The Productive Operating

Theatre the Gateshead way

Gateshead Health NHS Foundation

Trust

Joanne Coleman

TPOT Integration within the trust

objectives

• Lean methodology: RPIW and Kaizan events

• Safecare

• Productive series

• Compact and vision work with all staff groups

The Vision

Overview of our progress

• Knowing how we are doing

• Well organised theatre

• Operational status at a glance

• Team working

• Scheduling

• Patient turnaround

• Recovery module

Barriers to a Perfect Day• Capacity

• Individual commitments

• Job plans

• Porters

• Staff shortages

• Attitudes

• Skill

• Training

• Patients

• No flexibility

• Lack of productivity bonuses

• Ineffective communication

• Lack of kit

• Lack of standardisation

• Culture / custom and practice

• Unrealistic scheduling

• Availability of staff

• No opportunity for multi-stake holder gathering (like today)

• Change ( fearful of and resistance to)

• Awaiting permission to change

• Money

• Champions to take it forward

• Effective co-ordination of the whole suite

• Room for bulk IV’s not ready yet

• Historically theatre cupboards not standardized

• No CD usage patterns/ no adequate storage for CD’s

• No visual controls in theatre

• Pharmacy not understanding stock control

• Down time between cases

• Inappropriate listing /order of lists

• List not starting on time

• Patient DNA

• Patient not fully prepared

• Behaviour of medical staff

• IT systems malfunctioning

• Lack of critical care beds/ward beds

• Sickness

Oh What a Perfect Day !!!!• Sufficient equipment / all kit

available to start

• Good staffing levels

• Start and finish on time

• Theatre fully prepared

• Co-ordination of medical staff

• Correct personnel present

• Quick turnaround of patients/ beds. Porters ready to bring patient to and from theatre. Staff available to bring patients to and from theatre. No waiting around.

• Pre-assessment pathways with patient with up to date/ relevant tests available.

• Theatre lists are realistic in terms of capacity

• Patient consented prior to day of surgery

• All IV bulk on direct delivery to theatre

• No cancelled operations

• All drugs available

• Realistic stock levels

• Good channels of communication

• Respect for all team members

• Team brief before the start of the list (WHO)

• Minimal list alterations

• No patient harm

• Efficient use of storage areas

• Break times respected by all team members

• Ease of recognition of MDT

• Appropriate fasting times/ pre-op meds

• Bar codes and auto top up

• No expired drugs

• No datix’s for drug errors in theatres

• No manufacturer supply problems

Theatre Vision

• All patients and staff will be ready for the procedure to be undertaken

• All drugs and sterile equipment to be in the expected place in the quantity requested at the right time with no product defects or wastage.

• All storage locations neat and tidy with visual prompts.

• Good partnership working between provider departments and core theatre staff to support effective logistic supply.

• Documentation records in line with legal requirements

General Theatre Areas

Equipment storage layout

before

After

CSSD Store

Before

After

Utilisation

Theatre capacity

Start times, over runs

-300

-250

-200

-150

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-50

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100

RF RE/KG AM SNK NT JH KC ME PP AH JC

Series1

Delays leaving recovery

• Staff from ward not available

• More than 1 patient to return to the ward at the same time

• No porter available

• Ward had received 5 medical borders admitting them

• Tea time

• Drugs round

Pharmacy’s Role

Pharmacy’s Role

Pharmacy’s Role

• To improve access to medications

• To reduce wastage

• To save money

• To ensure documentation in line with legal requirements

Drug CupboardsBefore

Drug Cupboards

After

Before

After

After

Cost saving £400 per cupboard400 x 12 theatres = £4800

Emergency Boxes

(frequently known as oops

boxes!!!)

Combined Drug Cupboard

• 2 drug cupboards identified as expensive

• Space identified for:

– combined drug cupboard

– IV fluid store

Combined Drug Cupboard

Combined Drug Cupboard

• Old cupboards = £44062

• 1st CDC value = £31444

• Current stock value = £26175

• Cost avoidance = £17887

Recurrent savings

• Working closely with anaesthetists and nursing staff to reduce usage of:

• Sevoflurane

• IV Paracetamol

• Paracetamol & Ibuprofen pre-packs for day cases

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Volatile liquids: Usage

Sevoflurane

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Volatile Liquids: Cost

Sevoflurane

Desflurane

Isoflurane

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Theatres: IV Paracetamol Usage

No. of vials

Cost (£)

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100150200250300350400450

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No. of pre-packs issued (SCDT)

Paracetamol

Ibuprofen

Improving documentation

• A CD review from Summer 2010 highlighted :

– Some entries made in error completely crossed out to make original record illegible

– No standard way of recording the quantity in the register, some use dose other use ampoules/vials

– Doses recorded against wrong page

– Where vials shared between multiple patients, amount given to each patient often not recorded

Improving documentation

Team Working Module

• Previous work with NPSA

• Human Factors

Comments from NPSA Report

Profile: Senior Scrub NurseJ is a senior and well respected scrub nurse who has significant experience at the hospital. He thinks the team need to be empowered to speak up this will help the team learn quicker and help reduce misunderstandings. Some of his team have reported that they don’t know what is going on and they do not feel that they can raise this in theatre. There is the perception that the some of the surgeons and anaesthetists do not listen to the more junior staff

Concerns / Barriers

•I think this is likely to fail.

•What will be the impact on

the patient?

•What will be the impact on

my staff?

•A big priority for J is the

patient journey and how

often the patient is asked

questions

•He finds the

documentation is a real

chore and is worried about

the team getting bogged

down in this

Concerns /Barriers•The checklist has been

developed on the back of a

political motive that will not

have any impact on patient

safety

•It could even have a

detrimental effect if it takes

staff away from the job in hand

•Experienced theatre staff are

seasoned professionals who do

not make errors

•It is not good for the patient –

they already have to respond to

too many checks and questions

as it is

Profile: Consultant SurgeonA is a long serving consultant who is

well known respected and influential.

He feels assured that he and his

team already complete all these

checks during the pathway. He does

not feel he makes or is at risk of

making errors. He feels the checklist

is a political tool that is not really

going to have any effect on quality or

safety of surgery.

Profile: Anaesthetic RegistrarM does not know the team very well

as she is a relatively junior

anaesthetist who does not always feel

easy communicating with the team.

She feels that there are sometimes

communication issues

She feels the checklist would be a

great mechanism for improving

communications and making sure all

of the team are on the same page

Concerns/Barriers•Theatre is a noisy place-

will whoever is doing this be

assertive enough to speak

up and enforce it?

•Who will lead this in

theatres and how will it be4

implemented?

•I am not sure if others will

buy into this, as they might

not need it as much as me

and might think it is a waste

of time

SIGN IN

Before induction of Anaesthesia

Has the patient confirmed their identity, site, procedure and consent?

Y

Is the anaesthetic machine check complete?

Y

ASA grade of patient

Does the patient have a:♦Know allergy/metal work♦An airway management plan♦Relevant blood sampling ♦Adequate venous access

♦Has VTE prophylaxis been planned/undertaken?

Y/NY/ NA

Y/N/NAY

Y/N/NA

Has the Surgical Site Infection bundle been planned and undertaken?

♦Antibiotic prophylaxis within the last 60mins♦Patient warming♦Hair removal♦Glycaemic control

Y/NAY/NAY/NAY/NA

TIME OUT

Before Start of Surgical Intervention

Have all team members introduced themselves by name and role?

Y

Has the surgeon/anaesthetist and registered practitioner confirmed :♦The patients name

♦The planned procedure, site and position♦Patient allergies and metal work

YYY

Anticipated critical events

Anaesthetist♦Any patient specific concerns♦Level of monitoring and support

♦Confirm SSI bundle/ASA grade/VTE prophylaxis Surgeon♦Anticipated blood loss♦Any critical steps

♦Other equipment /investigations requiredNurse/ODP

Equipment sterility confirmed, any equipment issues/concerns

YYYYYYY

Is essential imaging displayed? Y

SIGN OUT

Before any member of the team leaves the operating room

Registered practitioner verbally confirms with the team:

♦Has it been confirmed that the instrument, swab and sharps count are complete?

♦Have the specimens been labelled, including patient ID♦Amount of blood loss

YYY

Has the name of the procedure been recorded?

Y

Have any equipment issues been identified?

Y/N

Surgeon/Anaesthetist and Registered Practitioner:

What are the key concerns for the patients recovery?

Please give details of any failure to complete any part of the checklist and the reason why.

WHO SURGICAL SAFETY CHECKLIST

(Adapted for England and Wales and for Gateshead Health NHS Foundation Trust

After comments from staff, and

surgeons

Theatre Staff,

Allows us to prompt

surgeons and ask questions, so all

possible information is available.

Complicated patients, everybody

aware of what is going to happen

Ensures that all equipment is

available should extra things be

required.

Allows lists to be discussed so that

any change in order is known by all

Surgeons

Prevents delays, as all

equipment is available.

Everybody knows

exactly what is required,

minimizing delays.

Ensures that if list is

incorrect, it can be

changed

WHO Safer Surgery compliance

WHO Safer Surgery compliance

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1Briefing

Sign In

Time out

Sign out

Scheduling Module

Process Map

Achievements

• Starting to see an improvement in theatre utilisation from 89% to 92%

• 11% reduction in late starts

• 10% reduction in late finishes

• Cost savings in both kit and drugs spend

• 66% reduction in cancelled ops

• Reduced sickness absence levels from 6.9% to 3.9%

• Reduced bank usage from 1220 hours to 234 hours

• Improved team work and morale

Lessons learned

• It’s worth the hard work

• Champions will help you achieve an end result

• Everyone is valuable

• Tangible improvements encourage more improvements

• Stick with it and just do it

Thank You

• Any Questions

Before

After