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 workloadConsultants'
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 UTILISATIONGETTING
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 TIMEMINIMISING
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 timeAdditional
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 TIMESPEEDING
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
SAFETYENSURING
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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