elective surgery redesign at concord hospital - challenges and successes

Fergus Davidson

Staff Specialist Anaesthetist

Chair, Perioperative Governance Committee

Concord, NSW

Wait List Management

Improving “On Time Start” Performance

Managing Day of Surgery Cancellations, and Emergency cases

Debra Pickrell, Manager Patient Services and Information Department

Fiona Wallace, SNUM Perioperative Service

Kathy Musson, Perioperative Data Manager

Ellen Villeneuve, NUM Day Surgery and PAC

Prof Peter Haertsch, Head of Department of Surgery

Staff at every level within peri-operative areas

Reliable Data

Regular scrutiny of data

Continuous communication

Clinical and corporate leadership

Maintain focus on the goals

Weekly Meetings.... Central Bookings manager meets with

General Manager

District Director of Clinical Operations

Head of Anaesthetics and SNUM theatre

Regular Data Reports Facility data reports monthly

SLHD dashboard monthly

Patient Administration System reports weekly Updated lists of waiting patients

Lists of patients approaching due date

Reports sent to surgeons weekly Tentative lists

Unallocated wait-listed patients

Structured audits of waiting lists Reconfirmation of those waiting longer than 6 months

Surveillance for those admitted through ED

Follow-up of FTAs

Follow-up of delayed patients

Reports generated daily/weekly/monthly

Processes Staff orientated in all areas, and roles are flexible

RFA triaged on receipt, according to Clinical Priority Category

CPC is immediately in focus

Building of theatre lists 6 weeks to 3 months ahead

Highlighting potentially overdue cases

Wait list report by CPC, highlighting unallocated cases and their due date

PAS programmed to warn staff if attempting to book beyond CPC date

Mostly manual: room for more IT help

NSW Bureau of Health Information BHI

Constantly monitoring

Anticipating several months ahead

Patients needing theatre time

Theatre time needing patients

Auditing of waiting lists

Re-confirmation processes

Follow up FTAs

Communicating with decision makers

Referring to Policy and CPC guidelines

Communication Widespread awareness of goals

Strongly collaborative approach

Building relationships

Funding-related motivation has helped focus on common goals

Off to a Good Start

Off to a Good Start Definitions

Why bother?

Efforts to date

Barriers and plans

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ja

nu

ary

Fe

bru

ary

Ma

rch

Ap

ril

Ma

y

Ju

ne

Ju

ly

Au

gu

st

Septe

mb

er

Octo

be

r

No

ve

mbe

r

De

ce

mbe

r

CRGH Operating Theatres On Time Compliance % Allocated Elective AM Sessions (In OR Time)

2010 to 2012

2012

2011

2010

On time starts On agenda for some years

DPU “Readiness by 0740”

Audited and managed

“In the bay” by 0745

On time starts 0800 Nursing rostering changes

Flexible nursing roles at start of day

Anaesthetic staff formally start 0745hrs

Senior surgeon champion, to chase up stragglers

Better communication about potential delays

On time starts 0800 Files reviewed to anticipate delays to start

First 2 patients admitted 0630hrs

Scrubbed and opening packs well before 0800

On Time Starts

Adjusted On time starts Sept 2012 (69.1%)

Within 10 min of schedule 84%

Within 20 min of schedule 94%

Oct 2012 (69.3%)

Within 10 min of schedule 85%

Within 20 min of schedule 93%

The last 30% Formal project to review residual delays

Education and Awareness

Focus groups

Debates about definitions

“This project is garbage & meaningless”

Accounting for “legitimate” reasons for late entry to theatre

Managing Emergency cases and

Day of Surgery Cancellations

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

2012

2010

2011

CRGH Operating Theatres

Monthly ElectiveCancellations as a % of Booked Elective Procedures

Equipment issue

No bed

Surgeon related

Displaced by Emergency

Pt other

Surg no longer required Preexisting

illness

FTA

Patient refused

List over booked

Acute illness Displaced by case overrun

Other

Day of Surgery Cancellations 2007-2012 n = 2403

Cancellations 2007-8 vs 2011-12 N= 941 N= 644

No bed 26 10

Equipment prob 24 14

Surgeon related 37 10

Displaced by emerg 34 26

Not prepared 38 27

Surg no longer required 18 49

Pt other 18 54

Pre-existing illness 76 28

FTA 74 54

Pt refused 182 37

Overbooked list 113 58

Acute Illness 143 131

Displaced by Overrun 125 133

Equipment issue

No bed Surgeon related

Displaced by Emergency

5

Pt other

Surg no longer required

Preexisting illness

FTA Patient refused

List over booked

Acute illness

Displaced by case overrun

Other

Day of Surgery Cancellations 2011-12 n = 644

Day of Surgery Cancellations Detailed records of each cancelled case

Monthly data review at Periop meetings

Periodic audit of medical record

Day of Surgery Cancellations - Recurrent weaknesses

Anticoagulants

Over-optimistically booked lists

Burns surgery

Country patients

Mis-communication

Poor quality data

Minimising Cancellations RFA revision

Anticoagulant instructions

Theatre instructions

Feedback to surgeons to raise awareness

Better review of long wait and FTA cases

Cleaner data

Non-elective surgery at Concord

Only 25% of cases

Modest impact on DOS cancellations

Not high on our agenda until 2010

Emergency surgery done within benchmarks Target 90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

2010

2011

2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

January March May July September

Bankstown

Concord

Liverpool

RPA

Urgent KPIs - Hospital Comparison 2011

Non-elective surgery at Concord Daily emergency list

Morning trauma lists 2-3 /week

Cases generally added to end of elective list unless clinically more urgent

Surgical Super liaises when elective surgery needs to be interrupted

Non-elective surgery at Concord Surgical champion identified: much more involved

Surginet on-line booking

Pro-active management by co-ordination desk staff

Guided more by urgency codes

Improved reliability of urgency coding

Monthly dashboards to focus on performance

Peri-operative Performance at Concord Hospital

Reliable and accessible data, regularly scrutinised

Continuous communication

Clinical and corporate leadership

Maintain focus on the goals