This large NHS Trust was an integrated care organisation, employing approximately 7,500 staff and responsible for the care of 530,000 local people within the north-west region of one of the UK’s largest cities. The organisation had installed various initiatives around its Operating Theatres, but was still struggling to align its capacity with its demand. Many specialties were not fulfilling their contracted levels of activity and as such the Trust was operating with a significant financial deficit. There was a desire to implement a new, universal process for the management of the theatres resource, but a lack of internal skill and capacity to successfully manage and deliver the change.
An analysis was carried out in the day to day running and management of the Operating Theatres to identify and quantify opportunity for improvement.
The analysis findings were as follows:
- The specialty management teams did not ‘own’ their capacity plans, meaning a lack of ability to fulfil them.
- The theatre access allocated to individual specialties was not adequately controlled.
- Job plan programmed activity commitments versus held sessions was not routinely known.
- The compliance to the internal theatre ‘countdown’ process was poor, leading to an inability to accurately schedule nurses and anaesthetists.
- Forecasted theatre list utilisation was not routinely known nor controlled, and also disconnect from the contracted targets.
- Actual list utilisation was not systematically reviewed or acted upon.
What Meridian proposed:
a) To fully utilise the rolling capacity & demand planning process already installed within the organisation.
b) To ensure that procedure and patient volume was delivered accordingly, including current business position and repatriation opportunities.
c) To support the operational management teams to take responsibility for theatre session uptake, balanced with need, job plans and waiting list initiatives and comply with the agreed ‘way of working’.
d) To define responsibilities and planning process for theatre list utilisation.
e) To utilise all existing tools and data and to understand and act upon the basic numbers and metrics.
f) To fully implement the ‘8-6-4-2’ method of theatre list planning.
The Operating Theatres Improvement Project was scheduled for 18 calendar weeks and covered all of the proposed deliverables.
Due to the wide-ranging scope of stakeholders, the first activity was to form a project group comprising of representatives from each of the key departments, namely Theatres, Surgery Anaesthetics and Operational Management. A series of workshops were then scheduled to bring together the stakeholders to discuss, explore and agree the principles that would be worked to in the future. Meridian hosted each of these sessions, each of which had a key set of objectives relating to the overall theatre countdown process.
The overall process of ‘8-6-4-2’ was a known concept. In this process, consultant leave is agreed at 8 weeks from the day of surgery, theatre lists start being built at 6 weeks from the day of surgery, lists are signed off at 4 weeks from the day of surgery and at 2 weeks all lists are ‘locked down’ (subject to only exceptional changes). However, the intricacies, logistics and operational aspects of each step required exploration, detailing and agreement by all parties before being fully implemented.
The project was designed around an agreement installation cycle, whereby concepts were agreed and then implemented on a two-weekly basis, thereby commencing the respective countdown step. At each stage, the key needs were identified and controls were developed and installed to maximise management grip on the performance of the resource.
Various other aspects of theatre planning were incorporated into the debate as and when they became relevant. For example, the process of 2 patient pre-assessment, the coding of theatre procedures and the refinement of management information used to review performance. The newly agreed process was fully documented at each step, creating a clear set of processes and protocols which were signed up to by all associated stakeholders.
- A single, universal planning mechanism that replaced many, disparate and unclear processes.
- In increase in theatre in-session utilisation and an improved position against contracted activity plans.
- Theatre lists being built 6 weeks from day of surgery, allowing ample time to optimise the list content and minimise the possibility of detrimental changes.
- Sign-off on list content 4 weeks from the theatre day. This was against a starting point in some specialties where lists were not known until the morning of the theatre session.
- A sense of collaboration between departments that had until then not worked together to improve the performance of the shared resource of the Operating Theatres.
- A set of clear management tools to control each aspect of the theatre activity, from planned through to actual.
- The ability to, at the click of a button, view the forecasted utilisation of all theatres, by specialty, by consultant, by theatre session. This also allowed advance review of the planned patients, the list order and patient alerts prior to the day in theatre.
- An electronic theatre list sign-off process, providing clarity around which sessions had been formally agreed and finalised, as well as highlighting clearly those that were amended post-sign-off.
- A reduced number of patient cancellations as a result of phone contact with patients 72 hours prior to TCI (‘to come in’ date)
- An end-to-end mapping of the patient pre-assessment process, with associated critique and action-setting.
- A rigorous weekly review process where planned (and actual) variances to plan were identified and actions set to eradicate them.
- A more controlled, timely and systematic method for approval of consultant leave.
- Far improved communications between operational management teams, booking teams and clinicians.