SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Cancelled Operations Report to: Trust Board September 2009 Report from: Sponsoring Executive: Sponsoring Divisional Director: Dee Parker Deputy Head of Performance and Capacity Management Andrew Asquith Head of Performance and Capacity Management Steve McManus, Chief Operating Officer Aim of Report/ To report cancelled operations performance, the impact on national Principle Topic: core standards, annual health check and FT scores set by Monitor, action plans to improve performance within each Division, and Trust improvement trajectories. Review History to date: Draft reviewed by Trust Executive Committee July 2009 Assurance Framework Strategic Objective Ref: Trust Board July 2009 S.O. 1 Hospital of Choice, S. O. 6 One of the best regarded public organisations, S.O 7 Sustainable Financial Position Recommendation(s): 1. To agree the actions being taken by Divisional Management Teams and the Trust Improvement Trajectory 2. To monitor improvement at Trust Board, TEC, Divisional Boards, Divisional Performance Reviews and Delivery Group 1. Strategic context: Cancelled Operations have a significant impact upon patient s perceptions of the care they receive, and may influence decisions by patients regarding the hospital they choose to be referred to. Cancelled Operations may result in poor utilisation of resources, such as staffed operating theatres or hospital beds. National Contracts require NHS Trusts who are unable to rebook patients for a date within 28 days of their cancellation to fund the treatment at a time and place (e.g. private hospital) chosen by the patient. Cancelled Operation measures are included in the frameworks used by external organisations to make assessments, and publish their judgements, regarding the capability and performance of SUHT. Such organisations include the Care Quality Commission, DH, Monitor, and Primary Care Trusts. 2. Staff, Patient and Public Involvement: This matter has been assessed for potential impact on personal data and privacy: Yes, no impact This matter has been assessed in relation to Equality & Diversity: Yes, no impact 3. Specific Detail: This report focuses on Cancelled Operations where the intended operations are elective rather than nonelective operations, and where cancellation takes place at the last minute i.e. Cancellation is communicated to the patient on or after their day of admission, and where the reason for cancellation is not the clinical condition of the patient. This is the scope of the national performance regime for cancelled operations. Postponements when the patient remains an admission are not included. Cancellation of non-elective operations, or earlier cancellation of elective operations, are also important, however last minute cancellations have a particularly profound impact upon patients because of the physical, emotional and social preparations that may take place for the event. 1
Performance to end August 2009 is as follows: Cancelled operations: % elective operations cancelled on day of admission % cancellations not readmitted within 28 days Target Month Quarter to Date Year to Date Forecast Year End Jun-09 Jul-09 Aug-09 <0.8% 1.4% A 1.4% A 1.3% A A 1.3% 1.5% 1.4% <5% 1.6% G 5.7% A 13.6% A A 3.2% 9.0% 1.6% Performance trends over two years (monthly results) are illustrated below: Cancelled operations as a % of FFCEs 3% 2% 1% 0% Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Cancelled ops as % FFCEs by month Predicted % w ith 10 Canc ops Predicted % w ith 30 Canc ops Predicted % w ith 60 Canc ops Target 2
28 day breaches as a % of cancelled operations 60.00% 55.00% 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Breaches as a % of cancelled ops by month Predicted % w ith 5 breaches Predicted % w ith 10 breaches Target Predicted % w ith 15 breaches It can be seen that difficulty meeting these performance targets has been persistent despite previous improvement plans and initiatives. Since presentation of a previous report to Trust Executive Committee and Trust Board improvements have been achieved in the rebook target however. Analysis by Care Group and Cancellation Reason is provided at Appendix A. 5. Target maximum levels 5.1 Cancellations Analysis of elective activity levels during Q1 09/10 indicates that for Divisions to achieve the targeted maximum of 0.8% cancellation in relation to their elective activity, these would need to be reduced as follows: Target monthly maximum Q1 monthly average Division 1 11 20 Division 3 8 12 Division 4 7 31.3 5.2 28 Day Rebook To achieve a maximum of 5% failure to rebook, such failures will be reduced to 2 per month across the Trust. 3
6. The Improvement trajectories which will be delivered by implementation of the divisional improvement plans and against which progress will be monitored are as follows: 6.1 Cancellations Trustwide cancellations trajectory 90 80 70 No. of cancellations 60 50 40 30 20 10 0 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Months Actual Improvement Trajectory Target Maximum 6.2 28 day rebooking target Trustwide breaches trajectory 18 16 14 No. of breaches 12 10 8 6 4 2 0 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Months Actual Improvement Trajectory Target Maximum Extracts from Divisional Improvement Plans are provided at Appendix B. 4
Appendix A A.1 Performance by Care Group 2009/10 1/4/09 31/8/09: Total Count of Month for inclusion as Cancellation Surgery Cardiothoracic Orthopaedics Ophthalmology Child Health Care Group Cardiothoracic Child Health Neurosciences Obs and Gynae Ophthalmology Orthopaedics Surgery Obs and Gynae Neurosciences A.2 Top 6 reasons for cancellation of surgery 2009/10 1/4/09 31/8/09: Count of Month for inclusion as Cancellat TIS - Insufficient time to complete operation Comments TEO - Emergency Op in Theatre TIS - Insufficient time to complete operation TEO - Emergency Op in Theatre The three main reasons for cancellation reported by Care Groups are: Insufficient time to complete operation No bed available Higher priority patient was treated in the slot 5
A.3 Main reasons for cancellation reported by Division 1/4/09 31/8/09: Division 1 Division Div 1 Total TIS - Insufficient time to complete operation Count of Month for inclusion as Cancellat AU - Anaesthetist Unavailable HEC - Exceptional Circumstances (eg Major HEF - Equipment Failure HOC - Transferred to other consultant Comments AU - Anaesthetist Unavailable HEC - Exceptional Circumstances (eg Major HEF - Equipment Failure HOC - Transferred to other consultant HTA - Theatre unavailable TEO - Emergency Op in Theatre TEO - Emergency Op in Theatre HTA - Theatre unavailable TIS - Insufficient time to complete operation Division 3 Division Div 3 Total Count of Month for inclusion as Cancellat TIS - Insufficient time to complete operation HEC - Exceptional Circumstances (eg Major TEO - Emergency Op in Theatre Comments HEC - Exceptional Circumstances (eg Major TEO - Emergency Op in Theatre TIS - Insufficient time to complete operation 6
Division 4 Division Div 4 Total Count of Month for inclusion as Cancellat AU - Anaesthetist Unavailable Comments AU - Anaesthetist Unavailable TIS - Insufficient time to complete operation TEO - Emergency Op in Theatre HNA - Cons not Available HEC - Exceptional Circumstances (eg Major HEF - Equipment Failure HEC - Exceptional Circumstances (eg Major HEF - Equipment Failure HNA - Cons not Available TEO - Emergency Op in Theatre TIS - Insufficient time to complete operation 7
A.4 Impact on the 28 day rebooking target 1/4/09 31/8/09 Data Division Care Group Specialty Count of Count of % not Month for Month for rebooked inclusion as inclusion as within 28 days Cancellation Breach Div 1 Ophthalmology EYE 27 0.00% Ophthalmology Total 27 0.00% Orthopaedics ORT 29 5 17.24% Orthopaedics Total 29 5 17.24% Surgery ENT 18 5 27.78% SUR 27 5 18.52% URO 4 0.00% Surgery Total 49 10 20.41% Div 1 Total 105 15 14.29% Div 3 Child Health PED 7 1 14.29% PES 12 3 25.00% PO 15 1 6.67% Child Health Total 34 5 14.71% Obs and Gynae GYN 30 4 13.33% Obs and Gynae Total 30 4 13.33% Div 3 Total 64 9 14.06% Div 4 Cardiothoracic CAS 33 1 3.03% CAY 7 1 14.29% PAC 6 2 33.33% THO 27 3 11.11% VAS 6 2 33.33% Cardiothoracic Total 79 9 11.39% Neurosciences MF 7 0.00% NES 56 9 16.07% ORT 6 1 16.67% Neurosciences Total 69 10 14.49% Div 4 Total 148 19 12.84% Grand Total 317 43 13.56% It can be seen from the above table that we have been failing (year to date) to meet the target to rebook cancelled patients for a date within 28 days of their cancellation (the threshold for achieving this target is 5%). An improvement has been achieved in the most recent 3 months however. Care groups with the greatest impact upon Trust failure to rebook within 28 days are Surgery, Neurosciences and Cardiothoracic. 8
Appendix B Divisional Improvement Plans include the following: Division 1 Reinforcement of the requirement that any potential cancellation is escalated to the care group management team prior to a decision being taken to ensure that all possible solutions are implemented to prevent cancellation. All patients will be appropriately pre assessed before being admitted following the agreed protocol (nurse, nurse and doctor, nurse and anaesthetic) Patients with a specific condition which affects their surgery will be flagged (diabetes warfarin, latex allergy etc) All specialist kit requirements to be identified at outpatient, or at latest pre assessment All operating lists to be given 72 hours before operating date to ensure kit can be ordered and HDU beds can be requested All listed patients will be phoned to check whether they have any condition not flagged on the card All listed patients will be phoned immediately prior to admission reinforce the need to wash with antimicrobial preparation (Reduction in cancellations 10 per month) Orthopaedics will ensure 2 slots retained per week for rebooks (Particular focus on specialties where capacity is scarce and demand is greatest) (No breaches of this standard expected as a result) Surgical Care group will also introduce retained slots for rebooks. Division 3 Ensure that when a date within 28days is offered and parents decline this date for their child this is recorded on PAS and reviewed by the Care Group management team (Reduction in rebooking breaches by 2 per quarter) Introduce firebreaks to urology lists supported by commencement of additional Consultant post. Use emergency theatre lists as appropriate. (Reduction in rebooking breaches by 2 per quarter) Weekly assessment in advance to ensure that theatre lists and bed availability are correctly aligned to avoid bed related cancellation at the last minute. Identify the 28 day breach patients on the weekly TCI list so that the Bed Manager knows which patients to prioritise from a 'target perspective'. (Reduction in both cancellations and rebooking breaches by 2 per quarter) Improve theatre management and utilisation of time to avoid cancellations due to over-run of lists (Reduction in cancellations by 2 per quarter) 9
Division 4 Scheduling of more carefully constructed cardiac theatre lists (in terms of number and complexity of cases) to ensure that unachievable lists are not planned Multidisciplinary planning of theatre schedules All Cancelations are reviewed weekly by the Matrons, Operations Manager and Project lead and monthly by a multi professional team Seek to postpone patients when appropriate, keeping them in hospital and operating at the earliest opportunity, rather than discharging and rebooking for a later date Pilot two additional evening attendances per week, to provide for postponed elective cases or undertake non elective cases if no postponements have occurred. Patients on all lists will be prioritised and this documented, supported by a nominated cancellation co-ordinator. This will result in quicker decision making and thus fewer patients will be cancelled when issues do occur. Operational Managers were appointed at start of July to provide more robust operational management which will include prevention of the causes of cancellation / ensuring rebooking Improve availability of Neuro Intensive Care beds by eliminating delays in discharge for the unit, through care pathway review, audit of delays, role of internal bed manager, study of ortho spinal activity Improve ward bed availability through reducing pre-operative LOS in both emergency and elective, review policy for transfer to other hospitals following treatment, review of all patients over 7 days stay systematically Additional cardiac intensive care capacity - Level 2 now open, Level 3 October 2009 Use of new heart and lung machines by end July, will resolve delays and cancellations caused by the current equipment Review on call rota for Anaesthetists to avoid cancellations due to non-availability of the scheduled anaesthetist. 10