benchmarking in day surgery skues.pdf · post-op recovery day unit ... effect of pathway redesign...
TRANSCRIPT
British Association of Day Surgery www.bads.co.uk
Benchmarking in Day Surgery
Mark Skues President, British Association of Day Surgery
British Association of Day Surgery www.bads.co.uk
Across the Irish Sea...
Issues with
• Financing
• Demographics
• Morale
British Association of Day Surgery www.bads.co.uk
Making Day Surgery count…
An opportunity for care that is:
• Better quality
• More patient focussed
• More cost efficient
Getting started…
British Association of Day Surgery www.bads.co.uk
•Circumcision
•Excision of breast lump
•Varicose veins
•Dupuytren’s contracture
•Ganglion excision
•Cataract removal
•Myringotomy
•MUA # Nose
•D&C
•Termination of Pregnancy
The Audit Commission Basket of Procedures 1990
•Orchidopexy
•Inguinal hernia repair
•Anal Fissure excision
•Cystoscopy
•Carpal Tunnel Decompression
•Arthroscopy of Knee
•Squint correction
•Sub Mucous Resection
•Pinnaplasty
•Laparoscopy + Sterilisation
British Association of Day Surgery www.bads.co.uk
BADS Trolley of Procedures (1999)
• Laparoscopic cholecystectomy
• Thorascopic sympathectomy
• Partial thyroidectomy
• Wide excision of breast lump
• Urethrotomy
• Laser prostatectomy
• Eyelid surgery
• Arthroscopic meniscectomy
• Dentoalveolar surgery
• Haemorrhoidectomy
• Tonsillectomy
• Submandibular gland excision
• Bladder neck incision
• TCRE
• Hallux valgus ops
• Arthroscopic shoulder ops
• Tympanoplasty
• Rhinoplasty
British Association of Day Surgery www.bads.co.uk
•Orchidopexy
•Inguinal hernia repair
•Anal Fissure
•Lap Cholecystectomy
•TURBT
•Carpal Tunnel Release
•Arthroscopy of Knee
•Removal of metalware
•Squint correction
•Tonsillectomy
•MUA # Nose
•D&C, Hysteroscopy
•(Termination of pregnancy)
Audit Commission Basket of 24 Procedures (2000)
•Circumcision
•Excision of breast lump
•Haemorrhoidectomy
•Varicose veins
•Dupuytren’s contracture
•Ganglion excision
•Bunion operations
•Cataract removal
•Myringotomy + Grommet
•Sub Mucous Resection
•Pinnaplasty
•Diagnostic Laparoscopy
British Association of Day Surgery www.bads.co.uk
‘Watch Wayne Littlejohn have his kidney removed and return home the same day.’
"It's a challenge and a brave decision, but our patients are driving it," says Anurag Golash,
Consultant Urologist at the University of North Staffordshire Hospital.
"I was given the choice - I chose going home," said Mr Littlejohn, just arrived home after having a kidney removed.
"I get bored in hospital,
Nothing is better than being in your own bed.” "I have my sport on TV and my family around to help me."
British Association of Day Surgery www.bads.co.uk
Time to move away from the “Basket”
• Gives the impression that these procedures are the only ones to concentrate on
• Advances in surgical and anaesthetic techniques
mean much more can be managed as day surgery
• Non comparable across all Trusts
British Association of Day Surgery www.bads.co.uk
BADS Procedure Directory
Breast Surgery ENT General Surgery Gynaecology Head and Neck Ophthalmology Orthopaedic Surgery Urology Vascular Surgery
Paediatric Surgery Emergency Surgery Medical Procedures
170 Procedures
British Association of Day Surgery www.bads.co.uk
BADS Procedure Directory
•Therefore, achievement of these goals may require: •Reconfiguration of day surgery lists •Redesign of the clinical pathway •Investment in appropriate technology
•Some procedures may need longer recovery or observation times
•Others may required specialised equipment or training for Clinicians to achieve their full potential
British Association of Day Surgery www.bads.co.uk
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Day Case Laparoscopic cholecystectomy
2000
2010
English Hospitals
British Association of Day Surgery www.bads.co.uk
Why the variability?
• Clinician “resistance”?
• Suboptimal anaesthesia?
• Pathway and process
British Association of Day Surgery www.bads.co.uk
Day Surgery Pathway
• “Intention to treat”
• Outpatient review
• Preoperative assessment
• Information provision
• Admission management
• Nurse led discharge
• Discharge information
• “Help line” backup
British Association of Day Surgery www.bads.co.uk
Unified Day Surgery Pathway
GP Surgical OPD Preop assessment
Diagnostics Day Surgery Waiting List
Admission and Surgery
Inpatient Waiting List
Surgical OPD
Post-op Recovery
Day Unit
Inpatient / Short Stay Unit
Unanticipated overnight admission
Discharge
Immediate Post-
operative support
British Association of Day Surgery www.bads.co.uk
Rapid Improvement Sites
All English Trusts invited
– 10 chosen
– 1 per SHA
Low day case rates
– 1 “high performer”
British Association of Day Surgery www.bads.co.uk
0
25
50
75
100
Start Oct 2008
Applying Basic Principles
Day surgery
rate (%)
Trusts
A B C D E F G H I
Smith et al. J One-Day Surgery 2010;20:80-4.
British Association of Day Surgery www.bads.co.uk
Effect of Pathway Redesign
Post-discharge support
Documentation
Patient discharge
Recovery facilities
Operating lists
Admission
Booking
Selection criteria
Preoperative assessment
Surgical outpatients
Patient referral
British Association of Day Surgery www.bads.co.uk
0
25
50
75
100
Start Oct 2008
Applying Basic Principles
Day surgery
rate (%)
Trusts Smith et al. J One-Day Surgery 2010;20:80-4.
End Nov 2009 (Self-reported data)
A B C D E F G H I
British Association of Day Surgery www.bads.co.uk
0
25
50
75
100
Start Oct 2008
Sustainable?
Day surgery
rate (%)
Trusts
End Nov 2009 National Data, Mid 2012
A B C D E F G H I
British Association of Day Surgery www.bads.co.uk
0
25
50
75
100
Start Oct 2008
Sustainable?
Day surgery
rate (%)
National
Trusts
End Nov 2009 National Data, Mid 2012
A B C D E F G H I
British Association of Day Surgery www.bads.co.uk
How do we update the Procedure Directory?
Collaboration with external organisations:
• Audit Commission
• “Payment by Results” Tariff Team
• NHS Information Centre (HES data)
• NHS Institute “Better Care” indices
British Association of Day Surgery www.bads.co.uk
How do we update benchmarks?
Collaboration with
Individuals and Professional Organisations;
• Gynaecology and the RCO&G
• Paediatric Surgery and APA
Trusts:
• BADS Efficiency Assessment Tool
British Association of Day Surgery www.bads.co.uk
Comparative benchmarking
Basket of “25” Scores: 73% 89% 82%
British Association of Day Surgery www.bads.co.uk
Other Benchmarks / Outcome Indicators
• Individual
• Departmental
• Hospital
• National
• What the patient thinks?
• Environment efficiency
Clinical
Organisational
Social
Economic
British Association of Day Surgery www.bads.co.uk
Clinical Indicators: Individual Anaesthetists
• Audit for appraisal
• Unplanned overnight admission rates
• Pain scores in recovery
• PONV rates
• Regional anaesthesia “success” rates
• Patient (MSF) feedback
British Association of Day Surgery www.bads.co.uk
Unanticipated Overnight Admission Rate
• A useful outcome marker?
• “...Should be less than 2%.....”?
British Association of Day Surgery www.bads.co.uk
How to reduce this rate to zero..
Ultra-conservative selection criteria
British Association of Day Surgery www.bads.co.uk
Reasons for overnight admission Predictable Unpredictable
Medical • Pre-operative co-morbidity
• Complications • Cardiovascular • Respiratory
Surgical • A challenging individual patient for day care
• Pain • More complex
operation • Misadventure • Bleeding
Anaesthetic • Staff roster – skill mix • PONV • Somnolence
Social • No home support
Administrative • Wrong time of day for day case operation
• Wrong environment
British Association of Day Surgery www.bads.co.uk
Reasons for overnight admission Predictable Unpredictable Outcome
Medical • Pre-operative co-morbidity
Complications • Cardiovascular • Respiratory
17.2%
Surgical • A challenging individual patient for day care
• Pain • More complex
operation • Misadventure • Bleeding
38.1%
Anaesthetic • Staff roster – skill mix • PONV • Somnolence
25.1%
Social • No home support 19.5%
Administrative • Wrong time of day for day case operation
• Wrong environment • Capacity pressures
Can J. Anaesthesia 1998;45.7:612
Pre-Operative
Assessment
British Association of Day Surgery www.bads.co.uk
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%A
ug
-02
No
v-0
2
Fe
b-0
3
Ma
y-0
3
Au
g-0
3
No
v-0
3
Fe
b-0
4
Ma
y-0
4
Au
g-0
4
No
v-0
4
Fe
b-0
5
Ma
y-0
5
Au
g-0
5
No
v-0
5
Fe
b-0
6
Ma
y-0
6
Au
g-0
6
No
v-0
6
Fe
b-0
7
Ma
y-0
7
Au
g-0
7
No
v-0
7
Fe
b-0
8
Ma
y-0
8
Au
g-0
8
No
v-0
8
In-Patient Admission after Day Surgery
Mean
UPL/LPL
British Association of Day Surgery www.bads.co.uk
Other Benchmarks / Outcome Indicators
• Individual
• Departmental
• Trust
• National
• What the patient thinks?
• Environment efficiency
Clinical
Organisational
Social
Economic
British Association of Day Surgery www.bads.co.uk
Patient Satisfaction
• Effective postoperative analgesia
• Minimal emetic sequelae
• Staff courtesy and privacy in the unit
• Short waiting times on the day of surgery
• No perception of being rushed
• Post-operative telephone contact
• Good surgical outcome
Smith I, Skues MA, Philip B. Miller’s Anaesthesiology, 8th Edn: in Press
British Association of Day Surgery www.bads.co.uk
Other Benchmarks / Outcome Indicators
• Individual
• Departmental
• Trust
• National
• What the patient thinks?
• Environment efficiency
Clinical
Organisational
Social
Economic
British Association of Day Surgery www.bads.co.uk
Economic Efficiency
• Cancelled lists
• Substitution?
• Timely notification of leave
• Late starts / early finishes
• Patient booking remits
• DNAs
• ‘Gap times’ in theatre
British Association of Day Surgery www.bads.co.uk
Other benchmarks or “barriers”...
National facilities?
British Association of Day Surgery www.bads.co.uk
Selection criteria
BADS Guidelines (2012)
•Dedicated day surgery lists provide the best model of care. •Lists with a mix of day and short stay surgery can be efficient and provide flexibility. •Lists that have a mix of inpatient and day case patients cause tension between the needs of major cases and the day cases.
Operating lists
•A 24 hr telephone support number should be provided to each patient and their carer. •This support service should be provided by nursing staff with knowledge of the potential complications following surgery.
Post discharge support
•Guidelines have been published by the British Association of Day Surgery and the Association of Anaesthetists of Great Britain and Ireland. •There is no set maximum travelling time from hospital to home. •Carer support after discharge - usually 24 hrs but may be shorter or longer depending on the procedure. •BMI should not be used as an arbitrary contraindication to day surgery. •Co-morbidities should be assessed and optimised for day surgery. •Hypertension should not be used as a contraindication to day surgery.