Challenging and Changing Challenging and Changing Every Step of the Surgical Every Step of the Surgical
Pathway in an NHS HospitalPathway in an NHS HospitalEHMA Annual Conference, Athens, June 2008EHMA Annual Conference, Athens, June 2008
M. HEMADRIM. HEMADRIMBBS (Madras) FRCS (Edinburgh) MBA (Leicester)MBBS (Madras) FRCS (Edinburgh) MBA (Leicester)
In this presentationIn this presentation
Conventional surgical pathwayConventional surgical pathway Challenge each stepChallenge each step Single Visit pathway & resultsSingle Visit pathway & results People versus structurePeople versus structure Leadership from the ground and Leadership from the ground and
Feed-forward techniquesFeed-forward techniques ProblemsProblems LessonsLessons
Present/Traditional ModelPresent/Traditional ModelGP REFERS PATIENT
Up to 13 weeks
Specialist Consultation
Radiology Endoscopy +/- 13 Weeks
Other specialists, anaesthetic assessment
+/- 2 to 8 weeks
Bloods & review 6 weeks
Review and place on waiting list
Surgical operation
Nurse pre-assessmentUp to 6 months
Routine post operative visit/visits
2 to 12 weeks
18 WDP Impact31/62 Impact
12
2
2
34
5
6
Business Process Re-engineeringBusiness Process Re-engineering"... the fundamental rethinking and radical redesign of "... the fundamental rethinking and radical redesign of
business processes to achieve dramatic improvements in business processes to achieve dramatic improvements in critical contemporary measures of performance, such as critical contemporary measures of performance, such as
cost, quality, service, and speed.“cost, quality, service, and speed.“Hammer & Champy (1993)Hammer & Champy (1993)
Time compressionTime compression Process re-designProcess re-design
The shortest distance between two points is a straight lineThe shortest distance between two points is a straight line
Time compression of Traditional ModelTime compression of Traditional Model
GP REFERS PATIENT
6 weeks
Specialist Consultation
Radiology Endoscopy 6 Weeks
Other specialists, anaesthetic assessment
6 weeks
Bloods & review 6 weeks
Review and place on waiting list
Surgical operation
Nurse pre-assessment6 Weeks
Routine post operative visit/visits
6 weeks
18 WDP Impact
12
2
2
34
5
6
How useful is a post-operative follow up visit?How useful is a post-operative follow up visit?
70% of patients felt that they would 70% of patients felt that they would not benefit from a routine outpatient not benefit from a routine outpatient appointment.appointment.
Re-engineering of Traditional ModelRe-engineering of Traditional Model
GP REFERS PATIENT
6 weeks
Specialist Consultation
Radiology Endoscopy 6 Weeks
Other specialists, anaesthetic assessment
6 weeks
Bloods & review 6 weeks
Review and place on waiting list
Surgical operation
Nurse pre-assessment6 Weeks
12
2
2
34
5
Strong and abundant Strong and abundant evidence for effectiveness of evidence for effectiveness of telephone pre-assessment telephone pre-assessment
Especially for day case surgeryEspecially for day case surgery
Re-engineering of ModelRe-engineering of Model
GP REFERS PATIENT
6 weeks
Specialist Consultation
Radiology Endoscopy 6 Weeks
Other specialists, anaesthetic assessment
6 weeks
Bloods & review 6 weeks
Review and place on waiting list
Surgical operation
Telephone pre-assessment6 Weeks
12
2
2
3
4Lets look atVisit 2 & 3
Re-design: Emerging new modelRe-design: Emerging new model
GP REFERS PATIENT
6 weeks
Specialist Consultation
Radiology EndoscopyOther specialists,
anaesthetic assessment
Bloods
Surgical operation
Telephone pre-assessment
11
1
1
2Lets look atVisit 1 & 2
6 weeks
Dissatisfaction was due to waiting times between admission operation and discharge.
Single Visit ModelSingle Visit Model
Structured GP Referral Standard pathwayUnsuitable
Communication – Negotiation with patient
Suitable
Telephone Pre-assessment
Surgical Consultation, Investigations, Nurse Assessment, Anaesthetist Assessment, Admission and Operative Surgery
ALL ON THE SAME DAY
Discharge when stable
NO ROUTINE FOLLOW UP
Guarantee to see in 48 hours at request
1
New model performanceNew model performance Age range 20 to 83 years (M:F 2:1)Age range 20 to 83 years (M:F 2:1) Minor (small lesions, vasectomy): Intermediate (hernia, Minor (small lesions, vasectomy): Intermediate (hernia,
varicose veins): Major (gall bladder, incisional hernia):varicose veins): Major (gall bladder, incisional hernia): LA:GA=1:1LA:GA=1:1 No mortality, one unplanned admission, no 30 day No mortality, one unplanned admission, no 30 day
readmissions. readmissions. Reduced DNA rates. Reduced DNA rates. No cancellation due to hospital reasons. No cancellation due to hospital reasons. 20 declined due to lack of indication/complexity/fit with 20 declined due to lack of indication/complexity/fit with
exclusion criteria)exclusion criteria) Referral to treatment time: Average 4 weeksReferral to treatment time: Average 4 weeks No major complicationsNo major complications No significant complaintsNo significant complaints
COSTCOST
Patient FeedbackPatient Feedback
‘‘BETTER THAN PRIVATE’BETTER THAN PRIVATE’
Why are we different?Why are we different? Conventional ProjectsConventional Projects 18 WDP18 WDP Hospital at nightHospital at night 2/52 & 31/622/52 & 31/62
Conventional TeamsConventional Teams Chairman, Vice Chairman, Chairman, Vice Chairman,
Project Manager, Project Manager, Appointed/deputed multi-Appointed/deputed multi-discipline membersdiscipline members
Modernisation/Service Modernisation/Service Development Development sponsorship/supervisionsponsorship/supervision
Regular formal meetings, Regular formal meetings, reportsreports
Recipe booksRecipe books ‘‘‘‘Assured success’’Assured success’’
Unconventional projectUnconventional project
Spontaneously emerging, self Spontaneously emerging, self selected teamsselected teams
No hierarchical structureNo hierarchical structure No titlesNo titles
Self-monitoringSelf-monitoring
No budgetNo budget Very rare formal meetingsVery rare formal meetings Continuous informal contactContinuous informal contact Never produced a formal Never produced a formal
reportreport Action first – discussion and Action first – discussion and
documentation later.documentation later.
Rigid infrastructureRigid infrastructure
Flex/alter structure to get people in lineFlex/alter structure to get people in line
Use people to get around rigid structureUse people to get around rigid structure Example our patient admin IT systemExample our patient admin IT system
Emotional appeal one at a time builds up Emotional appeal one at a time builds up to a changeto a change
Sharing the glory is an investmentSharing the glory is an investment
Financial – forget it?Financial – forget it? Co-authoringCo-authoring Award applicationsAward applications Exclusive day outsExclusive day outs Appreciation lettersAppreciation letters Press exposurePress exposure
FEED FORWARD TECHNIQUES
Some of our team enjoying at the racecourse with a Brazilian
theme!!
The Rewards NetworkThe Rewards Network
ACTIVITY
CV
improvem
ent
Better A
ppraisals
PayRise
Promotion
AuthorshipAwards
Press citingLetters of appreciation
Other
PrestigeSelf worth
Emotional satisfactionSoft skills enhancement
FEED FORWARD TECHNIQUES
LosersLosers ResistorsResistors
DoctorsDoctors HospitalHospital OPDOPD WardWard Back office staffBack office staff
Busy surgeons Busy surgeons have long waiting have long waiting listslists
Genuine belief in Genuine belief in the old linear the old linear sequential process sequential process
Not invented hereNot invented here
Turkeys will not vote for Christmas
LEADERSHIP FROM THE GROUNDLEADERSHIP FROM THE GROUND
Goole District HospitalGoole District Hospital Accepting fluidityAccepting fluidity Accepting asymmetrical progressAccepting asymmetrical progress Saying ‘Yes’ more often than ‘no’Saying ‘Yes’ more often than ‘no’ Using the power of non-agendaUsing the power of non-agenda Short term micro feedbackShort term micro feedback Long term macro feed forwardLong term macro feed forward
Current StatusCurrent Status
Radiology/Ultrasound and out patient Radiology/Ultrasound and out patient predictive synchronisationpredictive synchronisation
Radiology/USS + OPD + Pre-Radiology/USS + OPD + Pre-Assessment synchronisedAssessment synchronised
Radiology/USS + OPD + Pre-Radiology/USS + OPD + Pre-Assessment + Anaesthetist Assessment + Anaesthetist Assessment synchronisedAssessment synchronised
NATURAL EXPANSION OF THE CONCEPT AND
GENERIC GROWTH OF THE TEAM
So what is the problem?So what is the problem?
Transformational change Transformational change but……………but……………
Small scaleSmall scale Roll outRoll out
WHAT IS THE SOLUTION?
Optimism.Strength of the model.Getting more political?
ConclusionsConclusions
Change programmes not centrally defined Change programmes not centrally defined can be done with equal or better successcan be done with equal or better success
People can be used to overcome rigid People can be used to overcome rigid infrastructureinfrastructure
Loose alliance of normal employees can Loose alliance of normal employees can achieve the same effects as formal teamsachieve the same effects as formal teams
The impact of small informal teams & their The impact of small informal teams & their projects could be local and limited but…..projects could be local and limited but…..
Lessons learntLessons learnt
Feed-forward is a useful tool not only Feed-forward is a useful tool not only for hard and soft career progression for hard and soft career progression but also a good political tool for but also a good political tool for enabling change.enabling change.
Leadership from the ground is Leadership from the ground is definitely possible and perhaps definitely possible and perhaps should be used more oftenshould be used more often
THANK YOUTHANK YOUAcknowledgement to our small core team which apart Acknowledgement to our small core team which apart
from myself includesfrom myself includes
Peter Moore, Consultant SurgeonPeter Moore, Consultant SurgeonJeanette Heaven-Terry, Surgical SecretaryJeanette Heaven-Terry, Surgical SecretaryJane Hopkins, Sister Day Surgery UnitJane Hopkins, Sister Day Surgery UnitTheatre floor in-charge of the dayTheatre floor in-charge of the dayAnaesthetist of the day (usually Dr. M Thant, Associate Anaesthetist of the day (usually Dr. M Thant, Associate Specialist or Dr S Jha, Staff Grade)Specialist or Dr S Jha, Staff Grade)
ANDANDAn increasing band of extended team members and An increasing band of extended team members and supporterssupporters