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Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria
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Daryl Williams, Melbourne Health: Achieving National Elective Surgery Target in Victoria

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Dr Daryl Williams, Director – Department of Anaesthesia & Pain Management, Melbourne Health delivered this presentation at the 2013 Elective Surgery Redesign Conference. The National Conference …

Dr Daryl Williams, Director – Department of Anaesthesia & Pain Management, Melbourne Health delivered this presentation at the 2013 Elective Surgery Redesign Conference. The National Conference focussed solely on assisting Australian Hospitals to meet the National Elective Surgery Target, including:
Streamlining Surgical Pathways
Improving Access & Patient Experience
Reducing Waiting Times
Incorporating Latest Technological Innovations
For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/electivesurgery

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  • 1. Achieving national elective surgery targets (NEST) in Victoria Professor Daryl Williams Divisional director surgery, perioperative, trauma & surgical oncology, Royal Melbourne Hospital
  • 2. Talk overview •  •  •  •  •  •  •  •  •  NEST targets and categorisation Referral, waitlists Optimisation of patients Streaming and elective/emergency mix Models of care Scheduling and queuing theory Optimal theatre efficiency Discharge planning Future trends
  • 3. Talk overview •  NEST targets and categorisation •  Referral, waitlists Optimisation of patients Streaming and elective/emergency mix Models of care Scheduling and queuing theory Optimal theatre efficiency Discharge planning Future trends •  •  •  •  •  •  • 
  • 4. National Elective Surgery Target NEST is divided into two complementary strategies:   Part 1: Stepped improvement in the number of patients treated within the clinically recommended time.   Part 2: A progressive reduction in the number of patients who are overdue for surgery beyond the clinically recommended time. *Na$onal  Partnership  Agreement  (NPA)  on  Improving  Public  Hospital  Services,  pg  14  -­‐  26   hCp://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/npa-­‐improvingpublichospitals-­‐agreement  
  • 5. NEST Part 1   By 2015 100% of patients waiting for elective surgery will be treated within their clinical recommended time. Time   Cat  1  Target   Cat  2  Target   Cat  3  Target   92.3%   86.6%   89.4%   By  Dec  2012   96%   90%   92%   By  Dec  2013   100%   93%   95%   By  Dec  2014   100%   97%   97%   By  Dec  2015   100%   100%   100%   Baseline  
  • 6. NEST Part 2   By 2015 the average overdue wait time will be zero days Cat   31  Dec  10   31  Dec  12   (Baseline)   (Target)   31  Dec  13   31  Dec  14   31  Dec  15   (Target)   (Target)   (Target)   1   0  days   0  days   0  days   0  days   0  days   2   39  days   29  days   20  days   10  days   0  days   3   130  days   98  days   65  days   33  days   0  days  
  • 7. Total numbers of additions & removals from ES waitlist
  • 8. Median wait time to surgery in public hospitals 2010-11
  • 9. Variation in clinical urgency categorisation 2010/11
  • 10. Australian data for hip replacement
  • 11. Australian admission data
  • 12. Current categories for elective surgery Surgical  Category   DescripBon   of  recommended  Bmeframes   Category   1   admission  within  30  days  desirable  for  a  condi$on  that   has   the  poten$al   to   deteriorate   quickly  to  the  point  that  it  may  become  an  emergency   admission  within  90  days   desirable  for  a  condi$on  causing  some  pain,  dysfunc$on   or   disability  but  which  is  not   likely  to  deteriorate  quickly  or  become  an  emergency   Category   2   Category   3   admission  at  some  $me  in  the  future  acceptable  for  a  condi$on  causing  minimal   or  no   pain,  dysfunc$on  or  disability,  which  is  unlikely  to  deteriorate  quickly  and  which   does  not   have  the  poten$al  to  become  an  emergency.   Na#onal  Benchmarks.  Urgency  with  which  the  pa$ent  requires  elec$ve  hospital  care/surgery   Source:  The  Australian  Ins$tute  of  Health  and  Welfare  (AIHW)  (2008)  Na$onal  Health  Data  Dic$onary  no.  14,  
  • 13. National definitions for categorisation
  • 14. National Categorisation Overarching principle   Patients who require an elective procedure are assigned an urgency category by the treating clinician     Appropriate to patient and their clinical condition Not influenced by availability of hospital/doctors
  • 15. Multifaceted approach to meet targets
  • 16. Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients Streaming and elective/emergency mix Models of care Scheduling and queuing theory Optimal theatre efficiency Discharge planning Future trends •  •  •  •  •  • 
  • 17. Referral Management   Electronic   Standardised   Appropriate for public hospitals   Acceptance based on the capacity to treat in a timely fashion
  • 18. Waitlists
  • 19. Talk overview •  NEST targets and categorisation Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix Models of care Scheduling and queuing theory Optimal theatre efficiency Discharge planning Future trends •  •  •  •  •  • 
  • 20. Optimising Health   General preventative strategies   Targeted   Improved initiatives cardiorespiratory capacity
  • 21. TKR and Pre-habilitation •  Pre-operative muscle exercise program may improve outcome –  –  –  resistance training, flexibility, step training 3x week, 8 weeks improved strength, functional outcomes at 1 and 3 months »  Swank A. J Strength Cond Res 2011; 25: 318
  • 22. Talk overview •  NEST targets and categorisation Referral, waitlists Optimisation of patients •  Streaming and elective/emergency mix •  Models of care Scheduling and queuing theory Optimal theatre efficiency Discharge planning Future trends •  •  •  •  •  • 
  • 23. Emergency Surgery trends Victoria
  • 24. Surgical caseload 2008-2011
  • 25. Who does emergency surgery?
  • 26. Elective – emergency mix
  • 27. Outcomes of EGS model   Direct clinical effects Decreased night time operating   Reduced length of stay   Decreased complication rates   Lower return to theatre rates     Staff Improved satisfaction of surgeons   Improved training of registrars     Electives Lower elective surgery cancellation rates   Maintenance of elective surgery numbers     Cost neutral
  • 28. RMH demand profile
  • 29. 70% can wait longer than 8 hours
  • 30. Emergency surgery demand & supply
  • 31. Timeliness of Emergency Surgery
  • 32. Talk overview •  •  •  •  •  •  •  •  •  NEST targets and categorisation Referral, waitlists Optimisation of patients Streaming and elective/emergency mix Models of care Scheduling and queuing theory Optimal theatre efficiency Discharge planning Future trends
  • 33. Queues
  • 34. Treat in turn
  • 35. Scheduling using Patient Flow Portals
  • 36. Variation
  • 37. Variation
  • 38. Variation
  • 39. Variation
  • 40. Care Bundles and Enhanced Recovery After Surgery (ERAS)   Care bundles are groupings of practice processes that individually improve care, but when applied together result in a substantially greater improvement.
  • 41. Colorectal ERAS
  • 42. Orthopaedic Joint ERAS Malviya  A.  Acta  Orthopedica  2011;  82:  577  
  • 43. ERAS outcomes       Lowered LOS Less complications ?Decreased Mortality           4500 consecutive joint replacements reduced 90 day mortality: 0.8% to 0.2% reduced LOS: mean 6 to 3 days less transfusion: 23% to 10% less complications   Malviya A. Acta Orthopedica 2011; 82: 577
  • 44. Checklists   A simple memory aid to ensure processes of care are completed   Example lives safe surgery saves
  • 45. Safe Surgery Checklist •  3 principles: "         Simplicity " Wide applicability " Measurability " Process "         literature review" consensus among experts" wide consultation" piloting and evaluation"
  • 46. Results: Death & Complications Change in Complications High Income Change in Death 10.3% -> 7.1%* 0.9% -> 0.6% Low and Middle 11.7% -> 6.8%* 2.1% -> 1.0%* Income Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360:491-9. (2009) * p<0.05
  • 47. Talk overview •  NEST targets and categorisation Referral, waitlists Optimisation of patients Streaming and elective/emergency mix Models of care Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning Future trends •  •  •  •  •  • 
  • 48. Perioperative patient flows •  Patient Streams –  –  –  •  Stratification systems –  –  •  Day case versus multiday Hubs of specialisation Flexible environments Suitability for pathways Perioperative Risk Stratification Efficiency Benchmarking –  Real time tracking
  • 49. On the day   Start   3 Time Matrix key constraints – theatres, PACU, beds   Transparency   Real of processes and flow time tracking of patients with automated alerts   ERAS, standardised pathways and bundles
  • 50. Start time matrix
  • 51. Start time matrix
  • 52. Electronic Patient Calling Systems
  • 53. Wireless Patient Tracking
  • 54. Electronic records & decision support
  • 55.   Traffic light filtering systems
  • 56. Parallel Processing
  • 57. PACU block
  • 58. Theatre View
  • 59. Dashboards
  • 60. Talk overview •  NEST targets and categorisation Referral, waitlists Optimisation of patients Streaming and elective/emergency mix Models of care Scheduling and queuing theory Optimal theatre efficiency •  Discharge planning •  Future trends •  •  •  •  •  • 
  • 61. Discharge Strategies   Rigorous discharge planning   Patient Flow Management Tool   Criterion based, nurse initiated discharge
  • 62. Talk overview •  NEST targets and categorisation Referral, waitlists Optimisation of patients Streaming and elective/emergency mix Models of care Scheduling and queuing theory Optimal theatre efficiency Discharge planning •  Future trends •  •  •  •  •  •  • 
  • 63. Balancing public and private   Private insurance hospital cover percentages   June 1999: 30.6% of 30% private health insurance rebate Private Public   Introduction   June 2011: 45.3% Swingers
  • 64. Australian elective & emergency surgeries in public and private 4.1% per annum increase in private elective surgery
  • 65. A decreasing queue discourages private insurance   If waiting times are diminished in public then private rates may decrease Public Private Swingers
  • 66. Victorian patients waiting >365 days for surgery
  • 67. Thank you

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