aaron shergis - maroondah hospital - tpot: the productive operating theatre
DESCRIPTION
Aaron Shergis delivered the presentation at the 2014 Operating Theatre Management Conference. Focusing on strategies for implementing the National Safety and Quality Health Service Standards and the importance of communication to improve patient safety and clinical practice, the 2014 Operating Theatre Management Conference brought together operating room management and perioperative professionals to review current initiatives across the country. For more information about the event, please visit: http://bit.ly/optheatremgmt14TRANSCRIPT
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
TPOT : The Productive Operating Theatre.
Aaron Shergis
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Surgery 2015
Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
1. Preparation : Surgery 2015 Project.
2. Journey of TPOT for Eastern Health.
3. Theatre Dashboard : Developing useable data on efficiency, Safety and Patient experience.
4. How Data has changed us.
Eastern Health
Box Hill
7 OT
Maroondah
5 OT
Angliss
3 OT
Yarra
Ranges
2 OT
Healesville
1 OT
Includes Endoscopy
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Background Surgery Services
• Clinical Services – Site Based across all areas • Differing Medical Payment Models • Lack of organisational structure (All site based) • Efficiency issues
Project Surgery 2015 Aims : 1. Create Eastern Health Clinical Streams -April 2012 2. Create Eastern Health structures and committees (unlock the
Silos) April 2012. 3. Implement Standard medical Payment Model - Feb 13 - May
13 4. Theatre schedule reform. 5. Work through modules of The Productive Operating Theatre.
Cage Brawl
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
•Creation of EH clinical streams per Surgical Specialty.
Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
Project Surgery 2015
Easter Health Unit director.
Site based lead (Associate director)
Staff Surgeons/Anaesthetists
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
•Align Eastern Health
Project Surgery 2015
EH Surgery Program Director
Site based APD (Associate Program Directors)
Perioperative services managers
Ward NUMS Admission/ward NUMS Theatre NUMS
Eastern Health Surgery aspires to provide excellent surgical care to patients by excellent staff in an
efficient and frustration free environment.
• Excellent surgical care means delivery of safe, high quality outcomes for
patients from their surgical care that results in an excellent patient experience.
• Efficient environment means decisions for care are based on clinical need and best use of available resources.
• Excellent staff means supported and supportive teams created from the best people.
• Frustration free environment means a motivated surgical team being able to deliver excellence of care.
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
•Creation of EH standard payment model
Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
Project Surgery 2015
Sessional payment for in hour’s surgery.
Sessional payments for in hours trauma (including emergency additions)
FFS/RVG for out of hours surgery (for plastics and ortho)
General Surgery Paid : On call/recall payment model for emergency surgery out of hours.
Surgery 2015 : Theatre Schedule Review.
• Historical
• Site Specific
• Not based on capacity or demand
• Cultural
Emergency Contact Hours
Elective Contact Hours
Elective O/N Beds
Emergency O/N Beds
ICU Hours Surgeon Contact Hours
After Hours and Weekend Work
Waiting List Data
Same Day Admissions
Multi Day Admissions
Aspects to Consider for Template Build.
Session Allocation Principles
• To maximise emergency surgery to within hours
• To separate emergency from elective procedures
• Ensure sessions are fully booked and usage of surgical beds is
optimised.
• Speciality and General sub-speciality elective lists will be identified
and planned in consideration of existing resources i.e. radiology.
Intensive care, to ensure optimal patient care and avoid clash of
resources.
• Endeavour to separate Same-Day from Multiday Elective &
Emergency by specialty.
• Best use of available resources required template build up from clean
sheet – reference to existing occurred after clinical stream
discussions
From this Speciality Aggregated
Wide variation week to week
This – February 14
Angliss – Box Hill – Maroondah - Sites ESIS Reportable
Decreased Variation
Procedures Week
Angliss – Box Hill - Maroondah ESIS Reportable
Week
0
100
200
300
400
500
600
700 Ja
n-1
3
Feb
-13
Mar
-13
Ap
r-1
3
May
-13
Jun
-13
Jul-
13
Au
g-1
3
Sep
-13
Oct
-13
No
v-1
3
Dec
-13
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
2013 2014
MAR
MAR
Stabilisation of electives (Small dip in April for Easter.)
No Cases.
Angliss – Box Hill - Maroondah ESIS Reportable
Decreased Variation Increasing
Contact Hours
Contact Hours Week
Achievements Surgery 2015
• Network focused Organisational structure that allows for escalation, reporting and review.
• Creation of Eastern Health task forces and committees to oversee the surgical service.
• Fair and equitable payment models. • A theatre schedule built on Data that matched more
closely our demand for theatre and our capacity. • Decreased variation in lists from day to day, week to
week, making best use of available resources.
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
TPOT : The Productive Operating Theatre. • NHS : Institute for Innovation and Improvement : Productive series
A modular improvement programme, co-produced with NHS organisations. A systematic way to deliver significant improvements in safety, efficiency and patient care. A method of involving and enabling front line theatre teams to transform the way they work.
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
TPOT : Modules
Key areas of focus • Session Start-up.
• Patient Preparation.
• Consumables and Equipment.
• Well Organised Theatre
• Knowing how we are doing
• Operational Status at a Glance.
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Confirmation of Theatre List
Order
- 120 mins
-90 mins
-70 mins
-60 mins
-50 mins
-40 mins
-30 mins
-20 mins
-10 mins
Registration & Admission process commences. Anaesthetic review of all patients except 1st patient on each list
1st Patient on AM List On-Time Starts
Patient transferred to anaesthetic room/theatre. Anaesthetic team begin anaesthetic interventions
Surgical team arrive in Theatre
Handover to the Surgical Team
Time Out
Fixed Point
1st Patient on PM List On-Time Starts
1st Patient of each list arrive in holding bay for
anaesthetic review
13:30
08:30
Session Start-up.
Clerical
Admission
5 minutes
Nursing
Admission
15 minutes
HMO
Anaesthetics
Surg. Registrar
Surgeon
Theatre –
Ring to
say they
are
Ready
Day of Surgery Patient Preparation.
Session start up improvements • 1st patients for AM and PM lists are seen in theatre not admission ward.
• Theatre order decided day before and not changed.
• Surgical Admission done when waitlisted
(Remove need for medical admission on Day)
• Anaesthetic assessment done to check fit for surgery.
• All 1st patients arrive to theatre at 0730 and no need for theatre to call (unless something out of ordinary)
• Staggered start times for PM admissions.
• Patient phone calls day prior to ensure patients are going to come and then are advised their arrival time and position on list (Main focal point of patient experience.)
Equipment and Consumables
Imprest
Barcoded
Items put
away by
Supply
Can be
direct entry
from
Company –
may sit
there for a
few days
before it is
looked at.
Ordered by
Supply – but
not barcoded
or over load
barcoded
item
One EFT from
Supply
Supply Entry
Processes
Inventory manager
– 2 days a week
Quick wins..
Overstocking EH = $ 19000+ Stock isolated and returned or not re ordered until stock used.
Stock spread through network.
Stock consolidation : All items reviewed and many line items deleted, Par levels dropped according to 12 month use.
Out of date stock removed (loss) = $5000
Process requiring NUM/APD/HOU sign off put in place for new or additional supplies required single time or ongoing.
Network consolidation of inventory (Ports, Hernia Mesh, Laparoscopic equipment, orthopaedic Joints, consumables) (HOU
and inventory coordinator lead)
Decrease in holding stock / returned overstock / product consolidation / Product changes to
cheaper alternatives
Saving = $194641 PA
Ongoing 6 monthly/as required stock review put in place. Inventory coordinator across sites is now employed to monitor and review holding stock and find cheaper comparable alternatives.
HTRAK
Real Time Data Acquisition, Prosthesis, Rebate, Coding and
Prosthesis Costing System
Well Organised Theatre (WOT)
Aim : •Increase patient touch time
•Make the theatres look and feel better. •Make the work environment easier to work in.
•Decrease mistakes and errors •Reduce risk.
Sort Set
Shine Standardise
Sustain
Apply 5S’s Principal
ADUIT
•Video walks •Activity follows of Nurses Support staff Anaesthetics Surgeons •Spaghetti diagrams •Waste walks
Nurse movement for Drugs New safes fitted
100.0%
53.3%
5.0%
5.0%
1.7%
3.3%
31.7%
0.0% 0.0% 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total Motion Paperwork / Administration Discussion Other Pateint Care Pre Op Phase Intra Op Phase Post Op
% o
f ti
me
Activity
Waterfall Chart for Nurse Activity Follow
Evaluation of Change
Team performance and staff wellbeing. Patients Experience
and Outcomes.
Value and Efficiency.
Safety and reliability of
care.
WOT : Everything now has a place and is easy to identify if/when something is missing.
Prosthesis/Loans Area
Unsafe storage, Cant use box lifter in a
corridor/Clutter
Wall to be removed
New Prosthesis Area
after Redesign
Creation of Safe operating practice (With Work safe Victoria) and
enforcement of minimum delivery standards for loan kits.
Measures for Success
Knowing how we are doing..
Developing useable data on Efficiency, Safety and
Patient experience.
• Deciding on what to display that is relevant to the
team • Daily, Weekly, Monthly and Yearly measures. • Focus on measures that clearly show if we are getting
better or worse. • Keep it simple. • Extract our own data for smaller improvement
projects.
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Weekly Start Time Report KHWAD : Efficiency
Operation Date
Theatre Spec
Arrival at
Theatre time
Anaesthesia Start Time
Surgery Start Time
Delay Reason
25/07/2014
Fri
1 ORTH 7:35 8:10 8:28
2 SUR2 7:35 8:25 8:50 Surgeon Late Arriving
3 PLAS 7:40 8:10 8:40
4 SUR1 7:50 8:10 8:45 Surgeon Late Arriving
DPA GAST 9:00 9:10 9:15
PACA PSY1 8:15 8:20 8:22
24/07/2014
Thu
1 SUR4 7:45 8:20 9:35 EQUIP/SUPPLIES NOT READY/AVAILABL
2 ORTH 7:50 8:00 8:30
3 PLAS 7:45 8:15 8:30
4 UROL 7:45 8:20 8:30 LIST ORDER CHANGED
DPA AMM1 7:55 8:05 8:12
23/07/2014
Wed
1 ORTH 7:40 7:55 8:35 Surgeon Late Arriving
1 VASC 7:40 8:05 8:36
2 SUR3 7:55 8:20 8:42 COMPLEX ANAESTHETIC
3 PLAS 7:35 8:15 8:37 SURGEON UNAVAILABLE
4 SUR1 7:55 8:20 8:30
DPA GAST 8:20 8:30 8:36
PACA PSY1 8:07 8:10 8:14
22/07/2014
Tue
1 ORTH 7:45 8:05 8:50 EQUIP/SUPPLIES NOT READY/AVAILABL
2 SUR4 7:50 8:05 8:40
3 PLAS 7:30 8:05 8:30 LIST ORDER CHANGED
4 UROL 7:45 8:00 8:30
DPA RESP 9:35 9:45 9:50
21/07/2014
Mon
1 SUR3 8:05 8:20 8:25
2 SURC 7:50 8:10 8:36
2 SUR4 7:50 8:25 8:45
3 PLAS 7:40 8:10 8:30
DPA GAST 9:00 9:10 9:15
Like most Health Services our Start on Time Initiative is Hard Work with gradual improvement
Small improvement to date
New template
KHWAD : Maroondah Session – Delay Reasons
28 Apr 14 to 04 May 14
05 May 14 to 11 May 14
12 May 14 to 18 May 14
19 May 14 to 25 May 14
26 May 14 to 01
Jun 14
02 Jun 14 to 08
Jun 14
09 Jun 14 to 15
Jun 14
16 Jun 14 to 22
Jun 14
23 Jun 14 to 29
Jun 14
30 Jun 14 to 06
Jul 14
Cases 59 55 55 55 49 61 57 60 54 58 Increase
Elective Cases 47 45 46 44 42 49 50 49 49 46 Decrease
Emergency Cases 12 10 9 11 7 12 7 11 5 12 Increase
Total Surgery Time(hrs)
48.85 47.93 49.73 49.42 62.08 57.93 54.37 54.30 50.83 43.82 Decrease
Average Surgery Time per Case
49.68 52.29 54.25 53.91 76.02 56.98 57.23 54.30 56.48 45.33 Decrease
Number of Sessions Starting On Time
4 5 4 7 5 1 9 7 6 8 Increase
Percentage of Sessions Starting On Time
20.0% 31.3% 20.0% 35.0% 26.3% 5.0% 45.0% 35.0% 30.0% 42.1% Increase
Late Start Hours Lost
3.77 5.70 7.77 4.07 5.63 9.03 2.88 3.83 4.45 5.50 Increase
Average Minutes Lost per Late Start
14.13 31.09 29.13 18.77 24.14 28.53 15.73 17.69 19.07 30.00 Increase
Number of Sessions Starting > 15 Mins Late
7 7 10 6 8 13 4 7 9 6 Decrease
KHWAD : Theatre AM weekly summary
KHWAD : Patient Experience
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Small Improvements in patient waiting time for surgery
Notes: Time to first surgery is calculated from admission time to first anaesthetic time. Excluded records where no anaesthetic time has been entered.
KHWAD : Safety
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Gradual Improvement.
We are seeing some
reductions
KHWAD : Generating your own data : Small improvements
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
15:36:00
16:48:00
18:00:00
19:12:00
20:24:00
21:36:00
1/0
4/2
01
4
8/0
4/2
01
4
15
/04
/20
14
22
/04
/20
14
29
/04
/20
14
6/0
5/2
01
4
13
/05
/20
14
20
/05
/20
14
27
/05
/20
14
3/0
6/2
01
4
10
/06
/20
14
After Hours Start Time
start time
Linear (start time)
1830 Target
Start time trend after
hours is increasing to later at night.
How we use what the dash board is telling us?
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Measurement for diagnosis Measurement for judgement Measurement for improvement or Measurement for sustainability.
Critical Success Requirements
• Executive level support • Aligned strategic direction. • Governance • Good measurements/ Correct Data • Maintaining momentum • Perseverance and resilience • Quick wins
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Key Success Factors to Date for EH • Data – in a form the clinicians
understand • Craft group meetings. • Meetings with Clinical Leads • Support from Directors of Anaesthesia &
Surgery • Weekly Session Meeting • Establish usable dashboards.
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Future priorities of TPOT •Continue to develop the theatre dashboard. •Recovery module of TPOT •Handover and patient turnaround. •Ongoing schedule review •Implementation of brief and debrief in theatres under team-working modules. •Theatre behaviours.
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
Questions ?