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Healthy Communities – Mauriora!
Lakes District Health BoardSurgical Services
Improvement Journey
Improving the System - Meeting the Challenge – April 2012Greg Vandergoot – Service Manager, Surgical & Elective ServicesMartin Thomas – Clinical Director Surgical & Elective Services
Healthy Communities – Mauriora!
Lakes District Health Board Background Project Outcomes Ongoing Work
Overview
Healthy Communities – Mauriora!
Lakes District Health Board
Population base (incorporating Lakes District) 108,000 Operates from two sites, Rotorua and Taupo Rotorua theatre capacity three elective, one acute and endoscopy unit Taupo day-case theatre with an endoscopy facility
Ageing facilities
Surgical & Elective Services covers the following specialties: Ear, Nose, and Throat (ENT) General Surgery Orthopaedics Ophthalmology (Provided through Lakes Ophthalmic Services Ltd (LOSL) Plastic Surgery (outpatients provided though Health Waikato) Urology (Provided through Venturo Subcontract) Vascular Surgery as part of General Surgery Audiology
Healthy Communities – Mauriora!
Background Issues regarding theatre throughput and utilisation
raised by medical and clinical staff 2005
Some work done historically to address issues but found that it was too complex and required sound project methodology
Recognised the need to set up as a project to ensure a sustainable outcome. Project Team established 2006
Service Improvement Project
Healthy Communities – Mauriora!
Over-arching Issues
Improvement in Theatre Utilisation identified Reactive vs Proactive system Recruitment and Retention (Anaesthetics and Nursing) Patient complaints High hospital driven day of surgery cancellations Negative view of service and service performance Data rich, information poor Staff frustrated and felt disempowered Rationing of services
Healthy Communities – Mauriora!
Project Principles
Patients at the Centre
Sustainability long term
Staff buy in and involvement
Short term and long terms
Healthy Communities – Mauriora!
A Good Place to Work - For Our PeopleA Good Place to Work - For Our People• Environment that supports effective service delivery
Clearly defined roles with KPI’s
Staff Satisfaction
Business Focus - For Our StakeholdersBusiness Focus - For Our Stakeholders• Achieve contract volumes within budget
Meet benchmarks
Increase theatre throughput
Provision of meaningful and useful reporting
Ministry compliance
Patient Experience – For Our CustomersPatient Experience – For Our Customers
• Timeliness and equity of access Reduce DOS cancellations and DNA’s
• End to end coherent process Patient Satisfaction
• Well coordinated services
Patient informed/responsible
Easy to engage with/participate in serviceOutpatient
Booking Process
Pre-assessment
Process
Acute Booking Process
Elective Booking Process
Through Theatre Process
Our Approach
Healthy Communities – Mauriora!
Cultural Lifebelt
To work in partnership with
patients/ clients ensuring they are the
f ocus of eff ective care
4. Provide evidence based care
2. Create an effective culture
1. Improve the patient experience
3. Develop new ways of working
Org
anisa
tion
Clinical areasGovernance
Healthy Communities – Mauriora!
Goals and Objectives
Quality care for patients
Improve efficiency and productivity within Surgical Service
Support Clinical Leadership
Redefine scheduling, reporting and rostering processes
Improve theatre roster co-ordination and communciation
Development of tools to ensure ongoing service improvement and decision making
To create an environment that supported and promoted staff involvement in service improvement
Healthy Communities – Mauriora!
Project Framework
•Radical change – quantum improvement• Long term (18-36 months)• Addresses strategic end to end processes
• Streamline existing process, best practice• Medium term (1-18 months)• Addresses segments of operational
processes within a defined area
•Quick hits – day to day activity• Short tem - immediate improvement opportunities (days – weeks)Quick Hits
Focused Improvement
StrategicChange
Healthy Communities – Mauriora!
Six Stages of the Improvement Process
Investigate – Gather evidence to explore the initial hypothesis
Evaluate – Assess validity of the concept in light of evidence
Determine Options – what are the courses of action open to us?
Communications– Who needs to know? How will they be informed?
Buy-in/approvals – Who’s approval or support will be necessary?
Report back to TMG– Who is accountable for reporting back? When will the report be made?
Healthy Communities – Mauriora!
Improvement Portfolio
Initiative Number
QH no.
Matrix Quadrant Initiative Name Hot List Area Status
4 1 Quick Hits Large whiteboard in theatre showing full week’s bookings Acute Booking Process Implemented5 5 Quick Hits ED whiteboard to improve 'Pts ready for theatre' communication Acute Booking Process Implemented9 Focused Improvement Direct Access GP bookings – currently trialling Elective Booking Process Implemented
10 Focused Improvement Review Admin Support for bookings and waitlist management for SMOs Elective Booking Process Implemented12 2 Quick Hits Define Peri-op Unit hours of operation Peri-Operative Assessment Implemented13 8 Quick Hits No changes accepted from Units without approval from Surgeon and Anaesthetist Elective Booking Process
Implemented
14 3 Quick Hits Review internal procedure and communications for exiting pts from Peri-op Unit Peri-Operative Assessment Implemented15 4 Quick Hits Update patient information outlining Peri-Op Unit procedures (pick-up from where, etc) Peri-Operative Assessment Implemented16 Focused Improvement Review who needs what info re Elective bookings/pts, i.e. Surgeon, Reg, HO, Units, Admin, etc Elective Booking Process Implemented
17 Focused Improvement Implement single point of contact for elective list co-ordination in theatre Elective Booking Process Implemented18 Focused Improvement Implement Central Scheduling Process Staff Scheduling Process Implemented22 7 Quick Hits Weekly Theatre Roster / Scheduling meeting Staff Scheduling Process Implemented23 9 Quick Hits Nominate a single contact person for roster changes Staff Scheduling Process Implemented36 6 Quick Hits Update expectations of patient readiness for Acute Surgery Acute Booking Process Implemented38 Focused Improvement Implement feedback loop to booking clerks on actual list utilisation by consultant Utilisation / Patient Flow Implemented39 Focused Improvement Theatre staff data entry of patient flow times saving 0.25 admin FTE duplicate data entry Data for Performance Monitoring Implemented
40 12 Quick Hits Expand TUG Membership Theatre User Group Implemented41 13 Quick Hits Redraft TUG Terms of Reference in line with NHS TMG model Theatre User Group Implemented42 Focused Improvement Roster H/S to PAC clinic - each H/S dedicated session to see their specialty patients Pre-Admission Process Implemented43 Focused Improvement Health questionnaire to be filled out by patients prior to seeing surgeon Pre-Admission Process Implemented44 Focused Improvement Health questionnaire: identify big ticket items on questionnaire for clarity Pre-Admission Process Implemented47 16 Quick Hits Set aside dedicated area in each unit to display pirinted PAC/Surgical Lists for following week Pre-Admission Process
Implemented
48 Focused Improvement Special Requirements Form re Task List for H/S prior to surgery for each patient Pre-Admission Process Implemented49 Focused Improvement Design process to ensure PAC tests followed up for patients who miss/fail surgery Pre-Admission Process Implemented50 17 Quick Hits Review and implement process for patient notes to be on ward prior to admission Pre-Admission Process Implemented53 18 Quick Hits Define and communicate responsibility for patient readiness for theatre - children Elective Booking Process Implemented
Healthy Communities – Mauriora!
BusinessImpact
LOW
HIGH
LOW HIGHImplementation Challenge
FOCUSED IMPROVEMENT
QUICK HITS BOTTLENECK
2
20
17
1 11
18 24,26-34
38
7
16
6
39
8
35
27
25
3
19
1023
374
22
12
36 13
1514
5 21
40
41
42 4344
45 4647
4849
50
52
53
54
56
57
58
59
60
61 62
64
65
66
67
68
70
71
72
73
74
75 76
77
79
80
81
82
83 84
STRATEGIC CHANGE
Prioritising Our ImprovementsPeri-operative Assessment
Staff Scheduling
Elective Booking Process Theatre Staffing Model
Acute Booking Process Utilisation / Patient Flow
Data for Performance Monitoring
Healthy Communities – Mauriora!
Project Focus
Structure
Resourcing
Reporting
Theatre Roster & Schedule Analysis
Patient Journey Mapping & Detailed Process Mapping
Healthy Communities – Mauriora!
What did we achieve?
Quick Hits – staff innovation and involvement
Establishment of a clinically led Theatre Management Group (TMG) – driver behind our improvement
Six weekly rolling theatre and anaesthetist roster sustained
Master Theatre Schedule Review
Introduction of flexible scheduling - sharing of lists within and across specialties
Re-designed theatre list formation and confirmation process – team focus
Healthy Communities – Mauriora!
What did we achieve?
A sustainable increase in elective theatre utilisation and productivity
Theatre Dashboard Report
Specialty Procedure Times Report
Culture change – no cancellation of elective surgery
A better understanding of our business
Motivation to drive service improvement
Healthy Communities – Mauriora!
General Surgery
The Challenge Unmanageable waitlist ESPI non compliance High cancellation of elective surgery High number of patient complaints Duplication of effort and rework Clinician and staff dissatisfaction - couldn’t see the wood for the
trees
Addressing the Challenges Validation of waitlist Collaboration with private provider Access criteria and thresholds Business rules - clinic volumes and FSA:Follow up ratios Pooling of patients MDT fortnightly Scheduling Meeting
Healthy Communities – Mauriora!
Monitoring and Improving our Performance
General Surgery Elective Procedure Trends
0
50
100
150
200
250
300
350
400
450
Jul-09
Aug-0
9
Sep-0
9
Oct-
09
Nov-0
9
Dec-0
9
Jan-1
0
Feb-1
0
Mar-
10
Apr-
10
May-1
0
Jun-1
0
Jul-10
Aug-1
0
Sep-1
0
Oct-
10
Nov-1
0
Dec-1
0
Jan-1
1
Feb-1
1
Mar-
11
Apr-
11
May-1
1
Jun-1
1
Jul-11
Aug-1
1
Sep-1
1
Oct-
11
Nov-1
1
Dec-1
1
Jan-1
2
Feb-1
2
Mar-
12
Total Waiting with Certainty New referrals Number treated Exited untreated
Jun-04 Jun-05 Jun-06 Jun-07 Jun-08 Jun-09 Jun-10 Jun-11 Apr-12
2. Patients waiting longer than six months for their First Specialist Assessment (FSA)
J J J
5. Patients given a commitment to treatment but not treated in six months
J J J J
General Surgery - Patient Flow Indicator Results
Healthy Communities – Mauriora!
Monitoring and Improving our Performance
Cholecystectomy and Hernia - Patients Waiting
170
189
100
77
51
0
50
100
150
200
Jan-09 May-09 Sep-09 Jan-10 Current0
20
40
60
80
100
120
140
160
180
200
Total Number Patients Waiting Cholecystectomy Hernia Patients Waiting >6 months
Healthy Communities – Mauriora!
Monitoring and Improving our Performance
Elective Theatre Utilisation
72
74
76
78
80
82
84
2006/2007 2007/2008 2008/2009 2010/2011 2011/2012
% U
tili
sati
on
Elective Utilisation
Day of Surgery Cancellations
150
200
250
300
350
400
450
500
550
2002 2003 2004 2005 2006 2007 2008 2009 2011 2012
Nu
mb
er
of
Pati
en
ts C
an
cell
ed
DOS Cancellations
Healthy Communities – Mauriora!
Monitoring and Improving our Performance
Day of Surgery Cancellations
0
20
40
60
80
100
120
140
160
2002 2003 2004 2005 2006 2007 2008 2009 2011 2012
Nu
mb
er o
f P
atie
nts
DNA Unfit No Bed
Healthy Communities – Mauriora!
Service Changes
Strategic Planning
Service Improvement
Clinical Governance Model
Quality Focus
Balance Scorecard
Healthy Communities – Mauriora!
Integration into Service Improvement
Embedded within Service Strategic Plan
TMG is fundamental to ongoing success of a Theatre Improvement Project
Needs buy in from Surgeons and other staff (clinical)
Maintaining engagement• Ownership• Delivery• Evidence
Concentrate on improvements but always reflect on successes
Healthy Communities – Mauriora!
Key Learnings
The Service Improvement Process is ownership and accountability
Staff engagement
Leadership is key
Change is a difficult process
Perseverance and persistence can and does change culture
No quick fixes but a lack of action is not an option
Complex problems require a framework to address
Change is not a one time effort!
Healthy Communities – Mauriora!
Making it Happen!
Enough need – a burning deck, a reason to change
Enough time – like a chronic disease, it’s a long journey
Enough money – waste reduction = resource gain
Enough knowledge / methodology
Enough support – at the right levels
Enough willingness, stamina and vision
Healthy Communities – Mauriora!
Current Challenges
Ministry of Health Targets – Strategic Direction
Regional collaboration for Elective Surgery
Theatre Management Group maintaining impetus
Adherence to specialty business rules – eg entry and access criteria
Ongoing development of the Clinical Governance Framework
Facility redevelopment and co-location of service staff – management, administrators, clinicians
Resource efficiency vs funding constraints
30
We are moving in the same direction
We have strong
Leadership
We work in partnership as a team
We share common
goals and vision
We communicate
with each other
We are confident in our ability together
We have the knowledge, skills and
tools we need to do our job
We respect
and support
each other
We are flexible and
open to change
We are focused on
service improvemen
t
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