Aaron Shergis - Maroondah Hospital - TPOT: The Productive Operating Theatre

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Aaron Shergis delivered the presentation at the 2014 Operating Theatre Management Conference.

Focusing on strategies for implementing the National Safety and Quality Health Service Standards and the importance of communication to improve patient safety and clinical practice, the 2014 Operating Theatre Management Conference brought together operating room management and perioperative professionals to review current initiatives across the country.

For more information about the event, please visit: http://bit.ly/optheatremgmt14

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Aaron Shergis - Maroondah Hospital - TPOT: The Productive Operating Theatre

  1. 1. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards TPOT : The Productive Operating Theatre. Aaron Shergis
  2. 2. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Surgery 2015 Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards
  3. 3. 1.Preparation : Surgery 2015 Project. 2.Journey of TPOT for Eastern Health. 3.Theatre Dashboard : Developing useable data on efficiency, Safety and Patient experience. 4.How Data has changed us.
  4. 4. Eastern Health Box Hill 7 OT Maroondah 5 OT Angliss 3 OT Yarra Ranges 2 OT Healesville 1 OT Includes Endoscopy
  5. 5. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Background Surgery Services •Clinical Services – Site Based across all areas •Differing Medical Payment Models •Lack of organisational structure (All site based) •Efficiency issues Project Surgery 2015 Aims : 1.Create Eastern Health Clinical Streams -April 2012 2.Create Eastern Health structures and committees (unlock the Silos) April 2012. 3.Implement Standard medical Payment Model - Feb 13 - May 13 4.Theatre schedule reform. 5.Work through modules of The Productive Operating Theatre.
  6. 6. Cage Brawl
  7. 7. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health •Creation of EH clinical streams per Surgical Specialty. Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards Project Surgery 2015 Easter Health Unit director. Site based lead (Associate director) Staff Surgeons/Anaesthetists
  8. 8. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health •Align Eastern Health Project Surgery 2015 EH Surgery Program Director Site based APD (Associate Program Directors) Perioperative services managers Ward NUMS Admission/ward NUMS Theatre NUMS
  9. 9. Eastern Health Surgery aspires to provide excellent surgical care to patients by excellent staff in an efficient and frustration free environment. •Excellent surgical care means delivery of safe, high quality outcomes for patients from their surgical care that results in an excellent patient experience. •Efficient environment means decisions for care are based on clinical need and best use of available resources. •Excellent staff means supported and supportive teams created from the best people. •Frustration free environment means a motivated surgical team being able to deliver excellence of care.
  10. 10. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health •Creation of EH standard payment model Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards Project Surgery 2015 Sessional payment for in hour’s surgery. Sessional payments for in hours trauma (including emergency additions) FFS/RVG for out of hours surgery (for plastics and ortho) General Surgery Paid : On call/recall payment model for emergency surgery out of hours.
  11. 11. Surgery 2015 : Theatre Schedule Review. • Historical • Site Specific • Not based on capacity or demand • Cultural
  12. 12. Emergency Contact Hours Elective Contact Hours Elective O/N Beds Emergency O/N Beds ICU Hours Surgeon Contact Hours After Hours and Weekend Work Waiting List Data Same Day Admissions Multi Day Admissions Aspects to Consider for Template Build.
  13. 13. Session Allocation Principles •To maximise emergency surgery to within hours •To separate emergency from elective procedures •Ensure sessions are fully booked and usage of surgical beds is optimised. •Speciality and General sub-speciality elective lists will be identified and planned in consideration of existing resources i.e. radiology. Intensive care, to ensure optimal patient care and avoid clash of resources. •Endeavour to separate Same-Day from Multiday Elective & Emergency by specialty. •Best use of available resources required template build up from clean sheet – reference to existing occurred after clinical stream discussions
  14. 14. From this Speciality Aggregated Wide variation week to week
  15. 15. This – February 14
  16. 16. Angliss – Box Hill – Maroondah - Sites ESIS Reportable Decreased Variation Procedures Week
  17. 17. Angliss – Box Hill - Maroondah ESIS Reportable Week 0 100 200 300 400 500 600 700 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 2013 2014 MAR MAR Stabilisation of electives (Small dip in April for Easter.) No Cases.
  18. 18. Angliss – Box Hill - Maroondah ESIS Reportable Decreased Variation Increasing Contact Hours Contact Hours Week
  19. 19. Achievements Surgery 2015 •Network focused Organisational structure that allows for escalation, reporting and review. •Creation of Eastern Health task forces and committees to oversee the surgical service. •Fair and equitable payment models. •A theatre schedule built on Data that matched more closely our demand for theatre and our capacity. •Decreased variation in lists from day to day, week to week, making best use of available resources.
  20. 20. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards TPOT : The Productive Operating Theatre. •NHS : Institute for Innovation and Improvement : Productive series A modular improvement programme, co-produced with NHS organisations.  A systematic way to deliver significant improvements in safety, efficiency and patient care. A method of involving and enabling front line theatre teams to transform the way they work.
  21. 21. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards TPOT : Modules
  22. 22. Key areas of focus •Session Start-up. •Patient Preparation. •Consumables and Equipment. •Well Organised Theatre •Knowing how we are doing •Operational Status at a Glance.
  23. 23. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Confirmation of Theatre List Order - 120 mins -90 mins -70 mins -60 mins -50 mins -40 mins -30 mins -20 mins -10 mins Registration & Admission process commences. Anaesthetic review of all patients except 1st patient on each list 1st Patient on AM List On-Time Starts Patient transferred to anaesthetic room/theatre. Anaesthetic team begin anaesthetic interventions Surgical team arrive in Theatre Handover to the Surgical Team Time Out Fixed Point 1st Patient on PM List On-Time Starts 1st Patient of each list arrive in holding bay for anaesthetic review 13:30 08:30 Session Start-up.
  24. 24. Clerical Admission 5 minutes Nursing Admission 15 minutes HMO Anaesthetics Surg. Registrar Surgeon Theatre – Ring to say they are Ready Day of Surgery Patient Preparation.
  25. 25. Session start up improvements •1st patients for AM and PM lists are seen in theatre not admission ward. •Theatre order decided day before and not changed. • Surgical Admission done when waitlisted (Remove need for medical admission on Day) •Anaesthetic assessment done to check fit for surgery. •All 1st patients arrive to theatre at 0730 and no need for theatre to call (unless something out of ordinary) •Staggered start times for PM admissions. •Patient phone calls day prior to ensure patients are going to come and then are advised their arrival time and position on list (Main focal point of patient experience.)
  26. 26. Equipment and Consumables
  27. 27. Imprest Barcoded Items put away by Supply Can be direct entry from Company – may sit there for a few days before it is looked at. Ordered by Supply – but not barcoded or over load barcoded item One EFT from Supply Supply Entry Processes Inventory manager – 2 days a week
  28. 28. Quick wins.. Overstocking EH = $ 19000+ Stock isolated and returned or not re ordered until stock used. Stock spread through network. Stock consolidation : All items reviewed and many line items deleted, Par levels dropped according to 12 month use. Out of date stock removed (loss) = $5000 Process requiring NUM/APD/HOU sign off put in place for new or additional supplies required single time or ongoing. Network consolidation of inventory (Ports, Hernia Mesh, Laparoscopic equipment, orthopaedic Joints, consumables) (HOU and inventory coordinator lead)
  29. 29. Decrease in holding stock / returned overstock / product consolidation / Product changes to cheaper alternatives Saving = $194641 PA Ongoing 6 monthly/as required stock review put in place. Inventory coordinator across sites is now employed to monitor and review holding stock and find cheaper comparable alternatives.
  30. 30. HTRAK Real Time Data Acquisition, Prosthesis, Rebate, Coding and Prosthesis Costing System
  31. 31. Well Organised Theatre (WOT) Aim : •Increase patient touch time •Make the theatres look and feel better. •Make the work environment easier to work in. •Decrease mistakes and errors •Reduce risk. Sort Set Shine Standardise Sustain Apply 5S’s Principal ADUIT
  32. 32. •Video walks •Activity follows of Nurses  Support staff Anaesthetics Surgeons •Spaghetti diagrams •Waste walks
  33. 33. Nurse movement for Drugs New safes fitted
  34. 34. 100.0% 53.3% 5.0% 5.0% 1.7% 3.3% 31.7% 0.0% 0.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Total Motion Paperwork / Administration Discussion Other Pateint Care Pre Op Phase Intra Op Phase Post Op % of time Activity Waterfall Chart for Nurse Activity Follow
  35. 35. Evaluation of Change Team performance and staff wellbeing. Patients Experience and Outcomes. Value and Efficiency. Safety and reliability of care.
  36. 36. WOT : Everything now has a place and is easy to identify if/when something is missing.
  37. 37. Prosthesis/Loans Area Unsafe storage, Cant use box lifter in a corridor/Clutter Wall to be removed
  38. 38. New Prosthesis Area after Redesign Creation of Safe operating practice (With Work safe Victoria) and enforcement of minimum delivery standards for loan kits.
  39. 39. Measures for Success
  40. 40. Knowing how we are doing.. Developing useable data on Efficiency, Safety and Patient experience. •Deciding on what to display that is relevant to the team •Daily, Weekly, Monthly and Yearly measures. •Focus on measures that clearly show if we are getting better or worse. •Keep it simple. •Extract our own data for smaller improvement projects. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  41. 41. Weekly Start Time Report KHWAD : Efficiency Operation Date Theatre Spec Arrival at Theatre time Anaesthesia Start Time Surgery Start Time Delay Reason 25/07/2014 Fri 1 ORTH 7:35 8:10 8:28 2 SUR2 7:35 8:25 8:50 Surgeon Late Arriving 3 PLAS 7:40 8:10 8:40 4 SUR1 7:50 8:10 8:45 Surgeon Late Arriving DPA GAST 9:00 9:10 9:15 PACA PSY1 8:15 8:20 8:22 24/07/2014 Thu 1 SUR4 7:45 8:20 9:35 EQUIP/SUPPLIES NOT READY/AVAILABL 2 ORTH 7:50 8:00 8:30 3 PLAS 7:45 8:15 8:30 4 UROL 7:45 8:20 8:30 LIST ORDER CHANGED DPA AMM1 7:55 8:05 8:12 23/07/2014 Wed 1 ORTH 7:40 7:55 8:35 Surgeon Late Arriving 1 VASC 7:40 8:05 8:36 2 SUR3 7:55 8:20 8:42 COMPLEX ANAESTHETIC 3 PLAS 7:35 8:15 8:37 SURGEON UNAVAILABLE 4 SUR1 7:55 8:20 8:30 DPA GAST 8:20 8:30 8:36 PACA PSY1 8:07 8:10 8:14 22/07/2014 Tue 1 ORTH 7:45 8:05 8:50 EQUIP/SUPPLIES NOT READY/AVAILABL 2 SUR4 7:50 8:05 8:40 3 PLAS 7:30 8:05 8:30 LIST ORDER CHANGED 4 UROL 7:45 8:00 8:30 DPA RESP 9:35 9:45 9:50 21/07/2014 Mon 1 SUR3 8:05 8:20 8:25 2 SURC 7:50 8:10 8:36 2 SUR4 7:50 8:25 8:45 3 PLAS 7:40 8:10 8:30 DPA GAST 9:00 9:10 9:15
  42. 42. Like most Health Services our Start on Time Initiative is Hard Work with gradual improvement Small improvement to date New template
  43. 43. KHWAD : Maroondah Session – Delay Reasons
  44. 44. 28 Apr 14 to 04 May 14 05 May 14 to 11 May 14 12 May 14 to 18 May 14 19 May 14 to 25 May 14 26 May 14 to 01 Jun 14 02 Jun 14 to 08 Jun 14 09 Jun 14 to 15 Jun 14 16 Jun 14 to 22 Jun 14 23 Jun 14 to 29 Jun 14 30 Jun 14 to 06 Jul 14 Cases 59 55 55 55 49 61 57 60 54 58 Increase Elective Cases 47 45 46 44 42 49 50 49 49 46 Decrease Emergency Cases 12 10 9 11 7 12 7 11 5 12 Increase Total Surgery Time(hrs) 48.85 47.93 49.73 49.42 62.08 57.93 54.37 54.30 50.83 43.82 Decrease Average Surgery Time per Case 49.68 52.29 54.25 53.91 76.02 56.98 57.23 54.30 56.48 45.33 Decrease Number of Sessions Starting On Time 4 5 4 7 5 1 9 7 6 8 Increase Percentage of Sessions Starting On Time 20.0% 31.3% 20.0% 35.0% 26.3% 5.0% 45.0% 35.0% 30.0% 42.1% Increase Late Start Hours Lost 3.77 5.70 7.77 4.07 5.63 9.03 2.88 3.83 4.45 5.50 Increase Average Minutes Lost per Late Start 14.13 31.09 29.13 18.77 24.14 28.53 15.73 17.69 19.07 30.00 Increase Number of Sessions Starting > 15 Mins Late 7 7 10 6 8 13 4 7 9 6 Decrease KHWAD : Theatre AM weekly summary
  45. 45. KHWAD : Patient Experience Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Small Improvements in patient waiting time for surgery Notes: Time to first surgery is calculated from admission time to first anaesthetic time. Excluded records where no anaesthetic time has been entered.
  46. 46. KHWAD : Safety Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Gradual Improvement. We are seeing some reductions
  47. 47. KHWAD : Generating your own data : Small improvements Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health 15:36:00 16:48:00 18:00:00 19:12:00 20:24:00 21:36:00 1/04/2014 8/04/2014 15/04/2014 22/04/2014 29/04/2014 6/05/2014 13/05/2014 20/05/2014 27/05/2014 3/06/2014 10/06/2014 After Hours Start Time start time Linear (start time) 1830 Target Start time trend after hours is increasing to later at night.
  48. 48. How we use what the dash board is telling us? Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Measurement for diagnosis Measurement for judgement Measurement for improvement or Measurement for sustainability.
  49. 49. Critical Success Requirements •Executive level support •Aligned strategic direction. •Governance •Good measurements/ Correct Data •Maintaining momentum •Perseverance and resilience •Quick wins Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  50. 50. Key Success Factors to Date for EH •Data – in a form the clinicians understand •Craft group meetings. •Meetings with Clinical Leads •Support from Directors of Anaesthesia & Surgery •Weekly Session Meeting •Establish usable dashboards. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  51. 51. Future priorities of TPOT •Continue to develop the theatre dashboard. •Recovery module of TPOT •Handover and patient turnaround. •Ongoing schedule review •Implementation of brief and debrief in theatres under team-working modules. •Theatre behaviours. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  52. 52. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Eastern Health: Winner of the Premier’s Health Service of the Year Award (Metropolitan) at the 2013 Victorian Public Healthcare Awards Questions ?

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