ascom roundtable report 1 - theatre utilisation...roundtable attendees felt that, while bed capacity...

Roundtable report 1

Theatre utilisation: The role technology can play in improving efficiency and maximising income

Ascom is a leading provider of mobile workflow and communication systems working with NHS trusts. It convened a roundtable to discuss theatre efficiency and the role that technology can play in improving efficiency and maximising income. This report was written following the roundtable event held in London chaired by Mike Farrar. Ascom would like to thank the following for their participation:

Andrew Reed, Chief Executive, Royal College of Surgeons of EnglandDawn Stott, Chief Executive, Association of Perioperative PracticeHelgi Johannsson, Consultant Anaesthetist/Clinical Director, Imperial College NHS Foundation TrustLesley Jordan, Consultant Anaesthetist, Royal United Hospitals Bath Foundation TrustMarie Nixon, Clinical Quality Advisor, Royal College of AnaesthetistsMatt Sykes, Transformation Lead, Theatres/Endoscopy, Chase Farm Hospital, Royal Free London NHS Foundation Trust Steven Spoerry, Adviser, NHS Improvement, Local Government Association

About this report

Tuesday 26th June 2018

2 ROUNDTABLE REPORT: THEATRE UTILISATION

Challenges facing NHS trusts in relation to theatre efficiencyThe need to improve theatre efficiency is well understood, not only because of the positive impact on patient experience and better working environment for staff, but ultimately because it enables trusts to use their resources more effectively and maximise income. For some trusts, theatre efficiency is not top priority when they are firefighting - with over-crowded A&E departments and ambulances parked unable to hand over their patients. There are also numerous barriers to improving theatre efficiency. These are internal as well as external and vary significantly from trust to trust.

When it comes to elective procedures, demand outweighs capacity. The NHS target is for 92 per cent of patients on incomplete referral to treatment (RTT) pathways to be seen within 18 weeks from the time of referral. Figures for March 2018 showed that only 87.2 per cent of patients were being seen in this time. The number of patients waiting to start treatment at the end of March 2018 was 3.84 million and this demand shows no signs of slowingi. A significant cash injection for the NHS comes with an expectation that waiting times will improve, but observers have warned this won’t be achieved if current inefficiencies prevail.

Structure and logisticsOne factor to consider when looking to improve theatre efficiency is patient flow, and theatres face several logistical challenges that impair this. The proximity of the admissions lounge to the theatre is important. Surgeons won’t use up valuable time visiting their next few patients and are also unlikely to be late for surgery if the distances are short - but this is often not the case. Long distances between theatre and recovery and the ergonomic design of the theatre suite can also have a big impact on the flow of patients.

Only 87.2% patients seen within 18 weeks

on waiting listsii

Over

4 millionpatients

ROUNDTABLE REPORT: THEATRE UTILISATION 3

Delays and cancellations

Delays and cancellations also affect patient flow. These can be caused by a lack of capacity, procedures overrunning, or emergency cases taking priority. Some delays and cancellations can be the result of surgeons not attending the team briefing at the start of the day, which may later cause disruption if they wish to make changes to the agreed schedule.

Feedback from the Association of Perioperative Practice members indicated they felt late start times were one of the leading barriers to more efficient use of theatres, causing surgery cancellations and staff to work overtime.

A lack of engagement from surgeons until the pre-operative assessment can lead to last-minute cancellations if they disagree with the suitability of the procedure. This causes undue stress to the patient who has prepared themselves for an operation as well as being an inefficient use of staff time.

Lack of capacity in admissions and recovery can cause congestion, which not only causes delays but often leads to a bad patient experience. This lack of space also creates a stressful working environment for staff.

Roundtable attendees felt that, while bed capacity was an issue, the way available beds are utilised could be improved. Dawn Stott, Chief Executive of the Association of Perioperative Practice, said: “Currently, the communication about the availability of beds is not good enough.” Members of the association believe that delays to patient discharge are also to blame for bed availability problems.

Late start times were one of the

leading barriers to more efficient use of

theatres.

“Currently, the communication about the availability of beds is not good enough.”

Patient pathways

The emergency pathway is undoubtedly a source of inefficiency because it is largely unpredictable and hence difficult to plan for. It is costly when elective surgeries are cancelled as a result of emergency procedures - not only because elective surgery generates more income for trusts but also because it takes up valuable time to visit patients and reschedule, while also causing patients undue stress and inconvenience.

Surgical procedures overrunning is sometimes unavoidable, but the consequences of this happening are exacerbated by mixing day cases and inpatient cases on theatre lists. Inpatient surgery is more complex and more likely to overrun, which may cause the cancellation of day surgery cases and undermines their efficiency. On the other hand, mixing the lists means that small day cases can fill in any small gaps that inpatient cases leave.


Executive support

Engagement with theatre processes at board level needs to increase. This largely stems from inaccurate output data, which does not give a clear indication of how the theatre is running. Good results are often achieved by staff being accustomed to the many inefficiencies and working around them, so the data does not paint a complete

picture of process. It is, therefore, hard to get approval for changes when the board only sees the end result. The technology to capture the types of data needed does exist within some hospitals, but it is not consistent across the UK. When each trust is recording and measuring performance differently, it makes parity of care hard to achieve.

These inefficiencies can also have a psychological effect on staff mentality, often becoming an excuse for not dealing with problems that could be solved. Cancellations and last-minute changes to lists can make clinical staff feel disengaged with the planning process and discourage them from signing off lists ahead of time.

Cancellations and last-minute changes

to lists can make clinical staff feel

disengaged


Theatre efficiency today

33% operating lists

start 30 mins late 38% operating lists

finish 30 mins early

More than 111,000 operating lists finish

60 mins early or more

This wastes precious time that could be spent on patients waiting for surgery

Over 4 million people waiting for elective surgery

By using this time more efficiently surgeons could do up to

291,327 more operations

Reducing waiting lists

making theatres more

efficientimproving

patient satisfaction

iii


Helgi Johannsson, Consultant Anaesthetist/Clinical Director at Imperial College NHS Foundation Trust, said good logistics at one of the trust’s hospitals facilitates efficient working: “You need to ensure that the patients you are expecting into theatre are somewhere near the theatre. At St Mary’s Hospital it works really well – it’s a 30-second walk from the admissions lounge to the anaesthetic rooms, and so it’s very easy to visit the next patient.”

Johannsson said they have also worked to improve efficiency through “mandate attendance of the consultant surgeon at the team briefing at the start of the day”, which means the team’s schedule is decided collectively and therefore less likely to be changed.

Matt Sykes, Transformation Lead for theatres/endoscopy at Chase Farm Hospital, Royal Free London NHS Foundation Trust, said when it comes to theatre scheduling he is an advocate of the 6-4-2 system: “At my last trust, we implemented a weekly activity meeting using the 6-4-2 rule, so we would have

everyone in the room when we were planning the next six weeks. At week six we would find out all the annual leave for surgeons and anaesthetists, and their uncovered sessions would be offered to other consultants. At week four and week two, any inactive lists are reviewed, and if by week two no-one can cover the list then the session doesn’t go ahead. This allows admissions to book the lists in advance and lessens the chance of cancellations on the day.”

Theatres are most efficient when staff can plan effectively. Having access to data that can help predict non-elective patient flow would be a huge asset when it comes to allocating theatre space and bed usage. Set processes for emergency pathways would reduce variability, also making it easier to plan for.

Planning only goes so far, though, and hospital care often requires staff to adapt to new situations as they happen. Having real-time information available would give staff an overview

of available resources, such as theatre equipment or beds, and enable them to make immediate changes without having to physically look, saving valuable time.

Former NHS Confederation Chief Executive Mike Farrar, who chaired the roundtable, cited the tracking system used by Sharp Healthcare in San Diego as an example of technology improving efficiency, with “real-time information identifying the bed availability and guiding patients through the organisation”.

From a broader perspective, engaging hospital boards with processes at a more in-depth level would help to drive change needed to improve efficiency. Investment in new technology, for example, is more likely to happen if senior leaders are given an accurate overview of how it will benefit the hospital as a whole.

What does good look like?

Good theatre efficiency means a smooth working day for staff and a good experience for patients, with minimal delays or time wasted.

“Theatres are most efficient when staff can plan effectively.”


The utopian vision

When a patient is booked on the EPR system for an operation, they fill in all their details including comorbidities and that information is automatically populated into the pre-assessment data set.

The scheduler then drags and drops this patient onto a theatre list. This won’t work if the surgeon that needs to do this particular operation is on annual leave as the system registers this information.

The surgery details are fed into the theatre management software, with all the pre-assessment information available to the anaesthetist who can review this on their tablet at home the day before to ensure they know who they are dealing with.

The length of stay expectation post-operation is built into the system based on the type of operation, difficulty level and the fact that there were no complications.

This information is then fed into the secondary care discharge planning and the place is kept available in secondary care.


Consultant Anaesthetist Lesley Jordan said Royal United Hospitals Bath Foundation Trust were using a paper-based traffic light system to inform emergency theatre use with the aim of improving flow and reducing delays. “We use a RAG system depending on the number of hours booked in each theatre, where less than six hours is green, six to 12 is amber and more than 12 is red. When you reach amber, the idea is that you will try to get surgery done in other theatres to avoid moving into red. At the moment it’s a paper system, with staff calculating as they go along, and it’s often inaccurate.”

“Live, visible data of theatre usage would be really valuable, and would enable an electronic traffic-light system that could flag up when a theatre approaches amber.”

Data was consistently cited as a valuable asset. Better planning would be facilitated by having more analytical information available, such as the average time different surgeons take to complete procedures or the average recovery time for each operation, which can be taken into account when scheduling theatre time and discharge planning. Data can also help

hospitals plan for the likely patient flow, which would then enable logistical management to factor in bed base and theatre slots, and use limited resources more effectively.

One roundtable attendee said that, in order to really improve theatre efficiency, data capture needs to be more detailed. “What seems to be missing when we talk about data is granular capture – we need that interoperative information. The time of the first incision, any complications that occur, any extra materials used, we need that to ascertain whether delays in procedures are in any way predictable. Are we seeing patterns in certain types of patient or certain surgical teams being delayed more often? Do we need to change the standard ops kit for a particular surgery? We can use that interoperative data to inform best practice. We have retrospective data, but we need that detail to really understand what’s going on.”

More detailed data sets would also facilitate a business investment case for change that can illustrate to boards where the areas for improvement are and where additional resources would bring the most value.

Cultural change is also an important factor in making theatres more efficient and can happen universally at every trust. This involves challenging the current mentality of tolerating inefficiency and instead engaging clinical teams in making theatres more efficient.

Real efficiency needs to take into account all the staff involved. Increased communication and information exchange between each stage of the perioperative process could have a positive impact on patient flow, making staff aware of any circumstances outside their sphere that may affect them. Similarly, patient information needs to be shared across the entire pathway, from GP to pre-operative assessment to discharge.

Marie Nixon, Clinical Quality Advisor at the Royal College of Anaesthetists, said: “We need to stand back and look at the total pathway, starting with the GP referral. This has the biggest potential for affecting efficiency. If we had all the information we need when the patient is referred – blood results for example – we could optimise the process.”

How do we get there?

A range of different ideas of how to improve theatre efficiency was presented during the roundtable discussion, but with some clear themes arising throughout.

Increased communication and

information exchange between each stage of the perioperative process could have a positive impact on

patient flow


One method of gathering data is patient wristband scanning, which has already been shown to work well. Staff scan the patient’s wristband at various perioperative stages and doing this provides accurate timings for the whole patient pathway. These kinds of data sets would also show patterns of disruption, such as which teams or procedures are most often delayed, allowing for surgery list co-ordinators to schedule more proactively.

While geographical factors are difficult to alter, logistical data could help to mitigate these. Knowing exactly how long it takes to get patients from admissions to the anaesthetist, for example, could enable staff to keep on schedule and minimise turnover time.

Access to information about surgical operations in real time would be highly valuable, particularly with regards to bed availability and visibility of capacity across different theatres. Lack of bed capacity could be mitigated to some extent by being able to view live availability of beds within the hospital, enabling staff to be dynamic and proactive, and ensuring that beds are made available for post-operative patients. Visibility of theatre activity as it happens would also be useful, making real-time reaction possible and optimising theatre capacity.

When used retrospectively, data can inform best practice. Interoperative data could reveal whether delays are predictable for certain teams or procedures and could mean that delays and mistakes are avoided in the future.

Data could also reveal patterns in the emergency pathway that would allow schedulers to plan for a likely spike in these types of procedures.

Using analytical data in ways that makes it meaningful to staff is also important. League tables in breakout rooms have been introduced at one trust, making surgeons aware of how many procedures they are completing and how much revenue they are generating. This overview of performance encourages them to view their work within the wider landscape of the hospital and motivates them to help with efficiency.

Increased access to patient data on a single system that covers the whole perioperative process is also needed to improve theatre efficiency. Immediate access to patients’ bloodwork, for example, would minimise delays in theatre. Likewise, clinical staff would benefit from mobile electronic access to upcoming patients’ details so that they can adequately prepare. Cancellations could be avoided by giving consultants

access to patient information at an earlier stage, so patients are not turned away on the day of their surgery but do not make it to the list in the first place.

Members of the Association of Perioperative Practice support this idea, believing that technology could enable more efficient working by making patient information such as imaging and blood work more readily accessible to all theatre staff, particularly at the point of conducting WHO safer surgery checklist.

It will not be a one-size-fits-all solution as each trust has different requirements and systems already in place. There should, however, be a national standard for data sets and benchmarking so that theatre performance and efficiency can be measured and evaluated in the same way across all trusts, to make results relative and to share best practice.

Simply having hospital data is not an end point – it also needs to ignite further meaningful discussion with senior management to create long-term change – but certainly having the right types of information available is a step towards making NHS theatres more efficient.

What is the role of technology?

Technology will undoubtedly have a big role to play in improving theatre efficiency, primarily by providing access to data. Different types of data are valuable to different roles and, in order to be valuable, it needs to be detailed, accurately collected and available to access in real time.

“Access to information about surgical operations in real time would be highly valuable”


Recommendations1. Reduce late starts, delays between cases and

cancellations by ensuring that:• patients and clinicians arrive on time. Effective

staff messaging and communications systems will dramatically improve timely arrival.

• pre-operative assessments are available for every patient. Clinical systems can prevent patients being added to lists unless this information is complete.

• clinicians have the correct specialist equipment for the procedure. Specify pre-defined equipment packs in advance and record any new equipment used throughout procedures for later review and audit.

2. Optimise theatre list planning and sequencing by: • using the 6-4-2 theatre management process. • collecting and using theatre data to predict patient

flow, set normative rules, audit outcomes and share best practice.

3. Maximise the use of your theatres by understanding the status of all of your theatres in real-time so that procedures may be moved where necessary.

4. Maintain a single, complete record that provides ready access to clinical data for all who need it. Record information electronically – not on paper.

5. Implement the right clinical and communications systems to enable your theatre and support teams to work more effectively and efficiently together.

i https://www.rcseng.ac.uk/news-and-events/media-centre/press-releases/half-a-million-patients-now-waiting-over-18-weeks-for-hospital-treatment/

ii https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2018/06/RTT-Annual-Report-2017-18-PDF-1295K.pdf

iii https://improvement.nhs.uk/resources/operating-theatres-opportunities-reduce-waiting-lists/


About AscomAscom closes digital information gaps across points of care, creating actionable, context-rich insight that supports enhanced clinical decision making. Ascom streamlines the flow of critical information and care activity to help clinicians improve care management, coordination and delivery. Bringing a dynamic portfolio of clinical and care solutions into one integrated, flexible framework, the Ascom Healthcare Platform enables healthcare facilities to harness the power of clinical information, optimise care workflows and maximise the value of their existing technology investments. Many of the world’s advanced healthcare institutions, including leading hospitals and digital-forward facilities, utilise Ascom technology to help elevate clinical and operational performance.

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Ascom (UK) Ltd is a company registered in England and Wales. Registered number: 00599145. Registered office: Ascom, Building 3, Wall Island, Birmingham Road, Lichfield, England, WS14 0QP. March 2019.

ascom roundtable report 1 - theatre utilisation...roundtable attendees felt that, while bed capacity...

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