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.

1. The challenge of day case
surgery
Dr Anna Lipp
Lead for Day Surgery, Norfolk and Norwich University Hospital
President-elect British Association Day Surgery
Mike Davidge
Head of Measurement, NHS Institute for Innovation and Improvement
Responsible for Better Care, Better Value indicators
British Association of Day Surgery www.bads.co.uk

2. Outline
• Identifying day surgery challenges locally
• Case studies in different surgical
specialties
– Orthopaedics
– General surgery
– Breast surgery
• What you can do
• Recommendations
British Association of Day Surgery www.bads.co.uk

3. Do we have a problem with day
surgery rates at NNUH ?
NHS Better Care,
Better Value
Indicators
British Association of Day Surgery www.bads.co.uk

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. 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. 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• Patient information leaflets out of date
British Association of Day Surgery www.bads.co.uk

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. 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. 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 discharges
British Association of Day Surgery www.bads.co.uk

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 discharges
British Association of Day Surgery www.bads.co.uk

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. Day Case lap cholecystectomy
rates
Day case rate
80
70
60
50
40
Day case rate
30
20
10
0
2008 2009 2010 2011
British Association of Day Surgery www.bads.co.uk

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
• Inertia
British Association of Day Surgery www.bads.co.uk

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. Common barriers
• Preconceptions
– Doctors, nurses, patients, carers
• Booking issues
• Organisational and scheduling issues
• Lack of awareness of benefits
• Inertia
British Association of Day Surgery www.bads.co.uk

16. WHAT CAN YOU DO?
British Association of Day Surgery www.bads.co.uk

17. Day case rates for selected
procedures
• Review day case
rates for individual
procedures
• Use BADS directory
to compare rates
with targets
British Association of Day Surgery www.bads.co.uk

18. British Association of Day Surgery www.bads.co.uk

19. National Dataset
• Data from CHKS
• Outcomes for
England 2011
• Top 5%,25% and
50% of hospitals by
procedure
British Association of Day Surgery www.bads.co.uk

20. British Association of Day Surgery www.bads.co.uk

21. How to access Better Care
Better Value indicators
• Web address:
www.productivity.nhs.uk
British Association of Day Surgery www.bads.co.uk

22. Select your
organisation
British Association of Day Surgery www.bads.co.uk

23. Summary for your organisation
Click on indicator to drill down
British Association of Day Surgery www.bads.co.uk

24. British Association of Day Surgery www.bads.co.uk

25. British Association of Day Surgery www.bads.co.uk

26. British Association of Day Surgery www.bads.co.uk

27. British Association of Day Surgery www.bads.co.uk

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 case
British Association of Day Surgery www.bads.co.uk

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 stays
British Association of Day Surgery www.bads.co.uk

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 stays
British Association of Day Surgery www.bads.co.uk

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 improving
British Association of Day Surgery www.bads.co.uk