Mike Davidge & Anna Lipp: The challenge of day case surgery

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In this slideshow, Mike Davidge, Head of Measurement, NHS Institute for Innovation and Improvement and Anna Lipp, President Elect for the British Association of Day Surgery, outline the challenges faced in improving performance in day case surgery, focusing on the strategies used at Norfolk and Norwich University Hospital to increase efficiency and productivity in this area.

Mike Davidge and Anna Lipp presented at How can hospitals do more with less? in October 2012.

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Mike Davidge & Anna Lipp: The challenge of day case surgery

  1. 1. The challenge of day case surgeryDr Anna LippLead for Day Surgery, Norfolk and Norwich University HospitalPresident-elect British Association Day SurgeryMike DavidgeHead of Measurement, NHS Institute for Innovation and ImprovementResponsible for Better Care, Better Value indicators British Association of Day Surgery www.bads.co.uk
  2. 2. Outline • Identifying day surgery challenges locally • Case studies in different surgical specialties – Orthopaedics – General surgery – Breast surgery • What you can do • RecommendationsBritish Association of Day Surgery www.bads.co.uk
  3. 3. Do we have a problem with day surgery rates at NNUH ?NHS Better Care,Better ValueIndicatorsBritish Association of Day Surgery www.bads.co.uk
  4. 4. NNUH rates vs. BADS targets Procedure NNUH day case BADS Target Top 5% rate day case rate Hospitals 2011 2011 Lap Chole 9%(2008) 60% 65% Bunions 45% (2011) 85% 88% Mastectomy 11% (2011) 30% 14%British Association of Day Surgery www.bads.co.uk
  5. 5. Bunions Consultant % day case % day case BADS Top 5% 2011 2012 target % A 67 B 25 C 33 D 100 E 20 Totals 45% 62% 85% 88%British Association of Day Surgery www.bads.co.uk
  6. 6. Barriers to Bunions • Scheduling on afternoon list • Physio gone home by time patients mobilising • Plaster room shut 5pm- they supply boots and crutches • Night staff on ward “don’t do discharges” • “Dinosaur Consultant” • Patient information leaflets out of dateBritish Association of Day Surgery www.bads.co.uk
  7. 7. Strategies • Multi-disciplinary bunion team • Updated information leaflets • Boots given out at pre-assessment • Crutches available on ward • Night staff trained in discharge process • Retirement of dinosaur, new, enlightened consultant appointed!British Association of Day Surgery www.bads.co.uk
  8. 8. Mastectomy rates Consultant No. No. in- % Day % Day BADS Top day patient case 2011 case 2012 target 5% cases s A 0 6 0% 15% 30% B 2 7 29% 27% 30% C 0 5 0% 33% 30% D 1 7 11% 29% 30% Totals 3 25 10% 26% 30% 14%British Association of Day Surgery www.bads.co.uk
  9. 9. Barriers to mastectomy day case • Pre conceptions of team • Major, cancer surgery, anxious patients, thought to prefer to be in hospital • Painful • Drains • Out of date patient information leaflets • Follow up for Friday dischargesBritish Association of Day Surgery www.bads.co.uk
  10. 10. Strategies • Multi-disciplinary team discussion re merits of hospital vs. home • Surgeons reviewed need for drains • Analgesia actually used on ward reviewed • Pain management at home information leaflet developed • Ward staff acted as contact point for Friday dischargesBritish Association of Day Surgery www.bads.co.uk
  11. 11. Lap cholecystectomy Consultant 2011 Day 2012 Day BADS Target Top 5% case % Case % A 75% (21) 94% B 25% (2) 100% C 81% (38) 88% D 40% (2) 100% E 50% (2) 100% F 74% (40) 71% Totals 71% (105) 81% 60% 65%British Association of Day Surgery www.bads.co.uk
  12. 12. Day Case lap cholecystectomy rates Day case rate 80 70 60 50 40 Day case rate 30 20 10 0 2008 2009 2010 2011British Association of Day Surgery www.bads.co.uk
  13. 13. Barriers to lap chole day cases • Booking process • Recorded as in-patient if not operated on in day unit, despite 0 length of stay • Belief that day cases could only be managed in the “Day Unit” • Scheduling after major cases, insufficient recovery time • InertiaBritish Association of Day Surgery www.bads.co.uk
  14. 14. Strategies for lap choles • Importance of intended management day case explained • Scheduling reviewed- lap–choles go first • Surgeons competitive tendency exploited!British Association of Day Surgery www.bads.co.uk
  15. 15. Common barriers • Preconceptions – Doctors, nurses, patients, carers • Booking issues • Organisational and scheduling issues • Lack of awareness of benefits • InertiaBritish Association of Day Surgery www.bads.co.uk
  16. 16. WHAT CAN YOU DO?British Association of Day Surgery www.bads.co.uk
  17. 17. Day case rates for selected procedures • Review day case rates for individual procedures • Use BADS directory to compare rates with targetsBritish Association of Day Surgery www.bads.co.uk
  18. 18. British Association of Day Surgery www.bads.co.uk
  19. 19. National Dataset • Data from CHKS • Outcomes for England 2011 • Top 5%,25% and 50% of hospitals by procedureBritish Association of Day Surgery www.bads.co.uk
  20. 20. British Association of Day Surgery www.bads.co.uk
  21. 21. How to access Better Care Better Value indicators • Web address: www.productivity.nhs.ukBritish Association of Day Surgery www.bads.co.uk
  22. 22. Select your organisationBritish Association of Day Surgery www.bads.co.uk
  23. 23. Summary for your organisation Click on indicator to drill downBritish Association of Day Surgery www.bads.co.uk
  24. 24. British Association of Day Surgery www.bads.co.uk
  25. 25. British Association of Day Surgery www.bads.co.uk
  26. 26. British Association of Day Surgery www.bads.co.uk
  27. 27. British Association of Day Surgery www.bads.co.uk
  28. 28. Strategies for change Post operative stay Yes: >1 day Yes: 1 day No D E Convert B Retain as proportion to day Easy win to Pre-operative stay Yes Inpatient but case but remove convert to remove pre- all pre-operative a day case operative stay stay C A F Convert Effectively No Retain as proportion to day already Inpatient case a day caseBritish Association of Day Surgery www.bads.co.uk
  29. 29. Specialty level example Summary Day Case Rates for Urology 2005/06 activity (2482 Elective IP Adms) 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% A B C D Current rate A + zero Inpatient B + pre-op stays C + 1 day post-op stays only stays Current DC rate Convert zero IP stays Convert Pre-op only stays Convert 75% 1 day post-op staysBritish Association of Day Surgery www.bads.co.uk
  30. 30. Estimate bed days savings Summary Bed days saved for Urology 2005/06 activity 2500 2000 1500 1000 500 0 A B C Convert Pre-op stays A + 1 day post-op stays B + remove pre-op stays only on all cases Convert Pre-op only stays Convert 75% 1 day post-op stays Remove pre-op stay for longer staysBritish Association of Day Surgery www.bads.co.uk
  31. 31. Top Tips for improving day case rates • Analyse rates by procedure and compare to BADS target and top 5% • Identify barriers specific for each specialty and procedure • Exploit surgeons competitiveness! • Keep improvingBritish Association of Day Surgery www.bads.co.uk

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