Aneurin Bevan Health Board Improving Theatre Performance 1 Introduction This report provides an overview on actions being taken to improve theatre performance within the Health Board. The report provides an update on the Transforming Theatres Programme which was recently considered at a briefing session for the Board and includes other actions being taken to improve theatre performance after the recent Wales Audit Office report on Theatres and Day surgery. Financial Assessment and link to Financial Recovery Plan Risk Assessment Annual Quality Framework Standards Health Wales for Services Equality Impact Assessment There are no direct costs applicable to the programme. Potential benefits are through improvements in safety and quality of care, more efficient use of resources and increased productivity. The Institute of Innovation and Improvement have suggested savings through improvements in efficiency, including stock reduction, better utilisation of theatre lists and fewer clinical incidents. A key aim of the programme is to reduce clinical incidents and glitches in theatres by implementing pre-list safety briefings, the WHO Checklist, and improving communication and teamwork. This will be pursued in association with more effective performance arrangements between Theatres and Directorates. The programme aims to improve patient safety and theatre KPIs of late starts, early finishes and session utilisation. The work of the programme is aligned to the Standards for Health Services, ensuring all changes are reviewed in line with the standards. The programme includes all patients and staff groups in theatres. 1
2 Introduction and Background The Transforming Theatres Programme is a national programme led by NLIAH. It is taken from the English Productive Operating Theatre programme and is aimed at improving four key areas in theatres across Wales: Patient Experience and Outcomes Safety and Reliability of Care Team Performance and Staff Wellbeing Value and Efficiency It has links with 100 Lives+ and SPI and focuses on staff engagement to deliver improvements which enable theatre teams to lead and develop their own priority areas. The programme commenced in ABHB in January 2011. The Transforming Theatres team presented to an informal board meeting on 2 nd June 2011 and were asked to report progress to the Board. The Wales Audit Office (WAO) recently published a report on the performance of theatres within the Health Board which was considered by the Audit Committee in June 2011. The report identified a number of key areas for the Health Board to consider in terms of generating efficiencies and improving services. The main themes included: Improve strategic planning and performance management Improving communications and staff morale Developing more effective and comprehensive pre-operative assessment processes Improve Theatre utilisation Increase Day Surgery rates Manage stock and equipment more effectively More effective use of the Health Information system These themes were developed through a six week data collecting period in June/July 2010, a staff questionnaire and detailed fieldwork. The Health Board has been continuing to focus on improvement in these areas during the past six to twelve months, including: implementation of the Transforming Theatres Programme the significant improvement in Day of Surgery admission rates increasing throughput in Orthopaedic Theatres targeting improvement in Day Surgery procedures, eg Arthroscopy 2
commissioned DSU to review pre-surgical assessment processes in Orthopaedics improving Unscheduled Care to reduce impact on Theatre performance This report provides a more detailed overview of action being taken during the remainder of 2011/12. 3 Plans to Improve Theatre Performance There are a number of actions being pursued to improve Theatre performance. 3.1 The Transforming Theatres Programme As previously stated the Transforming Theatres initiative is a national programme which is being sponsored by NLIAH. It has been sourced through the Institute for Innovation and Improvement in England where it was piloted under the banner of The Productive Operating Theatre. After gaining executive sponsorship and appointing the programme lead in January 2011, the Health Board is making good progress and is on course with its intended project plan. The success of the programme is linked to its robust structured approach which encourages strong clinical and staff engagement and is driven and owned by the front line clinical theatre teams. Following a series of presentations, Jade Orthopaedic theatre in Nevill Hall Hospital and the Urology theatres in the Royal Gwent Hospital were chosen as the show case theatres for ABHB. Focus Completed actions Net effect Transforming Theatres Process Executive lead identified Project lead identified 2 show case theatres established A structured approach for maximising the quality and safety of patient care whilst improving theatre efficiency Foundation completed workshops Board presentation Time line for roll out plans Patient safety Surgical briefings now common place Improved communication and planning 3
Improved quality measures for pain control and temperature Optimising patient care Empowering patients and a reduction in delays Patients walking to theatre Efficiency Knowing how you are doing boards established in key areas Glitch recording system implemented Vision statements agreed Live feedback and monitoring mechanism available centrally for all staff Provides weekly feedback identifying key issues to address Team engagement and a recognised departmental aim Environment Stock reduction and consumable review A number of key areas within theatres have been redeveloped using the 5S approach Drugs cupboards rationalised, standardised and stock reduced Anaesthetic standardised equipment reassessed rooms and requirements Reduce expenditure and standardise equipment Theatres are visibly cleaner and stock levels have reduced producing 13k worth of identified savings Staff awareness raised, minimum and maximum stock levels set Improved safety Store rooms condensed Theatre corridors cleared with designated areas for emergency equipment Team working Staff communication boards Pre list briefings A recent national inspection of fire arrangements in Theatres commended the improvements at NHH Improved communication a collaborative approach to team working Allocated responsibilities 4
The showcase theatres have been participating in the programme for 6 months and are currently completing the remainder of the process modules. A roll out plan has been agreed by the Steering Group and the second stage of the process commenced in June with the addition of the two remaining orthopaedic theatres in Nevill Hall, the orthopaedic surgical unit in St Woolos and the three orthopaedic theatres at the Royal Gwent Hospital. The programme is set to run until March 2013 and will involve in the region of 30 operating theatres in total. 3.2 Improving the use of ORMIS In 2004 the Health Board invested in a new theatre information system, ORMIS. This system has provided an electronic record of all its theatre data since its introduction allowing the management team to work collaboratively with surgical specialties in terms of highlighting key issues and suggesting a number of recommendations in order to improve efficiency. The crystal reporting element of ORMIS allows managers and clinicians to drill down to individual areas providing a key management tool for driving performance. In addition the Health Board is working with the DSU to improve arrangements for performance monitoring and management. The Theatre Productivity Tool (TPT) has been developed in partnership between the Delivery and Support Unit and the Cardiff University Health Board. It operates by taking monthly extracts of data which is then formulated into a series of reports using windows excel. It has been reported that the tool will be mandated across Wales and will form a standardised resource for measuring theatre utilisation and efficiency in a more focused way. The Scheduled Care Division has been working with the DSU in terms of its functionality and roll out within ABHB. Following a demonstration of the TPT in June, discussions are taking place with the information department with regards to its introduction into the Health Board. 3.3 Improving Pre-Operative Assessment processes Standard principles apply across all pre-assessment areas with a common document and process for assessing fitness for anaesthetic. Additional assessment tasks may be carried out depending on the speciality e.g. ENT ear assessments. Patient information on fasting and Day of Surgery Admission is common to all areas. Visits are minimised in most specialities e.g. the development of one stop processes from outpatients for General Surgery patients. The DSU has undertaken a review of orthopaedic pre-assessment and the final report is still outstanding. This is probably the specialty that has most patient visits and is being reviewed to reduce them. 5
The process of assessment of fitness for anaesthetic is the same for inpatients and day cases. To minimise the number of visits the outcome of the assessment will direct the patient into the appropriate stream. The PAC Steering Group which includes the Divisional Director of Scheduled Care and Clinical Director for anaesthetics does not support separate streams for these patients prior to preassessment. 3.4 Continuing to focus on improving day surgery and day of surgery admission rates The Health Board remains a good performer for day surgery rates compared to Welsh benchmarks but still needs to improve to meet English performance and beyond. The Health Board has been prioritising improvement in DOSA performance during the past 12 months and this has achieved substantial improvements. Performance has improved from circa 45% in the final quarter of 2009 to 73% during the past two months. There is further potential to improve on this position. 4 Priority actions during the next 6 months The Transforming Theatres programme is considered to be the main driving force for change within theatre services but the Divisional team recognise the need for greater focus and have identified a series of actions to sit along side the programme in line with the WAO recommendations. 4.1 Strategic planning and performance management The Scheduled Care Division acknowledges the need to strive for best in class which requires a review of existing performance management processes to ensure adequate and robust systems are in place for continual improvement. Actions Establish monthly theatre performance review meetings with clinical directors and directorate management teams Aug 2011 Include regular review of performance against targets at Service Leads forum Implement the use of the Theatre Productivity Tool in providing theatre specific, directorate and individual Consultant information on theatre utilization and turnaround times August/October 2011 6
4.2 Improving Communications and Staff Morale Communication is a crucial factor in ensuring services are delivered effectively and the Division accepts the need to ensure that all staff feel that there is a robust two way communication process that allows information to be cascaded as well as providing a method for escalating issues and concerns upwards to the appropriate level. Effective team working in theatre is vital for ensuring patient safety and the ongoing initiative to deliver pre and post theatre list briefings is having a real positive impact. Actions Theatre user groups to be set up on all sites July 2011 Divisional news letter to be established and cascaded to all staff Actioned Review options for updating the staff rest area in main theatres at the Royal Gwent hospital Aug 2011 Develop monthly drop in sessions for access to the theatre management team Actioned Establish and review theatre Web page September 2011 4.3 Improving Theatre Utilisation Operating theatre services are a complex, expensive and an essential resource. The Division recognises the importance of maximising its resources in order to meet the ever increasing demands. Actions Review weekly case mix review meetings at RGH, CDMH and St Woolos to ensure appropriate scheduling of lists July 2011 Review orthopaedic job plans for RGH theatres and establish all day consultant operating Actioned Organise visit to benchmark best in class as identified in the WAO report Sep 2011 Consider the options for protecting surgical bed capacity on all acute sites On going 7
4.4 Increasing Day Surgery Day surgery performance continues to be a focus for providing quality treatment pathways for patients in Gwent. Whilst the upgraded facilities at the Royal Gwent Hospital have delivered significant benefits and efficiencies to the Health Board, the joint endoscopy and day surgery facilities at Nevill Hall Hospital continue to pose challenges in terms of recognising similar benefits. Actions Review the extend opening hours pilot at the RGH day surgery unit Aug 2011 Conduct a scoping study to develop services at NHH in line with service need and recommendation by the Endoscopy Joint Advisory Group (JAG) Aug/Sep 2011 Explore capital costs for relocating Dermatology day case lists to St Woolos July 2011 Identify specialty clinical leads and re-establish day surgery performance review meetings Aug 2011 4.5 Managing Stock and Equipment Operating theatres are highly intensive areas in terms of stock and equipment. The recent review of the Oracle authorisation structures has reduced the number of people able to authorise requisitions. Staff are encouraged to authorise requisitions promptly in order to minimise delays and maintain service provision. Work is ongoing in terms of reviewing consumable expenditure and the All Wales procurement strategy provides opportunities for standardisation and reduced costs. 4.6 Staff Issues At the time of the WAO report issues with the availability of anaesthetists were raised as a concern by certain members of the Health Board. Subsequently an extensive job planning exercise has been under taken and a number of vacancies that existed at the time have been recruited to. In addition, the movement of staff between hospitals and the capacity to undertake mandatory training was also identified as requiring actions in terms of addressing the issues raised. 8
Actions Review and implement mandatory training plans through audit day programmes July 2011 Review flexible working processes in order to maximise resources On going 4.7 Data collection and use The current data collection systems in ABHB are considered to be robust and will compliment the roll out of the Theatre Productivity Tool. Action Develop roll out plans for the TPT monitoring tool Aug/Sep 2011 5 Conclusion The WAO report has provided a number of recommendations for the Health Board to focus on. Theatre utilisation and day case performance is considered to be relatively low in Wales when reviewed against Health Trusts in England. The Scheduled Care Division acknowledges the need to improve performance and is planning a benchmarking exercise with Trusts identified in the upper quartile. The recent appointment of a Clinical Director for Theatre Services has already had a positive affect in developing clinical engagement and support within the Scheduled Care Division. Transforming Theatres is identified as being the main strategy for improving theatre services in Wales. The impact within ABHB to date has been encouraging and the Health Board has been identified by NLIAH as leading the way in Wales. This acknowledgement has been recognised and followed up by a request from NLIAH for ABHB to present their progress at the next national event in July. 9
6 Recommendations The Health Board is asked to: 1. Endorse the Transforming Theatres Programme and approve the roll out across the Health Board. 2. Support the priorities included in the Divisional plan to improve theatre and day surgery performance. Report sponsored by: Judith Paget, Director of Planning & Operations Report prepared by: Nick Gidman, Directorate Manager, Theatres and Day Surgery July 2011 10