rapid change in orthopaedics acc friday 30 april 2010 seabridge house robert middleton the royal...
TRANSCRIPT
![Page 1: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/1.jpg)
Rapid change in Orthopaedics
ACC Friday 30 April 2010
Seabridge House
Robert MiddletonThe Royal Bournemouth Hospital
NHS Institute for Innovation and Improvement
![Page 2: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/2.jpg)
What were the issues?
Waiting times Balancing demand with capacity Reduce costs Competition Outcomes
![Page 3: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/3.jpg)
Why do our solutions fail?
We treat the symptoms of the problem The end result doesn’t change because
we don’t change the whole system
Every system is perfectly designed to get the results it gets (Deming)
![Page 4: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/4.jpg)
Variability
Operating times
![Page 5: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/5.jpg)
Variability
There was huge variability in outcomes. Mean length of stay = 7.8 days and St Dev = 5.5 days
0
20
40
60
80
100
120
0 200 400 600 800 1000 1200 1400 1600 1800
![Page 6: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/6.jpg)
Deming
Understanding variation is the most important aspect when trying to understand a system
How do we go about this in healthcare when so many factors vary from patient to patient?
![Page 7: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/7.jpg)
What were the issues?
Approx 6000 procedures per year 10 procedures = approx 70% of the workload
Hip and knee replacement Approx 25% of the workload 7.8 day average length of stay Many pathways
![Page 8: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/8.jpg)
What did we do?
We analysed the issues Assessed the variability Recognised what we could change and
what we couldn’t Provided a framework which accounted for
variability Kept it patient centred
![Page 9: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/9.jpg)
Focused on what we could change
Non-confrontational SDSA (standardise-do-study-act) Single pathway Introduced daily and weekly outcome
measures Ongoing audit/performance
management
![Page 10: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/10.jpg)
Framework
Freedom and responsibility to work within a framework
Manage the system and not the people
![Page 11: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/11.jpg)
Patient-centred
The reason we are here Galvanises professional groups Evidence base for orthopaedics isn’t
controversial NHS Institute for Innovation and
Improvement There is no single magic bullet
![Page 12: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/12.jpg)
Results – First 1200 patients
100% of operation dates are mutually agreed Over 90% attendance at pre-op education
class 100% of patients admitted on day of surgery 99% of patients waited less than 4 hours
between admission and operation (Mean = 2hrs 43mins)
100% of patients received physiotherapy within 18 hours of surgery
![Page 13: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/13.jpg)
0
5
10
15
20
25
Length of Stay Before Change
![Page 14: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/14.jpg)
0
2
4
6
8
10
12
14
16
18
Length of Stay After Change
![Page 15: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/15.jpg)
Average length of stay by NHS trust
0
5
10
15
20
25
0
2
4
6
8
10
12
14
16
18
0
5
10
15
20
25
0
2
4
6
8
10
12
14
16
18
TKR(H04) July 2007/08 – June 2008/09
THR(H80) July 2007/08 – June 2008/09
TKR(H04) July 2006/07 – June 2007/08
THR(H80) July 2006/07 – June 2007/08
Data from Dr Foster Intelligence – October 2008
![Page 16: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/16.jpg)
Performance against case-mix adjusted expected length of stay by NHS trust
TKR(H04) July 2007/08 – June 2008/09
THR(H80) July 2007/08 – June 2008/09
TKR(H04) July 2006/07 – June 2007/08
THR(H80) July 2006/07 – June 2007/08
-4
-3
-2
-1
0
1
2
3
4
5
6
-3
-2
-1
0
1
2
3
4
5
-4
-2
0
2
4
6
8
10
-4
-2
0
2
4
6
8
10
Data from Dr Foster Intelligence – October 2008
![Page 17: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/17.jpg)
Results – First 1200 patients
No cases of deep infection Complications rates below 1%. Re-admission rate decreased by 50% Patient satisfaction is extremely high Length of stay dramatically decreased
![Page 18: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/18.jpg)
Results - Length of stay
Mean LOS = 4.1 days St Dev LOS = 1.7
48% decrease on previous mean LOS (7.8 days)
Approx 4000 extra bed days
DIFFERENCE IN LENGTH OF STAY
0
10
20
30
40
50
1 2 3 4 5 6 7 8 9 10 11 12 13 14
DAYS
% O
F P
TS
PREVIOUS LOS
DERWENT LOS
![Page 19: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/19.jpg)
Results – Operative times
![Page 20: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/20.jpg)
Results - Variability
Example - Operative times
![Page 21: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/21.jpg)
Using knowledge of variability to plan ahead
We have developed a forward looking model
Informed by real data and consistent with principles from other industries and leading thought leaders
![Page 22: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/22.jpg)
Predicting variability
![Page 23: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/23.jpg)
Sequential vs staggered operating lists
Same distributions Sequential compounds
error (difference from mean) through all cases
Staggered softens errors through all cases
![Page 24: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/24.jpg)
Operative Time
00:00
00:28
00:57
01:26
01:55
02:24
02:52
03:21
03:50
04:19
1 9 17 25 33 41 49 57 65 73 81 89 97 105 113 121 129 137 145 153 161
![Page 25: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/25.jpg)
Benefiting the NHS
DOH 18 week workshops Dorset Gold Award 2009 Redesign of Orthopaedic services in Scotland National and International Presentations and Papers to
Orthopaedic and Health Management meetings
NHS Institute for Innovation and Improvement
![Page 26: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/26.jpg)
The 6 key characteristics of organisations providing high quality care and value for money in patients with hip and knee replacement
Patients’ expectations are consistently Patients’ expectations are consistently managedmanaged Patients are admitted on the day of Patients are admitted on the day of surgerysurgery
Patients’ planned procedures are not Patients’ planned procedures are not cancelledcancelled
Patients are mobilised within 12–18 Patients are mobilised within 12–18 hours of surgeryhours of surgery
Patients are discharged using a criteria-Patients are discharged using a criteria-based processbased process
The decision to change your serviceThe decision to change your service
![Page 27: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/27.jpg)
NHS Institute for Innovation and Improvement
Focus on seriesRapid Improvement ProgrammeRegional MeetingsNational Meetings
![Page 28: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/28.jpg)
Summary
Change the system Standardise Stream Variability is predictable and
controllable
![Page 29: Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and](https://reader035.vdocument.in/reader035/viewer/2022062803/56649f0c5503460f94c1f974/html5/thumbnails/29.jpg)
Thank you