theatre refurbishment programme city road 2 - meh board... · programme city road january 2015 ....
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www.moorfields.nhs.uk
Theatre Improvement programme
Work streams Key actions
1 Theatre staffing • Review of structure, roles and responsibilities
2 Service teams • Developing service team leaders
3 Operating lists • Review of scheduling and planning of lists
4 Admitted pathway • Feasibility study, develop options for 1st floor
5 Operational/Equipment • Defined management of contracts & stock control
6 MEH private • Identify service developments for private
7 Emergency admitted • Improve the pathways to improve communication
8 Information Technology • Review of software, systems and metrics available
9 Governance • Review of policy, processes and information
10 Safety • Team Brief and WHO checklists
11 Education & research • Recruitment of Practice facilitator
12 Efficiency and Value • Improve utilisation of theatre capacity
13 Performance Metrics • Accurate reporting tools
14 Communication /Progress • Reports /updates /user groups
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Work stream 1- Theatre Staffing Agreed structure, roles and responsibilities
Consultation undertaken with Clinical theatre teams
Significantly improved performance management processes,
absence management and appraisal management
Planned
Administrative consultation planned January 2016
Implementation of e-rostering programme
Identified Theatre Service Team Leader roles and job descriptions
agreed, banded and commenced January 2016
Planned
Each service team undertake a review of equipment and
instrumentation requirements
Each team leader attends service review meeting and service
Governance meetings to understand the needs of the services
Theatre Improvement programme
Work stream 2- Introduction of Service Teams
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Work stream 3- Ordering and Planning of Operating lists
Scheduling and planning of operating lists meeting held weekly
Pilot project with a Surgeon and anaesthetist from each service,
reviewing and ordering the operating list developed
Planned
Local safety standards finalised describing the agreed process for
scheduling and listing of procedures
Commence pilot of planned order of operating lists
Review current pathways and confirmation of key weaknesses or
non-compliances against guidance to admitted pathway
Developed an outline schedule of accommodation for facilities
Architect engaged to develop feasibility study and scope of service
Planned
Measured survey, structural survey, review of M&E infrastructure
Present feasibility study with option appraisal.
Theatre Improvement programme
Work stream 4 – Pathway for admitted activity
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Work stream 5- Operational + Equipment Identified all maintenance and service contracts for theatres
Introduction of material management processes in theatres with bar
coding – significant cost reduction in non-pay
Development of new operating theatre timetable
Planned
• Annual review of equipment and instrumentation
• Finalise the move of maintenance and service
Agreement for specific theatre to be made available to MEH private
Specific team leaders identified to lead MEH private
Reporting programme available for MEH private to review the utilisation
of their lists
Planned
New timetable developed and further discussions ongoing
Scoping programme to review capacity and demand requirements
Theatre Improvement programme
Work stream 6- Moorfields Private
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Work stream 7- Emergency Service A full service review and audit of the VRE service to establish the
current resources and future opportunities
Planned
Review of referral source to the VRE Clinic to ensure that referrals
are triaged and signposted effectively
Review of treatment and procedure options to ensure income
captured throughout the pathway.
Identified requirements for integration of PAS Silverlink and OpenEyes
Installation of ‘COW’ on wards to assist with communication and flow of
activity
Planned
Implementation of data and operational requirements for the successful
integration between PAS and OpenEyes
Theatre Improvement programme
Work stream 8- Information Technology
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Work stream 9- Governance
Review of all local procedures and standard operating processes
ensuring local safety standards are based on National Safety
Standards for Invasive Procedures (NATSSIP’S)
Weekly Theatre meeting to discuss the responsibility's of
adhering to the procedures and the impact on patients safety- all
staff encouraged to report safety incidents and/or near misses
Theatre representation to Infection control, Clinical Governance,
Risk Management and Health and safety meetings feeding back
to the theatre team
Significantly improved responsibility and accountability from
staff with clear job descriptions
Planned
Ongoing review of local safety standards to ensure compliance
against National Safety standards
Theatre Improvement programme
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Work stream 10- Safety Reinforce the use of the WHO checklist providing an accurate record
of checks being performed – delivers a written record of Procedural verification and site marking
Sign in, time out and sign out
Prosthesis verification
Conformity with the Pre-operative Team Brief encourages all staff to
express any concerns of planned procedures or patient safety
issues with a debriefing session at the end
Audit of Team brief undertaken, demonstrating improved compliance
Infection control audit
Health and safety audit
Medicines Management audit- all demonstrate compliance
Planned
Ongoing audit of Local safety standards
Continued discussion with staff of responsibilities for the
management of e.g. Prosthesis verification, equipment failure and
prevention of retained foreign objects
Theatre Improvement programme
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Work stream 12- Efficiency and Value Significant improvement in management of theatre budget both pay
and non pay
Open day being undertaken for recruitment of group of staff wishing
to work in theatres at City road- reduction of agency utilisation
Planned
• Programme to define reference costs per procedure
• Recruitment to fill staff vacancies via Open days
Introduction of programmes for monitoring and reporting of activity:
Theatre utilisation broken down by every session
Starting time of both am and pm sessions
Cancellation report for medical and non medical activity
Planned
Audit of cancellations and DNA’s to understand trends
Audit of activity between VR elective and VR emergency activity
Theatre Improvement programme
Work stream 13- Performance Metrics
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Work stream 14- Communications
Communications board in City Road theatres updated monthly
Monthly reports available for services and directorates of progress
and utilisation
Weekly scheduling and cancelation meeting at City Road including all
service managers and service admission co-ordinators with P&I
representative to discuss scheduling, utilisation and staffing issues
Update provided at Clinical Governance half days and clinical service
meetings
Planned
Develop a Moorfields Theatre group for all theatres leads from City
road and satellites to meet monthly to ensure consistency in
standards and resolution of concerns ensuring best practise initiatives
are communicated to all
Development of a Moorfields Medical Theatre user group
Theatre Improvement programme