Elective surgery management at FMC 2004-2013:

Improvement is a continuous process

Kerry Leaver Operations Manager Flinders Medical Centre

Outline

> Information management > Waiting list management > Service changes > Policy changes

Flinders Medical Centre

Flinders Medical Centre >  588-bed tertiary public teaching hospital

>  Major referral centre in southern Adelaide

>  Only hospital in SA offering services for people of all ages

>  62,000 ED presentations each year

>  55,000 admissions (45% emergency) each year

>  5, 500 emergency theatre procedures annually

Let’s go back, way back to 2004

Elective Surgery Strategy 2004-2008

Department of Health funding to:

> Appoint two Elective Surgery Coordinators

>  Improve waiting list management

>  Increase activity

> Reduce waiting times to national targets by 2008

> Use Checklist tool to assist

Where did we start?

> No admissions for category 3 overnight patients for 2 years

> No management of the patients whilst waiting for surgery

> No systems to monitor and report on waiting list management

> 576 overdue patients

Information management

> Data quality management (Ongoing)

> Weekly and monthly monitoring (2007- ongoing)

> Theatre utilisation reporting (2006-ongoing)

> Annual strategy (2007 – ongoing)

> Checklist reporting (2004-07)

Case study: Plastic Surgery scenario modelling

Case study: Plastic Surgery scenario modelling

>  Checklist used to model resources required to admit 60 major plastics patients

>  27 theatre hours per week, 4 quarantined beds

>  Head of Plastic Surgery devised a 3 month work plan

>  Patient clinical review process

>  Education sessions

>  Management protocol introduced

> Phone call to patient to obtain information to determine their ready for care status •  Collected health information that could impact on

surgical outcomes

•  Included Body Mass Index, smoking history, diabetes, heart disease, sleep apnoea, mobility issues

•  General discussion about family support, child care, activities of daily living and driving restrictions

•  Estimated time in hospital and follow up care

>  Senior registrar discussed the surgery, risks and surgical outcomes eg smoking - effect on wound healing

>  Preadmission & Ward Nurses discussed hospital care and expectations

>  Outpatient clinic nurses discussed wound care and dressings and the estimated time to be spent in clinics

>  Occupational therapist commenced the collection of life style data using the Short Form (SF36) and Multidimensional Body-Self Relations Questionnaire (MBSRQ)

>  Patients were given health information

Plastic Surgery Waiting List June 2005 to November 2006

>  Routine provision of written patient information required

>  Health assessment at 1st Outpatient visit necessary

>  Point of contact to assist with patient’s health concerns while on the waiting list valuable

Waiting list management

>  Patient information folder (2006)

>  Health questionnaire at outpatients (2006)

>  Case management for not ready for care patients (2007)

>  Cat 1 bookings for ENT and Plastics undertaken by ES coordinator (2011)

>  Reallocating resources within a unit

>  Treat in turn

>  Pooled list

>  Urgency categorisation

Plastic surgeon

Transfer of care

> FPH > Mount Barker Hospital > Noarlunga Hospital > Blackwood Hospital > Repatriation General Hospital

> Critical success factors •  Senior nursing co-ordination •  Health questionnaire introduction to OPD •  Health service structure •  Co-location

FMC Transfer of care

Hospital 05/06 06/07 07/08 08/09 09/10 10/11 11/12

NHS 247 368 410 384 305 192 187

FPH 55 48 184 180 228 253 312

RGH 525

Mount Barker 52 19

CNAHS 61    

Blackwood 5

TOTAL 354 416 613 625 533 450 1024

The challenges

> Treat in turn principle set aside

> First time quality - right patient, right hospital – set aside

> There is a lot of waste in the process

•  Additional visits pre op

•  Communication with many departments

•  Patient understanding of processes

Transfer of care

Hospital 05/06 06/07 07/08 08/09 09/10 10/11 11/12

NHS 247 368 410 387 305 192 187

FPH 55 48 184 242 228 253 312

RGH

Mount Barker 52 19

CNAHS 61

Blackwood 5

TOTAL 302 416 613 690 533

Service changes

> ENT and Plastics theatre time (2005)

> Ortho and Vascular service changes (2010)

> Theatres redevelopment (2011-2012) > DOSA unit co-location > Bariatric surgery service move (2013)

Theatre redevelopment

>  Emergency and elective theatres had been defined

>  Theatres all ran on an 8 hour roster

>  Redevelopment for 1 year had displaced theatre session times and locations

>  New theatre suite provided opportunity

•  to right size emergency capacity

•  review theatres governance

Average time waited for emergency theatre

0

100

200

300

400

500

600

700

800

900

Tim

e (M

inut

es)

Average wait time (mins) historical mean

Improved data collection

Right sizing

>  Reduce Muda (waste) •  Waiting - time spent by patient waiting for a

theatre •  Inventory – surgeon availability •  Patient cancellations caused by lack of theatre

time •  Queue jumping - caused by c-sections

>  Reduce Muri (unevenness or overburden) •  out of hours operating

“See today’s patients today”

See today’s patients today

Methodology

>  How much emergency theatre capacity do we have?

>  How much emergency demand do we have?

>  Should we define capacity for specific services and create streams? •  Obs and gynae •  Surgical division

Emergency theatre configurations

Requests made by the Clinical Director of Surgery and Clinical Director of Women’s and Children’s

1 2 3 4

Option 1: 24/7 Ortho trauma Surgical division Emerg gynae & obstetrics

Option 2: 24/7 Ortho trauma Emerg gynae & obstetrics

Option 3: 24/7 Ortho trauma Surgical division

Option 4: 24/7 Ortho trauma Undifferentiated Emerg theatre

How much theatre capacity do we have? >  Calculate theatre capacity in minutes per

theatre

>  Adjust to 85% capacity

>  Allow for 10 minute changeover

>  Adjust capacity to exclude 2200-0800 operating hours, assuming this is life and limb surgery only

How many theatres does the demand fit into?

Orthopaedic Trauma

Emergency gynaecology and all obstetrics

Surgical division

Emergency theatre configurations

Requests made by the Clinical Director of Surgery and Clinical Director of Women’s and Children’s

1 2 3 4

Option 1: 24/7 Ortho trauma Surgical division Emerg gynae & obstetrics

Option 2: 24/7 Ortho trauma Emerg gynae & obstetrics

Option 3: 24/7 Ortho trauma Surgical division

Option 4: 24/7 Ortho trauma Undifferentiated Emerg theatre

Results summary

> 3 theatres meets demand most of the time

> Two theatres need to run until 10pm to deal with the daily patient demand

>  Increased capacity for sections must be created in elective theatres

> The third theatre should be undifferentiated

>  Another proposal…..

General surgical specialties theatre

General emergency theatre proposal >  Consultant led emergency theatre service

>  Emergency theatre roster created

>  Commitments for the day cancelled

>  Responsible for managing the queue and doing the work

>  First patient identified day before and ready for a 1000 start time

>  Other specialties have access during the day if required

Elective theatre changes

>  Request for additional sessions, any timetable changes

>  Long standing complaint from surgeons that elective theatres finished at 3.30

>  10 hour rosters introduced for elective theatres

>  Flexible start time for theatres >  All theatres finish at 5pm, allow for a 30

minute overrun

Elective theatre changes

>  Reduce known subspecialty demand gaps >  Principle to schedule all day theatre lists >  Accommodate multiple theatres for clinical

units with VMO staffing >  Principle to remove ‘transfer of care’ as a

strategy for managing elective demand >  Create capacity for c-sections to avoid

delays to elective theatres > 191 additional hours

•  30 hours c-section lists

•  90 hours plastic surgery

Theatres governance

>  Elective and emergency value streams completely separated

>  Manager for each value stream (Theatre coordinators)

>  Management policies created >  Rostering changed to meet needs of each

stream •  8 hour rosters in emergency •  10 hours in elective

>  Huddles – match demand and capacity daily

Number of patients waiting longer than 24 hours

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70

80

Average time waited for emergency theatre

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Tim

e (M

inut

es)

Average wait time (mins) historical mean LCL UCL

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7000

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9000

10000

98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13

Added

Treated

0%

5%

10%

15%

20%

25%

30%

35%

40%

0

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1000

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Jul-99 Jul-00 Jul-01 Jul-02 Jul-03 Jul-04 Jul-05 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jul-11 Jul-12 Jul-13

waiting list

overdues

% overdues

0  

20  

40  

60  

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120  

140  

Total  FMC  Overdues  

New emerg model New elective model

Can we get to zero overdues?

Yes –

>  restructure consultant workforce >  insist on treat in turn >  remove sub specialisation >  remove patient choice for admission

date

What does it mean for the patient and the quality of the service?

Policy changes

2004: Payment to remove patients from the waiting list

2013: Unfunded activity ($6m in 2012-13)

2004-2012: increased elective admissions targets year on year. (2009-10 incentive payments for exceeding target)

2013: “commissioned” activity targets and planned reductions in activity

Where to next

> Network wide load levelling from point of referral

> Subspecialisation demand gaps remain >  Impact of New RAH > EPAS > MATES

>  Commissioning

What did we learn?

> Strength in the individual members’ different skill mix

> Understand the business, know the facts

> There is no such thing as the magic pill

>  Improvement is a continuous process

Thank you