Making Surgical practice improvement easy

S Connor, M Sakowska, D MacKay, M Furlong, R Roberts

CDHB and scOPe1 solutions

Introduction• Key component to improving surgical outcomes for patients is

ensuring completion of the audit cycle.

• To do so requires

• seamless mapping of the patient journey

• Accurate collection of coded data

• Leveraging of trusted data into meaningful information to the clinicians

• To obtain buy in any change in process or involvement by

clinicians must make their workflow process easier

Aim• To create an electronic workflow for managing patient journey through

surgical services

• Process change must improve clinicians work flow

• Create data that was as accurate and could be trusted by end viewer

• Data to be captured once by person most likely to be able to verify its

accuracy

• Exportable to meet requirements of multiple end users

Methods• Holistic approach to development

• Especially individual and Dept. “clinical champions”

• DHB

• Developers

• Non clinical champions: administrative and managerial

• End users of potential data

• Apply principles of lean thinking to design and workflow

• Staggered roll out across surgical services as clinical champions came on board

• Agile approach to new ideas

What is ?A clinical audit and outcomes tool using workflow support

to capture data

Waiting List• Streamline entry

• Visibility to surgeon

• Real time accuracy

Theatre Visualisation

• E-whiteboard in Theatre

• Ward viewer

• Accurate Op List

Post Op Note / Ward

Instructions

• Quicker for surgeons (template based)

• Published to core clinical documents system

• Core activity data captured (for list)

Complications / M&M

Meetings

• Core Audit

Results

Waiting list: Creating visibility

Time consuming process with lots of duplication and rework

Major risk to Hospital both in terms of errors and financially

Only visible by

printing piece of

paper

Excel sheets to plan lists

only book urgent patients

no visibility over the rest

Fill in Form

• Tailor the form by job description

• Ask only unique questions to the people who will provide most accurate response

• Remove redundancy

• Seek information in recognisable form and link back end to standard data sets (sno-med)

• New functionality

Managing Waiting Lists

Expected Time

Allows selection patient who been on list longest

to be chosen next

See several lists at a glance

By creating visibility encourage FIFOEnsure fair and even access to Rx

Operation Note

Requires data entry

Word template

Can we do Better?

Op Note with

Data collected without need for data entry person, capture by leveraging off

clinically useful application

Audit Research M and M

Synoptic notes

• Common operations can have standardised data and definitions

• Ensure complete information provided for the end user

• Consult the users of the “Op note”

• Re define what is an op notes function

Uptake of synoptic notes: Laparoscopic cholecystectomy

0

20

40

60

80

100

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160

180

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13

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31

37

43

49

55

61

67

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79

85

91

97

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12

7

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13

9

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3

Laparoscopic cholecystectomyCumulative use of synoptic note since inception

100%

Cumulative Sum

80%

Method Time

Pre-scope 3 days

Scope template 1 day

Synoptic 4 (3-8) minutes

Time for op note to be viewable

Increased Quality of note and ? changing practice

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Abx Retraction Rouviere's Peritoneal release Method Crit view Fascia

Comparison of documentation of variables pre and post synoptic notes

pre post

Morbidity and Mortality meeting

Outcomes of M and MTasks register with visibility over status

0

10

20

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60

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80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Surgeon

% o

f m

eeti

ng

atte

nd

ed

Attendance (n=33 meetings)

No. procedures with complications=432/4025 (11%)

66% Grade ≥3

5% discussed result in further action

Audit

Leveraging the data

Implementation at CDHB

KEY

Engagement /

Induction

Diag/

Procedures Complications Op Details Complications

Good

Compliance Initial Use

Audit

Achieved

Anvanced

Analysis e.g

Outliers

Full Partial

Start Up Core Data Capture Reviews / Analysis

General Surgery

Anaesthetic

Obs/Gynae

Orthopaedics

Plastics

Neurosurgery

Otolaryngology (ENT)

Vascular

Opthalmology

Maxillo Facial

Paediatrics

Urology

Start Up Core Data Capture Reviews / Analsyis

Conclusion• Have successfully replaced a disconnected and non functioning paper

based system into a seamless e-solution that is being fully implemented

into surgical services at a major DHB

• High degree of clinical buy in, uptake and engagement

• Structured so standardised format but bespoke for granularity to make

clinically useful

• Make the front end easy and will capture data required from the people

who can best provide most accurate data

• Outcomes now trusted which can lead process for practice improvement