12 minute read
Transforming eatre
by RCSI
IN RESPONSE TO LONG WAITING LISTS FOR SURGICAL CARE, RCSI HAS DESIGNED THE TRANSFORMING THEATRE PROGRAMME TO HELP HOSPITALS MAXIMISE THEIR THEATRE RESOURCES AS EFFICIENTLY AS POSSIBLE
Professor Deborah McNamara, MD, FRCSI
rofessor Deborah McNamara, MD, FRCSI is a Consultant General and Colorectal Surgeon at Beaumont Hospital in Dublin, a Clinical Professor of Surgery at RCSI, Co-Lead on the National Clinical Programme in Surgery and the chair of RCSI’s Working Group on Gender Diversity. Professor
McNamara is also Clinical Lead for the Transforming eatre Programme established by RCSI and, as the initial two-year pilot with the South/South West Hospital Group (SSWHG) draws to a close, she is currently seeking a second hospital group to participate in the programme.
“RCSI has been working in the area for some time,” explains Professor McNamara. “Our focus from the outset has been to make the patient’s journey in the operating theatre department the focus of standardised measurement and quality improvement.”
Professor McNamara has worked closely with Programme Manager, Charlie Dineen of RCSI, a process improvement expert, to develop and deliver the Programme using the principles of lean methodology – a way of optimising the people, resources, e ort, and energy of organisations toward creating value for the customer.
“ e Transforming eatre Programme design is a result of carefully constructed elements of lean methodology and principles, steeped in clinical knowledge and expertise,” says Dineen. “It is this coming together of lean experience coupled with clinical insights and awareness which has created a model speci cally applicable to a healthcare environment.”
Dineen explains that some of the lean principles paramount in the Transforming eatre Programme are Value, Flow and Respect for People.
“Value is to the fore in relation to people’s time,” he says. “For instance, we try to maximise the time surgical teams are engaged in surgical activity as opposed to waiting and other non-value activities, and likewise, from a patient’s perspective, prioritise timely access to the surgical care they require.
“Patient ow through theatre is captured using ve standardised key milestones which in turn generate a balanced suite of theatre metrics in a cascading tiered structure designed for frontline theatre teams, hospital managers and Hospital Group leaders. e measurement system also identi es the impact upstream and downstream processes have on the smooth transition of patients through theatre.
“To demonstrate respect for people, it is critical to engage and empower people closest to the work – in this situation, the operating theatre sta . e Transforming eatre Core Team at each site includes a surgical lead, anaesthetic lead and nurse lead, and together they determine locally the overall direction of the programme, while aligning with the suite of metrics provided. Lean tools are deployed as appropriate during Quality Improvement projects which are captured within an overall eatre Management System providing e ective action-based reviews and support.”
At the outset of the pilot, Professor McNamara was delighted when Professor Mark Corrigan, FRCSI, Clinical Lead within the SSWHG and Consultant Breast Surgeon in Cork University Hospital (CUH), volunteered to be the local surgical leader of the Programme.
“Surgeons hate waiting lists,” says Professor Corrigan, explaining his motivation for taking on the role. “We all want to work and our reward is seeing patients progress. If the service is to make the case for additional theatres, we need improved patient ow using the resources we have. What appealed to me about Transforming eatre is that it is one of the few initiatives that empowers clinical sta from the frontline rather than from management down.
“O en when management talks about e ciencies without providing the tools to achieve them, it can mean working people who are already stretched thin even harder. ey lose the locker room. e beauty of Transforming eatre is that it provides hospital sites locally with their own data from within. It’s a truism that what you measure, you improve, but once you start
seeing holes, projects start happening organically and being delivered. e greatest reward for the team is in seeing patients treated in a more timely fashion. And because you have buy-in from the Group, not just the hospital, the impact is horizontal and not just vertical.”
As Clinical Lead of the SSWHG, Professor Corrigan has found the experience of working with Professor McNamara, Charlie Dineen and Grace Professor Mark Corrigan, FRCSI Reidy, Transforming eatre Project Executive, refreshing. “Together they immediately prioritised the quick wins which would encourage everyone,” he says. “ e network of support from them has been outstanding; it feels as if we are wearing a common jersey. Nobody is cracking the whip making people work harder, and there is support from management.
“If we might need more resources in the future, we need data to make the case for those and the Programme adds a level of strategy to what we do. Because the data has to be interpreted locally, the system is built from the bottom up, and there is support to interpret the data and deliver improvement. e RCSI team was very visible on the ground in helping us to set up the database and people de nitely respond more positively if they feel they are in it together. It is quite refreshing and we have seen some encouraging outcomes.”
In his role as Consultant Breast Surgeon at CUH, Professor Corrigan has also seen the direct impact of the Programme on his day-to day-work. “At CUH we don’t have enough of anything and there is always more demand than capacity,” he says, “so by marrying together the hospitals in the group we are seeing tangible wins. As Bantry and Mallow develop daycase surgery, minor operations and endoscopy, they help and assist CUH with theatre capacity. Elsewhere in the SSWHG, Waterford and the SIVUH are two other hospitals which have done tremendous work looking at elective surgery. ere is enthusiasm across the group and we have increased the number of patients going through. Our experience shows that the Transforming eatre Programme is applicable to big hospitals such as University Hospital Waterford, and smaller hospitals such as Bantry General Hospital, and across all activities. at is very rewarding.”
At Mallow General Hospital, Denise Kearney, Assistant Director of Nursing over Day Services, has played a key role in the implementation of the Programme, and says it has been a wholly positive and empowering experience. “From the outset, Charlie and Grace, and hospital manager, Claire Crowley, have been amazing at explaining what they were trying to achieve in terms of making the theatre more e cient. Initially we had to identify the core team – Mr Aamir Majid as surgical lead, Dr Mike Pead as anaesthetic lead, Sheila Foley as nurse
TRANSFORMING THEATRE PROGRAMME
PROFESSOR DEBORAH MCNAMARA, CLINICAL LEAD
e Transforming eatre Programme is a collaboration between the Health Service Executive (HSE), the National Clinical Programme in Surgery (NCPS), the National Clinical Programme in Anaesthesia (NCPA) and each participating Hospital Group (HG).
It is an integrative approach to identifying and improving patient ow through the operating theatre. Unlike other theatre measurement systems, it is based wholly on the patient’s journey through the theatre department.
AIMS OF THE PROGRAMME
1. To embed a system of
standardised theatre metrics
enabling both locally-led improvements and high-level
Hospital Group development opportunities. 2. To establish a process for routine
review and action of these
metrics locally by theatre sta and Hospital eatre Governance
Group, and collectively by a Hospital Group eatre
Governance Group. 3. To provide a structured
Quality Improvement (QI) methodology to achieve
tangible improvements through a multidisciplinary
teams (MDT) approach. 4. To advance QI capability for all by providing training, facilitation and coaching at all stages of the programme. Nationally, the Transforming eatre Steering Group is chaired by Dr Siobhán Ní Bhriain, Integrated Care Lead, HSE Executive Sponsor with representation from NCAGL, the participating Hospital Group Senior Executive team and National Clinical leads from the NCPA & NCPS. e CEO of the participating HG is the Authorising Sponsor for the programme within that HG.
At the hospital level, ongoing support is provided by the National Transforming eatre team to each site including training, facilitation and coaching but there are key elements of the programme that each hospital and hospital group must deliver on for this support to continue. e aim of the support is to ensure independent sustainability of the programme by the hospital group.
Key to this is having the right
multidisciplinary governance
in place to lead, drive and own the programme locally. It is essential that this governance includes a consultant anaesthetic lead, consultant surgeon lead, perioperative nurse lead and a programme lead for the hospital. e operating theatre is a complex, resource-intensive environment and careful oversight of theatre capacity is vital to ensure this resource is used to optimal e ect. RCSI has designed a eatre Measurement Model to deliver a standard set of cascading metrics that are relevant for use at each theatre, theatre department, hospital and hospital group level. Standardisation of key terms used to document critical points in the patient’s journey through the operating theatre department in this measurement model enables consistency in measuring across all hospitals. Training is provided to ensure consistency and accuracy in the data input and how to interpret and use data to optimal e ect.
Each hospital’s Transforming eatre team identi es an initial quality improvement objective relevant to improving the use of their theatre(s). is objective
must be linked directly to the eatre Measurement Model metrics to ensure the impact of what is being improved is tangible and measurable. Each local team’s improvement project is supported by the National Transforming eatre team in using a structured Improvement methodology thereby building internal QI capability to support further improvement work.
Embedding the eatre Measurement Model as part of ‘everyday practice’ will ensure that current, consistent data is available for data-informed decisionmaking and it is critical to have the perioperative practice in place for regular review and action of these metrics.
From an operational point of view, this measurement model provides hospital theatre teams and theatre managers with standardised metrics on the use of their theatre resource including on-time starts, inter-operative interval times, overruns, underruns, throughput of cases and overall theatre utilisation by day.
To be of value, these metrics must be reviewed regularly by key sta working in the theatre department and the data used to
inform potential improvements
to support better use of the theatre resource locally, thereby improving patient ow. rough the Transforming eatre Programme, the HG has
access to standardised theatre metrics from the participating
hospitals at the Tier 4 level. e HG executive leads, clinical leads from the NCPS and NCPA engage in regular ‘site traction calls’ with individual hospital teams where information is shared, and key learnings are disseminated throughout this programme network. lead and myself and Claire – and get buy-in from all the theatre sta .” e Mallow team set their rst objective as starting on time. “We thought it would be an easy x,” says Kearney, “but it turned out to be more di cult than we had envisaged. Reassuringly, lots of theatres nd this di cult but it makes the most impact. ere were simple, simple things, like our clocks being set to di erent times and we needed to ensure they were all in sync.
“Charlie and Grace helped us to develop a simple template that everyone could use to record data; we had to learn how to use the so ware and generate charts, and we created a theatre transformation wall which we update each month with graphs and charts, so everyone can see the improvements easily. COVID-19 impacted our progress but we are now starting to hit our target of starting on time 40% of the time, two days a week. One simple x identi ed by our Multi Task Attendant (MTA) was that he needed to come in 15 minutes earlier to help get the rst patient over. We involved everyone from the Health Care Assistants (HCAs) to nurses to anaesthetists to surgeons.”
Professor McNamara says she has been impressed by the positive attitude of everyone at Mallow General to the pilot, and credits Kearney and her colleagues there with the idea for the second initiative under the Programme. “We could see as many as 15 local anaesthetics taking place in the general theatre on any given day,” says Kearney, “which explained why the theatre was only being used to 33% of capacity. We looked to see if those procedures could be done elsewhere and identi ed a space adjacent to the theatre and Day Services ward, and spoke to senior management. anks to Charlie and Grace, we had the data and knew how to discuss it. We needed equipment but management backed us and we have now set up a minor procedure unit. We are now a couple of months into the trial and it is going well, we are getting through eight lists a month of six patients with no expansion of sta ng, and reduced locals to theatre, and now we are starting cystoscopies.”
Denise Kearney is full of praise for the positive attitude inherent in the way the Programme is implemented. “Oversight is not negative so we have been honest about the challenges and we never got negative feedback which might have been discouraging,” she says. “We might have failed without the continuous support and encouragement, Charlie’s IT expertise and Grace’s theatre experience – it’s like having access to a constant helpline!
“Every three months they have brought the team together, and Professor McNamara came down herself, which was huge for us – someone of her calibre demonstrating such an understanding of a small hospital. It’s all about getting the right patient to the right place at the right time. We are taught to drill down and gure out the problems, no one is ever publicly outed for mistakes and sta ng problems, such as time-keeping, are dealt with on a peer-to-peer basis, surgeon to surgeon, or nurse to nurse. Some of the people you least expect, such as HCAs, feel really involved and are excited by the Programme. ey all realise that the data we are collecting is being looked at and listened to. We are not perfect, but there’s great power in non-biased data.
“As a Model 2 hospital we feel we have a place in the Group, and we were never once made to feel inferior. Everyone talks about Model 4 hospitals, but for a Model 2 it’s really important to have a purpose. I feel we have shown a bit of grit and resilience; we want our theatre to stay and it won’t if we don’t make it work.”
For ProfessorMcNamara and her colleagues, the project is already rewarding and they see the potential impact on surgical waiting lists as a huge motivation for progressing the Transforming eatre Programme.
“We also believe that additional investment could allow many more surgical patients to be treated using our existing infrastructure,” she says. ■
Charlie Dineen, Programme Manager
Denise Kearney, Assistant Director of Nursing/Programme Lead
