This large University Hospital in the Republic of Ireland served one of Ireland’s major cities and its surrounding localities. It also acted as a specialist site for various surgical procedures.
The Theatres Suite housed 5 operating theatres, accessed by a variety of surgical specialties and serving both inpatients and day cases. The Theatres Department had limitations in both constraining physical estate capacity, as well as resource constraints in the nursing team in place.
The hospital as a whole was under significant pressures in terms of access to inpatient beds and the levels of overtime being paid to the nursing team to accommodate poor planning of the theatre lists. An improvement programme was required to alleviate some of the demand pressures through increasing the efficiency and productivity of the theatres.
An analysis was carried out covering various aspects of the running of the theatres. Live studies were performed to understand the way in which the department operated on a day to day basis, theatre information was interrogated to provide a statistical overview of the performance and the management control system in place was assessed. The analysis findings were as follows: • There was no overall connected management of theatres as a resource. • Silo planning added inefficiency, resulting in nurses being rostered longer than sessions were actually scheduled to run. • Theatres were found to be ‘victims’ of bed management, individual clinicians’ ‘practice’ and ‘acts of patient’. • There was no evident ‘master plan’ or management tools in place. • The incumbent Theatre Users Group was ineffective and without purpose or definition.
What Meridian proposed:
a) To develop an Executive Management Function within theatres and a suite of fully functioning tools to assist theatres to fulfil the needs and demands of patients, waiting times and unscheduled demands within an identifiable cost envelope.
b) To give certainty in funding demands/capacity ability to deliver into the future – based on fact and not assumptions.
c) Clear and consistent management decisions, based on fact, and not ‘tantrums and tiaras’.
The Theatres Improvement Project was scheduled for 16 calendar weeks and covered all of the proposed deliverables.
The initial objective of the project was to establish and train a Theatre Management Team, define its terms of reference, span of control and decision making power and to set up clear review processes in which it could exert its authority and decision making ability.
In addition, the project worked with the new Theatre Management Team, as well as clinicians, to establish definitions for Emergency, Unscheduled and Elective procedures. An order of precedence was then defined for each of these case types.
With the Theatre Management Team in place, processes were defined for list planning and a ‘countdown to theatre day’ formulated. A mechanism for viewing planned utilisation of theatres sessions was designed and installed, meaning that for the first time the Hospital was able to proactively manage its theatre utilisation based on solid management information.
To allow the Theatre Management Team to act upon robust information, a full suite of reports was created incorporating:
- In-session Theatre Utilisation
- Theatre Session Punctuality
- Elective/Emergency Ratio
- Planned Theatre Utilisation
- Utilisation of ‘dual sessions’
- Theatre Capacity versus Demand
The key principle within all reports developed was that of variance. Targets were set for all key performance indicators and subsequently any variances to these targets were investigated and actioned through a newly installed fixed weekly review process.
- A newly formed Theatre Management Team, comprising of the senior representatives of each department responsible for the Operating Theatres resource.
- A clearly defined set of responsibilities and accountabilities that had never before existed within the running of the Theatres.
- A full suite of management reports, bringing to life information that had previously been captured, but never used.
- A fundamental principle of ‘variance management’, allowing actions to be taken on the barriers limiting the organisation from achieving its own performance objectives.
- Development and agreement of a comprehensive list of ‘planning norms’ by consultant and by procedure, allowing planned theatre lists to be translated into a planned utilisation of the theatre resource.
- Transparency around the levels of work being incorrectly classified as ‘emergency’, and a subsequent natural reduction of same.
- A clear correlation between the capacity of the Theatres (based on both consultant contracted time and the theatre schedule in place) and the demand by individual consultant. This allowed decisions to be made around the allocation of theatre time
- A universal ‘Master Schedule’, which for the first time represented the true plan for theatres; including scheduled sessions, cancelled sessions, planned number of cases, session start and end times and planned utilisation percentage.
- A re-invigorated bed management team, who took full responsibility for the management of list booking using the newly installed productivity principles.
- A notable reduction in the number of late finishes in theatre (and subsequent reduction in nursing overtime) brought about by increases in in-session utilisation of theatres within the same cost base.