Benchmarking in Day Surgery. Mark Skues President, British Association of Day Surgery

Transcription

1 Benchmarking in Day Surgery Mark Skues President,

2 Across the Irish Sea... Issues with Financing Demographics Morale

3 Making Day Surgery count An opportunity for care that is: Better quality More patient focussed More cost efficient Getting started

4 The Audit Commission Basket of Procedures 1990 Orchidopexy Inguinal hernia repair Anal Fissure excision Cystoscopy Carpal Tunnel Decompression Arthroscopy of Knee Squint correction Sub Mucous Resection Pinnaplasty Laparoscopy + Sterilisation Circumcision Excision of breast lump Varicose veins Dupuytren s contracture Ganglion excision Cataract removal Myringotomy MUA # Nose D&C Termination of Pregnancy

5 BADS Trolley of Procedures (1999) Laparoscopic cholecystectomy Thorascopic sympathectomy Partial thyroidectomy Wide excision of breast lump Urethrotomy Laser prostatectomy Eyelid surgery Arthroscopic meniscectomy Dentoalveolar surgery Haemorrhoidectomy Tonsillectomy Submandibular gland excision Bladder neck incision TCRE Hallux valgus ops Arthroscopic shoulder ops Tympanoplasty Rhinoplasty

6 Audit Commission Basket of 24 Procedures Orchidopexy Inguinal hernia repair Anal Fissure Lap Cholecystectomy TURBT Carpal Tunnel Release Arthroscopy of Knee Removal of metalware Squint correction Tonsillectomy MUA # Nose D&C, Hysteroscopy (Termination of pregnancy) (2000) Circumcision Excision of breast lump Haemorrhoidectomy Varicose veins Dupuytren s contracture Ganglion excision Bunion operations Cataract removal Myringotomy + Grommet Sub Mucous Resection Pinnaplasty Diagnostic Laparoscopy

7 Watch Wayne Littlejohn have his kidney removed and return home the same day. "It's a challenge and a brave decision, but our patients are driving it," says Anurag Golash, Consultant Urologist at the University of North Staffordshire Hospital. "I was given the choice - I chose going home," said Mr Littlejohn, just arrived home after having a kidney removed. "I get bored in hospital, Nothing is better than being in your own bed. "I have my sport on TV and my family around to help me."

8 Time to move away from the Basket Gives the impression that these procedures are the only ones to concentrate on Advances in surgical and anaesthetic techniques mean much more can be managed as day surgery Non comparable across all Trusts

9 The BADS Procedure Directory

10 The Directory 2012

11 Procedure Directory Use

12 BADS Procedure Directory Breast Surgery ENT General Surgery Gynaecology Head and Neck Ophthalmology Orthopaedic Surgery Urology Vascular Surgery Paediatric Surgery Emergency Surgery Medical Procedures 170 Procedures

13 BADS Procedure Directory Some procedures may need longer recovery or observation times Others may required specialised equipment or training for Clinicians to achieve their full potential Therefore, achievement of these goals may require: Reconfiguration of day surgery lists Redesign of the clinical pathway Investment in appropriate technology

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15 Laparoscopic Cholecystectomy

16 National Dataset

17 Laparoscopic Cholecystectomy

18 Day Case Laparoscopic 90% cholecystectomy 80% 70% 60% % 40% 30% 20% 10% 0% English Hospitals

19 NHS Atlas of Variation

20 Day case Laparoscopic Cholecystectomy

21 Why the variability? Clinician resistance? Suboptimal anaesthesia? Pathway and process

22 Day Surgery Pathway Intention to treat Outpatient review Preoperative assessment Information provision Admission management Nurse led discharge Discharge information Help line backup

23 Unified Day Surgery Pathway Diagnostics Surgical OPD GP Surgical OPD Preop assessment Day Surgery Waiting List Admission and Surgery Post-op Recovery Day Unit Unanticipated overnight admission Discharge Immediate Postoperative support Inpatient Waiting List Inpatient / Short Stay Unit

24 Illustration

25 Rapid Improvement Sites All English Trusts invited 10 chosen 1 per SHA Low day case rates 1 high performer

26 Applying Basic Principles 100 Start Oct Day surgery rate (%) A B C D E F G H I Trusts Smith et al. J One-Day Surgery 2010;20:80-4.

27 Patient referral Surgical outpatients Preoperative assessment Selection criteria Effect of Pathway Redesign Booking Admission Operating lists Recovery facilities Patient discharge Documentation Post-discharge support

28 Applying Basic Principles Start Oct 2008 (Self-reported data) End Nov 2009 Day surgery rate (%) A B C D E F G H I Trusts Smith et al. J One-Day Surgery 2010;20:80-4.

29 Sustainable? 100 Start Oct 2008 End Nov National Data, Mid 2012 Day surgery rate (%) A B C D E F G H I Trusts

30 Sustainable? 100 Start Oct 2008 End Nov National Data, Mid 2012 Day surgery rate (%) A B C D E F G H I Trusts National

31 Back to Benchmarks...

32 How do we update the Procedure Directory? Collaboration with external organisations: Audit Commission Payment by Results Tariff Team NHS Information Centre (HES data) NHS Institute Better Care indices

33 How do we update benchmarks? Collaboration with Individuals and Professional Organisations; Gynaecology and the RCO&G Paediatric Surgery and APA Trusts: BADS Efficiency Assessment Tool

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35 BADS Efficiency Assessment Tool

36 Comparative benchmarking Basket of 25 Scores: 82% 89% 73%

37 NHS Better Care website

38 Individual hospital performance

39 Other Benchmarks / Outcome Indicators Individual Departmental Hospital National What the patient thinks? Environment efficiency Clinical Organisational Social Economic

40 Clinical Indicators: Individual Anaesthetists Audit for appraisal Unplanned overnight admission rates Pain scores in recovery PONV rates Regional anaesthesia success rates Patient (MSF) feedback

41 Unanticipated Overnight Admission Rate A useful outcome marker?...should be less than 2%...?

42 How to reduce this rate to zero.. Ultra-conservative selection criteria

43 Reasons for overnight admission Medical Predictable Pre-operative comorbidity Unpredictable Complications Cardiovascular Respiratory Surgical A challenging individual patient for day care Pain More complex operation Misadventure Bleeding Anaesthetic Staff roster skill mix PONV Somnolence Social Administrative No home support Wrong time of day for day case operation Wrong environment

44 Reasons for overnight admission Medical Predictable Unpredictable Outcome Pre-operative comorbidity Complications Cardiovascular Respiratory 17.2% Surgical A challenging individual patient for day care Anaesthetic Staff roster skill mix PONV Somnolence Pain Pre-Operative 38.1% More complex operation Assessment Misadventure Bleeding 25.1% Social No home support 19.5% Administrative Wrong time of day for day case operation Wrong environment Capacity pressures Can J. Anaesthesia 1998;45.7:612

45 Aug-02 Nov-02 Feb-03 May-03 Aug-03 Nov-03 Feb-04 May-04 Aug-04 Nov-04 Feb-05 May-05 Aug-05 Nov-05 Feb-06 May-06 Aug-06 Nov-06 Feb-07 May-07 Aug-07 Nov-07 Feb-08 May-08 Aug-08 Nov-08 9% 8% 7% In-Patient Admission after Day Surgery Mean UPL/LPL 6% 5% 4% 3% 2% 1% 0%

46 Other Benchmarks / Outcome Indicators Individual Departmental Trust National What the patient thinks? Environment efficiency Clinical Organisational Social Economic

47 Patient Satisfaction Effective postoperative analgesia Minimal emetic sequelae Staff courtesy and privacy in the unit Short waiting times on the day of surgery No perception of being rushed Post-operative telephone contact Good surgical outcome Smith I, Skues MA, Philip B. Miller s Anaesthesiology, 8 th Edn: in Press

48 Other Benchmarks / Outcome Indicators Individual Departmental Trust National What the patient thinks? Environment efficiency Clinical Organisational Social Economic

49 Economic benchmarks

50 Economic Efficiency Cancelled lists Substitution? Timely notification of leave Late starts / early finishes Patient booking remits DNAs Gap times in theatre

51 Avoidable?

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53 Theatre Utilisation

54 In Theatre Delays

55 Other benchmarks or barriers... National facilities?

56 Barriers to Day Surgery?

57 BADS Guidelines (2012) Selection criteria Operating lists Guidelines have been published by the and the Association of Anaesthetists of Great Britain and Ireland. There is no set maximum travelling time from hospital to home. Carer support after discharge - usually 24 hrs but may be shorter or longer depending on the procedure. BMI should not be used as an arbitrary contraindication to day surgery. Co-morbidities should be assessed and optimised for day surgery. Hypertension should not be used as a contraindication to day surgery. Dedicated day surgery lists provide the best model of care. Lists with a mix of day and short stay surgery can be efficient and provide flexibility. Lists that have a mix of inpatient and day case patients cause tension between the needs of major cases and the day cases. Post discharge support A 24 hr telephone support number should be provided to each patient and their carer. This support service should be provided by nursing staff with knowledge of the potential complications following surgery.

58 Resources: From

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60 Benchmarking in Day Surgery Mark Skues President,