The Productive Operating Theatre Programme An enabler for productivity, safety and performance improvements in Operating Theatres. Joe McDonald Senior Advisor Clinical Improvement and Productivity Sector Capability and Innovation Directorate Ministry of Health TPOT is regarded as an enabler programme and hopr to tell you why it is considered so!

How The Productive Operating Theatre has been developed Understand the real issues and challenges. Identified co-production partners in the NHS and from industry Observing and enquiring in other high risk, lean organisations Terminal 5, Unipart –logistics Other healthcare settings, USA Generated and tested lots of ideas with the field test sites Test the idea in another environment / team with the Associate sites. Failure was learning Consolidate the learning, consider delivery mechanisms, marketing, launch Launch in Sept 2009, followed by regional start-up events for NHS England Ongoing ROI and benefits realisation capture Since April 2010 initiated 10 cohorts of training and implementation support to 90 of 174 acute trusts in NHS England. Delivered Master Training internationally in Wales , Scotland, and Northern Ireland and New Zealand. Coming to Australia, Canada and South Africa soon! Internal/external peer review. Frequent learning sets. Continual understand and reflect. Key message: Rigour, timescales and investment that has gone into developing the programme. Where the Programme came from, where we are with TPOT currently What to say In line with world class best practice, the institute uses a work process Structured way of developing innovative solutions Incorporates analysis, creativity and prototyping of ideas Based on experience with The Productive Ward Co-production with 3 hospitals starting small: 2 theatres Combining strategies: lean thinking (staff empowerment) team working (human factors & non-technical skills) Testing prototypes and measuring their impact 3 further hospitals Sequence of modules Rolling out to the NHS Implementation support package 2

UK compared to NZ Operating Theatres   UK NZ Trusts/DHBs 174 trusts 21 DHBs Operating Theatres numbers 2,871 203 Average theatres per Trust/DHB 16.5 9.6 Running costs for an Operating Theatre per hour £ 1,200 ($2,601) $ 1,680 2008/09 The slides acknowledges the difference between UK and NZ and the scale of the health systems

What is The Productive Operating Theatre? Modular improvement programme for theatre teams Systematic way to deliver significant improvements A proven method of enabling frontline teams to transform the way they work Concentrates on the HOW not the WHAT Vehicle to deliver organisational objectives Key message: What is this programme all about…….. Creating the perfect operating list!! Every day for every patient 4

The modules

Programme timeline key events and milestones Approx time at start of this slide – – (takes approx 2 mins) the steps that need to be taken to run the programme are …..explain timeline refer to PLG handbook pgs 18-19 There are three key events in the start up – Visioning, Measures workshop and Trust Board workshop – all outlined in PLG – but will hear more about this during the day The focus for today is to give you the information you need to get you started once your organisation has signed up to doing this programme of work and give you an opportunity to spend time in your Trust groups to start your plans 6

The Productive Operating Theatre aim: To improve 4 key dimensions of quality

The perfect operating list? Communications Training Staff Skill mix Equipment Attitudes/behaviours List Scheduling/utilisation Start/Finish Times Patient Prep Effortless for everyone Great team communication Quiet & smooth Fast but not rushed No glitches Safe, reliable care The black colour is what the UK research defines as aspects of the Perfect OT list, the BLUE is what has come up at NZ vision workshops

Programme focus areas: Team working MDT Scheduling Session start up Patient preparation Patient Turnaround Handover Consumables and equipment Recovery (PACU)

Critical success factors Leadership at Executive level Alignment with strategic direction Governance of the programme Continuous improvement / measurement Capability and knowledge Local expert with time allocated Clinical engagement

Benefits achieved in UK and potential opportunities for NZ Increase in the proportion of patients in recovery with a pain scores < 6 from 73% to 88%. Increase in the percentage of patients with temperature on arrival in recovery above 35.4°from 91% to 98%. Reduction in patient safety incidents and complications through improved team working and communication. Statistically significant increase in job satisfaction, team working and safety climate 63% reduction in average turnaround time. Start time delays reduced by average of 25 minute. 16% increase in touch time. Minimum £5K stock reduction per theatre. Minimum £9K recurring saving per theatre on theatre consumables per year.

Value and efficiency – benefit estimates (per annum) UK   Per theatre Per DGH Reduced cancellations £ 23k £ 388k Improved utilisation & reduced over-runs £ 120k £1,980k Avoiding cost of defects £ 30.5k £503k Materials management  £6k +£6k one-off £100k +£100k one-off Total £179.5 £2,971k 174 trusts in the NHS Total of 2,871 operating theatres, Average 16.5 theatres per trust

Efficiency: the financial ‘engine room’ Theatres represent 25-50% of most hospitals income generation Most theatres have had many Improvement Projects often with limited sustainable effect Theatres cost approximately £1000 – 1200 per hour (excluding medical personnel) Unstaffed hours still generate capital and estate costs

Impact on culture (safety attitudes questionnaire) Team-working Impact on culture (safety attitudes questionnaire) This graph shows the impact of team brief on staff attitudes By conducting a staff attitudes questionnaire before and after implementing team briefing this test site were able to demonstrate any improvement on staff attitudes Implementation of team brief was anticipated to improve attitudes to teamworking, safety and job satisfaction but it was not expected that perceptions of management, working conditions or stress recognition would improve An unpaired t-test was used to assess the statistical significance of the improvement – p values were found to be less than 0.05 i.e. statistically significant in the three categories predicted to improve p<0.05 14

Team-working

Session utilisation Over 8 weeks: Cost of unused sessions £105,600 Cost of extra sessions >£153,600 Potential saving over 1 year >£660,000 Over that same 8 week period where 22 sessions were unused, 32 extra sessions were run – Definitely a problem worth solving – explain costs…these were calculated based simply on staff salaries excluding the surgeon for cancelled sessions – in addition there are other costs that can be calculated such as loss of income from cancelled sessions 16

Number of waiting list initiative sessions Scheduling Session Utilisation Mean – 90% Mean – 98% Number of waiting list initiative sessions Over 8 weeks: Cost of unused sessions £31,746 Cost of extra sessions £81,664 Potential saving in 1 year £510,400 Based on another test site that has worked on scheduling - the % of funded sessions utilised has increased from a mean of 90% utilisation last year to a mean of 99% utilisation for the same period this year 17

Improved session start times

Patient safety 40 % admissions experience error in care 4 % harmed 0.8-1% die from errors 19

‘Culture eats strategy for breakfast’ Tribal non-alignment E X C s S U R G E O N M A N G E R S O D P S / T E C H s A N E S T H I N U R S E P O R T E S ‘Culture eats strategy for breakfast’

Whole system benefits These improvements may be further enhanced through improvements in benefits that are less easy to quantify financially, in particular, reducing errors or complications (reduced length of stay, reduced drug expenditure, reduced admissions to ICU).

Programme to date: Application and selection process (June 2010) Review panel selected 8 DHBs Review panel selected a DHB clinical expert group, to lead and train the programme in NZ Training delivered by NHSI experts (Aug 2010) DHBs involved: Waitemata, Auckland, Tairawhiti, Bay of Plenty, Hawkes Bay, Whanganui, Hutt Valley and Southern. Next steps: Process will begin again in 2011 for next adopting DHBs and NZ training will be delivered by NZ clinical expert group.

“TPOT improves communication between theatre staff and clinicians” Staff feedback from UK “Well organised theatre has improved the organisation of stores and equipment which has had a direct impact on theatre efficiency” Theatre Practitioner “Since introducing TPOT there has been a noticeable change in culture …staff are clearly empowered to make changes” Consultant Surgeon “Since TPOT everyone uses the data to evidence problems and measure improvements” Programme Lead “The team brief gives people a voice. Patient care improves, errors go down and morale goes up” Consultant Surgeon “Debrief is a terrific opportunity to give credit where it’s due and let people know they’ve done well. At the same time it’s an ideal opportunity to see where lessons need to be learned” Consultant Surgeon “TPOT improves communication between theatre staff and clinicians” Theatre Sister So what have staff been saying about the programme (read each quote in turn) Finish at 14:25 (IF 5 MINS SPARE ??? PLAY INTRO DVD) – ??OFFER 5 MIN COMFORT BREAK 23

Any Questions? THANK YOU! www.hiirc.org.nz Contact information: Joe McDonald Ph: 04 8162571 email: Joseph_McDonald@moh.govt.nz THANK YOU!