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ELECTIVE SURGICAL
TARGETS
Audrey Ha
Auckland’s District Health Boards
Greater Auckland has a total population of 1.5 million people
and is divided into three ...
CMDHB Population
Population 490,000
Diverse ethnicity
– Maaori 17%
– Pacific 19%
– Asian 21%
– European 40%
Middlemore
CMDHB is divided into two major sites
Middlemore Hospital
• This is a major hospital and includes:
– 920 beds
–...
Middlemore Hospital
Manukau Health Park
• Manukau Health Park is 9km from Middlemore
• Manukau SuperClinic - opened in 1997
• Expanded with ad...
Manukau Health Park
Model of Care
• Dedicated elective facility
• Started with Manukau SuperClinic built in 1997 as an
Ambulatory Care facilit...
Manukau Surgery Centre
• Separation of elective service from acute service to protect
the elective service performance
• P...
Services Today
• 220,000 outpatient attendances in the past year
• 14,456 elective surgical cases in the past year
• Speci...
Achievements - Manukau Surgery Centre
• Purpose designed to support elective surgical patients
• 85% of CMDHB elective sur...
Achievements
• Innovative health delivery by the Manukau Surgery Centre
offers the opportunity to work in an elective envi...
Elective Surgery Targets
• A dedicated elective facility enabled CMDHB to meet the elective
targets set by the organisatio...
New Zealand Government Targets
From 2001 the aim has been to provide clarity, timeliness and
equity of care on a national ...
Targets met and then
– No patient waiting for FSA or treatment over 5 months by
30th June 2013
– No patient waiting for FS...
Achieving no one waiting over 6 months
• Target was not negotiable
• Financial penalty if not achieved
• Need for accurate...
Targets - Achieving 6 months
• All services needed to take responsibility
• Can not remove patients without seeing / treat...
Results
• All Services at CMDHB achieved no patient waiting over 6
months by 30th June 2012
• Services are now tracking we...
Case Study
Ophthalmology
• Issue - low number of cataract procedures on each theatre list
• Needed to increase number as o...
If Private can do it why can’t we?
Was it an equipment issue?
• Aging microscope
• Only five cataract sets
• 5 phaco hand ...
Would Equipment alone solve the
issue?
• Needed to understand how the private sector achieve their
throughput
• Set up a p...
Model of Care Comparison
MSC Private Provider
Reception 2 receptionists 4 receptionists
Pre-op Nurse allocated to block
ar...
MSC Private Provider
Theatre Pre-op checking
Computer entries
Very little paper work
No computer
Lens checked by surgeon
d...
MSC Private Provider
Lens Surgeon loads Nurse loads
Anaesthesia Different
Anaesthetist
depending on
roster
Same Anaestheti...
MSC Private Provider
SSU 0 dedicated
12 theatres working
multi specialty
1 dedicated tech for
cleaning, sterilising
& repa...
Recommendations for MSC
• Preop nurse to be dedicated to eye list so the theatre nurse
does not leave OR
• Theatre model t...
Request for Equipment
• New microscope
• 2 new Stryker beds
• New surgical stool
• Increase in cataract sets to 10
• 5 ext...
Outcome of redesign for Cataract lists
• It is standard to have 5 - 6 patients on all lists
• New equipment, customised pa...
Where are we now?
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2200
2400
Jul-
11
Au
g-
Se
p-
O
ct-
N
ov-
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ec-
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Ophthalmology - Managing the
volume
• Keep dedicated appointment slots for new patients - not used
for follow ups
• Look f...
Surgery Waiting List
0
150
300
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1050
Jul-
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Ophthalmology - Managing the volume
waiting for surgery
• Development of a procedure room in clinic
• 1992 procedures perf...
CONGRATULATIONS
Local MP visits CMDHB to recognise and congratulate the achievement
Next Challenge - Now working on
achieving 5 months
• Target of 5 months is non negotiable
• FSA
– constant monitoring
– St...
Future Challenges - Achieving the 4
month targets
• Target of 4 months is non negotiable
• 5 months will be achieved due t...
Points to Take Away
• You only need to go from good to better
• Find your natural leaders
• Education
• Reward good perfor...
Acknowledgements
• My team for staying at work while I present
• Kathie Smith - Service Manager for ORL, Ophthalmology &
A...
International CASE STUDY: Elective Surgery in New Zealand
International CASE STUDY: Elective Surgery in New Zealand
International CASE STUDY: Elective Surgery in New Zealand
International CASE STUDY: Elective Surgery in New Zealand
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International CASE STUDY: Elective Surgery in New Zealand

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Audrey Hauraki, Theatre Manager, from Manukau Surgery Centre delivered this presentation at the 2012 Elective Surgery Redesign Conference. For more information about our wide range of medical and health events covering a broad range of industry issues, please visit www.healthcareconferences.com.au

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Transcript of "International CASE STUDY: Elective Surgery in New Zealand"

  1. 1. ELECTIVE SURGICAL TARGETS Audrey Ha
  2. 2. Auckland’s District Health Boards Greater Auckland has a total population of 1.5 million people and is divided into three district health boards comprising four major hospitals. • Auckland City Hospital ( ADHB ) • North Shore Hospital and Waitakere City Hospital ( WDHB ) • Counties Manukau District Health Board ( CMDHB )
  3. 3. CMDHB Population Population 490,000 Diverse ethnicity – Maaori 17% – Pacific 19% – Asian 21% – European 40%
  4. 4. Middlemore CMDHB is divided into two major sites Middlemore Hospital • This is a major hospital and includes: – 920 beds – Emergency department - one of the busiest in Australasia – Department of Critical Care – Burns Unit - Regional & National service – Medicine, General Surgery, Orthopaedics, Plastic Surgery, Women’s Health wards – Children’s Hospital - Kidz First – Rehabilitation Unit - Healthcare of Older People – Maternity – Mental Health
  5. 5. Middlemore Hospital
  6. 6. Manukau Health Park • Manukau Health Park is 9km from Middlemore • Manukau SuperClinic - opened in 1997 • Expanded with additional modules in 2000 & 2009 – Now consists of 10 Modules with 114 clinic rooms and 15 procedure rooms • Manukau Surgery Centre – extended in 2001 and now – 74 beds – 4 HDU beds – 10 operating theatres – 2 procedure rooms – 40 chair dialysis unit
  7. 7. Manukau Health Park
  8. 8. Model of Care • Dedicated elective facility • Started with Manukau SuperClinic built in 1997 as an Ambulatory Care facility - transferring majority of outpatients and day surgery from the Middlemore campus • In the late 1990s the Government identified elective surgery as a priority with “Waiting Time” funding and Middlemore was at maximum capacity for theatres and beds • Decision to build Manukau Surgery Centre
  9. 9. Manukau Surgery Centre • Separation of elective service from acute service to protect the elective service performance • Phased approach to commissioning – October 2001 started as an overnight 5.5 day facility – July 2002 Orthopaedic Surgery all elective surgery except of spine and joint revisions – July 2003 General Surgery moved medium acuity cases – Confidence quickly developed and access was given to higher acuity cases – 2005 a second floor was fitted out to manage the volume
  10. 10. Services Today • 220,000 outpatient attendances in the past year • 14,456 elective surgical cases in the past year • Specialties include: – Orthopaedic Surgery - including joint revisions – General Surgery - including Bariatric, Oesophageal & Colorectal – Vascular - cases not requiring ICU – Renal - for tunnel lines – Plastic Surgery - including Breast Reconstruction – Hand and Upper Limb joint replacement – Gynaecology – Ophthalmology - including corneal transplants – ENT - including secondary Head & Neck and Thyroidectomy, Sialendoscopy – Urology - currently day cases with regional service (expanding to become CMDHB based service with inpatient beds)
  11. 11. Achievements - Manukau Surgery Centre • Purpose designed to support elective surgical patients • 85% of CMDHB elective surgery performed uninterrupted by acute services • General Surgery recognised the benefits for patient recovery and started a research programme on why patients recover faster when operated on at MSC • Staff are rostered separately for each site therefore elective surgery lists are not impacted on by the acute workload • Decreased length of stay
  12. 12. Achievements • Innovative health delivery by the Manukau Surgery Centre offers the opportunity to work in an elective environment in a public hospital setting • 38 additional elective beds plus a 4 bed HDU added to meet demand and increased acuity • Decreased complications • High level of patient satisfaction
  13. 13. Elective Surgery Targets • A dedicated elective facility enabled CMDHB to meet the elective targets set by the organisation and Government – Initially the targets were total contracted volumes (CWD) – Waiting lists were managed by highest score/longest waiting – Then in 2007 Government set volume targets for Total Joint replacements and Cataract surgery – Introduction of Government mandated Elective Surgery Targets – Then notification of a future target of no one waiting longer than 6 months – Target had to be achieved by 30th June 2012
  14. 14. New Zealand Government Targets From 2001 the aim has been to provide clarity, timeliness and equity of care on a national basis The current National Government set targets of: – No patient waiting over 6 months for First Specialist Assessment (FSA) by 30th June 2012 – No patient waiting over 6 months for treatment by 30th June 2012
  15. 15. Targets met and then – No patient waiting for FSA or treatment over 5 months by 30th June 2013 – No patient waiting for FSA or treatment over 4 months by 31st December 2014
  16. 16. Achieving no one waiting over 6 months • Target was not negotiable • Financial penalty if not achieved • Need for accurate waiting lists - housekeeping • Led to improved processes e.g. ensuring patients needing surgery were fit to proceed before being added to the waiting list • Led to improved customer service - need to negotiate appointments in a timely way
  17. 17. Targets - Achieving 6 months • All services needed to take responsibility • Can not remove patients without seeing / treating – once on the list service is committed to seeing that patient • Maximising the use of all available theatre lists • Outsourcing surgery to private providers (publicly funded)
  18. 18. Results • All Services at CMDHB achieved no patient waiting over 6 months by 30th June 2012 • Services are now tracking well to achieving the 5 month target by 30th June 2013 • Some services on target to achieve the 5 month target by 31st December 2012
  19. 19. Case Study Ophthalmology • Issue - low number of cataract procedures on each theatre list • Needed to increase number as only one Ophthalmology theatre available • To increase 06/07 internal production to achieve annual target of 1037 procedures set by Ministry 05/06 only achieved 855
  20. 20. If Private can do it why can’t we? Was it an equipment issue? • Aging microscope • Only five cataract sets • 5 phaco hand pieces • 3 operating beds • A stool with limited function Was it a staff issue? • Aging workforce • Skill mix
  21. 21. Would Equipment alone solve the issue? • Needed to understand how the private sector achieve their throughput • Set up a project for streamlining the Surgical Pathway Objective: • To observe the differences between a private provider and compare to Manukau Surgery Centre processes
  22. 22. Model of Care Comparison MSC Private Provider Reception 2 receptionists 4 receptionists Pre-op Nurse allocated to block area May help in pre-op Distance between pre-op and theatre Special room for theatre check and eye drops Pre-op wait opposite the theatre Theatre 2 RNs & HCA ORL/Ophthalmology 3-4 RNs experienced in ophthalmic surgery
  23. 23. MSC Private Provider Theatre Pre-op checking Computer entries Very little paper work No computer Lens checked by surgeon day before Microscope Mobile Nurses set up Ceiling mounted and surgeons helps set up Session 8.30 -12 1.30 - 5 8-12/until list finishes 1-5/until the list finishes
  24. 24. MSC Private Provider Lens Surgeon loads Nurse loads Anaesthesia Different Anaesthetist depending on roster Same Anaesthetist every week Helped with positioning, monitoring set up Post Op Theatre nurse takes patient to second stage Nurse comes into theatre to collect patient
  25. 25. MSC Private Provider SSU 0 dedicated 12 theatres working multi specialty 1 dedicated tech for cleaning, sterilising & repacking
  26. 26. Recommendations for MSC • Preop nurse to be dedicated to eye list so the theatre nurse does not leave OR • Theatre model to be 3 RNs & 1 HCA • Anaesthetists to be encouraged to be part of team to streamline flow • 2 RNS allocated to 2nd stage to manage volume - allows the theatre nurse to handover
  27. 27. Request for Equipment • New microscope • 2 new Stryker beds • New surgical stool • Increase in cataract sets to 10 • 5 extra phaco hand pieces • Development of customised procedure pack • Introduction of Ozil technology
  28. 28. Outcome of redesign for Cataract lists • It is standard to have 5 - 6 patients on all lists • New equipment, customised packs and increased instruments have all helped to improve throughput • Staffing model of dedicated preop staff, 3 RNs & HCA in theatre and 2 RNs in 2nd stage has improved the work flow • Stable workforce • A purpose built Ophthalmology suite would give additional gains
  29. 29. Where are we now? 0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200 2400 Jul- 11 Au g- Se p- O ct- N ov- D ec- J an- F eb- Ma r- A pr- Ma y- J un- Month Seen Removed Other Return to GP TOWL Waiting > 3 months Waiting > 5 months Waiting > 6 months Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
  30. 30. Ophthalmology - Managing the volume • Keep dedicated appointment slots for new patients - not used for follow ups • Look for alternative clinics to free up SMOs – Technician led stable post Avastin – Technician led Anterior Segment photo clinic – Nurse led post op Cataract clinic – Stable Glaucoma clinics • Saturday clinics • Recruitment
  31. 31. Surgery Waiting List 0 150 300 450 600 750 900 1050 Jul- 11 Au g- Se p- O ct- N ov- D ec- J an- F eb- Ma r- A pr- Ma y- J un- Month Treated Removed Other TOWL Waiting > 3 months Waiting > 6 months Waiting > 5 months Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
  32. 32. Ophthalmology - Managing the volume waiting for surgery • Development of a procedure room in clinic • 1992 procedures performed 2011/12 that used to be done in theatre • Maximising the available theatre lists - 5-6 cataract on each list • Flexible rostering for lists covering leave • Reducing cancellations and DNA on day of surgery • Outsourcing – 600 Cataract patients outsourced 2011/12 year
  33. 33. CONGRATULATIONS Local MP visits CMDHB to recognise and congratulate the achievement
  34. 34. Next Challenge - Now working on achieving 5 months • Target of 5 months is non negotiable • FSA – constant monitoring – Still working on sustainability of 6 months – Saturday custom clinics as required – outsourcing to private sector 100 FSA for Occular Plastic • Surgery – Streamlining preadmission processes – Very close to achieving this target – Still outsourcing 600 Cataract procedures
  35. 35. Future Challenges - Achieving the 4 month targets • Target of 4 months is non negotiable • 5 months will be achieved due to additional clinics and theatre lists • Achieving 4 months needs a new way of managing patients across the continuum – Teamwork at scheduling meetings to maximise theatre use – Currently looking at treatment pathways – Discharge from follow up clinics – What can be managed in the community – Alternative workforce roles
  36. 36. Points to Take Away • You only need to go from good to better • Find your natural leaders • Education • Reward good performance • Ignore dinosaurs
  37. 37. Acknowledgements • My team for staying at work while I present • Kathie Smith - Service Manager for ORL, Ophthalmology & Audiology, MSC Operational Manager • Catherine Larsen - Service Manager of Theatres • Sue Shipperlee - Elective Services Manager • Photographic Department CMDHB • Conference Organising Committee
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