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 Breakthroughs in Operating Room Efficiency : Breakthroughs in Operating Room Efficiency Presented by Dr Terry Loughnan Director of Anaesthesia


Why? : Why?


Why? : Why? Emerged from specialist survey in June 2004 that operating room efficiency was the highest priority improvement opportunity.


Our Objectives : Our Objectives Maximise utilisation of current theatre resources Reduce time lost due to late starts and changeover Reduce Cancellations Increase patient throughput Improve Satisfaction of Patients, Specialists, OR Staff


Scope : Scope Four Procedural Areas across 2 sites Rosebud 1 Theatre for Low risk patients undergoing elective surgery excluding joint replacements and laparotomies Frankston Day Surgery Unit (free standing) Endoscopy Unit (separate to Main Theatre) Theatre Suite of four operating rooms


Our Team : Our Team Director of Anaesthesia (Project Manager) Executive Director Medical Services Director of Surgery Orthopaedic Surgeon (VMO representative) Consumer Representative Operations Director Surgery and Inpatient Services Nurse Managers of the 4 Procedural Areas and Admission/Discharge Lounge Consultants and Six Sigma Facilitator Manager Admissions/Discharges Project Officer ESAC Coordinator


Project Plan : Project Plan Establish Structure of Team Define Project Measure Current Situation Complete Analysis Plan and Trial Improvements Control/Redesign Process Evaluate and Review Project


Methodology : Methodology Six Sigma Improvement Process Define Measure Analyse Improve Control Structured approach with emphasis on appropriate quality tools.


Meetings : Meetings Initially every second Monday morning at 0800 – 0930. Located away from Operating Suite. Activities have generated free flowing discussion and far greater understanding of the challenges faced in other areas.


Quality Tools : Quality Tools Affinity Diagram (brainstorming session of relevant issues) Value Chain/Process Mapping Critical to Quality Analysis Survey of Issues by Site Cause and Effect Diagrams


Affinity Diagram : Affinity Diagram


Value Chain : Value Chain


Data Collection : Data Collection Issues Identified by Site


Cause & Effect Diagram: Cancellations on the Day : Cause & Effect Diagram: Cancellations on the Day Causes Environment Technology Data Effect Cancellations on the day Poor bed availability data Poor predictive data re length of operations & equipment required No real time data re in-patients for theatre who are fasting/nil by mouth We don’t know whether beds available Undiagnosed, sick patient (acute illness after preparation) Emergencies - management & semi- urgent cases Overruns Inappropriate health questionnaire screening (for day theatre) through PAC, eg. Anaesthetists miss pieces of information (patient completed questionnaire) Staff/People Illness - Sick staff Staff unavailable between 4.30pm and 6.00pm /safe hours Staff attitude not working out of hours safe working hours required Surgeons/staff on holiday and PH not notified Pathology equipment/ staff unavailable/ inappropriate on the day Equipment breakdown Poor planning for/booking of appropriate equipment Processes/Procedures Bed unavailability: - ICU/general beds Delayed starts Overruns Lack of an emergency theatre ‘Fasting’ guidelines/used not understood by patients (use ‘nil by mouth’) Scheduling to fill the time & emergency cases intervene Non-worked up patients Rostering (safe hours) Poor bed availability Equipment Unavailability Breakdown


Cause & Effect Diagram: Delays in Theatre : Cause & Effect Diagram: Delays in Theatre Causes Staff/People Processes/Procedures Environment Technology Data Effect Unplanned delays, late starts “Late culture” Everything runs a little late - No expectation to start ‘on time’ Medical, education teaching - scheduled deferred starts - skills mix Surgeons bookings from other hospitals Poor forecasting of equipment required How do we know when surgeons due? Arthroscopy need digital equipment increasingly Start times do not relate to surgeons Poor predicted times of length of operation - compounds as the day goes on Poor knowledge of accurate list Poor data re wards/ ICU status (& beds), post 9.30am meeting No “team driver” - surgeons are key in the process Poor patient discharge Poor booking of eg. Pacemaker technician Staff availability/absences eg. Monday technician (sick leave) Processes reliant on surgeon (who didn’t start on time) Surgeons don’t want to wait around/be kept waiting with patients not ready Are we scheduling to give surgeons enough time? lists are too full all day lists at Rosebud/one site? Theatre staff have to wait for surgeons Overrun of other lists earlier in the day causes delays Poor parking for staff People work on other things & are legitimately late On time theatre not a priority Impact of emergencies Morning/night theatre overruns Poor CSSD capacity & logistics: need a quicker cycle Machines being sent between sites, eg Endoscopy equipment not available until 9.00am


Challenges : Challenges Christmas break and Public Holidays. Availability of Visiting Medical Officers (VMOs). Everyone is willing to be involved but no-one can attend a meeting. Shortened time-lines and need to start . Avoiding use of the word “Efficiency”.


Successes : Successes Discovering the true functions of our procedural areas. eg Admission and Discharge Lounge


Communication : Communication


Communication : Communication Letters to all surgeons endoscopists other proceduralists Regular contact with VMO representative


Current Activities : Current Activities Data Collection Rosebud Operating Suite Frankston Operating Suite Frankston Endoscopy Frankston Day Surgery Surgeon Interviews Focus Groups


Data Collection : Data Collection Simple forms specific to each area Compatible with NHS Definitions Common Data Items: examples Times of arrival of Surgeon Times of arrival of Anaesthetist Time patient called for by OR Time patient sent to OR from preparation area Time induction commenced Time “knife to skin” Time transferred to recovery Time ward called to collect patient Time patient left recovery


Surgeon Interviews : Surgeon Interviews Surgeons from each specialty were nominated by Director of Surgery Letter sent to all surgeons with list of suggested interviewees Those not on the list were invited to make contact if they wished to be interviewed. Appointment times and locations scheduled to suit surgeon


Surgeon Interviews : Surgeon Interviews Quantify expectations of the surgeons regarding issues such as Knife to skin time, Perceptions of current performance of the Theatre Suggested improvements within current resources


Focus Groups : Focus Groups Patients Anaesthetists/Registrars Surgeons/Registrars Theatre Nursing Staff (both day and evening groups) Theatre technicians/PSAs/Reception Ideally 8-9 participants for 40-50 minutes Letter to staff to explaining process and inviting them to participate


Planned Future Activity : Planned Future Activity Process re-design workshop. To be held in the evening with interested stakeholders to review the data collected and address issues raised, to improve theatre utilisation. Aim is to have stakeholders re-design the process to meet the customers expectations.


Questions? : Questions?