Jenny Abernethy - Intensive Care Unit Frankston Peninsula Health - Operating Theatre Efficiency -...

Operating Theatre Efficiency Models of Care, Measures and

Sustainability

Jenny Abernethy

Operations Director

Surgery, Anaesthetic Services, Intensive Care Unit

Peninsula Health

About Peninsula Health

• Provides a full range of services across 14 major sites

• Operating revenue of $450 million

• 820 beds and growing

• 9 operating theatres

• Building a new ED and 3 new wards

• Serves a population of 295,000 plus visitors

• 4,900 staff, and over 800 volunteers

• Changing Culture Creating Certainty • Create certainty for the patient and staff • No patient cancellations on the day of surgery • Patients who require emergency surgery will be

clinically prioritised and operated upon in a timely manner

• Surgery and interventional procedures will occur in a safe and effective manner

• Create the perfect list

Aspirational Goals

Service

Arrive on time

Be available as rostered/scheduled

Be here for the patients

Open to the new challenges

Open to change

Work within Scope of Practice

Seek teaching/learning opportunities

Excellence

Honest

Openness

Transparent

Takes responsibility for own actions]

Does not blame others

Integrity

Arrive on time

Equality of all staff

Consider the situation when making requests

Put yourself in their position

Interact with colleagues as you would like to be interacted with

Acknowledgement of others actions

Respect

Be aware of colleagues situation

Take holistic view of patient

Communicate

Be approachable

Work together

Staff enjoy their role & workplace

Positive attendance

Take responsibility

Help others

Compassion

Professionalism

Staff Behaviour

Surgery & Anaesthesia – Team Working - Behaviour

Team Dynamics Workshop

Principles

• Themed Operating Theatres

• Move to 4 week schedule

• Dedicated emergency Theatre 24hrs / 7 days

• Separate Emergency Orthopaedic Surgery from the Emergency Theatre

• Additional Elective Surgery Time for Orthopaedic & Vascular Surgery

• Additional capacity for targeted initiatives in Plastics, Urology &

ENT

• Increase Rosebud Theatre Utilisation

Balancing Elective & Emergency Surgery – Peninsula Health’s Journey

Emergency

Elective

Challenges faced

• Theatre Capacity • Emergency Surgery • Staff availability • Funding • Elective Surgery Targets • Emergency Dept. Targets • Equipment • Bed access

Waiting times!

This page is intended to help you think about how you feel at different stages in your journey through the Surgical Pathway.

Put a circle around the words that best describes your feeling at each stage, or write your own words at the bottom.

How did you feel ?

If you’ve got time, we’d like to know why you felt like this. Was it friendly staff, a nice conversation, a long wait or an uncomfortable chair... whatever it is we’d like to know...

Arriving/Checking In Waiting Going to Theatre Post Op. Phase Check Ups (Physio,

OT, Nurse, Doctor) Leaving Information

Happy

Supported

Safe

Good

Comfortable

In pain

Worried

Lonely

Sad

Why ?

Peninsula Health – Surgery Patient Survey

Happy

Supported

Safe

Good

Comfortable

In pain

Worried

Lonely

Sad

Happy

Supported

Safe

Good

Comfortable

In pain

Worried

Lonely

Sad

Happy

Supported

Safe

Good

Comfortable

In pain

Worried

Lonely

Sad

Happy

Supported

Safe

Good

Comfortable

In pain

Worried

Lonely

Sad

Happy

Supported

Safe

Good

Comfortable

In pain

Worried

Lonely

Sad

Happy

Supported

Safe

Good

Comfortable

In pain

Worried

Lonely

Sad

Happy

Supported

Safe

Good

Worried

In Pain

Lonely

Sad

Comfortable

Patient Experience

Emotional Experience

Clarity about what happens to me

Informed about procedures & risks

Awareness of course of treatment

“Certainty”

Understanding aftercare/self-care

Compliance assured

Lifestyle changes

Where to get help

Worried

Lonely

In Pain

Sad

Supported

Safe

Good

Comfortable

Happy

Patient Experience Emotional Experience Out of comfort zone Looking for answers

“Uncertainty” Distressed/Waiting

Clarity about what/when will happen

Informed about procedures & risks

Awareness of course of treatment

“Certainty” Understanding

aftercare/self-care Compliance assured

Lifestyle changes Where to get help

Elective Patient Emergency Patient

Patient Story – Emergency Patient • Admitted on the 12/7 with Cholecystitis and discharged on the 21/7

• Her emergency surgery was cancelled 6 times

Her issues:

• Casual worker who will lose up to 3 weeks work

• Told she should be grateful as another lady upstairs was waiting one day longer

• Staff were afraid to tell her she had been cancelled

• When told she was cancelled, she just wanted a hug to release emotions

• Angry at being pumped full of drugs for best part of 8 days

• When going to surgery finally, paperwork not completed correctly and she was scared she would be cancelled

• First happy face she saw was the surgeon who said he was going to operate on her

“Patients and families will bring ideas to the table that expand the horizons of health care professionals”

Patient Centred Care

Tom Delbanco, M.D., and Sigall K. Bell, M.D.

N Engl J Med 2007; 357:1682-1683

Impact of the Emergency Model

• Reduces twilight and after hours surgery

• Decreases tension through increased resource allocation within hours

• Creates certainty by focusing on standard operating procedures

• Decreases on-the-day cancellations for elective surgery patients

• Decreases cancellations of unplanned surgical cases

• Creates certainty o for emergency surgery o for the elective patient o for staff

Balancing Elective & Emergency Surgery

vs

It is not just about chipping away but rather shaping and

transforming the future

Why start operating sessions on time?

• We should respect our patients • We should respect our fellow team members • Starting the day on time means we have a better chance of

finishing the day on time • We may be able to do additional minor procedures in the session • Risk of patients being cancelled is reduced • Create certainty for patients and staff

“I have noticed that the people who are late are often so much jollier than the people who have to wait for them.” E.V Lucas (1868-1938)

Surgery Start Time Project

• Patient arrival was defined as 6.45 am • Results showed 23% late • Patient tracking (arrival to surgery start) • Admission process was time consuming on

day of surgery (up to 30 min) • Nursing and medical staff wanting to access

the patient on day of surgery – multiple interruptions, staff coming and going

• Patients waiting in the Admission consulting rooms – unclear why they were delayed

Patient perspective Patient comments: “lost in the dark” “poor signage and lighting - arrived in wrong area” “confused with instructions” “slept in!”

Defines patient steps and staff responsibilities Working towards common goal Shared understanding of ‘start time’ Staff rosters re-aligned to support agreement

Surgical ‘Team Agreement’

First Case Surgical Start Time Author: Lauren Manning, Peninsula Health, VIC

Co-Authors: Karen Barker, LEAN This Way, VIC and Ally O’Dell, Nurse Manager Surgical Services

Problem: Delayed surgery start time impacted on the ability to finish on time. Goal: To have reliable first case surgery start time.

Background: Multiple problems associated with delays to first case surgery start time • Extended wait times for

patients to access surgery even despite being the first case

• Frustrations for staff as the co-ordination of timely and safe care was problematic at the start of the day and some staff were waiting for the patient be processed in Admissions

• Staff downtime, high staffing costs

• Affected the ability to provide additional surgical cases

VSM surgical services.igx

Patient

Clerical

Total C/T = 1 minutes

Value Add: 1 minutes

NVA = 0 minutes

2

OR timeout



NVA = 0 minutes

Central W/L

1 minutes

6 minutes

11.3 minutes

36.3 minutes 12 minutes

8 minutes 1 minutes 11 minutes

28 minutes 22 minutes

24 minutes

Lead Time = 138 minutes

VA / T = 56.3 minutes

NVA = 72 minutes0 minutes 6 minutes 15 minutes 12 minutes 0 minutes 0 minutes 17 minutes 22 minutes 0 minutes

Consulting Rooms

Total C/T = 36.3 minutes

Value Add: 11.3 minutes

NVA = 15 minutes

3

Pre Op Area



NVA = 0 minutes

2Total C/T = 12 minutes


NVA = 12 minutes


Value Add: 0 seconds

NVA = 6 minutes

Distance Traveled: 5 m

Anaesthetic



NVA = 17 minutes



NVA = 22 minutes

Pre Admission

Total C/T = 4 hours

Uptime = 35%

admissions

desk - IPM



NVA = 0 minutes

Pink Hat

Coordinator

improve add on

notification

Standardise pt

processing by

nursing

Improve patient arrival times

Defect = 65%

Visual Mgt &

Signalling b/w

disciplines

Introduce pull

systems into Pre Op

Shared understandng of

time out and subsequent

processing times by all staff

Introduce Early Warining System to

escalate first case delays

Day prior processing ?

telephone assessments

and EWS for issues

Review staffing and balance to

meet timeout aims

Key performance measures

avaliable visually on a daily

basis for all staff

Value Stream Mapping - First Case Surgical Start Time

Patient's information packs -

opportunities to improve

Aims with Interventions: Improve patient arrival time delays by: • Consistent and streamlined information • Improved signage for day of arrival • Introduction of day prior phone call and

admission checklist Reducing patient processing time on day: • Dedicated patient processing time with a Time Out agreement • Revised scheduling and staggered admission times • Standard consulting rooms layout

Achievements: We have achieved average

start time delay from 16 min to 9 min (37% reduction in delays to first case surgery start time)

Patient arrival times have improved by at least 11%

Patients happier with clear written and verbal instructions

Reduced processing times through the admissions area

Staff aligned in their definition of surgery start time

Staff morale has significantly improved

Stakeholder Engagement: Regular staff workshops Staff surveys across all disciplines Process mapping and Value Stream

mapping Clerical staff audits - patient arrival

times Regular meetings with management

Visual patient tracking board in Admissions to • Identify patients steps from arrival

to pre-op hold • Reduce interruptions • Improve flow of patient by moving

in one direction

Key Learning's: Define the problem, engage all staff, strong leadership , executive support and continuously improve

ARRIVED PRE-OP

07:30 07:30 07:30 08:00 07:30

07:45 07:45 07:45 08:15 07:45

08:00 08:00 08:00 08:30 08:00

WITHIN 15 MINUTES

Green Starts 6 5 7 8 7

Red/Amber 3 4 2 1 2

% On Time 66.67% 55.56% 77.78% 88.89% 77.78%

Mon Tue Wed Thu Fri

F Theatre 1 07:38 07:35 07:45 07:54 07:32

F Theatre 2 07:44 07:30 07:37 07:36 07:27

F Theatre 3 07:25 07:47 07:23 07:27 07:50

F Theatre 4 07:35 07:21 07:27 07:59 07:34

F Theatre 5 07:28 07:26 07:33 07:45 07:25

F Theatre 6 07:41 07:45 07:32 07:55 07:25

F Theatre 7 07:55 08:19 07:42 08:27 08:02

F Theatre 8 07:47 07:50 07:29 08:10 07:20

R Theatre 1 08:10 07:50 07:58 08:22 07:45

TIME OUT – AM – SESSION START TIME

WITHIN 10 MINUTES

Green Starts 4 4 5 7 6

Red/Amber 5 5 4 2 3

% On Time 44.44% 44.44% 55.56% 77.78% 66.67%

08:15 08:15 08:15 08:50 08:15

08:25 08:25 08:25 09:00 08:25

08:35 08:35 08:35 09:10 08:35

Mon Tue Wed Thu Fri

F Theatre 1 08:28 08:30 09:00 08:53 08:08

F Theatre 2 09:12 08:21 08:32 09:05 08:26

F Theatre 3 08:15 08:35 08:20 08:45 08:21

F Theatre 4 08:24 08:25 08:18 09:04 08:20

F Theatre 5 08:36 08:26 09:10 08:50 08:27

F Theatre 6 08:30 08:27 08:25 08:40 08:34

F Theatre 7 08:39 09:00 08:15 09:20 08:40

F Theatre 8 08:18 08:15 08:10 08:30 08:16

R Theatre 1 08:18 08:23 08:07 08:27 08:18

FINISH TIMES OF LAST CASES FOR THE DAY

16:30 16:30 16:30 16:30 16:30

16:45 16:45 16:45 16:45 16:45

17:00 17:00 17:00 17:00 17:00

WITHIN 15 MINUTES

Green Finish 2 2 5 2 3

Red/Amber 6 6 3 6 5

% On Time 25.00% 25.00% 62.50% 25.00% 37.50%

Mon Tue Wed Thu Fri

F Theatre 1 16:45 15:00 16:40 15:30 16:20

F Theatre 2 16:25 15:59 16:35 17:15 16:32

F Theatre 3 15:50 17:05 16:45 15:43 19:45

F Theatre 4 16:50 16:00 15:20 16:42 16:10

F Theatre 5 17:03 16:30 16:10 16:30 15:50

F Theatre 6 16:52 18:00 16:30 16:50 14:30

F Theatre 7 22:24 22:45 21:50 15:45 22:41

F Theatre 8 09:35 16:45 12:00 15:32 16:00

R Theatre 1 11:05 14:30 16:27 14:40 16:25

Start Time Improvement - Frankston

Patient comments…

“Love that the same nurse who calls the night

before sees me the next morning for my admission”

Senior Anaesthetist’s comments…

"This project has resulted in one of the most successful change management processes in Surgery and Anaesthesia Services at

Peninsula Health...“

Surgeon’s comments …

“ its great, patients are arriving on time

and are ready - there is now a reason for us to be on time”

Surgery Start Time Project - Feedback

Redesigning Stock & Inventory

• Define the Problem

• Create a functioning stock area for receiving and distributing

of consumables

• Ordering system to gain inventory control and improve

efficiency

• Provide support to Theatre Staff and improve Theatre

function

• Decrease costs

• Provide accurate financial reporting

Changing Culture Creating Certainty

Defining the Problems

• Clutter in hall due to lack of delivery space • Risk of stock being lost or damaged • Excess stock on shelves • Staff coming out between procedures for stock • Patients and visitors having access to this non secure area

• Barcoding system implemented • Reduced Inventory Holding • Documenting Freight Charges • Product Analysis • Consumable Agreements

Receiving and Distributing of Consumables

Savings Opportunities

• Product analysis – Usage and cost

– Not relying on companies to provide analysis

– Gowns savings disposable vs. linen

– Review pricing agreements

• Freight costs – Ensure correct cost centre charged

– Identifies suppliers who charge incorrect costs

– Product costs vs. freight costs analysis

• Theatre recycling – Identified opportunities

– Recycling PVC and segregating waste items

Measures of Efficiency and Theatre Optimisation

• Start Times • Contact hours • Number of Procedures • Theatre Utilisation • Anaesthesia RVG’s • Pre-operative time to surgery • Elective Cancellations for emergencies • Elective cancellations on day of surgery • Length of stay • Elective Surgery Waiting List impact

Frankston - Procedures & Contact hours

Contact Hours Mon - Fri

Contact Hours - Weekend

Contact Hours - Session

CONTACT HOURS PER WEEK

Time Period Mon Tue Wed Thu Fri Sat Sun Grand Total

07:00 - 12:00 32.33 36.82 32.52 32.02 27.75 9.87 9.82 181.12

12:00 - 17:00 21.43 25.65 20.77 21.97 52.18 6.83 7.23 156.07

17:00 - 22:00 3.00 3.42 3.38 0.00 5.97 4.57 6.58 26.92

22:00 - 07:00 2.00 0.75 1.25 0.00 1.08 2.80 1.43 9.32

Grand Total 58.77 66.63 57.92 53.98 86.98 24.07 25.07 373.42

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Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Ho

urs

Total Contact Hours Per Week

Previous Year 2014 - 2015

NUMBER OF PROCEDURES BY SESSION AND DAY OF WEEK

Time Period Mon Tue Wed Thu Fri Sat Sun Grand Total

07:00 - 12:00 27 30 28 28 34 5 5 157

12:00 - 17:00 16 20 21 27 26 3 6 119

17:00 - 22:00 3 2 4 0 3 2 3 17

22:00 - 07:00 1 4 1 0 1 2 1 10

Grand Total 47 56 54 55 64 12 15 303

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Pro

ced

ure

s

Total Procedures Per Week

Previous Year 2014 - 2015

THEATRE UTILISATION

Theatre Minutes Available Minutes Used % Used Number of Ops

Emergency Theatre 10066 1814 52% 66

FH Theatre (Excluding Emerg) 16796 11060 93% 207

Rosebud Theatre 2250 2160 61% 33

0%

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120%

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Per

cen

tage

% Used of Available

Emergency Theatre FH Total (Excluding Emerg) Rosebud Theatre

Anaesthesia

Unplanned Surgery

Cancellations for Emergency Patients

Cancellations on Day of Surgery

Length of Stay – Appendicectomy & Lap Chole

YEAR 2010 2011 2012 2013 2014

G07A 6.52 4.98 5.23 3.71 3.35

G07B 2.55 2.48 2.27 2.03 1.92

H08A 7.92 6.9 5.62 4.21 3.61

H08B 1.83 2.12 1.72 1.69 1.5

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2010 2011 2012 2013 2014

Average of LOS

G07A

G07B

H08A

H08B

G07A = Appendicectomy with Complication G07B = Appendicectomy without

H08A = Laparoscopic Cholecystectomy with Complication

H08B = Laparascopic Cholecystectomy without

Length of Stay – Hip Fractures

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2010 2011 2012 2013 2014

Average of LOS

I08A

I08B

I08A = Other Hip and Femur Procedures W Catastrophic CC I08B = Other Hip and Femur Procedures W/O Catastrophic CC

YEAR 2010 2011 2012 2013 2014

I08A 17.01 14.53 13.73 10.93 8.45

I08B 8.98 6.65 7.63 6.42 5.14

Elective Surgery Activity 2013 to 2014

Elective Surgery Activity 2013 to 2014 Total Elective Surgery Waitlist 2013 to 2014

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Actual Activity Target 2013-14 Previous Year

2013-14 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

Actual Activity 555 549 549 635 490 462 534 560 536 540 604 585

Target 2013-14 552 530 528 616 550 460 532 558 590 532 540 590

Previous Year 600 584 484 594 589 387 371 482 490 506 500 506

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Actual Waitlist Target 2013-14 Previous Year


Actual Waitlist 1801 1872 1800 1718 1678 1588 1637 1616 1594 1543 1445 1379

Target 2013-14 1816 1875 1850 1830 1810 1790 1700 1650 1600 1550 1500 1435

Previous Year 1664 1724 1737 1742 1740 1778 1896 1914 1862 1861 1901 1765

Elective Surgery Long Waits 2013 to 2014

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Actual Long Waits Target 2013-14 Previous Year


Actual Long Waits 607 611 531 535 481 500 515 469 457 456 435 385

Target 2013-14 610 630 610 590 565 540 520 495 470 440 410 380

Previous Year 467 475 495 489 514 598 675 683 639 607 639 585

Elective Surgery Long Waits 2013 to 2014

Elective Surgery Cat 2 Long Waits 2013 to 2014 Elective Surgery Cat 3 Long Waits 2013 to 2014

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Target 2013-14 91 100 95 90 85 82 80 75 70 65 60 55

Previous Year 43 46 46 56 71 72 85 88 90 84 82 85



Target 2013-14 519 530 515 500 480 458 440 420 400 375 350 325

Previous Year 424 429 449 433 443 526 590 595 549 523 557 500

General Surgery Long Waits 2013 to 2014

Category 2 Category 3

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General Cat 2 - '13 to '14

All Patients Long Waitetrs

2013 to 2014 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

All Patients 353 318 284 256 247 218 210 215 214 176 152 178

Long Waitetrs 142 129 116 90 67 70 71 61 49 37 30 28

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General Cat 3 - '13 to '14

All Patients Long Waitetrs

2013 to 2014 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

All Patients 40 44 37 30 23 22 26 20 23 19 18 17

Long Waitetrs 7 9 3 4 2 1 2 1 1 0 1 0

Sustainability

• Daily operating suite meetings x 3

• Weekly report to Surgical Executive to monitor performance

• Early identification and escalation of issues

• Review outliers

• Weekly review of theatre lists

• Monitor Elective KPI’s

• Celebrate the successes

• Create certainty for the patient and staff • Cancellations reduced • Patients prioritised • Safe and timely surgery and interventional

procedures • Length of stay improved • Activity optimised • The perfect list!

Summary

“Care is constantly reviewed and opportunities for improvement identified”

http://au.wrs.yahoo.com/;_ylt=Aknbpzc_0EeqhtnIiTPHRTAN5gt.;_ylu=X3oDMTA2bTQ0OXZjBHNlYwNzcg--/SIG=1hcsm7fb4/EXP=1126740858/**http%3A%2F%2Fau.search.yahoo.com%2Fimages%2Fview%3Fback%3Dhttp%253A%252F%252Fau.search.yahoo.com%252Fsearch%252Fimages%253Fp%253Dsuccess%2526ei%253DUTF-8%2526b%253D21%26h%3D269%26w%3D250%26imgcurl%3Dwww.bagcity.net%252Fimages%252Fcheckout_success.jpg%26imgurl%3Dwww.bagcity.net%252Fimages%252Fcheckout_success.jpg%26size%3D28.2kB%26name%3Dcheckout_success.jpg%26rcurl%3Dhttp%253A%252F%252Fwww.bagcity.net%252Fimages%26rurl%3Dhttp%253A%252F%252Fwww.bagcity.net%252Fimages%26p%3Dsuccess%26type%3Djpeg%26no%3D31%26tt%3D860%2C992%26ei%3DUTF-8

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Jenny Abernethy - Intensive Care Unit Frankston Peninsula Health - Operating Theatre Efficiency -...

Health & Medicine

Transcript of Jenny Abernethy - Intensive Care Unit Frankston Peninsula Health - Operating Theatre Efficiency -...