Why?Internally recognised that improving the performance of operating theatres is a key to improving services for patients.

Independent Review in 2003 concluded that there were gains to be made within existing resources. (Giffney Report)

Why?Emerged from specialist survey in June 2004 that operating room efficiency was the highest priority improvement opportunity.

Our Objectives

Maximise utilisation of current theatre resourcesReduce time lost due to late starts and changeoverReduce Cancellations Increase patient throughputImprove Satisfaction of Patients, Specialists, OR Staff

ScopeFour Procedural Areas across 2 sites Rosebud1 Theatre for Low risk patients undergoing elective surgery excluding joint replacements and laparotomiesFrankstonDay Surgery Unit (free standing)Endoscopy Unit (separate to Main Theatre)Theatre Suite of four operating rooms

Our TeamDirector of Anaesthesia (Project Manager)Executive Director Medical ServicesDirector of SurgeryOrthopaedic Surgeon (VMO representative)Consumer RepresentativeOperations Director Surgery and Inpatient ServicesNurse Managers of the 4 Procedural Areas and Admission/Discharge LoungeConsultants and Six Sigma Facilitator Manager Admissions/DischargesProject OfficerESAC Coordinator

Project PlanEstablish Structure of TeamDefine ProjectMeasure Current SituationComplete AnalysisPlan and Trial ImprovementsControl/Redesign ProcessEvaluate and Review Project

MethodologySix Sigma Improvement ProcessDefine MeasureAnalyse Improve ControlStructured approach with emphasis on appropriate quality tools.

MeetingsInitially every second Monday morning at 0800 0930.

Located away from Operating Suite.

Activities have generated free flowing discussion and far greater understanding of the challenges faced in other areas.

Quality ToolsAffinity Diagram (brainstorming session of relevant issues)Value Chain/Process Mapping

Critical to Quality Analysis

Survey of Issues by Site

Cause and Effect Diagrams

Affinity Diagram

Value Chain

Data CollectionIssues Identified by Site

Cause & Effect Diagram: Cancellations on the Day

CausesEnvironmentTechnologyDataEffectCancellations on the dayPoor bed availability dataPoor predictive data re length of operations & equipment requiredNo real time data re in-patients for theatre who are fasting/nil by mouthWe dont know whether beds availableUndiagnosed, sick patient (acute illness after preparation)Emergencies- management & semi- urgent casesOverrunsInappropriate health questionnaire screening (for day theatre) through PAC, eg. Anaesthetists miss pieces of information (patient completed questionnaire)Staff/PeopleIllness- Sick staffStaff unavailable between 4.30pm and 6.00pm /safe hoursStaff attitudenot working out of hours safe working hours requiredSurgeons/staff on holiday and PH not notifiedPathology equipment/ staff unavailable/ inappropriate on the dayEquipmentbreakdownPoor planning for/booking of appropriate equipmentProcesses/ProceduresBed unavailability: - ICU/general bedsDelayed startsOverrunsLack of an emergency theatreFasting guidelines/used not understood by patients (use nil by mouth)Scheduling to fill the time & emergency cases interveneNon-worked up patientsRostering (safe hours)Poor bed availabilityEquipmentUnavailabilityBreakdown

Cause & Effect Diagram: Delays in TheatreCausesStaff/PeopleProcesses/ProceduresEnvironmentTechnologyDataEffectUnplanned delays, late startsLate cultureEverything runs a little late- No expectation to start on timeMedical, education teaching - scheduled deferred starts- skills mixSurgeons bookings from other hospitalsPoor forecasting of equipment requiredHow do we know when surgeons due?Arthroscopy need digital equipment increasinglyStart times do not relate to surgeonsPoor predicted times of length of operation - compounds as the day goes onPoor knowledge of accurate listPoor data re wards/ ICU status (& beds), post 9.30am meetingNo team driver - surgeons are key in the processPoor patient dischargePoor booking of eg. Pacemaker technicianStaff availability/absences eg. Monday technician (sick leave)Processes reliant on surgeon (who didnt start on time)Surgeons dont want to wait around/be kept waiting with patients not readyAre we scheduling to give surgeons enough time? lists are too full all day lists at Rosebud/one site?Theatre staff have to wait for surgeonsOverrun of other lists earlier in the day causes delays Poor parking for staffPeople work on other things & are legitimately lateOn time theatre not a priorityImpact of emergenciesMorning/night theatre overrunsPoor CSSD capacity & logistics: need a quicker cycleMachines being sent between sites, eg Endoscopy equipment not available until 9.00am

ChallengesChristmas break and Public Holidays.

Availability of Visiting Medical Officers (VMOs). Everyone is willing to be involved but no-one can attend a meeting.

Shortened time-lines and need to start .

Avoiding use of the word Efficiency.

SuccessesDiscovering the true functions of our procedural areas. eg Admission and Discharge Lounge

Communication

CommunicationLetters to all surgeonsendoscopists other proceduralistsRegular contact with VMO representative

Current ActivitiesData CollectionRosebud Operating SuiteFrankston Operating SuiteFrankston EndoscopyFrankston Day SurgerySurgeon InterviewsFocus Groups

Data CollectionSimple forms specific to each area Compatible with NHS DefinitionsCommon Data Items: examplesTimes of arrival of Surgeon Times of arrival of AnaesthetistTime patient called for by ORTime patient sent to OR from preparation areaTime induction commencedTime knife to skinTime transferred to recoveryTime ward called to collect patientTime patient left recovery

Surgeon InterviewsSurgeons from each specialty were nominated by Director of SurgeryLetter sent to all surgeons with list of suggested intervieweesThose not on the list were invited to make contact if they wished to be interviewed.Appointment times and locations scheduled to suit surgeon

Surgeon InterviewsQuantify expectations of the surgeons regarding issues such as Knife to skin time, Perceptions of current performance of the TheatreSuggested improvements within current resources

Focus GroupsPatientsAnaesthetists/RegistrarsSurgeons/RegistrarsTheatre Nursing Staff (both day and evening groups)Theatre technicians/PSAs/ReceptionIdeally 8-9 participants for 40-50 minutesLetter to staff to explaining process and inviting them to participate

Planned Future ActivityProcess re-design workshop. To be held in the evening with interested stakeholders to review the data collected and address issues raised, to improve theatre utilisation.Aim is to have stakeholders re-design the process to meet the customers expectations.

Questions?