The productive operating the Gateshead way - Joanne Coleman, Gateshead Health NHS Foundation Trust Presentation from the Productive Endoscopy Workshop, Tuesday 15th October 2013 at Ambassadors Bloomsbury , London, WC1H 0HX This meeting brought together teams from around the country, and embarked on creating and testing the productive endoscopy toolkit. The aim of the day is to allow time with your team for sharing of experiences and exchange of good practice, learn how to apply lean techniques and hear the impact of successfully implemented case studies.

1. The Productive Operating
Theatre the Gateshead way
Gateshead Health NHS Foundation
Trust
Joanne Coleman

2. TPOT Integration within the trust
objectives
• Lean methodology: RPIW and Kaizan events
• Safecare
• Productive series
• Compact and vision work with all staff groups

3. The Vision

4. Overview of our progress
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Knowing how we are doing
Well organised theatre
Operational status at a glance
Team working
Scheduling
Patient turnaround
Recovery module

5. Barriers to a Perfect Day
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Capacity
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Individual commitments
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Job plans
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Porters
Staff shortages
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Attitudes
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Skill
Training
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Patients
No flexibility
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Lack of productivity bonuses
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Ineffective communication
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Lack of kit
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Lack of standardisation
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Culture / custom and practice
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Unrealistic scheduling
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Availability of staff
No opportunity for multi-stake holder•
gathering (like today)
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Change ( fearful of and resistance to)
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Awaiting permission to change
Money
Champions to take it forward
Effective co-ordination of the whole
suite
Room for bulk IV’s not ready yet
Historically theatre cupboards not
standardized
No CD usage patterns/ no adequate
storage for CD’s
No visual controls in theatre
Pharmacy not understanding stock
control
Down time between cases
Inappropriate listing /order of lists
List not starting on time
Patient DNA
Patient not fully prepared
Behaviour of medical staff
IT systems malfunctioning
Lack of critical care beds/ward beds
Sickness

6. Oh What a Perfect Day !!!!
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Sufficient equipment / all kit
available to start
Good staffing levels
Start and finish on time
Theatre fully prepared
Co-ordination of medical staff
Correct personnel present
Quick turnaround of patients/ beds.
Porters ready to bring patient to
and from theatre. Staff available to
bring patients to and from theatre.
No waiting around.
Pre-assessment pathways with
patient with up to date/ relevant
tests available.
Theatre lists are realistic in terms of
capacity
Patient consented prior to day of
surgery
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All IV bulk on direct delivery to theatre
No cancelled operations
All drugs available
Realistic stock levels
Good channels of communication
Respect for all team members
Team brief before the start of the list
(WHO)
Minimal list alterations
No patient harm
Efficient use of storage areas
Break times respected by all team
members
Ease of recognition of MDT
Appropriate fasting times/ pre-op meds
Bar codes and auto top up
No expired drugs
No datix’s for drug errors in theatres
No manufacturer supply problems

7. Theatre Vision
• All patients and staff will be ready for the
procedure to be undertaken
• All drugs and sterile equipment to be in the
expected place in the quantity requested at the
right time with no product defects or wastage.
• All storage locations neat and tidy with visual
prompts.
• Good partnership working between provider
departments and core theatre staff to support
effective logistic supply.
• Documentation records in line with legal
requirements

8. General Theatre Areas

10. Equipment storage layout
before

11. After

12. CSSD Store
Before

13. After

14. Utilisation

15. Theatre capacity

17. Start times, over runs
100
50
0
RF
RE/KG
AM
SNK
NT
JH
KC
ME
PP
AH
JC
-50
-100
-150
-200
-250
-300
Series1

18. Delays leaving recovery
• Staff from ward not available
• More than 1 patient to return to the ward at
the same time
• No porter available
• Ward had received 5 medical borders
admitting them
• Tea time
• Drugs round

19. Pharmacy’s Role

20. Pharmacy’s Role

21. Pharmacy’s Role
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To improve access to medications
To reduce wastage
To save money
To ensure documentation in line with legal
requirements

22. Drug Cupboards
Before

23. Drug Cupboards
After

24. Before

25. After

26. After
Cost saving £400 per cupboard
400 x 12 theatres = £4800

27. Emergency Boxes
(frequently known as oops
boxes!!!)

28. Combined Drug Cupboard
• 2 drug cupboards identified as expensive
• Space identified for:
– combined drug cupboard
– IV fluid store

29. Combined Drug Cupboard

30. Combined Drug Cupboard
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Old cupboards = £44062
1st CDC value = £31444
Current stock value = £26175
Cost avoidance = £17887

31. Recurrent savings
• Working closely with anaesthetists and
nursing staff to reduce usage of:
• Sevoflurane
• IV Paracetamol
• Paracetamol & Ibuprofen pre-packs for
day cases

32. £
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
No' of bottles
Volatile liquids: Usage
90
80
70
60
50
Sevoflurane
40
Desflurane
Isoflurane
30
20
10
0
Volatile Liquids: Cost
Sevoflurane
Desflurane
Isoflurane
Total

33. No. of pre-packs
450
400
350
300
250
200
150
100
50
0
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Febr…
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
Theatres: IV Paracetamol Usage
700
600
500
400
300
No. of vials
200
Cost (£)
100
0
No. of pre-packs issued (SCDT)
Paracetamol
Ibuprofen

34. Improving documentation
• A CD review from Summer 2010 highlighted :
– Some entries made in error completely crossed
out to make original record illegible
– No standard way of recording the quantity in the
register, some use dose other use ampoules/vials
– Doses recorded against wrong page
– Where vials shared between multiple patients,
amount given to each patient often not recorded

35. Improving documentation

36. Team Working Module
• Previous work with NPSA
• Human Factors

37. Comments from NPSA Report
Profile: Senior Scrub Nurse
J is a senior and well respected scrub nurse
who has significant experience at the
hospital. He thinks the team need to be
empowered to speak up this will help the
team learn quicker and help reduce
misunderstandings. Some of his team have
reported that they don’t know what is going
on and they do not feel that they can raise
this in theatre. There is the perception that
the some of the surgeons and anaesthetists
do not listen to the more junior staff
Concerns / Barriers
•I think this is likely to fail.
•What will be the impact on
the patient?
•What will be the impact on
my staff?
•A big priority for J is the
patient journey and how
often the patient is asked
questions
•He finds the
documentation is a real
chore and is worried about
the team getting bogged
down in this

38. Concerns /Barriers
Profile: Consultant Surgeon
A is a long serving consultant who is
well known respected and influential.
He feels assured that he and his
team already complete all these
checks during the pathway. He does
not feel he makes or is at risk of
making errors. He feels the checklist
is a political tool that is not really
going to have any effect on quality or
safety of surgery.
•The checklist has been
developed on the back of a
political motive that will not
have any impact on patient
safety
•It could even have a
detrimental effect if it takes
staff away from the job in hand
•Experienced theatre staff are
seasoned professionals who do
not make errors
•It is not good for the patient –
they already have to respond to
too many checks and questions
as it is

39. Concerns/Barriers
Profile: Anaesthetic Registrar
M does not know the team very well
as she is a relatively junior
anaesthetist who does not always feel
easy communicating with the team.
She feels that there are sometimes
communication issues
She feels the checklist would be a
great mechanism for improving
communications and making sure all
of the team are on the same page
•Theatre is a noisy placewill whoever is doing this be
assertive enough to speak
up and enforce it?
•Who will lead this in
theatres and how will it be4
implemented?
•I am not sure if others will
buy into this, as they might
not need it as much as me
and might think it is a waste
of time

40. WHO SURGICAL SAFETY CHECKLIST
(Adapted for England and Wales and for Gateshead Health NHS Foundation Trust
SIGN IN
TIME OUT
SIGN OUT
Before Start of Surgical Intervention
Before induction of Anaesthesia
Before any member of the team
leaves the operating room
Has the patient confirmed their
identity, site, procedure and consent?
Y
Is the anaesthetic machine check
complete?
Y
ASA grade of patient
Does the patient have a:
♦Know allergy/metal work
♦An airway management plan
♦Relevant blood sampling
♦Adequate venous access
♦Has VTE prophylaxis been
planned/undertaken?
Y/N
Y/ NA
Y/N/N
A
Y
Y/N/N
A
Has the Surgical Site Infection bundle
been planned and undertaken?
♦Antibiotic prophylaxis within the last
60mins
♦Patient warming
♦Hair removal
♦Glycaemic control
Y/NA
Y/NA
Y/NA
Y/NA
Have all team members introduced
themselves by name and role?
Y
Has the surgeon/anaesthetist and
registered practitioner confirmed :
♦The patients name
♦The planned procedure, site and
position
♦Patient allergies and metal work
Y
Y
Y
Anaesthetist
♦Any patient specific concerns
♦Level of monitoring and support
♦Confirm SSI bundle/ASA grade/VTE
prophylaxis
Surgeon
♦Anticipated blood loss
♦Any critical steps
♦Other equipment /investigations
required
Nurse/ODP
Equipment sterility confirmed, any
equipment issues/concerns
Y
Y
Y
Y
Y
Y
Y
Is essential imaging displayed?
Y
♦Has it been confirmed that the
instrument, swab and sharps
count are complete?
♦Have the specimens been
labelled, including patient ID
♦Amount of blood loss
Y
Y
Y
Has the name of the procedure
been recorded?
Anticipated critical events
Please give details of any failure to complete any part of the checklist and the reason why.
Registered practitioner verbally
confirms with the team:
Y
Have any equipment issues
been identified?
Y/
N
Surgeon/Anaesthetist and Registered
Practitioner:
What are the key concerns for the
patients recovery?

41. After comments from staff, and
surgeons
Theatre Staff,
Allows us to prompt
surgeons and ask questions, so all
possible information is available.
Complicated patients, everybody
aware of what is going to happen
Ensures that all equipment is
available should extra things be
required.
Allows lists to be discussed so that
any change in order is known by all
Surgeons
Prevents delays, as all
equipment is available.
Everybody knows
exactly what is required,
minimizing delays.
Ensures that if list is
incorrect, it can be
changed

42. WHO Safer Surgery compliance
WHO Safer Surgery compliance
120
100
Briefing
80
Sign In
60
Time out
40
Sign out
20
11
gAu
n11
Ju
1
r- 1
Ap
11
bFe
c10
De
0
ct
-1
O
Au
g-
10
0

43. Scheduling Module
Process Map

46. Achievements
• Starting to see an improvement in theatre
utilisation from 89% to 92%
• 11% reduction in late starts
• 10% reduction in late finishes
• Cost savings in both kit and drugs spend
• 66% reduction in cancelled ops
• Reduced sickness absence levels from
6.9% to 3.9%
• Reduced bank usage from 1220 hours to
234 hours
• Improved team work and morale

47. Lessons learned
• It’s worth the hard work
• Champions will help you achieve an
end result
• Everyone is valuable
• Tangible improvements encourage
more improvements
• Stick with it and just do it

48. Thank You
• Any Questions

49. Before

50. After