure. Supervising surgeon/clinician: Surgeon/clinician supervising the procedure. Main anaesthetist: Medical practitioner responsible for the administration of anaesthesia/sedation. Assistant anaesthetist: Medical practitioner assisting the main anaesthetist in the administration of anaesthesia/sedation. Sub Code A: Medical practitioner Sub Code B: Non-medical practitioner Supervising anaesthetist: Anaesthetist supervising the anaesthetic procedure. Anaesthetic assistant: Non-medical person assisting the anaesthetist(s) in the administration of anaesthesia/sedation. Scrub practitioner: Registered practitioner responsible for the preparation and handling of instrumentation, swabs, needles, etc. during a surgical procedure. Circulating practitioner: Practitioner assisting the scrub practitioner. Recovery room practitioner: Registered practitioner responsible for care of patient during recovery from procedure. Radiographer Other: Includes medical and nursing students, medical trainees, medical representatives, AHP trainees or any other observers.

19 16 National Theatres Project HEALTHCARE PROFESSIONALS (Contd.) Associated The grade of the associated professional in the operating theatre. Professional Grade (Operating theatres) Attributes: Associated Professional Status - Permanent Locum Temporary Agency Bank Code 01: Consultant Code 02: Associate Specialist Code 03: Staff Grade Code 04: Seamless training grade Sub code A: Year 1 Sub code B: Year 2 Sub code C: Year 3 Sub code D: Year 4 Sub code E: Year 5 Sub code F: Year 6 Sub code G: Year 7 Sub code H: Year 8 Code 05: Specialist Registrar year 1-4 Code 06: Senior House Officer Code 07: Foundation Year 2 (Senior House Officer 1) Code 08: Foundation Year 1 (Pre-Registration House Officer) Code 09: Nurse: bands 2-8 Code 10: Operating Department Practitioner Code 11: Operating Department Assistant Code 12: Physicians assistant - anaesthesia Code 13: Surgical Practitioner Code 98: Other Level of surgical/ clinical supervision Where a non-consultant is involved this indicates the level of supervision in place and the location or whereabouts of the supervising consultant/clinician. Code 00: No supervision Code 01: Operating room environment: Sub code A: Present in operating room - Scrubbed Sub code B: Present in operating room - Not scrubbed Sub code C: In operating department but not in operating room Code 02: Office Code 03: Home Code 98: Other

20 Appendix A: Glossary and Definitions 17 HEALTHCARE PROFESSIONALS (Contd.) Level of anaesthetic supervision Where a non-consultant is involved this indicates the level of supervision in place and the location or whereabouts of the supervising consultant anaesthetist. Code 00: No supervision Code 01: Operating room environment: Sub code A: Present in operating room Sub code B: In operating department but not in operating room Code 02: Office Code 03: Home Code 98: Other SOURCE AND DESTINATION PATIENT Source of admission to operating theatre Intended destination from operating theatre/recovery The originating location within the hospital from where the patient was brought to theatre. Code 01: Inpatient ward: Local identifiers may include ward numbers, names, etc. Code 02: Day bed unit Code 03: Emergency care unit Code 04: A&E Code 05: High Dependency Unit Code 06: Intensive Care Unit: Synonyms include Critical Care Unit (Adult/Paediatric), Intensive Therapy Unit, etc. Code 07: Admissions unit Code 98: Other source The planned or intended location to which the patient is to be sent from the operating theatre/recovery area. Code 01: Inpatient ward: Local identifiers may include ward numbers, names etc. Code 02: Day bed unit Code 03: Emergency care unit Code 04: Extended recovery unit: Where patients are admitted, operated on and stay for one night post-operatively in a hospital facility (overall stay up to 23 hours). (International Association for Ambulatory Surgery.) Code 05: High Dependency Unit Code 06: Intensive Care Unit: Synonyms include Critical Care Unit (Adult/Paediatric), Intensive Therapy Unit, etc. Code 07: Transfer to other hospital Code 08: Home Code 98: Other destination

21 18 National Theatres Project SOURCE AND DESTINATION PATIENT (Contd.) Actual destination from operating theatre/recovery The actual location to which the patient was sent from the operating theatre/recovery. Code 01: Inpatient ward: Local identifiers may include ward numbers, names, etc. Code 02: Day bed unit Code 03: Emergency care unit Code 04: Extended recovery unit: Where patients are admitted, operated on and stay for one night post-operatively in a hospital facility (overall stay up to 23 hours). (International Association for Ambulatory Surgery.) Code 05: High Dependency Unit Code 06: Intensive Care Unit: Synonyms include Critical Care Unit (Adult/Paediatric), Intensive Therapy Unit, etc. Code 07: Transfer to other hospital Code 08: Home Code 09: Mortuary Code 98: Other destination

22 Appendix B 19 APPENDIX B: Balanced Scorecard National Theatres Project Balanced Scorecard 3rd October 2006 Financial National Cost of idle capacity Direct cost per case (case mix adjusted) Total cost per head population (adjusted for cross-boundary flow) and by theatre level Local Financial measures are currently thought to be less useful at local level Patient/Quality National Deaths Cancellations Local Cancellations Complaints Resource unavailability Deaths Critical Care Time in recovery Risk management episodes Length of stay outliers Surgical re-admissions Waiting list efficiency ratio Theatre delays Re-operation within the same admission Sickness abscence % emergency procedures at night Efficiency National Surgical theatre hours Anaesthetic theatre hours Downtime Utilisation Case-mix adjusted throughout Elective/non-elective mix Local Available theatre time Allocated theatre hours Actual theatre hours Procedural theatre hours Surgical theatre hours Anaesthetic theatre hours Turnover time Case-mix adjusted throughput Elective/non-elective mix Over-runs Under-runs Late-starts Cancelled sessions Delayed discharges (from Recovery) Future/Capability National Information capture Local Theatre staff compliance ratio Development of new ways of working PDPs (learning/development) Utilisation of theatre information Level of dataset capture Role within capacity planning Level of supervised training procedures Level of unsupervised training procedures

23 20 National Theatres Project Application of the Balanced Scorecard Individual Scotland Board Hospital Specific condition/procedure review and standard Specific Condition/ Operation Board Scorecard Hospital Scorecard Theatre Scorecard Individual Event Log (Nurse, Surgeon, Anaesthetist) A balanced scorecard can be produced for each (elliptical) interface on the diagram. As the scorecard becomes more high level the level of detail and a requirement for individual identifiers becomes less. 1) At an individual level the scorecard should collate all the procedures carried out by one individual (nurse, surgeon or anaesthetist) to populate the individual s personal dataset. This information should be in a format using the definitions for the national dataset and be exportable to existing operation logs, the scorecard forming the event log for the individual. Colleges (Anaesthesia and Surgical) have already defined formats and datasets for these reports to which can be added data about theatre utilisation, start, finish times, etc. from the collated personal data. By providing feedback on the dataset available this will encourage local ownership and verification thus ensuring buy-in and data quality at a local level. The information can be validated through use in the appraisal process and link in to any national audit processes. By incorporating all the items from the national scorecard (and any specialty standards) the individual will be able to set their performance in context. This is key to any working system. 2) The theatre level scorecard will collate all data for that theatre. This dataset will contain more managerial factors (start and finish times, utilisation, etc.) and will be used to manage theatre capacity. A typical dataset for managerial purposes can be derived from the national theatres audits by the Audit Commission and advice and rules to utilise the data arising can be found in these reports. The top-level information on utilisation, etc. can be used to compare theatres within the suite. 3) The hospital level scorecard takes all of the individual theatre datasets and distils the data towards the Board dataset. In performing this process local comparisons on critical incidents and performance can be used to change practice locally at an early stage if necessary. 4) The Board level scorecard has progressively fewer indicators however the basis of the scorecard is the detail contained in the local scorecards. Any outlying information can be tracked through the system.

24 Appendix B 21 5) At a national level it is important that the information is easily understood by the public (who will be seeking reassurance that the system is working safely and efficiently) and is concise. Comparison of the Board data at a national level will set the standard for Scotland. It is clear from previous attempts to produce a global figure for theatre activity that it is very case-mix dependant. Case-mix adjustment is complex and not always accurate. Efficiency figures should be applicable across the board and quality measures unequivocal. To provide performance data for individual specialty departments it is suggested that relevant professional advisory groups be asked to produce a basket of procedures that occur in sufficient numbers and have consistent profiles of care in terms of length of anaesthetic, operation, grade of surgeon and anaesthetist, outcome and at a Board level population based incidence of procedure. This approach has been in place and is successful for hip fractures. Each specialty should identify one major procedure and one day case procedure together with a further developing procedure.

25 22 National Theatres Project APPENDIX C: Mandatory Scorecard Mandatory Indicators Financial Opportunity cost of unused hours Comparative cost of theatres activity Patient/Quality Risk management episodes Surgical re-admissions Theatre delays Cancellations Deaths/10,000 patients % emergency procedures at night Efficiency Unutilised hours/allocated hours Over-runs/Allocated hours Under-runs/Allocated hours Procedural time/actual hours Operative time/allocated hours % cancelled sessions Late start hours/allocated hours % emergency cases in planned sessions Future/Capability Information quality % dataset captured Use of theatres information Development of new ways of working

26 Appendix D: Measure Definitions 23 APPENDIX D: Measure Definitions The contents of the square brackets within the text cross-reference these definitions with Appendix A. Opportunity cost of unused hours: the cost associated with the number of patients who could have been operated upon during unutilised time: unutilised hours divided by 3.5, multiplied by the average number of patients per session for the Board, multiplied by the average cost per patient. Comparative cost of theatres activity: Cost per theatre hour. Allocated hours: total theatre time allocated to each session holder and specialty. Allocated hours are the difference between the session allocated start time and the session allocated finish time [Operating times]. Unutilised hours: the difference between allocated hours and actual hours as a percentage of allocated hours. Actual hours are the difference between the session actual start time and the session actual finish time [Operating times]. Over-runs: the number of over-run hours as a percentage of allocated hours. An over-run occurs when the actual session length exceeds the planned session length [Operating times]. Only over-runs of more than 30 minutes will be included. Under-runs: the number of under-run hours as a percentage of allocated hours. An under-run occurs when the planned session length exceeds actual session length [Operating times]. Only under-runs of more than 45 minutes will be included. Procedural time: procedural hours are the time from start of anaesthetic to time of exiting the operating room [Dates and times of theatre processes and operative procedures]. Operative time: the difference between the start time of the procedure and the finish time of the procedure [Dates and times of theatre processes and operative procedures]. Cancelled sessions: the percentage of allocated sessions unused due to cancellation by the holder [Reason for cancellation of list/session]. Late starts: the number of hours lost due to late starts as a percentage of allocated hours. A late start occurs when the list actual start time exceeds the planned start time [Reason for late start of list/session]. Only late starts of more than 5 minutes will be included. Emergency cases: the number of emergency cases [NCEPOD category: 01, 02] carried out within planned sessions as a percentage of the total number of cases carried out within planned sessions [Operating session type: 01A]. Risk management episodes: the number of risk management episodes per 1000 procedures. Surgical re-admissions: the number of surgical patients re-admitted for surgery within 28 days as a percentage of total number of patients. Theatre delays: the average number of minutes lost per session due to delays, e.g. no porter, patient not ready. Only delays of more than 5 minutes will be included. Cancellations: percentage of elective patients whose procedure is cancelled within 10 working days of due date for operation [Reason operative procedure not performed]. Deaths: the number of deaths in theatre per 10,000 patients [Actual destination from operating theatre/ recovery: 09].

27 24 National Theatres Project % emergency procedures at night: the percentage of emergency [NCEPOD category: 01, 02] procedures carried out between 00:00 and 07:59 [Time of day/night]. Information quality: an assessment High, Medium or Low of the quality of theatres information available. The criteria for assessment are shown in sections 5.3, 5.4 and 5.5 of the main report. Dataset capture: the proportion of the mandatory indicators available. Use of theatre information: an assessment High, Medium or Low as to the effective use of theatres information. New ways of working: an assessment High, Medium or Low as to the degree of innovation and extent to which new ways of working are being adopted. The criteria for assessment are shown in section 5.7 of the main report. It is proposed to further develop and test Risk Management and Quality Assurance measures through the National Theatres Implementation Group (NTIG). This work will also include development of training measures: Supervised training: the number of supervised training procedures carried out as a percentage of total procedures. A supervised training procedure occurs when the main operator [Associated professional role: 02] is a trainee [Associated professional grade: 04-06], and a consultant [Associated professional grade: 01] is present scrubbed or not scrubbed [Level of surgical/clinical supervision: 01/A or 01/B]. Unsupervised training: the number of unsupervised training procedures carried out as a percentage of total procedures. An unsupervised training procedure occurs when the main operator [Associated professional role: 02] is a trainee [Associated professional grade: 04-06], and there is no consultant present [Level of surgical/clinical supervision: neither 01/A nor 01/B]. Efficiency and Patient/Quality indicators will be reported at session holder, specialty, hospital and Board level. Indicators will be reported for scheduled (planned and emergency) and unscheduled sessions. NTIG will produce a detailed specification for each of the above measures prior to commencement of data collection.

28 Appendix E: Reporting Framework 25 APPENDIX E: Reporting Framework Level 1 Overall Theatre Appendices F, G, H Level 2 Specialty Appendices F, I Level 3 Procedure Appendices J, K By Board/Site/Theatre Type/Team/Individual/Clinician Theatres Variance Specialty Variance Analysis Procedural Variance COST - Comparative cost of theatres activity - Opportunity cost of unused hours Cost Mix Volume Cost Patient Volume EFFICIENCY - Unutilised hours/allocated hours - Late start hours/allocated hours - % Cancelled sessions - Turnover time - Operative time - Over-runs/Allocated hours - Under-runs/Allocated hours - % Emergency cases in planned sessions - Procedural time - Anaesthetic time - Operative time - Turnover time - Recovery time - Procedural time - Anaesthetic time - Operative time - Turnover time - Recovery time PATIENT/ QUALITY - Deaths per 10,000 patients - Cancellations - Theatre delays - Surgical re-admissions - Risk management episodes - % emergency procedures at night As Level 1 - Deaths per 10,000 patients - Re-admissions - Risk management episodes FUTURE - Information quality - % dataset captured - Use of theatre information - Development of new ways of working

29 26 National Theatres Project APPENDIX F: Pilot Management Reports National Theatres Project Benchmarking Pilot Hours Usage Analysis (Elective Sessions Only) Period: 01/02/2006 to 30/04/2006 Hospital A C8: Orthopaedics Hours Breakdown Percentage Breakdown A B C D E F G H I J K Actual Procdrl Surg Anaesth Other Turnover Procdrl Surg Anaesth Other Turnover B+F C+D+E A-B H+I+J Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Session holder: Total C9: Plastic Surgery Session holder: Session holder: Session holder: Session holder: Total CB: Urology Board X Session holder: Session holder: Session holder: Session holder: Total Report version August 2006

30 Appendix F: Pilot Management Reports 27 National Theatres Project Benchmarking Pilot Board Y Analysis of Actual Hours Usage versus Planned List Hours Usage (Elective Sessions Only) Period: 06/02/2006 to 30/04/2006 Over-Runs Under-Runs Sessions No. % Average Duration (Hours) No. % Average Duration (Hours) Hospital B Urology Plastic Surgery Minor Ops Cardiology Community Dental Vascular E N T General Surgery Gynaecology Kids Dental Max Fax Oral Surgery Orthopaedics Renal Total Report version August 2006 Findings: 88% of sessions did not run to plan 114 hrs (32 sessions) of unplanned time was used 336 hrs (96 sessions) of planned theatre time was not used

31 28 National Theatres Project National Theatres Project Benchmarking Pilot (Contd.) Board X Cancellations Analysis Period: 01/02/2006 to 30/04/2006 Patient cancelled Patients Cancellations Number % Patient cancelled Patient DNA Theatre cancelled Surgeon/ anaesth cancelled Hospital cancelled No reason supplied Hospital C A1 General Medicine C1 General Surgery C8 Orthopaedics CB Urology D3 Oral Surgery Total 1, Report version August 2006

32 Appendix G: Pilot Scorecard 29 APPENDIX G: Pilot Scorecard Board X Hospital B Patient/Quality Cancellations % 13 7 Complaints No 2 Resource unavailability hrs lost Deaths per 1000 pats Critical care % Time in recovery Avg (Mins) 38 Risk management episodes No 21 Length of stay outliers % Surgical re-admissions per 1,000 Waiting list efficiency ratio Theatre delays % 2 Re-operation within the same admission No Efficiency Available theatre time hrs 13,671 3,780 Allocated threatre hours hrs 11,767 Actual theatre hours hrs 8,601 1,098 Procedural theatre hours % Surgical theatre hours % Anaesthetic theatre hours % Turnover time hours % Case-mix adjusted throughput per theatre 1,136 1,180 Elective/emergency/unplanned mix % Elective Over-runs (sessions) % Under-runs (sessions) % Late starts (sessions) % Cancelled sessions % Delayed discharges (from Recovery) No Scheduled Utilisation = Allocated Hours = 11,767 X 100 = 86% Available Hours 13,671 Actual Utilisation = *Actual Theatre Hours Worked X 100 = 8,601 = 73% Allocated Hours 11,767 *(Allocated Hours + Over-run Hours Under-run Hours Cancelled Sessions)

33 30 National Theatres Project APPENDIX H: Pilot Analysis Hours Breakdown Board X 13,671 Available Hours 1,904 11,767 Allocated Hours Unallocated Hours 8,029 3,738 Used Used 572 Unused Used Late starts Early Finishes Cancelled Cancelled Sessions Sessions Early Starts Late Finishes 952 1,145 1, ,601 Used (8029) (572) Unused 3,738 Actual Hours Turnover time (-99) Procedural Time = Anaesthetic Time + Surgical Time + Other (8,700) (1,169) (5,054) (2,378) Overruns Under-runs Cancelled Sessions 356 1,881 1,640 Notes Times are in hours. Analysis based on the period 1st February 2006 to 30th April 2006, elective sessions only. Available hours is a theoretical maximum based on two 3.5 hours sessions per weekday for the above period for all significant theatre loci (children s theatre, dental theatre, DSU procedure rooms, DSU theatres, gynaecology theatres, maternity theatres, main theatres and endoscopy room). Procedural time is defined as into anaesthetic to into recovery. It is therefore possible for turnover time (the difference between actual time and procedural time) to be negative next patient goes into anaesthetic before the previous one goes into recovery. An over-run is a session where the actual duration exceeded the planned duration (irrespective of planned and actual start and end times), similarly an under-run is a session where the actual duration is less than the planned duration.

34 Appendix I: Pilot Analysis Session Duration 31 Session holder 1983 Session holder 1033 Session holder 264 Notes: (1) Under-Runs are only calculated if they are over 45 mins. (2) Over-Runs are only calculated if they are over 30 mins. APPENDIX I: Pilot Analysis Session Duration Theatre Sessions, Under-Runs and Over Runs Board X, Ophthalmology, 01/02/2006 to 30/04/ Session holder 184 Session holder 97 Session holder 44 Session holder %Under-Runs %Over-Runs Under-Runs Under-Runs Board X Over-Runs Over-Runs Board X Notes 1 Under-Runs are only calculated if they are over 45 minutes. 2 Over-Runs are only calculated if they are over 30 minutes. 3 Note that the session holder is not necessarily the session user.

35 32 National Theatres Project APPENDIX J: Pilot Analysis Patient Pathway Patient Pathway Cataract Surgery, Board X Delays Cancellations There were no cancellations recorded for cataract surgery. There were 23 cataract operations delayed (3% of the total). Reason No porter available 13 Patient not ready 10 There were 737 cases for cataract surgery Sent for - Arrival Arrival - Anaesthetic start Mean time minutes (Standard Deviation) (4) 8 (6) Anaesthetic start - Into theatre 8 (8) Into theatre - Surgery start 11(7) Surgery start - Surgery end 18 (14) Surgery end - Into recovery 4 (4) Into recovery - Out of recovery 4 (7) Destination The destination for all 737 patients was a Standard Ward Grade of Surgeon n % Consultant SPR SHO Medical Student 4 1 STFDOC 4 1 Not recorded 1 0 Grade of Anaesthetist n % No Anaesthetist Associate Specialist 66 9 Consultant 38 5 SPR 29 4 SHO 20 3 Medical Student 11 1 LSTFGRD 4 1 PTGDP 3 0 Not recorded 1 0 HO 1 0 LCONS 1 0 Findings 30% of time is surgical time 26% of time is preparation and anaesthesia 38% of time is down time wide variation in anaesthetic start - into theatre wide variation in surgical time wide variation in time for into and out of recovery

36 Appendix K: Pilot Analysis 33 APPENDIX K: Pilot Analysis Surgical & Anaesthetic Times Surgical Time for Cataract Operations by Surgeon Board Y, 30/01/2006 to 28/04/2006 (Elective procedures only) Surgical time (mins) C 2C 3NC 5C 6C 7NC 8NC 9NC 10C 11C 12NC Surgeon ID and grade (C=Consultant, NC=Non-consultant) Surgeon ID and grade 1C 2C 3NC 5C 6C 7NC 8NC 9NC 10C 11C 12NC No. of cases

37 34 National Theatres Project Anaesthetic Time for Hip Replacement by Anaesthetist Board X, 01/02/2006 to 30/04/2006 (Elective procedures only) C 47C 48C 93C 123C 129C 152C 181C 221C 291NC 293C 354NC 1020C 1109NC 1132C 1139C 1140NC 1143C 1154C 1182NC 1196C 1222C 1226C 1227C 1625NC 1685NC 1858NC 2012NC 2053NC 2272NC 2312NC 2653NC 2685NC 2694NC 2697NC 2767NC 2793NC 2825NC 2826NC APPENDIX K: (Contd.) Anaesthetic time (mins) Anaesthetist ID Anaesthetist ID and grade (C=Consultant, NC=Non-consultant) 38C 47C 48C 93C 123C 129C 152C 181C 221C 291NC 293C 354NC 1020C 1109NC No. of cases C 1139C 1140NC 1143C 1154C 1182NC 1196C 1222C 1226C 1227C 1625NC 1685NC 1858NC 2012NC No. of cases NC 2272NC 2312NC 2653NC 2685NC 2694NC 2697NC 2767NC 2793NC 2825NC 2826NC No. of cases

38 Appendix L: Capability Scoping 35 APPENDIX L: Capability Scoping Nationally Reported Data A number of common themes emerged regarding the information published in the annual Scottish Health Service Costs (Cost Book): In most Boards, theatres hours information is collected either manually or through existing Theatre Management Systems and provided to Finance who combine with corresponding financial information. In a number of Boards, there was uncertainty as to how Finance sourced theatre hours statistics. There were general concerns over the quality of the published data, these primarily related to consistency of definitions, inaccuracies in the numbers of theatres per site, and capture of local procedures. Cost book submissions prepared by Finance are not validated by theatres personnel. Other issues/concerns related to: the clarity of cost book definitions the prescriptive nature of cost book requirements the potential skewing of financial statistics by waiting list initiative funding. Comments on how to improve nationally reported data consisted of a mixture of common themes and more detailed data-related suggestions. The main themes comprised: the need for clear and consistent definitions improved liaison with Finance, including validation of figures. In some Boards, it was recognised that improved local reporting capability was required. There were a number of suggestions on how to improve the value and accuracy of the data reported, as well as thoughts on potentially useful additional information: Improvement: separation of used/unused theatres separation of emergency and elective theatres reporting at site and specialty level identification of CEPOD, out of hours, etc. improvements in quality of coding a facility for local managers to provide a supporting commentary to identify assumptions made relating to their submissions. Useful additional data: cost per case for standard procedures more robust utilisation statistics the extent to which pre-operative assessment is used use of capacity within the private sector available funded capacity by site and specialty education and training statistics staffing statistics. National Theatres Metrics An early piece of work by the National Theatres Project involved combining Cost Book information with SMR01 activity data to derive a number of Board level theatres metrics. These were reviewed as part of the scoping visits. On the whole Boards felt that the metrics derived would be potentially useful subject to the accuracy of the underlying Cost Book data. Again consistency of definitions was a key issue.

39 36 National Theatres Project A number of factors and concerns were raised relating to the use and interpretation of the metrics: Potential inconsistencies in the types of theatre included and their impact on utilisation, e.g. emergency theatres will reduce utilisation figures and these should be excluded or reported separately The need to handle endoscopy activity on a consistent basis Some Boards felt that the use of 41 hours per theatre as a capacity measure was either too high or too blunt a statistic Cost book statistics assume a 52 week year, which will understate utilisation for theatres run/funded for shorter periods Using SMR01 Procedure not done will under-report cancellations Figures would be more use by site and specialty Cost per procedure information would be better by specialty The impact of teaching sessions on throughput Post-operative infection ratios would be more useful if based on inpatient activity only Grouping together DGH and Teaching hospitals would be useful. Local Information Boards across Scotland are moving towards real-time theatres information capture via a variety of Theatre Management Systems, with several Boards implementing systems in recent months. There are however still a number of mainland and island Boards which do not yet have systems. Systems in Use Board System Vendor/In-house Updating Comments (Former) Argyll and Clyde ORSOS* Per-Se Real-time Inverclyde RH using Galaxy as at March 2006 Ayrshire and Arran RES-Q RES-Q Real-time Borders Sapphire Newgate Technology Real-time Expected to go live September 2006 Dumfries and Galloway Sapphire Newgate Technology Real-time Fife Forth Valley Sapphire Newgate Technology Real-time Golden Jubilee Grampian Stopped using Galaxy in 2000 ORSOS Per-Se Real-time Greater Glasgow TIS In-house Real-time Meditech Real-time Meditech theatre module integrated with HISS Highland TheatreMan Tri-Soft Real-time Not Broadford Lanarkshire ORMIS isoft Real-time Lothian ORSOS Per-Se Moving to Pets In-house real-time St. John s Hospital only Tayside In-house Manual data capture * Implementation ongoing at time of visit

40 Appendix L 37 For Boards with systems, data is typically captured using a combination of touch screen and keyboard inputs. In one case, information is recorded manually and then entered into the Theatre Management System. It is common for surgeons and anaesthetists to add information to the system (operation note, procedure codes, ASA grading information), but this does not happen in all Boards. Submitted information is usually verified, and can be amended if necessary. Within Boards without systems, manual data collection allows at least some key theatre performance information to be provided, e.g. hours, cancelled sessions, cancelled patients, utilisation, etc. Existing Systems Support and Ease of Use Board System Support Ease of Use (Former) Argyll and Clyde ORSOS Standard upgrades. User group. Users confident about using in live Quality - patchy to-date. environment. Ayrshire and Arran RES-Q Annual license provides very basic System quite basic and lacks basic support. validation facilities. Borders Sapphire Standard upgrades. Very intuitive. Dumfries and Galloway Sapphire Two upgrades per year. User No major problems. group. Quality no problems. Forth Valley Sapphire Standard upgrades. Quality Easy to use but some issues. variable. ORSOS Periodic updates. Per-Se help desk. Quality pretty reliable. On the whole, staff are happy with the Greater Glasgow systems. TIS In-house. Quality excellent. Meditech Major upgrades every two years. Relatively easy to use. Highland TheatreMan Optional periodic upgrades. Fairly intuitive to use, few issues. Quality okay. Lanarkshire ORMIS Quarterly releases. User Group. No problems easy to use. Quality fine to-date. Lothian ORSOS Input time consuming, user interface Pets requires improvement. Tayside In-house support. Very happy with system.

41 38 National Theatres Project Existing Systems Reporting and General Comments Board System Reporting Other Comments (Former) Argyll and Clyde ORSOS Standard reports, Crystal Reports Major potential benefits anticipated Ayrshire and Arran RES-Q System reports, exports to Recently upgraded flat files Borders Sapphire Standard reports Significant time savings envisaged Dumfries and Galloway Sapphire 40 Standard Reports, Crystal Upgraded to SQL Server, new version Reports, Exports to Excel due soon Forth Valley Sapphire Crystal Reports, exports to Access System in place for 2-3 years ORSOS Crystal Reports No current plans for upgrade for Greater Glasgow TIS Built-in reports, Crystal Reports replacement. Generally simple to use and outputs considered useful Meditech Able to provide a wide variety All relevant patient management infomation collected in one place Highland TheatreMan Business Objects and Crystal Minor developments planned only Reports Lanarkshire ORMIS Standard reports, Crystal Reports Reporting framework based on NTP outputs Lothian ORSOS Flexible relational database Moving towards real-time data capture: Pets 2-3 month delay on average at present Tayside Wide range available, easy to add Very robust, no plans to upgrade or replace

42 Appendix L 39 Reporting and Accountability There are huge differences in the nature and level of theatres performance reporting between Boards in Scotland. This can vary from Boards where regular performance reporting is not currently required, to Boards where reports covering a range of key indicators are circulated widely around theatre users and managers. Reports produced include: utilisation reports cancelled sessions patient cancellations theatre activity over-runs, under-runs and late starts log books audit reports. In addition, theatre information is used to: support ad hoc analyses provide baselines develop business cases report performance against specific targets provide comparisons support research activities validate data for national returns. Reporting is typically a combination of weekly and monthly outputs. Report distribution and theatre accountability can include: Theatre Users Clinical Groups Anaesthetic Management Teams Surgical Management Teams Theatre Service Managers Clinical Service Managers Heads of Service Clinical Directors Medical Directors General Managers Performance Review/Management Specialty Management Directorate Managers Divisional Managers Senior Management Team Executive Directors Operating Division Chief Executives. In at least one Board, Theatre Management System outputs are displayed on notice-boards with plans to include the information on the intranet.

43 40 National Theatres Project Minimum Dataset The table below gives a high-level indication of the availability of the dataset required to produce the draft balanced scorecard across Boards with Theatre Management Systems. Sessional by holder, specialty and site Available theatre hours Allocated sessions/hours: - booked start time (first patient into anaesthesia) - actual start time - booked end time (last patient into recovery) - actual end time - cancellation - plus reason and notice period Procedural Date and location Session holder Operating surgeon Main anaesthetist Operation type - Emergency (usually within 1 hour) NCEPOD 1 - Urgent (within 6 hours) NCEPOD 2a - Urgent (within 24 hours) NCEPOD 2b - Scheduled (within 3 weeks) NCEPOD 3 - Elective NCEPOD 4 Time into anaesthetic Start time of anaesthesia Time into theatre Start time of procedure Time operation completed Time into exit room Time into recovery Time ready to leave recovery Time out of recovery Delays - reason and duration Destination (DSU, Ward, HDU, ICU, Mortuary, Transfer) Cancellation - plus reason Specialty OPCS4 code(s) Other information by specialty and holder/surgeon Advance hospital cancellation of procedure - date and reason Complaints Theatre hours lost to resource unavailability, e.g. equipment failure, staff shortage Risk management episodes Surgical re-admissions (within a specified period) Re-operation within the same admission Dark Blue high coverage Lilac medium coverage Light Blue low coverage

44 Appendix L 41 Glossary and Definitions For terms relating to the derivation of the minimum dataset, relatively little disagreement was found between the proposed national definitions and current Board practice (for Boards where there was a Theatre Management System in use). There were two notable exceptions: list finish time operating time and in each of these cases at least several Boards were working to different definitions. Use of Theatres Information The final sections of the capability scoping visits looked at the use of theatres information within Boards (with or without an implemented system), in three parts: What information is required? How is information used in capacity planning and operations management? How do Boards manage theatres within the context of the whole system? Required Information As well as highlighting the usual theatres indicators, e.g. cancellations, utilisation of sessions, utilisation within sessions, throughput, start and finish times, etc., a number of other potential requirements were highlighted. In particular, the need for individual data to support log books, job planning and appraisals. Other requirements included: surgical rates implant tracking costs per procedure times per procedure patient journey case-mix analysis bed utilisation re-operation rates surgical infection rates patient risk assessment operation records audit. Capacity Planning and Operations Management There was tremendous variety between Boards in the use of theatres information to support these activities. In many Boards, such work tended to be restricted to one-off analyses for specific purposes, often as a consequence of the limitations of the theatres information currently available. Capacity reports, monthly capacity plans and/or meetings were highlighted by a number of Boards, and the need to improve capability and awareness in this area was also recognised. Several Boards are using or developing capacity planning models. The impact of anaesthetist availability has also been the focus of attention in a couple of Boards, and in one instance this has led to the development and successful implementation of an anaesthetist roster system. Whole System Again, this is an area where the level of activity varies widely. A significant number of Boards currently undertake little work in this area, but are seeking to address this. Much of the work that is undertaken is of an ad hoc nature and again effort has been constrained by data issues. In some Boards, whole system issues are addressed through Performance Management, or through relevant stakeholder groups. Of the whole system related activities currently taking place, much of this is focussed on bed requirements.

45 42 National Theatres Project Annex: Theatre Facilities by Site Location Main Day Satellite Specialist Comments Ayrshire and Arran Arran 1 2 Specialist Ayr Endoscopy 2 Urology procedure rooms Anaesthetic procedure room Ayrshire Central 2 Obstetrics Crosshouse Endsocopy Borders Borders General Endoscopy One main theatre is A&E, one is exclusively Obstetrics Dumfries and Galloway Dumfries 6 1 Ophthalmology One main theatre is dedicated 1 Obstetric 24-hour emergency, two are Endoscopy designated day surgery Garrick 1 Fife Queen Margaret Hospital 8 1 Cataract 1 Dental Victoria Hospital 6 1 Dental One further main theatre mothballed Forth Park Maternity 1 Gynaecology 1 Obstetrics St. Andrews Memorial One main theatre mothballed Forth Valley Falkirk 5 3 Endoscopy Main theatres include day surgery, no emergency Stirling Endoscopy Main theatres include one for CEPOD and one for Trauma. One satellite theatre is for Obstetrics Golden Jubilee 8 Endoscopy Six main theatres and two Ophthalmology treatment rooms in use. Main 4 Treatment rooms theatres include day surgery

46 Appendix L 43 Location Main Day Satellite Specialist Comments Grampian Aberdeen Royal Infirmary Urology Endoscopy suite A&E 2 Children s Hospital 3 1 Dental Elgin 4 Endoscopy room Maternity Hospital 1 1 Procedure room Woodend 4 ECT facility Greater Glasgow and Clyde Gartnavel General Glasgow Royal Infirmary RHSC Yorkhill 7 Endoscopy Imaging suite includes GA cover Stobhill General Southern General 10 2 Victoria Infirmary 5 2 Western Infirmary 6 Inverclyde Endoscopy Royal Alexandra Endoscopy 2 Maternity Vale of Leven Endoscopy Highland Inverness 9 2 Endoscopy One main theatre used 1 Maternity exclusively for emergency work Monday to Friday Belford 1 Endoscopy Caithness 2 Endoscopy McKinnon 1 Endoscopy Lawson 1 Endoscopy Oban 1 1 Endoscopy Lanarkshire Wishaw 12 2 Endoscopy Main theatres include day surgery one main theatre mothballed Monklands Endoscopy Hairmyres 8 2 Endoscopy Main theatres include day 2 Cardiac surgery 1 Dental 1 Radiology

47 44 National Theatres Project Location Main Day Satellite Specialist Comments Lothian New Royal Infirmary Three mothballed Eye Pavillion 3 Western General Roodlands 2 St. John s 9 4 Lauriston 1 RHSC 5 Tayside Stracathro 3 2 Endoscopy Perth Plus, one day surgery treatment room. One satellite theatre is mothballed Ninewells Ophthalmology Main theatres include 1 twin. Maternity theatre and Plust two day surgery emergency room treatment rooms. Off-site Dental suite ECT facilities. Dental Hospital Paediatric theatre (sedation only)

48 Appendix M: Capability Template 45 APPENDIX M: Capability Template Board: Primary Contact Name: Position: Telephone/ CAPABILITY SCOPING Planning Extract baseline information: Cost Book 2003/04 & 2004/05 National metrics 2003/04 & 2004/05 Identify specific data issues Forward Requirements Summary to Primary Contact Visits Preliminary NTP, introduction, background and information pack: Datapoints Day Background Document Draft Glossary and Definitions Balanced Scorecard Pilot Framework

49 46 National Theatres Project Mechanism for Feedback Number of Theatres Site Main Day Satellite Specialist Key Theatres Contacts (for inclusion in NTP distribution list) Name Role

50 Appendix M 47 Nationally Held Data Review of 2003/04 and 2004/05 baselines: Are the figures reasonable, are the metrics potentially useful, general comments? Specific data issues and resolution: Sourcing of nationally reported data Sources of activity and cost data Issues and risks Quality of data, ease to obtain, etc.

51 48 National Theatres Project Potential improvement (Including what information is useful, and what additional information would be useful) Local information 1. Collection of local information Process and issues, flowchart of process

52 Appendix M 49 Theatres System For recent/ongoing implementations request ITT and evaluation documents System: Vendor details (or in-house): Software environment: Purchase arrangements: Support arrangements Supported by, cost, SLA, quality of support, enhancements and upgrades Ease of use User comments on user-friendliness of system, like and dislikes Reporting Range and content of reports available, ability to define and configure reports

53 50 National Theatres Project Implications of revised definitions and dataset Ability to add and revise data fields, are there cost and operational implications General comments Existing plans for upgrade or replacement, major features and/or deficiencies, overall user assessment of system. 2. Timeliness of information Average delay between activity and recording: Information added at a later date and average delay

54 Appendix M Range and content of reports available Reports if no Theatres System, or those produced outwith the Theatres Sytstem Use of reports, who uses them and how are they used to drive improvement and/or corrective action 4. Data fields collected Field list and definitions, input forms, etc. (Any source providing all fields available) If not readily available, request and/or obtain contact details for provider

55 52 National Theatres Project Minimum Dataset Many of the theatres scorecard measures can be calculated from the sessional and procedural datapoints listed below. The remaining measures have been detailed separately. Sessional by holder, specialty and site Available theatre hours Allocated sessions/hours: - booked start time (first patient into anaesthesia) - actual start time - booked end time (last patient into recovery) - actual end time - cancellation plus reason and notice period Avail (Y/N) Source Procedural Date and location Session holder Operating surgeon Main anaesthetist Operation type - Emergency (usually within 1 hour) NCEPOD 1 - Urgent (within 6 hours) NCEPOD 2a - Urgent (within 24 hours) NCEPOD 2b - Scheduled (within 3 weeks) NCEPOD 3 - Elective NCEPOD 4 Time into anaesthetic Start time of anaesthesia Time into theatre Start time of procedure Time operation completed Time into exit room Time into recovery Time ready to leave recovery Time out of recovery Delays - reason and duration Destination (DSU, Ward, HDU, ICU, Mortuary, Transfer) Cancellation - plus reason Specialty OPCS4 code(s) Other information - by specialty and holder/surgeon Advance hospital cancellation of procedure - date and reason Complaints Theatre hours lost to resource unavailability, e.g. equipment failure, staff shortage Risk management episodes Surgical re-admissions (within a specified period) Re-operation within the same admission Other Length of stay outliers (see note 1) Waiting list efficiency ratio (see note 2)

56 Appendix M 53 Notes: 1. Individual cases compared with a historical analysis based on length of stay, specialty, and OPCS4 code(s). 2. Ratio of throughput to demand. Requires throughput and snapshots of opening and closing waiting list size over a period of time by specialty. Definitions For comparison against the draft Glossary and Definitions Definition Elective Emergency Operating theatre Consultant responsible for care Operating surgeon Supervising surgeon Surgical first assistant Assistant surgeons Main anaesthetist Supervising anaesthetist Assistant anaesthetist Specialty - consultant/patient Destination on leaving theatre List start time List finish time List run time List under-run List over-run Patient procedure hours Planned hours Operating time Turnover time Time of booking Time patient sent for Time patient arrived in theatre suite Time into anaesthetic room Start time of anaesthesia Time into theatre Start time of procedure Time operation completed Time into recovery Time ready to leave recovery Time actually left recovery Description of any difference in definition

57 54 National Theatres Project 5. Data quality and issues Comments on general quality of data, issues, data validation, matching data to costs, etc. 6. Health Board view on local theatres data Information found to be useful, data gaps and information that would be useful Extent to which theatres information is used in capacity planning (inc. demand and demand forecasting, e.g. OP referrals, emergency), decision making and operations management

58 Appendix M Whole Systems View How do Board anticipate/accommodate whole system two-way interactions: Consultant/Doctor sessions (e.g. theatre v. outpatients); Surgical beds; Length of stay; Occupancy; ICU beds; HDU beds Visit Details Location: Date: Board Representatives: NTP Representatives: Document History