The productive operating the gateshead way   joanne coleman
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The productive operating the gateshead way joanne coleman



The productive operating the Gateshead way - Joanne Coleman, Gateshead Health NHS Foundation ...

The productive operating the Gateshead way - Joanne Coleman, Gateshead Health NHS Foundation
Presentation from the Productive Endoscopy Workshop, Tuesday 15th October 2013 at Ambassadors Bloomsbury , London, WC1H 0HX

This meeting brought together teams from around the country, and embarked on creating and testing the productive endoscopy toolkit. The aim of the day is to allow time with your team for sharing of experiences and exchange of good practice, learn how to apply lean techniques and hear the impact of successfully implemented case studies.



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    The productive operating the gateshead way   joanne coleman The productive operating the gateshead way joanne coleman Presentation Transcript

    • 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 100 50 0 RF RE/KG AM SNK NT JH KC ME PP AH JC -50 -100 -150 -200 -250 -300 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 Cupboards Before
    • Drug Cupboards After
    • Before
    • After
    • After Cost saving £400 per cupboard 400 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
    • £ Jan-13 Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 Jan-12 Dec-11 Nov-11 Oct-11 Sep-11 Aug-11 Jul-11 Jun-11 May-11 Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Jan-13 Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 Jan-12 Dec-11 Nov-11 Oct-11 Sep-11 Aug-11 Jul-11 Jun-11 May-11 Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 No' of bottles Volatile liquids: Usage 90 80 70 60 50 Sevoflurane 40 Desflurane Isoflurane 30 20 10 0 Volatile Liquids: Cost Sevoflurane Desflurane Isoflurane Total
    • No. of pre-packs 450 400 350 300 250 200 150 100 50 0 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Febr… Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Jan-13 Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 Jan-12 Dec-11 Nov-11 Oct-11 Sep-11 Aug-11 Jul-11 Jun-11 May-11 Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 Theatres: IV Paracetamol Usage 700 600 500 400 300 No. of vials 200 Cost (£) 100 0 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 Nurse J 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 Profile: Consultant Surgeon A 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. •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
    • Concerns/Barriers Profile: Anaesthetic Registrar M 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 •Theatre is a noisy placewill 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
    • WHO SURGICAL SAFETY CHECKLIST (Adapted for England and Wales and for Gateshead Health NHS Foundation Trust SIGN IN TIME OUT SIGN OUT Before Start of Surgical Intervention Before induction of Anaesthesia Before any member of the team leaves the operating room 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/N Y/ NA Y/N/N A Y Y/N/N A Has the Surgical Site Infection bundle been planned and undertaken? ♦Antibiotic prophylaxis within the last 60mins ♦Patient warming ♦Hair removal ♦Glycaemic control Y/NA Y/NA Y/NA Y/NA 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 Y Y Y 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 required Nurse/ODP Equipment sterility confirmed, any equipment issues/concerns Y Y Y Y Y Y Y Is essential imaging displayed? Y ♦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 Y Y Y Has the name of the procedure been recorded? Anticipated critical events Please give details of any failure to complete any part of the checklist and the reason why. Registered practitioner verbally confirms with the team: Y Have any equipment issues been identified? Y/ N Surgeon/Anaesthetist and Registered Practitioner: What are the key concerns for the patients recovery?
    • 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 120 100 Briefing 80 Sign In 60 Time out 40 Sign out 20 11 gAu n11 Ju 1 r- 1 Ap 11 bFe c10 De 0 ct -1 O Au g- 10 0
    • 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