Operating Theatre Efficiency Improvements using Operations Management Science
First Name: Andrew  Fordyce
Job Title:
Organisation: South Devon Health Care NHS Trust
Date Submitted: Thursday 16 August 07

January 2006 – December 2006

Short Description:
This project was established to tackle the problem of down time in operating theatres. The literature estimates that about 50% of available operating time is actually used for operating. This wasted time reflects a high cost to the organisation. South Devon Trust worked with Stuart Chambers of Warwick Business School to define the problem using Operations Management techniques and to take forward a process of change to improve efficiency of their theatres.

The project aimed to: - reduce wasted time - understand the current processes for getting patients to theatre - understand the flow through theatre and out of recovery - identify and eliminate blocks to patient flow - improve the patient experience

Project team and stakeholders:
The project team evolved over time depending on what aspect of the project they were working on. Core members of the team were: Sudheer Medakkar, Associate Specialist Anaesthetist (project leader) Andrew Fordyce, Consultant Surgeon Stuart Chambers, Warwick Business School Sasha Karakusevic Director of Performance (Project Champion) It is important to realise that this was a team effort and at different points in time the team included frontline staff in theatres, admissions, outpatients, pre-assessment, wards and discharge. The team was multi-disciplinary and included anaesthetists, surgeons, theatre sisters, operational managers and other staff. The team met on a weekly basis.

Approach used, methods and improvement tools:
The Trust commissioned a process improvement expert from Warwick Business School to work closely with them. Consequently the team were able to draw on a wide range of managerial improvement tools including brainstorming, Lean, Root Cause Analysis, Pareto analyses, histogram analyses and Ishikawa (fishbone). The project was very much data driven to identify problems and issues. Nothing was taken at face value. If a problem was identified by a member of staff anecdotally, then management data was used to verify that this was indeed the case. All relevant issues were examined in detail and presented back to the team in a meaningful way. The quality of the data collected for management information purposes was checked. Sometimes it was necessary to go back and collect primary data to get to the real root cause of a problem. The use of high quality data to identify the problem meant that presentations of the problem to clinical staff could build on the evidence and make a powerful case for doing something about it. Ishikawa was used to achieve consensus over where the problems lay. Pareto analysis was then used to pick off the problems. Initially attention was focused on the start time. The team wanted to be clear about what actually happens at the start time of 9am and what is supposed to happen at this time. A questionnaire was sent to all clinicians and elicited different views on this topic. The results showed that there was a lack of clarity about what should be happening to the patient at 9am and whose responsibility it was to ensure that the correct process took place. Work then focused on four theatres as a pilot where data was collected about what was happening to the patient before 9am. The data collection showed where the delays were in the process. Analysis showed that there were multiple causes of delay. In particular there were issues in the pre-operative pathway e.g. patients arriving for surgery without specific tests having been undertaken, without consent having been taken and also issues around the admission process on the day of surgery.

Criteria of success:
The main criteria for success was a reduction in the percentage of downtime in surgeon’s operating time.

Measures of success:
The main measure of success was a reduction in downtime in surgical operating time. By ensuring the anaesthetised patient is delivered into theatre at 9am, it was possible to shave 16 minutes off the wasted time per operating theatre. Opportunity costs in theatres are estimated to be £15 a minute per theatre per session. If 16 wasted minutes are eliminated at the beginning of the operating session, this is equivalent to potentially increased revenue of at least £3,000 across all theatres in the hospital per working day. Other measures of success are: Increased activity Reduced waiting times Improved staff morale Reduced staff turnover Reduced sickness absence Increased income

Evaluation methods:
Theatre staff have been informally monitoring start times in theatre. There has not been a formal evaluation. Data on start times collected by theatre staff has been used to calculate the amount of wasted time. A cost benefit analysis has been carried to measure the cost of the time saved. A formative evaluation of the process is underway.

Risks identified:
There was a risk of alienating clinical staff if they hadn’t been adequately engaged in the project, in which case the project would not have been successful.

Although the pilot was restricted to just four theatres, the changes were rolled out to all nine theatres. Changes were made to the pre-operative pathway to ensure that the correct tests had been carried out prior to surgery and also to ensure that consent had been sought. Patients were brought in earlier on the day of surgery arriving at 7.30 rather than 8.00am to allow ward staff to admit the patients prior to being seen by clinical staff. The flow of patients through to the surgical admissions was reviewed and changed to improve it. In particular the escorting of patients to the surgical admissions unit had previously been carried out on a one to one basis and now patients are escorted into the unit in groups, thus freeing up valuable nursing time. There has been a reduction in downtime as outlined above and this in turn should also translate into increased capacity and reduced waiting lists. Apart from the changes brought about to the start time as mentioned above, the project looked at other parts of the patient journey which might also result in wasted time. In particular they looked at the time between patients in surgery. However it appeared that downtime between patients was relatively small especially given that the most of the cases themselves were fairly long. They examined the impact of key staff being absent e.g. when an anaesthetist is off sick this could result in a list being cancelled. The cost of bringing somebody else in to fill this role more than outweighed by the cost of cancelling the list. Other expected outcomes of the process include improved staff morale and satisfaction, reduced sickness and absence, improved staff recruitment and turnover, and overall increased surgical activity.

Much of the success of this project has been based on subtle culture change driven by demonstrating the evidence of the problems and therefore the need to change. Clinicians and frontline staff have been successfully engaged and involved in this change and were involved in every step of the process. The solutions to many of the problems were not difficult to identify once the problems were correctly identified and were developed in the main by the frontline staff who knew what was required to make it work. All the way through this project there has been a strong emphasis on getting the process right, resulting in achieving a strong degree of ownership from all staff. It was particularly helpful to have a process improvement expert from Warwick Business School on the project team because as an independent person outside of the NHS he was able to ask all the ‘naive’ questions that NHS staff who work in the system may not have asked. His skills in identifying, extracting, analysing, and presenting relevant operational data to surgical and managerial staff was invaluable. This enabled us to focus quickly on the most effective areas for targeting improvement, whilst obtaining buy-in and commitment from the staff.

Further work is going on to review theatre activity at the end of the day to ensure that staff finish in a timely fashion. There are plans to produce a publication and make presentations.

(Last Updated: Tuesday 30 November 99 - Hits: 3440)

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Reviews (2)
Reviewed by Wyn Price, 2007-12-14

I commend the authors for their work on a difficult subject to change due to it's historical adhoc development and large number of factors involved. A couple of observations from me:- the 16 minutes you removed from the start of the list is useful but does not equate to adding another patient to the list which would be better financially and will not equate to £3000 per year as projected unless you add them together to make an extra list. Could you explain the statement "cost of bringing somebody else in to fill this role more than outweighed by the cost of cancelling the list." does it mean it is worth you pay someone over sessional payment to cover the list and where do you find these individuals. Delays between cases could add up if the list is a lot of small case added with the 16 minutes at the start could mean an extra case. I look forward to your future work. Can Gerry Robinson really fix the NHS?

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Reviewed by leighjones@nhs.net, 2007-09-13

We here at Rotherham are undergoing a similar process, as I'm sure are several acute trusts up and down the country. I would be interested to see some associated data (eg increase in cases through theatres as a result of increased efficiency) and would also be interested in the mentioned publication and presentations.

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