Achieving national
elective surgery targets
(NEST) in Victoria
Professor Daryl Williams
Divisional director surgery, perio...
Talk overview
• 
• 
• 
• 
• 
• 
• 
• 
• 

NEST targets and categorisation
Referral, waitlists
Optimisation of patients
Str...
Talk overview
• 

NEST targets and categorisation

• 

Referral, waitlists
Optimisation of patients
Streaming and elective...
National Elective Surgery
Target
NEST is divided into two complementary
strategies:
  Part

1: Stepped improvement in the...
NEST Part 1
  By

2015 100% of patients waiting for elective
surgery will be treated within their clinical
recommended ti...
NEST Part 2
  By

2015 the average overdue wait time will
be zero days

Cat	
  

31	
  Dec	
  10	
   31	
  Dec	
  12	
  
...
Total numbers of additions &
removals from ES waitlist
Median wait time to surgery in
public hospitals 2010-11
Variation in clinical urgency
categorisation 2010/11
Australian data for hip
replacement
Australian admission data
Current categories for elective
surgery
Surgical	
  Category	
  

DescripBon	
   of	
  recommended	
  Bmeframes	
  

Categ...
National definitions for
categorisation
National Categorisation
Overarching principle
 

Patients who require an elective procedure are
assigned an urgency categ...
Multifaceted approach to meet
targets
Talk overview
• 

NEST targets and categorisation

• 

Referral, waitlists

• 

Optimisation of patients
Streaming and ele...
Referral Management
  Electronic
  Standardised
  Appropriate

for public hospitals
  Acceptance based on the capacity...
Waitlists
Talk overview
• 

NEST targets and categorisation
Referral, waitlists

• 

Optimisation of patients

• 

Streaming and ele...
Optimising Health
  General

preventative strategies

  Targeted

  Improved

initiatives
cardiorespiratory capacity
TKR and Pre-habilitation
• 

Pre-operative muscle exercise
program may improve outcome
– 

– 
– 

resistance training, fle...
Talk overview

• 

NEST targets and categorisation
Referral, waitlists
Optimisation of patients

• 

Streaming and electiv...
Emergency Surgery trends
Victoria
Surgical caseload 2008-2011
Who does emergency
surgery?
Elective – emergency mix
Outcomes of EGS model
 

Direct clinical effects
Decreased night time operating
  Reduced length of stay
  Decreased co...
RMH demand profile
70% can wait
longer than 8 hours
Emergency surgery demand &
supply
Timeliness of Emergency
Surgery
Talk overview
• 
• 
• 
• 

• 
• 
• 
• 
• 

NEST targets and categorisation
Referral, waitlists
Optimisation of patients
St...
Queues
Treat in turn
Scheduling using Patient
Flow Portals
Variation
Variation
Variation
Variation
Care Bundles and Enhanced
Recovery After Surgery (ERAS)

  Care

bundles are groupings of practice
processes that individ...
Colorectal ERAS
Orthopaedic Joint ERAS

Malviya	
  A.	
  Acta	
  Orthopedica	
  2011;	
  82:	
  577	
  
ERAS outcomes
 
 
 

Lowered LOS
Less complications
?Decreased Mortality
 

 

 
 
 

4500 consecutive joint
repla...
Checklists
  A

simple memory aid to ensure
processes of care are
completed

  Example

lives

safe surgery saves
Safe Surgery Checklist
• 

3 principles: "
 
 
 

 

Simplicity "
Wide applicability "
Measurability "

Process "
 
...
Results:
Death & Complications
Change in
Complications
High Income

Change in Death

10.3% -> 7.1%* 0.9% -> 0.6%

Low and ...
Talk overview

• 

NEST targets and categorisation
Referral, waitlists
Optimisation of patients
Streaming and elective/eme...
Perioperative patient flows
• 

Patient Streams
– 
– 
– 

• 

Stratification systems
– 
– 

• 

Day case versus multiday
H...
On the day
  Start

  3

Time Matrix

key constraints – theatres, PACU, beds

  Transparency
  Real

of processes and ...
Start time matrix
Start time matrix
Electronic Patient Calling
Systems
Wireless Patient Tracking
Electronic records & decision
support
  Traffic

light
filtering
systems
Parallel Processing
PACU block
Theatre View
Dashboards
Talk overview

• 

NEST targets and categorisation
Referral, waitlists
Optimisation of patients
Streaming and elective/eme...
Discharge Strategies
  Rigorous

discharge

planning
  Patient

Flow
Management Tool

  Criterion

based, nurse
initiat...
Talk overview

• 

NEST targets and categorisation
Referral, waitlists
Optimisation of patients
Streaming and elective/eme...
Balancing public and private
  Private

insurance
hospital cover
percentages
 

June 1999: 30.6%

of 30%
private health
...
Australian elective & emergency
surgeries in public and private

4.1% per annum increase in private
elective surgery
A decreasing queue
discourages private insurance
  If

waiting times are
diminished in public
then private rates may
decr...
Victorian patients waiting >365
days for surgery
Thank you
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 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

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

  1. 1. Achieving national elective surgery targets (NEST) in Victoria Professor Daryl Williams Divisional director surgery, perioperative, trauma & surgical oncology, Royal Melbourne Hospital
  2. 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. 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. 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$onal  Partnership  Agreement  (NPA)  on  Improving  Public  Hospital  Services,  pg  14  -­‐  26   hCp://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/npa-­‐improvingpublichospitals-­‐agreement  
  5. 5. NEST Part 1   By 2015 100% of patients waiting for elective surgery will be treated within their clinical recommended time. Time   Cat  1  Target   Cat  2  Target   Cat  3  Target   92.3%   86.6%   89.4%   By  Dec  2012   96%   90%   92%   By  Dec  2013   100%   93%   95%   By  Dec  2014   100%   97%   97%   By  Dec  2015   100%   100%   100%   Baseline  
  6. 6. NEST Part 2   By 2015 the average overdue wait time will be zero days Cat   31  Dec  10   31  Dec  12   (Baseline)   (Target)   31  Dec  13   31  Dec  14   31  Dec  15   (Target)   (Target)   (Target)   1   0  days   0  days   0  days   0  days   0  days   2   39  days   29  days   20  days   10  days   0  days   3   130  days   98  days   65  days   33  days   0  days  
  7. 7. Total numbers of additions & removals from ES waitlist
  8. 8. Median wait time to surgery in public hospitals 2010-11
  9. 9. Variation in clinical urgency categorisation 2010/11
  10. 10. Australian data for hip replacement
  11. 11. Australian admission data
  12. 12. Current categories for elective surgery Surgical  Category   DescripBon   of  recommended  Bmeframes   Category   1   admission  within  30  days  desirable  for  a  condi$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. 13. National definitions for categorisation
  14. 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. 15. Multifaceted approach to meet targets
  16. 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. 17. Referral Management   Electronic   Standardised   Appropriate for public hospitals   Acceptance based on the capacity to treat in a timely fashion
  18. 18. Waitlists
  19. 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. 20. Optimising Health   General preventative strategies   Targeted   Improved initiatives cardiorespiratory capacity
  21. 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. 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. 23. Emergency Surgery trends Victoria
  24. 24. Surgical caseload 2008-2011
  25. 25. Who does emergency surgery?
  26. 26. Elective – emergency mix
  27. 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. 28. RMH demand profile
  29. 29. 70% can wait longer than 8 hours
  30. 30. Emergency surgery demand & supply
  31. 31. Timeliness of Emergency Surgery
  32. 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. 33. Queues
  34. 34. Treat in turn
  35. 35. Scheduling using Patient Flow Portals
  36. 36. Variation
  37. 37. Variation
  38. 38. Variation
  39. 39. Variation
  40. 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. 41. Colorectal ERAS
  42. 42. Orthopaedic Joint ERAS Malviya  A.  Acta  Orthopedica  2011;  82:  577  
  43. 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. 44. Checklists   A simple memory aid to ensure processes of care are completed   Example lives safe surgery saves
  45. 45. Safe Surgery Checklist •  3 principles: "         Simplicity " Wide applicability " Measurability " Process "         literature review" consensus among experts" wide consultation" piloting and evaluation"
  46. 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. 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. 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. 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. 50. Start time matrix
  51. 51. Start time matrix
  52. 52. Electronic Patient Calling Systems
  53. 53. Wireless Patient Tracking
  54. 54. Electronic records & decision support
  55. 55.   Traffic light filtering systems
  56. 56. Parallel Processing
  57. 57. PACU block
  58. 58. Theatre View
  59. 59. Dashboards
  60. 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. 61. Discharge Strategies   Rigorous discharge planning   Patient Flow Management Tool   Criterion based, nurse initiated discharge
  62. 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. 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. 64. Australian elective & emergency surgeries in public and private 4.1% per annum increase in private elective surgery
  65. 65. A decreasing queue discourages private insurance   If waiting times are diminished in public then private rates may decrease Public Private Swingers
  66. 66. Victorian patients waiting >365 days for surgery
  67. 67. Thank you

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