Select Committee on Health Written Evidence


Annex 1

INNOVATION AND BEST PRACTICE IN ISTCs

INTRODUCTION

  1.  Although innovation and best-practice exist within the NHS, ISTCs have demonstrated a propensity for combining a wide range of such practices in one place to generate improvements in efficiency and patient care. Staff are drawn from a wide range of sources and introduce best practices from their own countries. Although the good practices (eg swab counting) remain the inquisitorial process allows all preconceptions to be challenged in an non-accusatory environment that welcomes changes that improve patient care. As such, ISTCs do not conduct ground-breaking research nor do they introduce changes that cannot be found elsewhere.

  2.  It should be noted that ISTCs are not expected to be performing cutting edge research, but are expected to be consistently incorporating tried and tested world class best practice, whether clinical or management focused, in order to deliver high quality and patient centric solutions within an efficient operation. Some go on to act as focal points for the spread of innovation and best practice.

  3.  A significant element of the "innovation" related to ISTCs is in reality about diligence, being scrupulous about all the little things that can improve productivity and applying them rigorously across the board.

EXAMPLES

  4.  Some of the innovations and best practices that have been adopted in ISTCs (eg the use of mobile units, or blood conservancy measures) are well publicised, however they do not represent the full extent of the practices adopted by ISTCs. The following examples are taken from a recent survey of three ISTCs (Shepton Mallet Treatement Centre referred to as LP7, the Greater Manchester Surgical Centre referred to as LP8 and the Peninsula NHS TC referred to as LP9).

  5.  They highlight how ISTCs adopt innovative or best practices and ways of working across all areas of their operations, from physical layouts to administration and culture. Attributing practices here to certain ISTCs is not intended to suggest that they do not occur in other TCs.

ADMINISTRATION AND WAYS OF WORKINGTHE ISTC ETHOS

  6.  The administration and ways of working are centred on patient care rather than support services. The aim is to get the maximum use from the physical facilities while minimising service disruptions.

    —  No admin time: It is expected that surgeons will deliver 46-48 weeks operating time per year. There is no "admin time" in their contract and they share high quality admin support. They are expected to deliver pre-picked lists and to maximise the conversion from outpatient to surgery. Primary care screening is an important element that has been seen to facilitate this process.

    —  Efficient process design: (LP7) ISTCs that have designed their clinical and physical pathways from scratch, learning from NHS custom and practice have been able to make improvements. For instance some ISTCs can conduct six to seven arthroscopies per day compared with three to four in the NHS. because they work to take out extraneous processes or take them off line (eg they acquire consent at outpatient appointments and so do not delay the operation. Surgery can therefore commence at the start of the working day).

    —  Increased day surgery: Operational Productivity has been improved through the widespread adoption of day surgery and operating on a six day working basis as the norm with a 12 hour theatre day.

    —  Reminder calls: (LP9) Contacting patients two to three days before a planned operation, reduce Did Not Attend rates. Whilst this also occurs in some instances in the NHS, within ISTCs it is a widespread and routine practice.

    —  Workload management: (LP8 and LP9) Theatre manager/lead consultants oversee distribution of workload—Consultants' workload is monitored by a manager who ensures equitable distribution of work and minimises over- or under-work by consultants. Advance visibility into consultant leave schedules eliminates cancellation of planned procedures due to visibility into consultant availability.

    —  "One stop" pre-screening: (LP9) Every patient undergoes a comprehensive pre-screening appointment(s) in which they see a consultant, nurse, and anaesthetist. Candidates not fit for treatment are therefore quickly eliminated.

    —  Sharing best practice: (LP7, LP8 and LP9) As part of patient pathway design and surgical practice alignment process, staff are encouraged to discuss systems and practices which they have employed elsewhere or otherwise have heard about in order to identify improvements to the efficiency of the current system. In this way practices evolve in keeping with national and global best practice.

    —  Short notice cancellation list: Patients seeking accelerated care are put on a "to be notified" list and are called if cancellations occur. This saves vacated theatre slots from being "lost".

    —  Interchangeably scheduled consultants: (LP8) Patients do not have to be operated on by the same consultant who saw them in outpatient, increasing ability to schedule patients in earliest available slots.

THEATRE UTILISATION—GETTING THE MOST FROM THE ASSETS

  7.  Best practices surrounding theatre utilisation permit more efficient and predictable use of one of a key asset. This maximises throughput and decreases costs.

    —  "In place, on time" culture: (LP7, LP8 and LP9) All staff and equipment are in place and performing their required tasks on time. This minimises delays to operation starts, patient transfers, etc.

    —  Admission/recovery area close to theatre: (LP8 and LP9) Patients await operations in a space adjoining theatre area, minimising patient transfer delays and removing pre-operative bottlenecks caused by lack of bed availability, which can cascade to delay operations.

    —  Use of specialist nurses: Anaesthetic nurses working in support of anaesthetic consultants can increase the anaesthetic consultant's ability to attend to numerous patients quickly.

    —  Minimising bed transfers: (LP7) Patients walk into anaesthetic area for day case procedures, rather than being wheeled in, eliminating delays caused by need for four assembled staff to transfer a patient from a pre-operative to operative trolley.

THEATRE TIME—MINIMISING THE TIME UNDER THE KNIFE

  8.  Minimising the time an individual patient spends in theatre allows ISTCs to increase their overall productivity. In making the staff more efficient, several working practices also increase their expertise and increase the quality and safety of their work.

    —  Spinal anaesthetic: (LP7, LP8 and LP9) Appropriate administration of spinal anaesthetic instead of general, for some procedures, shortens preparation and recovery time.

    —  Limiting prosthesis ranges: All ISTCs limit the range of prostheses they stock. Not only does this introduce economies of scale in purchasing, but it allows staff, in particular the nursing teams, to develop slicker, more effective theatre processes, increasing the quality and decreasing the time spent in surgery.

    —  Repeat exposure of operating teams: (LP7, LP8 and LP9) Surgical consultants work repeatedly with small teams on the same types of procedures. Some centres have also decided not to use temporary fill-ins to ensure staff familiarity and quick execution of in-theatre duties. This staff familiarity breeds clarity of roles and the ability to anticipate needed tasks (eg, tools required by surgeon at different stages of the operation), resulting in streamlined execution.

    —  Varying schedules based on consultant operating times: (LP7, LP8 and LP9) A scheduler knows typical consultant operating time variability and schedules theatre lists accordingly. This results in fewer deviations from the theatre schedule, increasing the hospital's ability to effectively deploy resources where they are needed at the right times. Maximum number of theatre sessions used within scheduled staff time—Additional procedures are added to theatre lists as productivity improves. This maximises throughput and minimises idle staffed theatre time, eg, between operations.

    —  Physical Design: Optimising layouts in the design of facilities, incorporating a great attention to detail on minimising staff and patient movement distances, the use of ceiling mounted utilities and accessible, efficient storage has resulted in many "small time savings".

    —  Responsiveness: The relatively small scale of some ISTCs promotes efficiency in patient care. An example of this is that on completion of a procedure, porters are ready to move the patient, they do not need to be called.

    —  Staff expectations and awareness of timelines: (LP8 and LP9) Internal publication of or blinded sharing of consultant surgery durations drives awareness of performance, accountability to timelines, and elimination of unnecessary mid-operative delays.

BED TIME—SPEEDING UP RECOVERY

  9.  ISTCs have adopted a range of practices that increase recovery rates. Not only do these reduce bed time and increase the productivity of the centre, they also improve the patient's experience.

    —  Setting patient expectations: (LP7) Patients attend a class two weeks prior to their operation through which their expectations are set around their recovery trajectory (eg, mobilisation on day one, discharge on day four or five), and in which they are trained in exercises and the use of specialised equipment. This prepares the patient for speedy recovery and discharge.

    —  Early initiation of discharge requirements: (LP8 and LP9) "Rehab teams" (external or internally-employed therapists) are activated in advance of patient operations to ensure post-operative readiness, eg, installation of handrails in the home. This eliminates discharge bottlenecks of lack of home preparedness or inavailability of step-down care.

    —  Admission of patients day of procedure: (LP7) Admission of fit patients for major surgery (eg, hip or knee replacement) the day of the procedure, eliminating resource utilisation for unnecessary pre-operative overnight care.

    —  Chair-based post-operative recovery: (LP9) Rather than being moved to a bed for post-operative recovery, for some cases, patients recover in a special chair and are mobilised quickly after the operation (eg, within two hours). This expedites patient recovery and reduces bed blocking.

    —  Post-operative monitoring: After operations, such as joint replacements, patients are monitored very closely for 24 hours to ensure that any issues are captured and dealt with. This has allowed inpatient stays to decrease to 4.4 days for hip replacements. An NHS Trust has adopted similar protocols and is achieving similar improvements in bed times down from 12 days.

    —  Discharge lounge: (LP9) A separate discharge is available for patients who are clinically fit to leave but must wait for pick up. This reduces frequent non-clinical delays to patient discharge.

QUALITY AND SAFETY—ENSURING HIGH STANDARDS

  10.  Quality and safety are key to the successful operation of the ISTCs. Through incentives, increased accountability and the propagation of best practice ISTCs seek to guarantee high quality services and improve the patient's experience.

    —  Review of complications: (LP8 and LP9) Consultants participate in a weekly review of all major procedures that week and any minor procedures in which there was a complication. Slides are reviewed and issues discussed. Differences in clinical practice among doctors are quickly identified and best practices are shared. Poor performance/outcome trends either clinic-wide or tied to a single clinician are immediately surfaced, discussed and resolved.

    —  Infection pre-testing of all inpatients: (LP7, LP8 and LP9) All patients are tested for MRSA (and in some cases, specialty-appropriate other high risk infections), before being admitted. Infected patients are treated for any infections prior to admission and are required to test clean one to three times (depending on provider) before being cleared for admission.

    —  Isolation of infected patients: (LP7, LP8 and LP9) Any admitted patient identified to have one of several specified infections, including MRSA, is isolated from other patients and given a dedicated "contamination" nurse. The infection is therefore far less likely to be passed on to other patients.

    —  Tight infection monitoring and root cause analysis: (LP8) All detected infections such as MRSA are rigorously identified and root causes identified. Data on what type of infection and its likely source is tracked and investigated. The quality team discusses any occurrences of infection and possible additional preventative measures required, and may also raise these at JSR meetings. As a result, trends are identified, causalities uncovered, and additional preventive measures can be put in place, as needed.

    —  Patient surveys: (LP9) Patients are offered a patient survey across up to six dimensions of care, and are repeatedly surveyed throughout their stay using an easy to use electronic tool. Patients can register satisfaction and dissatisfaction easily at multiple points in their visit.

    —  Post discharge check-up: (LP7) Patients are called 24 hours after discharge for a mini phone-based checkup and so that any questions may be answered.

    —  Fringe activities: It has been submitted[2] that the NHS has traditionally been very poor at providing "fringe activities" that whilst not directly linked to quality of clinical care are valued by patients. It is recognised that it is ISTCs that have succeeded in providing such benefits as polite staff, easy car parking, refreshments, little or no waiting, etc.

INNOVATION IN THE NHS

  11.  As previously stated these practices are not unique to the ISTC community, they are also not universal throughout the IS, however they are representative of philosophy demonstrated by IS providers in maximising their efficiencies while maintaining high standards. It is likely that each of the practices outlined here can be found somewhere in the NHS, however, in 2002, the NHS Modernisation Agency Elective Care Team reported that good practices it had identified in NHS TCs were not widespread, nor did any TC embody more than a small fraction of them.



2   Oral Evidence taken before the Health Committee on 16 March 2006, HC 934-ii, Qq 305-308 [Mr Johnson]. Back


 
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Prepared 25 July 2006