Scheduled Care Patient Pathway

National Clinical Programme in Surgery

The National Clinical Programmes commenced in 2012 and represent a strategic initiative between the Health Service Executive’s Quality and Clinical Care Directorate and the various post-graduate training bodies. The aim is to design and implement change initiatives to improve and standardise the quality of care and access for all patients.

The EMB is committed to the full implementation of the Clinical Care Programme in Surgery and it is clear that such implementation will bring significant benefits to the overall performance of the hospital and to patient’s experience. To oversee the implementation of the Programme, the EMB established a governance structure overseen by the Surgical Directorate and developed a comprehensive work programme that is outlined in a Quality Improvement Plan.

The Hospital was identified as an exemplar site for the implementation of the Programme and this has been supported through the multidisciplinary approach adopted by the staff involved and their willingness to embrace change. In addition the Hospital prioritised capital investment in key infrastructural projects including;

(i) Provision of a dedicated acute surgical ward incorporating a 6 bed surgical assessment unit, 6 surgical day beds and 10 inpatient beds;

(ii) Construction of a pre – admission assessment unit;

(iii) Construction of a day of surgery admission unit (DOSA);

(iv) Allocation and staffing of a dedicated emergency theatre

(v) Provision of a second Orthopaedic trauma theatre.

These investments in infrastructure have provided an environment in which significant changes have been made in patient flow improving efficiency and the patient experience.

Theatre Management - Electronic Theatre Scheduling System

The optimal management of highly specialised resources in the theatre complex requires that managers have available to them timely, accurate and comprehensive management information to support decision making and to provide direction for theatre services. The EMB recognising the requirement to have such a system in place established a working group to oversee the development of an Electronic Theatre Scheduling System.

The Hospital is committed to implementing Lean and Six Sigma principles to improve the efficiency of services and to minimise redundancies therein. To maximise the deliverables from the implementation of the Electronic Theatre Scheduling system it was necessary to undertake Lean & Six Sigma Processes to identify other steps in the pathway that required to be streamlined. Based on the outcomes from the Lean & Six Sigma Processes a theatre management information system was implemented in 2014. This represented a large change in work practices and processes but now provides a suite of management reports that allow the governance group to manage resources optimally. The following are a number of the improvement realised following the implementation of the system:

• Structured approach is now in place for the notification of Consultant leave so that scheduling of cases and theatre capacity can be managed to its maximum.

• The utilisation of sessions and a theatre calendar with the objective of enabling anticipated structural improvements

• The creation of a centralised Bed Booking function

• The implementation of an electronic theatre list that improves communication between wards and theatre.

• Completion of an electronic bed booking pilot project.

• The alignment of theatre access as per activity

• The management of rolling theatre closures

• The implementation of the National Inpatient and Day Case Management Policy.

The Productive Operating Theatre (TPOT)

The Productive Operating Theatre is a comprehensive improvement initiative designed to enable hospitals to improve patient experiences and outcomes by pursuing three main objectives:

• increase safety and reliability of care

• effective teamwork and improved staff morale

• value and efficiency.

Implementing the TPOT programme will provide the hospital with an opportunity to improve the quality and safety of surgical services through Quality Improvement (QI) methodologies and effective team-working. Cost containment measures and greater safety coupled with an increased demand for healthcare services are well-established drivers for change and improvement. External factors such as new treatment modalities and revised international norms and standards must also be observed. These factors all impact on work processes and systems within the operating theatre environment.

CUH has commenced the process of implementing TPOT and is presently signing off the criteria for Participating Acute Hospitals undertaking the TPOT Quality Improvement (QI) initiative. Listed hereunder are the benefits realised to date from the implementation of the programme:

• Reduction in number of theatre nurses on call from 11 WTE per night to 8WTE per night;

• Opening of in hours emergency theatre in November 2011-initial call savings approximately €85,000 - €90,000;

• Installation of computers in in each theatre;

• iPMS installed l in theatres and data inputted by staff. Data being captured on excel spread sheet in Theatre 9, Emergency Theatre and orthopaedic theatre;

• Installation of interactive white board in theatre recovery facilitation real time information for staff;

• Twice daily meetings in theatre with CNM3 and CNM or deputy of each theatre to ensure communication of any issues related to theatre flow;

• €305,000 saved with introduction of customized procedure packs;

• €15,000 saved on sutures and other inventory savings were made and this is an on-going project in theatre with streaming of inventory;

• On-going work in each theatre aiming to standardise areas;

• 5S project in theatre 9 facilitated the organisation of a minor ops room for local anaesthetics;

• Improved patient pathways with DOSA and Pre-admission opening, staggered admissions for patients-Increase in WTE to support this, plus full time administration support;

• Further improvement between DOSA and Theatre with the amalgamation of theatre reception and DOSA;

• Standardisation of patient documentation- inpatient and day case patients;

• Change in opening times of admissions from 7.30am to 7am as a result of project work and involving all relevant departments;

• Reorganisation of theatre stores and creating better standard and flow of sterile instrumentation packs;

• Lean education – Staff education in green belt, black belt and yellow belts – improvement projects undertaken by staff while undertaking these courses;

• Walking patient to theatre and now where feasible walking patients directly into theatre- more efficient;

• Improved theatre start times due to improved pathways;

• Reduction in Intra Operative Interval (IOI) by 10 min;

• Electronic schedule (always available);

• Kanban introduced-cost of stock to be removed from pilot Savings in stock issues in pilot theatre Theatre (based on average cost price);

• Cabinet and 5S inventory savings;

• Standard work practice for all medical secretaries;

• Greater visibility across the different functions.

The EMB is mindful of the resources expended in theatre and information from the theatre management system will be critical in supporting the implementation of Activity Based Funding.

Surgical Assessment Unit

The EMB continues to implement change initiatives that support overall the performance of the hospital. In this regard the opening of the Surgical Assessment Unit which streams patients that present at the Emergency Department who need surgical assessment has the potential to significantly improve the performance of the Emergency Department in respect of PET times and patient flow. This 5 bed unit is now in the process of being commissioned and when fully operational will as outlined above have a positive effect on patient flow.

Outpatient Services

The HSE has determined that optimisation in the delivery of outpatient services is a key priority for the organisation and in 2010 the Executive Management Board at Cork University Hospital established a steering group, chaired by the CEO to provide leadership in this area. The steering group meets on a monthly basis and is representative of various stakeholders involved in the delivery of outpatient services.

The hospital sees approximately 250,000 outpatients each year and works within the framework of the national guidelines for the management of outpatient services. The key priorities for the group are:

• Identification of capacity and opportunities for optimisation in the functioning of the Outpatients Department;

• Implementation of systems improvement in the delivery of Outpatient services;

• Achievement of improvements in planning processes and productivity;

• Reduction in the non-attendance rate to 10% as determined by the HSE;

• Development of a model for managing the financial and other resources used by the Department;

• Management of systemic problems that may arise in the Department and resolution of contentious issues;

• Re-design processes to simplify the system using available management techniques;

• Development of a quality programme for outpatient services.

The following are examples of specific change initiatives that have been implemented in respect of the Outpatient service:

• Restructuring of clinic appointments to allow for timed appointments;

• Reorganisation of schedules to provide a consultant led speciality service at the outpatient clinic;

• Reorganisation of clinical profiles by new and return ratio to meet the targets set out in the national waiting list targets;

• Continuous monitoring of the start and finishing times of clinics to maximise capacity;

• Monthly review of clinic Did Not Attend (DNA) rates each month;

• Introduction of Physiotherapy led clinics in the Orthopaedics and Neurosurgery specialties resulting in earlier access for patients;

• Introduction of GP sessions in the outpatient clinics to maximise the number of patients reviewed at each clinic and to develop closet links with GP’s and community services.