Operating Theatres and Day Surgery
Cardiff and Vale University Health Board
Audit year: 2010
Issued: February 2013
Document reference: 388A2011
Status of report
Page 2 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
This document has been prepared for the internal use of Cardiff and Vale University Health Board as part of work performed in accordance with statutory functions, the Code of Audit Practice and the Statement of Responsibilities issued by the Auditor General for Wales.
No responsibility is taken by the Wales Audit Office (the Auditor General and his staff) in relation to any member, director, officer or other employee in their individual capacity, or to
any third party.
In the event of receiving a request for information to which this document may be relevant, attention is drawn to the Code of Practice issued under section 45 of the Freedom of
Information Act 2000. The section 45 Code sets out the practice in the handling of requests that is expected of public authorities, including consultation with relevant third parties. In
relation to this document, the Auditor General for Wales (and, where applicable, his appointed auditor) is a relevant third party. Any enquiries regarding disclosure or re-use of
this document should be sent to the Wales Audit Office at [email protected]
The team who delivered the work was led by Anne Beegan.
Contents
Page 3 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
While there are a number of initiatives underway to improve theatre utilisation in the UHB,
action needs to be accelerated within the context of a whole system plan for operating
theatres.
Summary report
Summary 4
Recommendations 6
Detailed report
A combination of factors is resulting in underutilisation of theatres and low day
case rates within the UHB
9
The UHB recognises theatres as a priority but a number of factors are
preventing it from delivering the actions set out in the operational plan
30
Although there are some positive aspects, staff raised concerns around
communication, staff morale, training and development and aspects of the
safety culture
36
The UHB has made good progress to improve the collection and analysis of
theatre data and now needs to use this information to challenge and change
working practices
44
Appendices
Methodology 48
UHB‟s Management Response to Recommendations 50
Measures of Theatre Utilisation 55
Day Surgery and Short Stay Surgery comparison against best quartiles
performance by each BADS procedure
56
Summary report
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Summary
1. Operating theatre services are an essential part of patient care and range from routine
procedures to highly specialised operations. These procedures can be carried out as
part of scheduled care (elective) or unscheduled care (urgent/emergency). In recent
years advances in medical practice mean that many operative procedures can be
performed as day case or short stay episodes. The Designed for Life aspirational
target is that by 2015, 85 per cent of patients undergoing elective surgery will stay in
hospital for less than 48 hours.
2. It is in the interests of patients and NHS organisations to ensure that operating theatre
resources are used to best effect to ensure they are cost effective, support the
achievement of waiting time targets and contribute to a more positive patient
experience.
3. Previous work carried out by the Wales Audit Office has identified significant scope for
improvement in operating theatre and day surgery1 performance. In 2006, the Wales
Audit Office report, „Making better use of NHS day surgery in Wales’, identified that
although the overall rate of day surgery was improving, it remained low and there
remained barriers to improvement. Local reviews of the Welsh NHS trusts at that time
identified opportunities for improving theatre performance and our most recent legacy
reports demonstrated long-standing areas of underperformance in theatres and short
stay surgery for a number of the predecessor trusts.
4. In September 2009, the Welsh Government carried out an end-of-year assessment of
performance against the 2008-09 efficiency and productivity programme measures.
This assessment emphasised the considerable improvements and potential
productivity gains that could be realised by improving operating theatre and day
surgery performance.
5. In recent years, the Welsh Government has made a number of significant
improvements to the way that short stay and day surgery delivery is measured. The
Welsh Government has issued a revised basket of 50 short stay procedures2 which
replaced the basket of 33 procedures. The associated targets reflect a departure from
emphasis solely on „day case‟ delivery towards a focus on longer stay aspects of short
stay surgery delivery; i.e. less than 24 hours and 72 hours and is in line with the British
Association of Day Surgery 2009 Directory of Procedures.
6. For the Annual Operating Framework (AOF) 2010-11 efficiency and productivity
programme, the Welsh Government has included operating theatres development
work, the Theatre Productivity Tool, which is aimed at providing a holistic and accurate
picture of delivery and utilisation. Further, theatre and day surgery improvements are
key components of the National Delivery Board for Acute Productivity.
1 Day surgery means elective (pre-planned) surgery carried out on a day case basis (where the
patient is admitted and discharged on the same day). 2 EH/ML/041/09 which came into effect from 1 April 2010.
Page 5 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
7. During the latter part of 2010 and early 2011, the Wales Audit Office undertook an
examination of health boards‟ arrangements to manage and run their operating
theatres (Appendix 1). The work was undertaken in partnership with the Audit
Commission to facilitate comparison of performance between NHS bodies in England
and Wales. Our review asked the following question: Is Cardiff and Vale University
Health Board (the UHB) effectively planning and using its operating theatres?
8. We found that while there are a number of initiatives underway to improve theatre
utilisation in the UHB, action needs to be accelerated within the context of a whole
system plan for operating theatres.
A combination of factors is resulting in underutilisation of theatres and low day
case rates within the UHB:
‒ there is scope to improve utilisation of main theatres including emergency
and trauma sessions;
‒ day surgery theatre utilisation is variable and, whilst lengths of stay are
short, the day case rate is low when compared to performance across
England and Wales; and
‒ there are a number of factors that adversely affect utilisation in theatre
suites across the UHB.
The UHB recognises theatres as a priority but a number of factors are preventing
it from delivering the actions set out in the operational plan:
‒ theatres is recognised as a strategic priority which is underpinned by clear
priorities within the UHB‟s operational plan; and
‒ financial challenges and capacity levels has meant that the UHB has
struggled to deliver many of the actions identified in its 2010-11 operational
plan.
Although there are some positive aspects, staff raised concerns around
communication, staff morale, training and development and aspects of the safety
culture:
‒ staff have raised concerns about communication and morale which will
need to be addressed as a matter of urgency; and
‒ although there are signs of a positive safety culture, some aspects of
safety need to be addressed and staff have mixed views around training
and development.
The UHB has made good progress to improve the collection and analysis of
theatre data and now needs to use this information to challenge and change
working practices:
‒ data collection within theatres involves a good mix of measurements which
have been strengthened through the development of the „Theatre Cube‟;
and
‒ the UHB has monitoring arrangements in place but needs to demonstrate
that it is using the improved information at its disposal to challenge and
change working practices by engaging with its workforce.
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Recommendations
9. We make the following recommendations. The UHB‟s response to these
recommendations is included in Appendix 2.
Strategy and Planning
R1 Develop a coherent, all-encompassing plan for operating theatres. This plan should:
be realistic in its nature;
clearly set out priorities and the reasons for focusing on these issues;
be supported by clear action plans, with accountabilities and timescales;
be underpinned by a medium and long term capacity plan;
be consulted upon with operational staff involved in operating theatres; and
set out how the UHB will move surgical activity for future service transfers.
Preoperative assessment and list preparation
R2 Maximise the impact of preoperative assessment and list preparation by:
accelerating work to standardise preoperative assessment processes across the
UHB, learning from practice already in place in the short stay surgery unit;
ensuring theatre lists preparation maximises the use of theatre time, for example
using consultant specific procedure times to minimise under or over listing, and
providing training for staff preparing lists; and
reintroducing scheduling meetings.
Theatre Utilisation
R3 Maximise the utilisation of both elective and emergency theatres by:
ensuring lists are flexed to reflect known clinical commitments which impact on
the start of theatres lists;
considering the allocation of all day lists, wherever possible;
working with other parts of the hospital and UHB to smooth patient flow through
theatres, and anticipating peaks in activity to prevent blockages for example,
within the holding bay;
modelling bed capacity against service reconfiguration to ensure bed availability
does not cause cancellations;
ensuring patients are fully prepped for theatres and that all appropriate tests and
investigations are completed and reported prior to a patient arriving in theatres;
reviewing the pathway for all categories of emergency activity;
ensuring the centralisation process for reallocation of lists includes all surgical
specialties; and
working with the Transforming Theatres programme, spread transferable
practices shown to improve patients flow across the UHB.
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Day Surgery
R4 Reinforce the need to deliver improved levels of day surgery performance by:
reinvigorating efforts to drive up rates of day surgery and short stay surgery,
using the data in this report to identify key procedures to target, ensuring that:
‒ opportunities to improve short stay surgery and day case rates are considered
across the whole BADS basket;
‒ all patients with intended management as day-cases are coded as such; and
‒ all BADS basket procedures are listed as day-cases, unless clinically
indicated as inpatients.
analysing the day surgery and short stay surgery theatre capacity to identify
opportunities to redistribute day case activity that currently occurs in main
theatres and/or increase day surgery throughput; and
establishing a clinical champion for day surgery.
Equipment
R5 Strengthen the management of equipment by:
undertaking an audit of all theatre equipment and ensuring appropriate
maintenance and replacement programmes are in place; and
working with the UHB‟s procurement department to ensure procurement
practices within theatres are standardised and the level of differing equipment is
kept to a minimum.
Staffing
R6 Effectively manage staff resources across the theatre suites by:
reviewing staffing levels across the theatres suites to ensure that there is an
appropriate distribution of staff;
reviewing arrangements for supporting new staff;
proactively managing down the current levels of sickness absence;
ensuring consultant job planning includes an allowance for back-filling vacant
theatre sessions, wherever possible;
monitoring the impact of controls on vacancies and temporary usage on front line
staffing levels;
ensuring allowances are made within staffing establishments to allow staff to
undertake mandatory training; and
providing staff adequate access to IT resources.
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Communications and morale
R7 Improve two-way communication with staff and address cultural and morale issues by:
establishing a range of communication mechanisms including the establishment
of a Theatre User Group or similar forum;
developing an understanding about the issues affecting morale and perceptions
of management and workload, taking appropriate actions to address causes;
ensuring all staff have clarity on roles and responsibilities within the management
structure;
promoting the use of safety briefings both before and after lists;
ensuring that executives, independent members and senior management are
more visible to staff in the theatre suites; and
using the Transforming Theatres teamwork module to rebuild team morale,
particularly at UHW.
Performance Management
R8 Strengthen the existing performance management arrangements by:
promoting awareness amongst operational staff of aspects of theatre
performance in a way which is not demoralising to staff;
ensuring theatre performance is used to inform job planning discussions as a way
of informing improvements and providing constructive challenge; and
expanding performance measures to include:
‒ financial aspects of performance;
‒ equipment and use of stock; and
‒ utilisation of space, to ensure that best use is being made of the available
space particularly at UHW.
Source: Wales Audit Office
Detailed report
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A combination of factors is resulting in underutilisation of theatres and low day case rates within the UHB
10. In this section of the report we discuss the performance of the UHB‟s operating
theatres and its day case rates. We also discuss the factors underpinning this
performance. For the purpose of this report, theatres within the UHB have been
divided into two groups:
Main Theatres, encompassing all inpatient theatres at University Hospital of
Wales (UHW), referred to as „UHW Main Theatres‟, and all inpatient theatres at
University Hospital Llandough including the Cardiff and Vale Orthopaedic Centre
(CAVOC), referred to as „Llandough Main Theatres‟; and
Day Theatres, encompassing the Short Stay Surgery Unit at UHW and the Day
Surgical Unit at Llandough hospital.
There is scope to improve utilisation of main theatres including
emergency and trauma sessions
Overall utilisation of main theatres is typical of many of others although there is still some
considerable time lost through inefficiencies
11. Our review considered four main measures of theatre utilisation. Full details of these
measures are included in Appendix 3 but brief details of the measures we have used
are included below:
end utilisation – this provides an impression of the overall utilisation of planned
theatre time and is calculated by multiplying together each of the three elements
below:
‒ planned list utilisation – this measure focuses on the hours lost due to
session cancellations;
‒ run time indicator – this measure considers whether surgery begins and
ends on time; and
‒ operating hours utilisation – this measure focuses on the gaps between
patients on a list.
12. Exhibit 1 shows that the end (overall) utilisation of elective lists within the UHB‟s main
theatre suites is above average when compared with other sites3. End utilisation for the
period reviewed4 was 82 per cent in University Hospital Wales (UHW) and 80 per cent
in Llandough hospital.
3 Comparative group includes all main theatres in England and Wales, with a sub-comparator group of
main theatres in Wales. 4 The sample period started on 21 June 2010 and ran for six weeks.
Page 10 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 1: End utilisation of elective lists in main theatres
End U
tilisation (
%)
Theatre Suites
CV
UH
W U
HW
Ma
in
CV
UH
W L
lan
do
ug
h M
ain
UPPER QUARTILE
LOWER QUARTILE
0
50
100
150
Source: Wales Audit Office and Audit Commission
13. Exhibit 2 gives an estimation of the actual operating hours lost per week in terms of
sessions as a result of inefficiencies within or impacting upon elective theatres. The
table assumes one session equates to 3.5 hours, calculated over the six week period
reviewed.
Exhibit 2: Sessions lost per week as a result of poor theatre utilisation
Theatre suite Estimated sessions lost per week
University Hospital Wales – main theatres 22 sessions
Llandough – main theatres 18 sessions
Source: Wales Audit Office and Audit Commission
Some time is lost due to session cancellations although this is minimal in main theatres at
UHW
14. The „planned list utilisation‟ (see Appendix 3) indicator allows consideration of the time
lost due to cancelled sessions. Exhibit 3 shows that cancelled sessions are not a
problem in UHW with planned list utilisation at the upper quartile performance of all
comparable theatre suites. Performance in Llandough was comparatively average. For
the period reviewed, UHW lost fewer than four per cent of planned operating hours
through cancelled sessions compared with just over seven per cent at Llandough.
Page 11 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 3: Planned elective list utilisation
Lis
t U
tilisation (
%)
Theatre Suites
CV
UH
W U
HW
Ma
in
CV
UH
W L
lan
do
ug
h M
ain
UPPER QUARTILE
LOWER QUARTILE
0
50
100
150
Source: Wales Audit Office and Audit Commission
15. The sample period for our data collection was during the summer. It is expected that
session cancellations would be elevated due to key staff being on annual leave.
Theatre lists generally start and finish on time which is good practice
16. If a theatre session goes ahead it is important that it starts and finishes at the right
time. If sessions start late, time is wasted and can result in the patient at the end of the
list not having their surgery. Late starts can also result in the sessions overrunning. If
sessions finish early, this can be as a result of unforeseen reasons, such as patients
not turning up to hospital for their procedure, but it can also be due to too few patients
being put on the theatre list. We recognise the size and complexity of some of the
cases undertaken within the UHB can present challenges in making best use of a
theatre list, particularly when cases can take a considerable length of time.
17. The run time indicator (see Appendix 3) we measured in our sample period (which
covers time lost due to late starts and early finishes, rather than just the proportion of
lists affected) suggests the theatre sessions within the main theatre suites generally
start and finish on time. Run time utilisation for the period reviewed was at 98 per cent
at UHW and 97 per cent at Llandough. Performance in both theatre suites is above the
average for all comparative suites (Exhibit 4).
Page 12 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 4: Run time utilisation of elective lists
Run T
ime U
tilisation (
%)
Theatre Suites
CV
UH
W U
HW
Ma
in
CV
UH
W L
lan
do
ug
h M
ain
UPPER QUARTILE
LOWER QUARTILE
0
50
100
150
Source: Wales Audit Office and Audit Commission
Time lost due to gaps between patients is problematic in both theatres, particularly in main
theatres in UHW
18. As well as ensuring that sessions start and finish on time, health boards must minimise
the gaps between patients on a theatre list. The gap between patients, for the purpose
of this report, is recorded as starting from the point in which a patient leaves the
operating theatre through to the next patient being anaesthetised. Where less complex
patients, such as those undergoing day surgery procedures or having local
anaesthesia, are being operated on it is recognised that the gap should be much
shorter. The Delivery Support Unit (DSU) is working with health boards across Wales
to focus attention on the turnaround time5 of patients to minimise these gaps.
19. Gaps can occur for a variety of reasons, for example, late patient arrival in theatre from
wards or delays in receipt of sterile equipment. Exhibit 5 shows that the time lost due
to gaps between patients on lists in the main theatres at UHW is a particular problem
with performance at the lower quartile performance. Performance in Llandough is just
below the average for all comparative suites.
5 The turnaround time is calculated from the time the patient leaves the operating theatre through to
the time the next patient arrives in the operating theatre.
Page 13 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 5: Operating hours utilisation of elective lists
Opera
ting H
ours
Utilisation (
%)
Theatre Suites
CV
UH
W L
lan
do
ug
h M
ain
CV
UH
W U
HW
Ma
in
UPPER QUARTILE
LOWER QUARTILE
0
20
40
60
80
100
Source: Wales Audit Office and Audit Commission
20. When examining overall utilisation of theatre suites by speciality (including day surgery
theatres, as discussed in the following section), a highly variable picture is presented.
In some specialities there is limited variation between theatre suite utilisation across
the UHB‟s theatres while in other specialities, overall utilisation varies widely between
theatre suites6.
Utilisation of both emergency and trauma sessions is comparatively low
21. In addition to elective operating sessions, there are also planned sessions for
emergency and trauma operating at UHW. Overall utilisation of the planned theatre
hours for emergencies and for trauma at UHW is below average for comparator
theatre suites and in some cases within the lower quartile performance (Exhibits 6
and 7).
6 A supplementary series of indicator charts is available to the UHB to help further examination of the
extent to which overall speciality utilisation of theatres is affected by planned list, run time and operating hours utilisation.
Page 14 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 6: Overall utilisation of emergency theatres U
tilisation o
f P
lanned H
ours
(%
)
Theatre Suites
CV
UH
W U
HW
Ma
in UPPER QUARTILE
LOWER QUARTILE
0
20
40
60
80
100
Source: Wales Audit Office and Audit Commission
Exhibit 7: Overall utilisation of trauma sessions (including those held in the Short Stay
Surgery Unit)
Overa
ll U
tilisation (
%)
Theatre Suites
CV
UH
W U
HW
Ma
in
CV
UH
W S
hort
Sta
y S
urg
ery
Unit
UPPER QUARTILE
LOWER QUARTILE
0
50
100
150
Source: Wales Audit Office and Audit Commission
Page 15 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
22. In considering the overall utilisation of trauma lists, we analysed planned list, run time
and operating hours utilisation. These indicators suggest that while all planned
sessions were used in main theatres and in the short stay surgery unit at UHW, there
were issues with lists not starting and/or finishing on time in the short stay surgery unit
and more time was lost due to gaps between patients in both theatre suites than many
other comparable suites. We have not carried out a similar in-depth analysis of the
utilisation factors for emergency lists as by definition, planning for emergencies is less
predictable.
Day surgery theatre utilisation is variable and, whilst lengths of stay are
short, the day case rate is low when compared to performance across
England and Wales
Overall utilisation of day theatres is variable across the two hospitals with list cancellation
and gaps between patients an issue
23. Our review found average performance in relation to day surgery theatres. Exhibit 8
shows that at 70 per cent, the end utilisation of the day surgery unit at Llandough was
just below the upper quartile performance when compared with similar units7 in
England and Wales. The performance of the short stay surgery unit at UHW was
comparable with other similar units at 59 per cent, although still relatively low.
Exhibit 8: End utilisation of day surgery theatres
End U
tilisation (
%)
Day Theatre Suites
CV
Lla
nd
ou
gh
Ho
spit
al
DS
U
CV
UH
W S
ho
rt S
tay S
urg
ery
Un
it
UPPER QUARTILE
LOWER QUARTILE
0
20
40
60
80
100
Source: Wales Audit Office and Audit Commission
7 Comparative group includes all day theatres in England and Wales, with a sub-comparator group of
all day theatres in Wales.
Page 16 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
24. When looking at the different aspects of utilisation within the day surgery theatres, the
data would suggest that:
The UHB lost fewer than 4 per cent of planned day surgery operating hours at
UHW but almost 12 per cent at Llandough due to cancelled sessions. The
performance at Llandough was just below average.
Late starts and early finishes are not a problem in the day surgery unit at
Llandough with performance within the upper quartile. Performance for the short
stay surgery unit at UHW was average when compared with similar units.
The utilisation of actual operating hours, accounting for gaps between patients
on lists, in the day surgery theatres is just below average in the day surgery unit
at Llandough but within the lower quartile performance in the short stay surgery
unit at UHW.
25. Exhibit 9 illustrates the comparative performance and identifies the percentage
utilisation rate for each of the utilisation indicators.
Exhibit 9: Utilisation indicators for day surgery units
Utilisation Indicator Short Stay
Surgery Unit
(UHW)
Day Surgical
Unit
(Llandough)
Upper Quartile
Benchmark
Planned List Utilisation 96.3%
in the UQ
88.3%
below average
94.6%
Run Time Utilisation 81.6%
average
96.8%
in the UQ
87.3%
Operating Hours Utilisation 74.7%
in the LQ
81.8%
below average
92.4%
Source: Wales Audit Office and Audit Commission
The UHB has comparably low lengths of stay for basket procedures although the day case
rate is amongst the lowest performing quarter of all NHS bodies in England and Wales
26. When compared with other organisations across England and Wales, the overall
length of stay for patients undergoing the day case basket procedures in Cardiff and
Vale is within the lower quartile performance, and the lowest of all teaching
organisations (sub-comparator group) (Exhibit 10) at 0.99 days which is recognised as
good performance.
Page 17 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 10: Length of stay for short stay surgery O
vera
ll Le
ngth
of S
tay
All Trusts and Health Boards
UPPER QUARTILE
LOWER QUARTILE
0
5
10
15
20
Source: Wales Audit Office and Audit Commission
27. A comparatively short length of stay could however suggest that many patients are
staying a relatively short period of time and could potentially have been managed as a
day case. At 57 per cent the UHB has a low day case rate. Exhibit 11 shows that the
overall rate of day surgery8 was the lowest of all teaching organisations and it was also
in the lower quartile performance of organisations in England and Wales.
Exhibit 11: Day case rate for basket procedures
Ove
rall
Day
Cas
e R
ate
(%)
All Trusts and Health Boards
Car
diff
and
Val
e
UPPER QUARTILE
LOWER QUARTILE
0
20
40
60
80
100
Source: Wales Audit Office and Audit Commission
8 We have used the total British Association of Day Surgery (BADS) basket of 188 procedures.
Page 18 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
28. We have used the total British Association of Day Surgery (BADS) basket of 188
procedures rather than the revised basket of 50 short stay procedures used in Wales.
The English and Welsh data has been matched by counting those patients who had an
intended management as a day case. This can result in a difference between the day
case rate reported under our BADS analysis and that reported under NHS Wales
definitions.
29. Data from the UHB‟s Integrated Performance Report reported to the Board in June
2011 reflected that the UHB‟s day surgery rate remained below the Welsh
Government‟s target level of 75 per cent. Performance was reported to have increased
from 66.6 per cent to 73 per cent in the second half of 2010-2011, although it is
important to note that the UHB also reported that the total number of day case
procedures is understated by circa 10 per cent because of issues connected with
coding. More recent data for 2012-13, shows that the performance has since
deteriorated to 67.2 per cent against the revised Annual Quality Framework (AQF)
target of 80 per cent.
30. Whilst we acknowledge that for some procedures the day case rate is affected by
coding issues which the UHB is already starting to address, the UHB needs to be
assured that everything is being done to encourage day surgery as the intended
management of patients where this is clinically appropriate.
31. This overall performance however masks variation within specialty procedure groups
and between the individual procedures within those groups. Analysis of the day case
performance by specialty also reveals large variation between specialties. Appendix 4
provides a full breakdown of the speciality procedures, their lengths of stay and the
associated day case rates, together with the benchmark targets for each procedure
based on upper quartile performance.
There are a number of factors that adversely affect utilisation in theatre
suites across the UHB
32. There are a number of factors affecting the UHB‟s theatre utilisation. Some factors are
under the control of the theatre department, but others arise from wider organisational
issues and involve other departments and organisational processes. The following
section of this report illustrates how these factors are impacting on theatre utilisation in
the UHB.
Cancellations are being kept to a minimum which would suggest that leave requests are
being well managed although there is scope to improve backfilling arrangements
33. As outlined in paragraphs 14 and 24, the cancellation of lists is resulting in lost theatre
time to varying degrees across all theatre suites, although the impact is generally
minimal when compared with other suites.
Page 19 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
34. Whilst we have identified variation across theatre suites, the data also shows variation
across specialties within theatres. However the analysis does not identify any
specialities, by theatre suite, where performance for the period reviewed is within the
lower quartile of the comparative group, or is below 84 per cent.
35. We recognise that the period that we reviewed coincided with the summer period
where list cancellations may have been elevated due to summer leave. It also
coincided with a period of theatre refurbishment within the UHB and at a time when
waiting list initiatives were ceased, reducing capacity to backfill lists particularly in
orthopaedics. This is confirmed with the UHB data on planned session utilisation
reported to the Performance Committee in April 2011 which indicated a decline in
performance for the period June through to September (Exhibit 12). However, due to
effective management of annual leave requests, arrangements for offering sessions or
backfilling staff, the impact of annual leave commitments on the utilisation of theatre
lists is generally kept to a minimum throughout the year.
Exhibit 12: Planned Session Utilisation reported to the Performance Committee
Source: Cardiff and Vale University Health Board Integrated Performance Report
36. Despite these arrangements, the UHB is still however losing a proportion of sessions
per month due to cancelled lists. During our fieldwork, we were told that lists can go
down due to the unavailability of surgeons. Our findings from the staff survey9 also
confirmed that this was a problem with 25 out of 71 (35 per cent) staff responding to
the survey across the UHB agreeing with the statement „in the last month, the reason
for session cancellation was surgeon availability‟. This compared to 30 per cent across
Wales and was the highest level of agreement across all of the health boards.
9 A staff survey was undertaken as part of this review across all health boards in Wales during
October and November 2010. Further details can be found in Appendix 1 of this report. At the UHB, only 80 staff responded, despite encouragement from the UHB to do so. While unlikely to be representative of all staff involved in theatres across the UHB, we have used these responses to illustrate particular issues.
Page 20 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
37. We were also told that communication of cancelled lists amongst staff can be
problematic and that on several occasions, theatre staff had turned up for a theatre list
to find that it had been cancelled. This is often as a result of the directorates holding
back from communicating to staff until last minute in the event that the list can be
backfilled.
38. When a list needs to be cancelled, good practice would suggest that the available
session is offered out firstly to other consultants within the same specialty and then to
other specialties using the theatres. Whilst we were told that there was a central
process for the reallocation of lists which used the good practice principles, we were
also told that this only applied to the specialties within the Surgical Services Division10.
This meant that lists were often not being offered out to specialties within other
divisions and vice versa, and as a consequence sessions could go unused.
39. Some health boards have provided backfill arrangements through the inclusion of
backfill sessions within consultant job plans. This ensures that theatre lists are not lost
through leave commitments and also promotes team working to ensure that resources
are used collectively. Our review of the consultant contract within the UHB would
suggest that this arrangement is not fully embedded across all specialties, although we
are aware of potential plans to allocate lists on a speciality basis as opposed to a
consultant basis to try to eliminate the problem of list cancellations.
Problems in securing beds are having a negative impact on theatre performance and the
wider use of elective resources
40. Cancellations due to lack of beds was identified as a common problem throughout our
fieldwork with performance consistently reported above the AOF target of two per cent.
A theatre admission lounge in the UHW main theatres is meant to support patients to
be admitted directly to theatres on the day of surgery. However, we were told that this
facility was not being used to its full extent due to concerns amongst clinicians that
there was no guarantee that a bed would be available for patients post-operatively. As
a consequence, we were told that patients were either being cancelled or consultants
were often admitting patients the day before surgery to ensure that surgical beds were
guaranteed.
41. Admitting patients on the same day as their surgery can provide a better patient
experience and reduce avoidable use of inpatient beds. Current performance in the
UHB indicates that with exception of orthopaedics which has some ring-fenced beds,
none of the specialties are achieving the national day of surgery admission (DOSA)
targets (Exhibit 13). The practice of bringing patients in on the day before surgery will
have a negative impact on the UHB‟s elective length of stay and place unnecessary
pressure on beds.
10
Surgical specialties within the Surgical Services Division include: Trauma and Orthopaedics, Ophthalmology, ENT, General Surgery and Urology.
Page 21 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 13: Day of Surgery Admission (DOSA)
Specialty Target (Revised
target for 2012/13)
Performance for
2010/11
Performance for
2012/13 to date
ENT 96% (81%) 74% 70%
General Surgery 58% (65%) 28% 23%
Gynaecology 62% (56%) 39% 48%
Ophthalmology 90% (87%) 79% 64%
Oral Surgery 82% (45%) 43% 40%
Orthopaedics 56% (64%) 64% 68%
Urology 71% (62%) 54% 39%
Source: Cardiff and Vale University Health Board Integrated Performance Report
42. During our review, we were told by theatre staff that access to ITU and HDU beds was
also affecting theatre cancellations. Concerns were raised about the willingness of
critical care staff to commit to accommodating patients post theatres particularly if
critical beds were fully occupied but were predicted to become free during the day. At
the time of the review, critical care facilities had been reconfigured at the Llandough
site, reducing the level of intensive care capacity. However staff were concerned that
the complexity of patients had not reduced and on some occasions, identified patients
having to been cared for on a 1:1 basis on wards in order to release blockages within
theatres and prevent cancellations. A data collection exercise was underway to look at
the level of theatre cancellations as a result of ITU capacity although we have not seen
the results of this exercise.
Improving day case rates has the potential to release inpatient bed days and make better
use of the day surgical capacity
43. The Wales Audit Office‟s 2006 report „Making the best use of NHS day surgery in
Wales‟ stated: “Where clinically appropriate, day surgery delivers benefits for patients
undergoing elective surgery. It reduces the length of stay in hospital thereby lowering
costs to the NHS, and the risk of hospital-acquired infections”. The report goes on to
provide evidence that day surgery should be the default position for elective surgery.
44. In paragraphs 26 and 27, we identified that the average length of stay of patients
undergoing any of the 188 BADS procedures in the UHB is comparatively low at 0.99
days which compares well. However we also identified that the day case rate is also
comparatively low at 57 per cent.
Page 22 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
45. During our fieldwork we were told by staff that more could be done to improve day
surgery rates. At the time of the review, the UHB had not re-established a clinical
champion for day surgery across the two sites and not all specialties had access to the
day surgery facilities, such as cardiothoracic surgery. Day surgery was also not always
considered the default position and we were also told that whilst the short stay surgery
unit had overnight provision, this was acting as a disincentive to discharge patients
quickly and resulting in some patients staying longer than necessary.
46. Our analysis of the BADS procedures includes an assessment of the potential bed day
savings per annum if best quartile performance levels are achieved when considering
day case and length of stay performance. If the UHB improved its day case
performance to that of the upper quartile performance alongside reducing its length of
stay for those patients needing to stay in overnight (where length of stay for the
individual procedure is not already comparatively low), a potential 3,434 bed days per
annum could be saved. The UHB should use the information included in Appendix 4 to
examine its current day case performance focusing particularly on procedures where:
there is greatest potential bed day savings; and
the average length of stay for patients is less than one day.
Preoperative processes for the short stay surgery unit at UHW are effective but less so for
patients going through other theatre suites
47. In advance of surgery, patients should undergo a preoperative assessment to ensure
they understand the risks of the procedure and confirm that they are suitable for
surgery. Effective preoperative assessment should therefore reduce cancellations from
patients not attending for surgery and from patients arriving in an unfit condition for
surgery.
48. Preoperative assessment arrangements vary across the UHB. Staff were generally
more positive about the standardised arrangements which have been put in place for
patients coming through the short stay surgery unit at UHW. However at the time of
the review, there was no consistent application of preoperative assessment across the
UHB and staff from Llandough and those working in UHW main theatres were much
more negative. The diverse views about the effectiveness of the UHB‟s preoperative
processes are reflected in the findings of our staff survey and are outlined in Exhibits
14 and 15.
Exhibit 14: Staff response to „There is effective patient screening and
pre-assessment processes‟
Strongly
agreed
Agreed Neither
agreed nor
disagreed
Disagreed Strongly
disagreed
Don’t
know
5 (7%) 23 (30%) 14 (18%) 17 (22%) 14 (18%) 4 (5%)
Source: Wales Audit Office survey of CVUHB theatres staff
Page 23 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 15: Staff response to „Preoperative patient screening and assessment has
improved theatre utilisation‟
Strongly
agreed
Agreed Neither
agreed nor
disagreed
Disagreed Strongly
disagreed
Other
6 (8%) 25 (33%) 18 (23%) 14 (18%) 7 (9%) 7 (9%)
Source: Wales Audit Office survey of CVUHB theatres staff
49. When reviewing this analysis by hospital site within the UHB, 50 per cent of staff
responding to our survey from Llandough hospital disagreed with the statement „there
is effective patient screening and pre-assessment processes‟. This compared to 33 per
cent at UHW and 25 per cent across Wales. This level of disagreement was one of the
highest in Wales and would suggest that lessons could be learnt from preoperative
arrangements currently in place in the short stay surgery unit at UHW.
50. Patients being treated through the short stay surgery unit, and some inpatient
specialties at UHW, are pre-assessed immediately after the decision to treat is made
by the consultant in outpatients. This process is supported by a dedicated nurse led
pre-assessment team which is underpinned by dedicated anaesthetic sessions.
Although capacity is identified as an issue, as is the location of the service, the general
processes for preoperative assessment for these patients was identified as working
well by all staff and specialties involved.
51. In other areas, and particularly Llandough where only general surgical patients were
being pre-assessed on the same day as the outpatient clinic, the majority of patients
are pre-assessed by nurse practitioners from within the relevant specialties six weeks
prior to „their come in‟ (TCI) date. This process was found to sometimes lead to last
minute changes to theatre lists as patients were too close to the waiting list breach
date to allow flexibility within the scheduling process. Staff also raised concerns that,
on occasions, appropriate tests had not always been completed by the time the patient
arrived in theatre, causing delays to lists and sometimes patient cancellations. These
tests should have been completed prior to admission following preoperative
assessment.
52. The UHB has the benefit of some proactive champions for preoperative assessment
and there has been a lot of work in recent years to develop the arrangements which
are now in place in the short stay surgery unit, but resource constraints and lack of
wider management support outside the division has not seen these arrangements
rolled out across the UHB. As a consequence, preoperative assessment has not been
able to contribute as fully as it could in improving theatre performance and this is
subsequently being conveyed in the views from the staff.
Page 24 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Although not generally a problem, the ability of theatre lists to start and finish on time can be
affected by untimely arrival of staff and list planning arrangements
53. Overall, our data indicated that late starts and early finishes are not a particular
problem for the main theatres, but were a problem for the SSSU at UHW. Just over
430 hours for the sample period across the UHB were lost due to this issue, an
average of 72 hours per week. The UHB‟s own performance data indicates that the
proportion of lists that have late starts and/or early finishes is consistently above the
AOF11 target of 10 per cent. There is variation however across specialties and across
sites as outlined in the following exhibit, which identifies the utilisation of lists by
specialty, after accounting for hours lost to late starts and early finishes. The exhibit
also demonstrates that while some lists are starting late and/or finishing early, others
are starting early and/or overrunning which can put pressure on staff to work extra
hours.
Exhibit 16: Variation in Run Time Utilisation across theatre suites and specialties
Source: Wales Audit Office and Audit Commission
11
For the purposes of the Annual Operating Framework, a late start is considered as being 15 minutes or more past the official start time of the list and an early finish is considered as being 30 minutes or more before the official end time of the list.
Page 25 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
54. There are two main reasons why the theatre lists within the UHB are starting late
and/or finishing early. Firstly, the findings of our staff survey identified that 33 out of 44
staff (75 per cent) at UHW disagreed with the statement „medical staff always arrive on
time to start their theatre list‟, compared with 14 out of 33 (42 per cent) at Llandough
hospital. The timely arrival of surgical and anaesthetic staff is affected by a number of
factors:
The majority of theatre lists within the UHB are all day lists, however, all of the
lists in the short stay surgery unit, and in some theatres in the other suites, were
half day sessions at the time of our review. Overruns in other clinical
commitments held in the morning, such as outpatient clinics, can invariably have
an impact on the start of a theatre session in the afternoon. This problem can be
exaggerated if staff have to travel between sites.
The lack of a consistent approach to preoperative assessment can also mean
that anaesthetists can be delayed due to the need to complete preoperative
assessments and checks on the wards, despite having clarity within individual
job plans. Similarly, surgeons can be delayed due to the need to undertake ward
rounds. The geographical spread of wards, particularly at the UHW site, can add
further delays.
55. Secondly, the effectiveness of list scheduling can have an impact on whether theatre
lists are used to their full potential. During our fieldwork we were told by staff that the
arrangements for putting lists together were variable, with good arrangements in place
for orthopaedics where lists were compiled at least four weeks in advance and for the
short stay surgery unit where lists were compiled by the preoperative assessment
nurses. In many other areas however, lists were compiled by a mix of junior doctors,
medical secretaries and preoperative assessment nurses, and often were not made
available to theatre staff until the afternoon or evening before.
56. This short notice leaves limited time for theatre staff to respond to equipment
demands. It also restricts opportunities to amend the running of the lists if necessary or
to suggest additions or deletions from the list in a manner which takes into
consideration the patient experience. Consequently, delays may be experienced in
starting lists or under listing may result in early finishes. These issues are reflected in
the findings of our staff survey which identified that:
only 21 out of 43 staff (49 per cent) responding at UHW and 12 out of 33 staff
(36 per cent) at Llandough hospital agreed with the statement „the majority of
theatre lists are effectively planned’; and
only 19 out of 44 staff (43 per cent) at UHW and 19 out of 34 (56 per cent) at
Llandough hospital agreed with the statement „operating list planning maximises
the number of operations which can be carried out safely’
Page 26 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
57. We were also told that due to the half day sessions within the short stay surgery unit,
staff were often reluctant to start cases after 11.30am to prevent any overruns into the
afternoon sessions. The complexity of some cases in main theatres can also mean
that some lists only have capacity for one case and the remainder of the list is left
unused. Steps have been taken to minimise the impact of this in Cardiology by
formally extending the list to allow other cases to be listed, although on occasions this
can mean that lists do run short. However, we understand that spare capacity on
elective lists can often be used to support the management of emergency demand.
58. Where lists are commonly known to frequently either start late or finish early, steps
should be taken to revisit the scheduling of those lists either through the reduction in
frequency of lists or by formally shortening lists to account for other known
commitments. Although the UHB has demonstrated flexibility on the duration of the
lists, for example, shortening some all day lists to accommodate the refurbishment
programme, the findings of our staff survey suggest that more could be done, with only
8 out of 44 staff (18 per cent) responding at UHW and 12 out of 34 (35 per cent) at
Llandough hospital agreeing with the statement „theatre list start times are flexed to
meet the collective needs of the team‟.
59. A number of staff identified that scheduling meetings used to take place two to three
weeks before a list was held to address issues that may affect the timing and
scheduling of lists. This process was found to be useful but was stopped prior to NHS
reorganisation in 2009 and at the time of the review had not been resurrected. We
understand that there are now daily scheduling meetings.
Various factors are resulting in some gaps between patients
60. Our earlier analysis of gaps between patients, as outlined in paragraphs 19 and 24,
showed that gaps between patients are reasonable in most theatre suites in the UHB.
The average gap between patients and the range across specialties is outlined in
Exhibit 17.
Exhibit 17: Average gap in minutes between patients
Theatre suite Average gap between
patients (minutes)
Range across
specialties (minutes)
UHW Main Theatres 22 11-27
Llandough Main Theatres 11 10-21
UHW Short Stay Surgery 13 9-22
Llandough Day Surgery 10 6-13
Source: Wales Audit Office and Audit Commission
Page 27 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
61. The extent to which hours are lost due to gaps between patients is affected by the
number of cases on a list, and whilst the gap between patients is comparatively short
for some specialties and suites, and within the DSU turnaround target, the findings
from our staff survey would suggest that more could be done:
only 25 out of 78 staff (32 per cent) responding to our survey across the UHB
agreed with the statement ’there are rarely delays in between each individual
theatre case’.
62. Delays between patients can be caused by problems accessing appropriate
equipment, instrumentation or disposables. Our findings would confirm that whilst
consumables and disposables are not a fundamental problem, access to appropriate
equipment and instrumentation can be an issue in theatres in the UHB. Our findings
from the staff survey identified that:
33 out of 78 staff (42 per cent) responding to our survey from across the UHB
disagreed with the statement „issues with operating theatre equipment availability
rarely results in patients being delayed or cancelled’; and
18 out of 44 staff (41 per cent) responding from UHW, and 12 out of 34 staff (35
per cent) from Llandough hospital disagreed with the statement „availability of
operating theatre instrumentation rarely results in patients being delayed or
cancelled’.
63. Earlier we reported that the last minute notification of lists can result in delays in the
flow of lists as staff have to spend time making sure that appropriate equipment is
available to carry out the procedure. Staff that we spoke to also raised concerns
around the maintenance of equipment and the need to ensure a robust equipment
replacement programme is in place within the UHB, reflecting examples where
equipment had broken down or had been unfit for use. Only 16 out of 44 staff (36 per
cent) responding to our survey from UHW agreed with the statement „the operating
theatre equipment is reliable‟, compared with 19 out 35 staff (54 per cent)
at Llandough hospital.
64. The level of equipment and lack of standardisation across the suites was also raised
as an issue. Staff identified the need to focus on standardising procurement practices
as current practice allowed individual consultant preferences to influence purchasing
decisions, and differing equipment across the sites made it difficult to rotate staff
around the units.
65. The transportation of patients to and from theatres across the UHB was also identified
as an issue. Although there are number of differing arrangements in place across the
suites, the time in which patients are sent for and/or the availability of staff to transport
patients can contribute to delays in patients arriving in theatre or leaving recovery.
These delays can result in recovery staff being used to escort patients back to the
wards, causing pressure on staff within the recovery units.
Page 28 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
66. The physical capacity within the suites can also cause blockages and delays in the
patient flow. In particular:
The holding bay at Llandough hospital can only accommodate two patients at
any one time, which is insufficient if all six lists start at the same time. A similar
issue is also identified in main theatres at UHW where the holding bay can only
accommodate three adult patients and a paediatric patient.
The demand placed on the recovery facilities can cause bottlenecks in the
system. When asked, 24 out of 44 staff (55 per cent) responding to our survey at
UHW disagreed with the statement „there are enough recovery beds to meet
current demand‟, compared to 14 out of 35 staff (40 per cent) at Llandough
hospital. Recovery blockages were identified as being a common problem,
particularly when there are difficulties accessing critical care and high
dependency beds as identified earlier in this report or when a number of patients
arrive in recovery at the same time.
67. The findings of our staff survey identified that only 15 out of 44 staff (34 per cent)
responding to our survey at UHW agreed with the statement „overall we have good
patient flow in this hospital‟, compared to 23 out of 34 (68 per cent) at Llandough
hospital.
Management of emergencies can have an impact on the overall utilisation of theatres
68. The level of CEPOD12 capacity, specifically at UHW, was identified as being a
constraining factor by staff, with demand for emergency theatres often outweighing the
dedicated sessions available. This can cause patients to have to wait for emergency
surgery, sometime leading to operations being carried out at night or emergency cases
to be brought onto elective lists. This latter factor was supported by the findings of our
staff survey with 21 out of 44 staff (48 per cent) based at UHW who responded
disagreeing with the statement „emergency and trauma cases rarely impinge on
elective lists‟.
69. Emergency surgical patients within the UHB are classified into three categories:
Category 1 – those patients who should receive surgical intervention within 60
minutes of the decision to operate;
Category 2 – those patients who should receive surgical intervention within six
hours of the decision to operate; and
Category 3 – those patients who should receive surgical intervention within 24
hours of the decision to operate.
70. During our fieldwork we were told by staff that current UHB guidance indicates that all
three categories of emergency patients should be managed through the dedicated
emergency CEPOD theatres. However, we were also told by staff that these
classifications were not working in practice with:
paediatric patients taking priority on emergency sessions on a Tuesday and
Thursday morning, which was leading to non-paediatric emergencies impinging
on elective lists or delays in treating these patients; and
12
Confidential Enquiry into Perioperative Deaths (CEPOD).
Page 29 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Category 3 patients being moved further down the emergency list to
accommodate Category 1 and 2 patients, which sometimes resulted in patients
waiting several days to be operated upon or the patient being re-classified as
Category 1 or 2 due to the increased clinical need to treat the patient.
71. Within the main theatres at UHW, emergency cases are being slotted on at the end of
elective lists which finish earlier than planned. This can make better use of resources
and minimise the time to get emergency patients to theatre. Capturing the level of
emergency cases done in elective lists is however problematic for the UHB and
therefore we are not aware to what extent that this happens. The data used in this
report does, however, reflect 27 emergency cases undertaken on elective lists for the
period reviewed.
72. Some staff viewed Category 3 patients as those requiring urgent treatment which
could be formally managed through elective lists, thus freeing up the demand for
dedicated emergency capacity. One exception to this is patients who require renal
transplant who utilise the emergency theatre due to a lack of commissioned theatre
capacity. However we were told that these cases can occupy emergency theatres for
long periods of time, again resulting in other emergency cases either being delayed or
emergency cases impinging on elective lists.
73. The UHB needs to look at the management of emergency cases through theatres and
be assured that it has sufficient emergency theatre capacity to meet the demand.
Page 30 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
The UHB recognises theatres as a priority but a number of factors are preventing it from delivering the actions set out in the operational plan
74. This section of the report discusses the strategic vision and planning arrangements for
operating theatres, as well as its associated capacity.
Theatres is recognised as a strategic priority which is underpinned by
clear priorities within the UHB‟s operational plan
Theatres is recognised as a strategic priority and the UHB is investing time in a number of
initiatives to improve performance
75. During our fieldwork it was clear that improving operating theatres is a growing priority
within the UHB. This is demonstrated through the number and range of improvement
initiatives ongoing within the Surgical Services Division and through the support from
the Innovation and Improvement Team. The focus on operating theatres is also
apparent in the attention that it receives in performance reviews and monitoring reports
to the Board.
76. There are a number of specific reasons for this heightened focus on theatres. These
reasons are summarised below:
Operating theatres is one of four UHB corporate efficiency projects. This work is
designed to focus attention on increasing session productivity, achieving upper
quartile performance for a number of key performance indicators, achieving
realisable financial savings and empowering staff to deliver.
One of the aims of the UHB‟s five year strategy13 is to give clarity to the roles of
the different hospitals within the management of the UHB. As a result, the UHB
has identified the need to develop UHW as a centre of excellence for emergency
and complex surgical services and Llandough hospital as a centre of excellence
for short stay elective surgical services, including elective orthopaedics. The
UHB recognises the role theatres has to play to drive through such
reconfiguration.
The involvement in operating theatres by bodies external to the UHB is focusing
attention in this area. External involvement includes the work of the Delivery and
Support Unit, the National Leadership and Innovation Agency for Healthcare
(NLIAH) via the Transforming Theatres14 programme and also our review of
operating theatres and day surgery.
13
The document „Programme for Health Service Improvement‟ sets out the UHB‟s strategic direction for the period 2011 – 2015. 14
Transforming Theatres is a national NHS Wales programme which is being facilitated by the NLIAH‟s Transforming care team. The programme aims to transform the quality and safety of patients care in operating theatres.
Page 31 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
77. Economic pressures being experienced by the UHB and by the division provide further
reasons for focusing on operating theatres. Since the establishment of the UHB, there
has been significant investment in theatres with the development of the tertiary tower
which includes two state of the art theatres and £1.8 million invested in ensuring the
staffing establishment is right for the level of activity at that point in time. This is
against a backdrop of an estimated £33.8 million per year to run the theatre services
and for 2010-11, an initial cost improvement plan of £1.2 million as part of the wider
£75 million cost improvement plan for the UHB. This was subsequently reduced to
£0.5 million.
78. There are, however, mixed views amongst staff about the extent to which improving
theatres is a priority for the UHB:
Some staff described theatres as a top priority for the UHB, recognising that
theatres are fundamental to the flow of patients through the hospital.
Other staff felt that theatres was a priority alongside many other areas due to the
financial challenges faced by the UHB. However, some staff felt that the focus on
cost savings had in some areas been at the detriment of the quality and
efficiency of care provided by the operating theatres across both sites. Examples
included the UHB‟s recruitment freeze and the decision to build the tertiary tower
at risk, with no additional investment in staffing levels to accommodate the
increased demand for neurosurgery from Abertawe Bro Morgannwg University
Health Board, which has placed increased workload pressures on the existing
workforce.
However, some staff did not perceive operating theatres to be a priority for the
UHB and raised concerns that they felt that there was a lack of visibility from the
Board. Staff also felt that despite the investment, theatres had remained static in
terms of its modernisation agenda.
79. Engaging with staff is fundamental to improving the delivering of operating theatres.
This issue is discussed in more detail on page 36 of this report.
The UHB has identified clear priority actions for theatres in its operational plan
80. The UHB‟s operational plan for 2010-11 clearly outlined a number of priority actions
that needed to take place to move operating theatres and the wider surgical services
towards the UHB‟s aim to have clarity on the roles of UHW and Llandough hospital.
Focusing on the three underlying principles outlined in the strategy of quality, efficiency
and contribution to improved patient care and outcome, the key operational priorities
and how the UHB intended to achieve these are outlined in Exhibit 18.
Page 32 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 18: Operational priorities for UHB for 2010-11 in relation to operating theatres
What needs to be achieved in 2010-11 How the UHB will achieve it
Increasing the number of patients
admitted on the day of their
procedure;
Delivering the required level of day
case procedures against a range of
procedures;
Ensuring 75% of all planned
procedures undertaken are done so
on a day case basis;
Reducing the number of cancellations
on the day of operation;
Ensuring that a maximum of 10% of
theatre sessions start early or finish
late;
Improving theatre utilisation to 95%
across all sessions;
Concentrating complex surgery on a
single site; and
Completing the capital requirements
to support surgical service redesign.
Embarking on a challenging demand
management programme to redesign
pathways to ensure they optimise
efficiency;
Optimising the use of existing resources
by focusing on the delivery of the
efficiency targets;
Reducing cancellations, and increase
the number of patients admitted on the
day of surgery;
Treating day surgery and day of surgery
admission as the norm;
Strengthening the existing preoperative
assessment service;
Relocating colorectal and complex
gynaecology from UHL to UHW to
centralise all complex surgery at UHW
as agreed previously; and
Completing the development of the
tertiary tower and transfer neurosurgery
and renal services into the new facilities.
Source: Cardiff and Vale University Health Board Operational Plan 2010-11
Financial challenges and capacity levels has meant that the UHB has
struggled to deliver many of the actions identified in its 2010-11
operational plan
81. Whilst it is a positive development to have such clear priorities for theatres, we
observed that the priorities are only set out at a high level and do not appear to be fully
supported by implementation or action plans. We also observed that whilst the UHB
has delivered against a range of the priorities it set out in the operational plan in
relation to operating theatres, many of the priorities relating to improved performance
have not yet been achieved and, consequently a number of these were repeated in the
2011-12 operational plan. This is demonstrated in the deterioration in a number of key
performance indicators for the 2010-11 period as outlined in the following exhibit.
Page 33 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 19: Comparative performance for the end of the financial years 2009-10 and
2010-11
Key Performance Indicator March 2010 March 2011 Status
Admission on day of surgery 56% 54% Deteriorated
Day case rate of planned elective
surgery
54% 73% Improved
Prompt starts in theatres 81% 76% Deteriorated
Utilisation of available theatre
sessions
90% 81% Deteriorated
Operations cancelled on day or day
before surgery
358 390 Deteriorated
Source: Cardiff and Vale University Health Board Integrated Performance Reports
82. The UHB recognises that operating theatres is a challenging area to address, and is
supportive of the Transforming Theatre programme as a way of achieving
improvements going forward. Our fieldwork would suggest that there are some
underlying factors that have caused progress against the operational plan to be
hampered.
83. Following on from the NHS reorganisation in 2009, the implementation of the UHB
organisational structure took some time to embed, particularly in relation to the
appointment of the divisional and directorate management teams. For the theatres
directorate this meant a change in personnel, resulting in a loss of continuity at a time
when the directorate was required to deliver its objectives.
84. The current organisation structure in the UHB promotes silo thinking. Our structured
assessment review identified that the UHB‟s structure promoted upwards and
downwards communication throughout the organisation, but there was limited
mechanisms however for directorates particularly to communicate sideways across the
organisation to understand and evaluate the impact of actions on other directorates for
example. As a consequence, development plans for different directorates are often
developed in isolation of each other.
85. The speed at which the UHB is trying to implement its vision could be impacting on the
efficiency of theatres. The UHB plans to concentrate emergency intake at UHW
alongside its plan to create UHW as the centre of excellence for all emergency and
complex surgery, with steps to start this process taken in 2010-11. Whilst recognising
that the UHB has made some progress in this area, the reality is that in the short term
much more demand has been placed on UHW without the corresponding shift in
demand to Llandough hospital and as a consequence staff perceive UHW to be under
pressure. A number of staff felt that the UHB needed to take a step back and revisit
what it is trying to achieve for operating theatres and the wider surgical services and
then be realistic about the implementation of such changes in a much more logical
manner.
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86. Staff also felt that whilst they recognised the need to make financial savings, the cost
improvement plan for theatres for 2010-11 had been unrealistic and driven from the
top with the financial challenges dictating decision making rather than the quality and
modernisation of the service provided to the patient. The most worrying aspect of our
staff survey was that a significant minority (22 out of 76 staff (29 per cent) of staff
disagreed with the statement „Hospital management does not knowingly compromise
the safety of patients‟. It should be clearly understood that the Wales Audit Office has
seen no evidence of managers compromising safety but nevertheless, it is important
that the UHB understands and addresses the reasons that may have led staff to make
these comments.
87. Finally, it is unclear as to whether the UHB has sufficient capacity to support the
transitional changes that need to take place to deliver on the UHB‟s strategy whilst
also maintaining the UHB‟s operational ability to deliver its AOF requirements.
Additional theatres will become available in Phase 2 of the Children‟s Hospital for
Wales. However this development is not scheduled to come on line until 2014, and we
found no plans in place to consider the capacity requirements in the interim period.
Whilst we recognise that a much greater focus is being given to capacity and service
delivery in the operational plan for 2011-12, much of this focuses on having sufficient
bed capacity with little reference to whether the UHB has sufficient theatre capacity.
88. Successful strategic planning within theatres should ensure that there is sufficient
capacity, in terms of staffing and physical resources, to meet demand for surgical
services. Almost half of the staff (35 out of 78 staff (45 per cent)) responding to our
survey said „there were not enough operating theatres for current demand‟ and over
half of the staff (45 out of 77 staff (59 per cent)) responding to our survey also said that
„there were not sufficient sessions to meet demand‟. When looking at the responses
from UHW based staff, the level of disagreement was much higher with:
32 out of 44 staff (73 per cent) saying that „there were not enough operating
theatres for current demand‟; and
36 out of 43 staff (84 per cent) saying that „there were not sufficient sessions to
meet demand’.
89. Staff also had negative views about the levels of staffing in theatres, which can impact
on the ability of the UHB to deliver on its priorities and vision, although it is important to
note that their views may be affected by vacancies and sickness absence rates. In
response to our survey only six out of 44 staff (14 per cent) at UHW and eight out of 35
staff (23 per cent) at Llandough hospital agreed with the statement „the levels of
staffing in our theatres are appropriate for the number of patients‟.
90. The staffing levels for the six week period reviewed identified that the whole time
equivalent per 1,000 theatre hours was above average and within the upper quartile
for three of the UHB theatre suites, but below average in the short stay surgery unit
when compared to all other theatre suites in England and Wales (Exhibit 20).
Page 35 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Exhibit 20: Whole time equivalent (WTE) in post per 1,000 theatre hours
WT
E in p
ost
per
1000 t
heatr
e h
ours
Theatre Suites
CV
UH
W U
HW
Ma
in
CV
UH
W L
lan
do
ug
h M
ain
CV
Lla
nd
ou
gh
Ho
spit
al
DS
U
CV
UH
W S
ho
rt S
tay S
urg
ery
Un
it
UPPER QUARTILE
LOWER QUARTILE
0
5
10
15
20
Source: Wales Audit Office and Audit Commission
91. Our data also identified that, with the exception of the day surgery unit at Llandough,
all the theatre suites were experiencing vacancies.
92. The management of the UHB‟s staffing resource is discussed further in this report.
Page 36 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Although there are some positive aspects, staff raised concerns around communication, staff morale, training and development and aspects of the safety culture
93. In this section we discuss a range of issues relating to the environment in which the
theatre staff support the performance of the operating theatres.
Staff have raised concerns about communication and morale which will
need to be addressed as a matter of urgency
We found scope to improve communications between senior managers and operational
theatre staff
94. Ensuring staff are fully informed of changes taking place within the UHB, hospital and
the theatre unit itself is important to allow staff to understand the reasons for the
change and to provide opportunities for staff to input and influence the way in which
services are shaped.
95. At an organisational level, the UHB has adopted a triumvirate model with operating
theatres located within the Surgical Support Directorate of the Surgical Services
Division. At each level, a management team of three has been put in place, headed by
a divisional or clinical director and supported by a manager and lead nurse.
96. The UHB has also adopted the team brief process which is a dissemination process
through the layers within the organisation, to include updates on the strategic
development of the organisation as well as operational issues. Updates on the
development of the organisational structure are also included in the UHB‟s „In Touch’
newsletter and other e-bulletins available to staff on the UHB intranet.
97. At an operational level, a nurse manager forum is in place to support
cross-organisational communication as well as professional matters to be raised and
discussed, and weekly meetings are in place at a divisional and directorate level.
98. Our findings from the staff survey however would suggest that whilst communication is
filtering down to middle management, communication to operational staff is an issue
within the operating theatres in the UHB, with greatest scope to improve
communications on the UHW site (Exhibit 21)
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Exhibit 21: Aspects of staff communication
Statement Percentage of staff agreeing
with the statement
UHW
(Sample - 44)
Llandough
(Sample - 34)
„Important issues are well communicated in:
the organisation‟ 16% 21%
the hospital‟ 16% 21%
the theatres‟ 33% 36%
„I feel fully informed about theatre issues in
the hospital‟
21% 24%
„There is good communication amongst staff‟ 16% 59%
Source: Wales Audit Office survey of CVUHB theatres staff
99. At the time of our review, the divisional nurse post for Surgical Services had not been
appointed and was being fulfilled through temporary arrangements, with the Surgical
Support directorate lead nurse at that time acting up into this post. As a backfill
arrangement, the senior nurse for SSSU was also acting up into the directorate lead
nurse post whilst also continuing to provide her existing duties. Consequently, the level
of senior nurse management supporting the theatres staff had been constrained and
the ability to enforce team briefing discussions was weakened. We understand that
whilst these posts continue to remain temporary arrangements, the senior nurse post
is now also being fulfilled by a member of staff acting up.
100. The triumvirate model adopted by the UHB has seen the appointment of three service
managers, to support the directorate manager, covering theatres, anaesthetics and
sterile services. At the time of our review, these posts had only recently been filled.
101. The fundamental organisational change that has taken place over the last 18 months
within the UHB will take time to embed and during our review, staff did raise concerns
that they were unclear as to the roles and responsibilities of staff, particularly given the
delays in appointment within their directorate and division, and concerns that they
were unclear as to how the structure operates and who they are responsible to.
102. With modern technology, the UHB uses electronic sources, such as the UHB intranet
and briefing emails, as one of its main forms of communication. However, many staff
identified access to the intranet as problematic, both in terms of physical access to IT
resources and the ability to make time in the working day to access information, as
well as not having access to an NHS email account.
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103. Arrangements for formal theatre user communication and stakeholder engagement at
the time of our review were also lacking. Despite having a Theatre Improvement
Group, which is discussed further in this report, the UHB did not have a formal Theatre
User Group. Theatre user groups can help improve communication between all parties
and act as a mechanism for bringing theatre service providers and users together to
resolve operational problems and plan services.
There is scope to improve staff morale despite positive team working and perceptions of
support from colleagues
104. When asked whether they agreed or disagreed with the statement „as a whole, staff in
this theatre work well as part of a team‟, 52 out of 76 staff responding (69 per cent) to
the survey agreed. This finding was supported by our discussions with staff which also
suggested that teamwork was working well within the UHB‟s theatres.
105. Other results from the staff survey suggested that staff felt supported by colleagues,
disagreements in the theatre were resolved appropriately and that theatre staff could
speak up if they perceived a problem with patient care. This picture is consistent with
that in other health boards across Wales.
106. Staff morale however is mixed across the UHB with greater concern around the morale
of staff on the UHW site. Whilst the respondents in Llandough hospital had mixed
views with the statement „morale is high in the operating theatres/day surgery unit’, a
large majority of staff at UHW (74 per cent) generally disagreed (see Exhibit 22). The
level of staff morale, as reported through our staff survey, is more negative in the UHB
than all other health boards across Wales.
Exhibit 22: Staff response to „Morale is high in the operating theatres/day surgery unit‟
Source: Wales Audit Office survey of CVUHB theatres staff
Page 39 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
107. The level of agreement with the statement „this hospital is a good place to work‟ was
also less positive than all other health boards across Wales, with greatest negativity
from those staff based at UHW (Exhibit 23).
Exhibit 23: Percentage of staff agreeing with „This hospital is a good place to work‟
Source: Wales Audit Office survey of CVUHB theatres staff
108. There are several factors that could be affecting morale in the UHB. These factors
include:
the perception of lack of communication and engagement within the theatre
suites as previously discussed;
staffing levels and a perception that the workload within operating theatres is
excessive, with only seven out of 44 staff (16 per cent) at UHW and nine out of
35 staff (26 per cent) agreeing with the statement „the level of workload is rarely
excessive‟; and
the disruption caused by the refurbishment programme which has been taking
place over the last 12 months, and the pace in which changes are happening.
109. With the exception of the day surgery unit at Llandough hospital, all other theatre
suites in the UHB were reporting vacancies for the period reviewed, suggesting that
the existing staffing levels particularly in the short stay surgery unit at UHW could be
overstretched. In addition, the sickness levels reported during the period reviewed
ranged from 1.5 per cent in the day surgery unit at Llandough hospital to 7.5 and 9.5
per cent in the main and short stay surgery theatre suites respectively at UHW, and
just over 10 per cent in main theatres at Llandough hospital.
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110. At the time of our review, temporary staff were being used to support staff numbers
although we recognise that the UHB‟s focus on financial savings has minimised the
use of bank and agency staff across the UHB. However, we were told that permanent
staff were having to come in on their days off to bridge any gaps, and that the
opportunities to have adequate breaks during lists were limited. These factors were
affecting the goodwill of staff and we were told that staff were leaving the UHB as a
result of this. The UHB needs to be assured that staffing levels are adequate and that
whilst temporary use of staff is being minimised, adverse impacts are not being felt on
permanent staff in post.
111. Overall, the general views of the availability of theatre staff were negative in the
findings of our staff survey (Exhibit 24).
Exhibit 24: Staff response to „There are rarely problems with the availability of theatre
staff‟
Strongly
agreed
Agreed Neither
agreed nor
disagreed
Disagreed Strongly
disagreed
Other
0 (0%) 23 (29%) 12 (15%) 30 (38%) 14 (18%) 0 (0%)
Source: Wales Audit Office survey of CVUHB theatres staff
112. This level of disagreement was the second highest in Wales and within the UHB the
results were more negative from staff at Llandough hospital, with 22 out of 35 staff (63
per cent) at Llandough staff disagreeing with the same statement. This is likely to
reflect the high level of sickness absence and vacancies which were reported at the
time. Availability of anaesthetists and surgeons was however not identified as a
problem, with our recent consultant contract review identifying that the UHB was
reporting very few medical vacancies.
Although there are signs of a positive safety culture, some aspects of
safety need to be addressed and staff have mixed views around training
and development
Staff feel that they are suitably trained to do the job but have mixed views about support for
new staff and training and development opportunities
113. Ever-changing developments in technology and surgical techniques are a particular
reason for theatre staff needing to be adequately trained and skilled. Our staff survey
however showed mixed results in this area:
Page 41 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Forty-one out of 78 staff (53 per cent) who responded to our survey across the
UHB agreed or strongly agreed that „the available staff are appropriately skilled’,
whilst 23 out of 78 staff (30 per cent) disagreed or strongly disagreed. Although a
majority of staff were in agreement, this level of agreement was the lowest of all
health boards in Wales and was less positive from staff working at Llandough
hospital.
Twenty-eight out of 77 staff (36 per cent) agreed or strongly agreed that „the
hospital does a good job of training new staff‟, whilst 31 staff (40 per cent)
disagreed or strongly disagreed. Similarly this level of agreement was also the
lowest in Wales and less positive from staff working at Llandough hospital.
However, 66 out of 76 (87 per cent) agreed or strongly agreed with the statement
„I feel fully trained to enable me to do my job‟, whilst only six staff (eight per cent)
disagreed. This level of agreement was one of the highest in Wales.
114. Staffing levels within a unit can dictate the ability to release staff to undertake training.
As reported in paragraphs 90, 108 and 109, the staffing levels within some of the units
may be overstretched and when recognising the level of workload undertaken within
the units, it is no surprise that staff identified the ability to access training to be a
problem:
Only 29 out of 77 staff (38 per cent) agreed or strongly agreed that „statutory
training needs are always met’, whilst a similar proportion of staff disagreed.
Half of the staff (38 out of 76) agreed or strongly agreed with the statement „my
professional development meets my needs‟, whilst 29 out of 76 staff (38 per
cent) disagreed or strongly disagreed. This level of agreement was the lowest in
Wales.
115. During our fieldwork, we were told by staff that there were limited opportunities to
develop skills because staff were rarely given time off to attend courses. We were also
told that whilst the use of e-learning was promoted, a large majority of the theatre staff
did not have appropriate access to IT resources (as already discussed) to enable them
to utilise the training material offered. As a university health board, the staff also
commented that there was too much focus on academic courses and felt that there
should be more focus on hands-on training. There is a dedicated Professional
Development Team however, who are responsible for ensuring hands on and statutory
training which the staff should be able to access.
Although there are aspects which demonstrate a positive safety culture within theatres, more
needs to be done on elements of safety and error reporting
116. The UHB has a clear focus on providing safe high quality services, and in doing so is
promoting an organisational culture which is one of openness and willingness to learn
from its past mistakes. This is reinforced in its statement of intent which outlines its key
values including:
to ensure that staff in the UHB will have the opportunity to provide a safe, high
quality and ever improving service; and
to ensure that patients:
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‒ have faith and confidence that they are getting safe, high quality care that
optimises patient outcomes; and
‒ are confident that issues raised will be managed openly and responsively.
117. The statement of intent also highlighted the UHB‟s commitment to be open in decision
making, explain actions and apologise when things go wrong.
118. The findings of our review however would suggest that not all of these values are fully
embedded in the culture within the operating theatres in the UHB. The findings of our
staff survey indicated that whilst patient safety is generally reinforced through the
operating theatres and staff knew the channels for raising questions regarding patient
safety, the level of agreement with other aspects of safety were low (Exhibit 25).
Exhibit 25: Staff views of aspects of theatre safety
Source: Wales Audit Office survey of CVUHB theatres staff
119. During our fieldwork, we were told that the World Health Organisation (WHO) surgical
checklists were taking place at the beginning of each theatre list although practice was
variable. Performance information reported to the Board would confirm that this was
the case, although performance has significantly improved over the last six months
with compliance now in the region of 95 per cent.
120. Staff identified that both safety briefings and the surgical checklists helped promote
better team working as outlined in paragraph 104. However it was identified that it was
sometimes difficult to get surgeons and/or anaesthetists to the safety briefings,
particularly if they were running late from a previous clinical commitment or because
they were keen to minimise delays to the start of the theatre list. It was also identified
that staff found it more difficult to undertake the debrief at the end of the lists, and if
they were completed, they were often left to junior staff to undertake. Only 17 out of 77
staff (22 per cent) who responded to our survey from across the UHB agreed with the
statement „Debriefings following shifts or lists are common in this operating theatre‟.
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121. Staff raised concerns over the quality of information and completion of necessary tests
prior to patients having their surgery as discussed in paragraph 51, which would
perhaps account for the low level of agreement with the statement „all the necessary
information is available before the start of the procedure‟. In addition, 26 out of 42 staff
(61 per cent) who responded to our survey from UHW identified that communication
breakdowns can lead to delays in starting surgical procedures. Whilst these issues can
cause inefficiencies in the running of lists as test results etc are tracked down, they
can also play a fundamental role in ensuring the safety of patients.
122. Interestingly when asked, 26 out of 34 staff (76 per cent) responding to our survey at
Llandough hospital agreed with the statement „I would feel safe being treated here as
a patient’. This was in line with the Welsh picture. However only 24 out of 43 staff (56
per cent) at UHW agreed with the same statement. This was the second lowest level
of agreement across Wales.
123. More positively, 60 out of all 76 (78 per cent) staff across the UHB identified that error
reporting was encouraged not only within the organisation, but also within the hospital
and within the operating theatres.
124. However, staff had mixed views as to whether „it is easy to discuss errors’, „medical
errors are reported and handled appropriately’ and the level of agreement by staff with
the statement „staff are not punished for errors reported through incident reports‟ was
the lowest in Wales. These views may reflect cultural issues that may exist within the
operating theatres, particularly at UHW, which is culminating in the low morale of staff
already discussed in this report. Staff also identified that whilst errors were being
reported, lessons were not always being learnt from errors and incidents at UHW to
inform the future delivery of service (Exhibit 26).
Exhibit 26: Staff views of aspects of error reporting
Source: Wales Audit Office survey of CVUHB theatres staff
Page 44 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
The UHB has made good progress to improve the collection and analysis of theatre data and now needs to use this information to challenge and change working practices
125. This section of the report discusses the ways in which the UHB collects and uses
information to improve its operating theatre services.
Data collection within theatres involves a good mix of measurements
which have been strengthened through the development of the „Theatre
Cube‟
The theatre system provides routine and live data collection and upgrades to the system will
improve the reliability of theatre information
126. Good management decisions can only be made if good management information is
available and easily accessible.
127. The UHB currently utilises the TheatreMan15 system, which at the time of our fieldwork
was being upgraded and extended to incorporate the short stay surgery unit at UHW.
This system supports routine data collection for each theatre and was easily able to
produce the necessary data for our benchmark (discussed in the first section of this
report).
128. Theatres data is input live into the systems giving staff real time information about the
patients going through theatres. However, on review of the data, we were told that
aspects of the system did not support good quality data, for example the system did
not allow emergency cases undertaken on elective lists to be assigned to the relevant
elective list. We were told that the planned upgrade to the theatre system should
improve functionality and eliminate these types of problems in the future.
The UHB reports a good range of performance indicators to effectively manage theatres
although this could be strengthened by including financial measures
129. The UHB employs a dedicated Theatre IT team to look after the theatre system and to
ensure the availability of accurate and useable information. As well as monitoring data
quality, the team also supports the reporting of a range of corporate performance
indicators.
15
TheatreMan is a theatre management system designed around the needs of theatre and day surgery departments in acute hospitals and provides total management of the patients‟ episode in a surgical environment.
Page 45 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
130. As required by the Annual Operating Framework, the UHB routinely reports high level
performance indicators such as late starts and early finishes. However over the last six
months, the UHB has also taken performance indicators a step further by transferring
theatre data into the corporate data intelligence warehouse to create the „Theatre
Cube‟. This reporting tool allows managers to drill down to individual consultant level
on a range of performance indicators and also supports links with other surgical
related performance indicators reported within the UHB such as those included
through the CHKS Signpost16 benchmarking tool, for example Risk Adjusted Mortality
Index (RAMI) and readmission rates.
131. Following the pilot work with the DSU to focus attention on turnaround times, the UHB
has also adapted the tool to report turnaround times as part of the data intelligence
warehouse on a list by list basis. During our review we were also told that work was
underway to develop a Theatres dashboard, which we understand is now in place.
132. The UHB has a wealth of performance information, however some staff raised
concerns that the UHB may not always be measuring the right thing. Whilst it was
recognised that turnaround times was a positive step, staff recognised that more could
be done to measure efficiencies and performance through financial measures such as
cost indicators, equipment usage and stock levels.
133. The UHB could benefit from taking their performance indicators even further by
bringing a financial aspect to performance reporting. By assigning financial costs to
performance for example, the UHB might be able to highlight the importance of
improvement and secure better performance particularly in relation to some lists. The
Transforming Theatres Programme identified that the cost of a theatre being idle for an
hour is £499.80. Considering that 1,628 elective hours were lost due to inefficiencies
for the six week period reviewed, the financial costs associated with this performance
would be in the region of £0.8 million.
The UHB has monitoring arrangements in place but needs to
demonstrate that it is using the improved information at its disposal to
challenge and change working practices
134. Theatre performance is monitored throughout the organisation with detailed
performance relating to a range of theatre aspects regularly reported to the Board and
the supporting Performance Committee (now the Strategic Planning and Performance
Committee).
16
Signpost is a web based benchmarking product provided by CHKS.
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135. Theatre performance is also monitored at an operational level on a daily basis for
some aspects of service such as under utilisation of lists and on a weekly basis for
other aspects of service such as late starts and early finishes. As discussed earlier,
managers are also able to monitor theatre performance through the dashboard which
shows trend analysis and interrogate performance through the „Theatre Cube‟.
136. The UHB has a Theatre Improvement Group in place with a remit to not only monitor
but to improve theatre performance. Having been established in January 2010, the
group is chaired by the Divisional Director, meets fortnightly and has representation
from a range of staff involved in the management of operating theatres. The group
provides a forum for raising operational issues affecting the performance of theatres
up to divisional and executive forums, such as the Operational Board of Directors and
has recently been the route for the Transforming Theatres project.
137. Through its corporate efficiency programme, the Theatre Improvement Group has
been making slow but steady improvements to theatre performance with a discrete
focus on planned session utilisation, late starts and early finishes, throughput and
scheduling. This has been aided by the recently appointed service improvement role
which has focused heavily on Orthopaedics.
138. However, the Theatre Improvement Group lacks engagement with the staff and is not
supported by a Theatre User Group, which has not been in place for some time. All
directorates are requested to send manager and clinical representation to the Theatre
Improvement Group but attendance from staff other than those directly involved in the
management and leadership of theatres has been lacking.
139. Staff told us that they felt disengaged in the improvement process within the UHB and
identified that they felt ill informed in relation to performance within their respective
area of theatre provision. Staff also referred to the „red cross and green tick‟
philosophy which had been implemented through the Theatre Improvement Group as
a way of identifying lists that were starting late and/or finishing early by placing the red
cross or green tick on the door of the theatre. We were told that this process
demoralised staff including clinicians and subsequently did little to spur improvements
in performance. The directorate has since appointed a Theatre Service Improvement
Manager whose role it is to engage with staff and take forward the modernisation
agenda in partnership between the division and the Innovation and Improvement
function of the UHB.
140. Medical staff also identified the lack of feedback on individual performance in respect
of the consultant contract, despite consultant level data being available through the
data intelligence warehouse. This is reflected in our findings from our consultant
contract review which identified that job planning has not been used systematically to
drive development and improvement of service delivery, and only 47 per cent of
consultants were able to access information to inform discussions about their existing
work. This suggests not only a lack of engagement with clinicians in helping the
organisation understand the reasons behind performance, but also a lack of challenge
from managers to understand why performance is the way it is and what can be done
to make improvements.
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141. The UHB has identified the Transforming Theatres programme will be key to getting
clinicians to own the issues preventing improvements being made and to help with
identifying solutions. It is too early in the process to comment as to whether the
Transforming Theatre programme is having an impact but the UHB needs to be
assured that its operational staff are engaged in, and feel ownership with, driving
improvements in theatre performance.
Appendix 1
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Methodology
Our review of operating theatres and day surgery was carried out in the latter half of 2010
and early part of 2011 and involved fieldwork at all health boards in Wales. The review used
a wide range of audit tools and methods developed in partnership with the Audit
Commission. Further details of these methods are included below.
Document review
In advance of our fieldwork, we requested and analysed a range of UHB documents. These
documents included:
Minutes of theatre group meetings;
Planning and strategic documents regarding theatres;
Theatre policies;
Financial reports; and
Reports resulting from internal reviews of theatre services.
Utilisation tool
The UHB was asked to complete a spreadsheet giving details of their theatre utilisation
during a sample period. The sample period in Cardiff and Vale University Health Board was
the six-week period starting 21 June 2010.
The spreadsheet required the UHB to enter details about the ways in which timing points are
recorded during theatre lists. These details were used to ensure that theatre suites across
England and Wales were compared on an equitable basis.
Day surgery and short stay surgery data
Our colleagues in the Audit Commission collated existing data regarding the rates of day
case and short stay surgery across Wales. No additional work was required from health
boards.
Staff survey
A survey covering a broad range of theatre-related issues was widely distributed to staff
involved in operating theatres. The survey was made available electronically but hard copies
of the survey were also distributed within theatres.
Responses were received from 80 staff which represented the fourth highest number of
returns from health boards across Wales. These staff included surgeons and anaesthetists,
theatre team leaders, theatre practitioners, clerical staff, orderlies and other staff. There
were 15 responses from surgical staff, 13 responses from anaesthetics staff and 36
responses from theatres staff.
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Staffing data forms
We asked health boards to complete a spreadsheet giving details of their theatre staffing
both actual and funded establishment, actual costs and sickness levels. This data needed to
cover the exact 6 week utilisation sample period and a separate spreadsheet was required
for each participating theatre suite.
Cardiff and Vale University Health Board submitted responses for all their theatre suites.
Fieldwork interviews and meetings
Our review team carried out detailed interviews and drop in sessions at various locations in
the UHB during week commencing 1 November 2010.
Interviewees included theatres staff, surgical and anaesthetic staff, staff involved in the
collection and analysis of theatres data, executive members of the Board, divisional and
directorate management teams
Appendix 2
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UHB‟s Management Response to Recommendations
As part of the clearance process, the Surgical Services Divisional team has had opportunity
to comment on the accuracy and content of the report. This appendix details the comments
made by the Divisional team in response to the recommendations made.
Strategy and Planning
R1 Develop a coherent, all-encompassing plan for operating theatres. This plan should:
be realistic in its nature;
clearly set out priorities and the reasons for focusing on these issues;
be supported by clear action plans, with accountabilities and timescales;
be underpinned by a medium and long term capacity plan;
be consulted upon with operational staff involved in operating theatres; and
set out how the UHB will move surgical activity for future service transfers.
The UHB has developed a coherent plan for its operating theatres, which is the
adoption of the Transforming Theatre Programme together with an associated
capacity plan. This has been endorsed by the Board following a dedicated session
at a Board Development Day (January 2011).
It has recognised the need for additional expertise to support modernisation through
the appointment of Mr Sion O‟Keefe as Theatre Service Improvement Manager in
December 2010. This is a key role supporting modernisation and is a partnership of
the Division and the UHB Facility of Innovation and Improvement.
The above is taken forward through the Transforming Theatre Group, which is a
modification of the structures established previous to deliver service improvement.
In terms of Capacity Planning, the UHB has clearly ascertained how theatre activity
will be reconfigured prior to Phase 2 of the Children‟s Hospital Development (which
will not occur until 2014). This is evidenced by the following which have been
undertaken since the fieldwork and in accordance with UHB plans that were
developed at the time of the fieldwork and which were based on detailed
consultation with stakeholders:
‒ Relocation of colorectal theatres from Llandough to UHW;
‒ Additional weekly liver surgery lists;
‒ Additional weekly trauma lists;
‒ Additional weekly scoliosis lists;
‒ Additional weekly MaxFax list;
‒ The creation of 2 dedicated neurosurgery theatres;
‒ Additional alternate weekly all day lists for renal transplant;
‒ The relocation of lithotripsy from SSSU to an outpatient setting;
Page 51 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
‒ The UHB has plans for the 2nd phase of theatre reconfiguration, aligned to the
transfer of Gynaecology services. This is contingent upon factors outside the
control of theatres and will be undertaken when these are completed.
Preoperative assessment and list preparation
R2 Maximise the impact of preoperative assessment and list preparation by:
accelerating work to standardise preoperative assessment processes across the
UHB, learning from practice already in place in the short stay surgery unit;
ensuring theatre lists preparation maximises the use of theatre time, for example
using consultant specific procedure times to minimise under or over listing, and
providing training for staff preparing lists; and
reintroducing scheduling meetings.
The pre-assessment process across the UHB has been standardised, with common
documentation across main theatres and SSSU at both UHW and Llandough.
Daily scheduling meetings were re-established in June 2011, with pilot electronic
scheduling being undertaken in Urology.
Theatre Utilisation
R3 Maximise the utilisation of both elective and emergency theatres by:
ensuring lists are flexed to reflect known clinical commitments which impact on
the start of theatres lists;
considering the allocation of all day lists, wherever possible;
working with other parts of the hospital and UHB to smooth patient flow through
theatres, and anticipating peaks in activity to prevent blockages for example,
within the holding bay;
modelling bed capacity against service reconfiguration to ensure bed availability
does not cause cancellations;
ensuring patients are fully prepped for theatres and that all appropriate tests and
investigations are completed and reported prior to a patient arriving in theatres;
reviewing the pathway for all categories of emergency activity;
ensuring the centralisation process for reallocation of lists includes all surgical
specialties; and
working with the Transforming Theatres programme, spread transferable
practices shown to improve patients flow across the UHB.
We do not agree with the recommendation that lists are flexed to reflect known
clinical commitments. Primacy in job planning is afforded to theatre lists allowing
these to commence at scheduled times.
Page 52 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
In Phase 1 of the theatre reconfiguration plan which was undertaken between
November 2010 and January 2011, all UHW Main Theatres lists have been made
all day lists (13 theatres, five days a week). Phase 2 of the reconfiguration will
extend this to Short Stay Surgery and Llandough.
Very detailed work has been undertaken to model the Bed Capacity required to
support the elective stream and prevent cancellations and this has underpinned the
UHB‟s Capacity Plan. There have however been delays in implementation and the
level of bed related cancellations remains disappointingly high.
Data demonstrates that the level of cancellations due to inadequate patient
preparation is very low. Weekly reviews in orthopaedics, for example, show that the
overwhelming majority of such cancellations could not be foreseen and result from
late changes in the patient‟s condition.
The only specialities outside the central reallocation process are those who have a
very high rate of backfilling.
Day Surgery
R4 Reinforce the need to deliver improved levels of day surgery performance by:
reinvigorating efforts to drive up rates of day surgery and short stay surgery,
using the data in this report to identify key procedures to target, ensuring that:
‒ opportunities to improve short stay surgery and day case rates are considered
across the whole BADS basket;
‒ all patients with intended management as day-cases are coded as such; and
‒ all BADS basket procedures are listed as day-cases, unless clinically
indicated as inpatients.
analysing the day surgery and short stay surgery theatre capacity to identify
opportunities to redistribute day case activity that currently occurs in main
theatres and/or increase day surgery throughput; and
establishing a clinical champion for day surgery.
The data actually demonstrates that the UHB‟s Day Surgery performance is very
good, when the key measure of total length of stay is used. It is recognised that
there are issues of coding but these should not distract from the high levels of
performance.
There are a number of Clinical Champions for Day Surgery.
Page 53 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Equipment
R5 Strengthen the management of equipment by:
undertaking an audit of all theatre equipment and ensuring appropriate
maintenance and replacement programmes are in place; and
working with the UHB‟s procurement department to ensure procurement
practices within theatres are standardised and the level of differing equipment is
kept to a minimum.
Detailed work is undertaken under the auspices of the Clinical Equipment Strategy
Group to maintain and replace theatre equipment. There is however a long standing
shortfall in the capital resources required to support the programme and that
required to replace equipment.
Detailed work is on-going on the standardisation of equipment (orthopaedic
prosthesis, gowns, mesh, tray specification to name just 5 of the areas currently
subject to review).
Staffing
R6 Effectively manage staff resources across the theatre suites by:
reviewing staffing levels across the theatres suites to ensure that there is an
appropriate distribution of staff;
reviewing arrangements for supporting new staff;
proactively managing down the current levels of sickness absence;
ensuring consultant job planning includes an allowance for back-filling vacant
theatre sessions, wherever possible;
monitoring the impact of controls on vacancies and temporary usage on front line
staffing levels;
ensuring allowances are made within staffing establishments to allow staff to
undertake mandatory training; and
providing staff adequate access to IT resources.
Led by the Divisional Nurse, detailed work has been completed on the
establishments of every theatre across the UHB.
Page 54 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Communications and morale
R7 Improve two-way communication with staff and address cultural and morale issues by:
establishing a range of communication mechanisms including the establishment
of a Theatre User Group or similar forum;
developing an understanding about the issues affecting morale and perceptions
of management and workload, taking appropriate actions to address causes;
ensuring all staff have clarity on roles and responsibilities within the management
structure;
promoting the use of safety briefings both before and after lists;
ensuring that executives, independent members and senior management are
more visible to staff in the theatre suites; and
using the Transforming Theatres teamwork module to rebuild team morale,
particularly at UHW.
We have concerns on the relative weight attributed to the staff survey in the report.
It is stated that the opinions of staff from the survey are valid yet with a response
rate of <10 per cent, it is difficult to agree that this is representative.
Performance Management
R8 Strengthen the existing performance management arrangements by:
promoting awareness amongst operational staff of aspects of theatre
performance in a way which is not demoralising to staff;
ensuring theatre performance is used to inform job planning discussions as a way
of informing improvements and providing constructive challenge; and
expanding performance measures to include:
‒ financial aspects of performance;
‒ equipment and use of stock; and
‒ utilisation of space, to ensure that best use is being made of the available
space particularly at UHW.
An exemplary weekly report is used to provide an overview of UHB performance
and that of individual specialties. This is augmented by access to detailed list and
consultant specific data via the Data Warehouse.
In addition, theatre specific data is provided to provide operational staff with data on
performance. The crosses and ticks approach was withdrawn following feedback
from staff.
Appendix 3
Page 55 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Measures of Theatre Utilisation
Description What it represents Calculation
End utilisation
This indicator gives you an
overall impression of the
proportion of the original planned
hours that was used for operating.
=(Patient operation hours/Total
planned hours)*100
This has been calculated by taking the total planned lists and establishing the changes in utilisation due to:
Lists being cancelled and not re-assigned
Lists beginning at a different time to the planned start time
Lists ending at a different time to the planned end time
Gaps between patients i.e. between the ending of surgery on one patients and the beginning of the next.
See below for the breakdown into
these constituent elements.
Planned list
utilisation
Planned hours of
sessions used, as a
percentage of planned
hours of all planned
sessions
This indicator helps you focus on
the hours lost due to cancelled
sessions, i.e. the number of
sessions used compared with the
number of sessions planned.
= (Planned hours of sessions
used/Planned hours of planned
sessions)*100
Calculations are based on the planned time of lists rather than the number of lists. Hence utilisation can exceed 100% in some cases.
Run time indicator
Actual run time of lists
as a percentage of
their sessions planned
hours
This indicator helps you focus on
lists that overrun or under run.
Hence this is a reflection of
whether surgery begins on time
and whether lists are effectively
planned to utilise the total
available time.
Many lists will be planned to be
3.5 hours while all day lists of 7
hours are increasingly common.
=(Actual run time of lists/Planned
hours of lists)*100
Run time utilisation is calculated as the start time of the first operation until the end of the last operation compared with the total planned list time.
Operating hours
utilisation
Patient operation
hours as a percentage
of anaesthetic and
surgical hours
This indicator helps you focus on
gaps between patients on a list.
=(Patient operation hours/Anaesthetic
and Surgical hours)*100
Operating hours utilisation consists of the actual time spent operating on patients compared with the start of the first and the end of the last operations.
Appendix 4
Page 56 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Day Surgery and Short Stay Surgery comparison against best quartiles performance by each BADS procedure
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Breast01: Excison/biopsy of breast tissue + localisation 77 170 33% 74% 0.98 0.95
Breast02: Wide local excision of breast 7 86 1% 17% 1.05 1.21
Breast03: Percutaneous core biopsy 0 8% 0.25
Breast04: Sentinal node mapping and resection 0 15% 1.25
Breast05: Simple mastectomy (including axillary node biopsy) 45 127 0% 3% 2.97 2.79
Breast06: Microdochotomy + other operations on duct of breast 4 8 25% 83% 0.83 0.6
Breast07: Operations on nipple 6 23 48% 100% 0.50 0.86
Emerg01: MUA Fracture and application of plaster cast 0 15 87% 60% 1.00 0.33
Emerg02: Incision and drainage of perianal abscess 11 4 75% 56% 12.00 0.98
Emerg03: Removal of products of conception from fallopian tube
(ectopic pregnancy) including laparoscopically
-6 29 66% 0% 0.10 0.7
Emerg04: Appendicectomy (including laparoscopic) (see note) 0 1 0% 0% 1.00 1
Page 57 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Emerg05: Removal of foreign body from skin 0 92% 0.33
Emerg06: Incision and drainage of skin abscess 72 20 50% 75% 8.00 2.13
Emerg07: Suture of skin wound 0 1 100% 80% 0.58
Emerg08: Repair of hand or wrist tendon 14 67 70% 45% 2.55 1
ENT01: Excision pre-auricular abnormality 3 3 0% 100% 1.00 0
ENT02: Excison/biopsy of lesion of pinna 16 226 96% 99% 1.78 0.52
ENT03: Pinnaplasty (including bilateral) 11 18 0% 81% 0.67 0.5
ENT04: Modified radical mastoidectomy (including meatoplasty) 2 20 5% 1% 0.95 0.97
ENT05: Tympanoplasty -1 87 14% 34% 0.53 0.81
ENT06: Myringotomy + insertion of tube, suction clearance 28 408 84% 92% 0.73 0.55
ENT07: Ossiculoplasty -4 20 40% 8% 0.67 0.86
ENT08: Removal of ventilation device 0 14 100% 100% 0.27
ENT09: Stapedectomy 4 18 11% 0% 0.81 0.84
ENT10: Septorhinoplasty + graft/implant 1 1 0% 17% 1.00 1
ENT11: Rhinoplasty 5 8 13% 25% 1.29 0.79
Page 58 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
ENT12: Submucous resection of nasal septum 3 8 13% 21% 0.71 0.89
ENT13: Septoplasty of nose -15 232 5% 60% 0.24 0.88
ENT14: Nasal septum cauterisation (and bilateral) 2 4 50% 73% 1.00 0.89
ENT15: Operations on turbinates of nose (laser, diathermy, out
fracture etc)
7 62 63% 64% 1.00 0.87
ENT16: Polypectomy of internal nose 11 101 5% 44% 0.55 0.93
ENT17: Intranasal antrostomy including endoscopic 7 30 10% 48% 0.70 0.84
ENT18: FESS Endoscopic uncinectomy, anterior and posterior
ethmoidectomy
3 4 0% 36% 1.25 0.91
ENT19: Manipulation under anaesthesia of fractured nose (as sole
procedure)
18 314 96% 96% 1.43 0.4
ENT20: Adenoid Surgery 5 132 2% 51% 0.42 0.87
ENT21: Therapeutic endoscopic operations on pharynx -1 2 100% 31% 1
ENT22: Pharyngeal pouch - endoscopic procedures 2 4 0% 0% 1.50 1
ENT23: Diagnostic endoscopic examination of pharynx/larynx +
biopsy
107 225 32% 78% 0.98 0.89
ENT24: Tonsillectomy -66 1060 3% 36% 0.40 0.94
Page 59 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
ENT25: Laser surgery to vocal cord (including microlaryngoscopy 14 20 30% 61% 1.29 0.75
Gen01: Repair of hiatus hernia with anti-reflux procedure (eg
fundoplication) (see note)
32 17 0% 0% 3.76 1.93
Gen02: Excision biopsy of lymph node for diagnosis (cervical,
inguinal, axillary)
186 132 19% 54% 2.67 1.54
Gen03: Closure of colostomy 0 21 0% 0% 6.76 6.75
Gen04: Transanal excision of lesion of anus 26 34 41% 50% 2.20 1.24
Gen05: Excision/destruction of lesion of anus 29 104 87% 87% 2.93 0.86
Gen06: Haemorrhoidectomy -1 47 70% 71% 0.93 1
Gen07: Injection or banding of haemorrhoids 3 23 91% 96% 2.00 0.75
Gen08: Circular stapling haemorrhoidectomy -2 30 63% 60% 0.55 0.98
Gen09: Anorectal stretch 3 15 80% 80% 1.00 0.79
Gen10: Excision/treatment of anal fissure 13 54 80% 84% 1.82 0.77
Gen11: Lateral sphincterotomy of anus 4 5 60% 90% 2.00 0.67
Gen12: Pilonidal sinus surgery - laying open or suture/skin graft -6 73 86% 74% 1.40 1
Gen13: Adrenalectomy - unilateral (see note) 3 12 0% 0% 4.08 4
Page 60 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Gen14: Diagnostic laparoscopy 67 186 62% 80% 1.51 1.04
Gen15: Cholecystectomy (see note) -104 432 23% 31% 1.09 1.56
Gen16: Splenectomy (see note) 10 4 0% 0% 7.50 5
Gen17: Primary repair of inguinal hernia 21 487 67% 69% 1.32 1.14
Gen18: Repair of recurrent inguinal hernia 62 47 38% 57% 2.93 1.1
Gen19: Primary repair of femoral hernia 5 8 63% 72% 2.33 1
Gen20: Repair of umbilical hernia 53 290 68% 75% 1.55 1.2
Gen21: Repair of incisional hernia (see note) 9 9 0% 17% 3.22 2.75
Gen22: Repair of other abdominal hernia 31 53 66% 55% 4.83 2.44
Gen23: Repair of rectal mucosal prolapse 0 51% 1.63
Gen24: Gastric banding (see note) 0 0% 1.11
Gynae01: Vaginal Hysterectomy (including laparoscopically assisted) -58 84 1% 0% 2.13 2.8
Gynae02: Subtotal abdominal hysterectomy (see note) 0 0% 3.06
Gynae03: Myomectomy (including laparoscopically) 1 9 11% 9% 3.13 2.92
Gynae04: Therapeutic endoscopic operations on uterus (including
endometrial ablation)
34 352 76% 86% 0.91 0.83
Page 61 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Gynae05: Endometrial biopsy/ aspiration + hysteroscopy 77 392 73% 90% 1.02 0.83
Gynae06: Oophorectomy and salpingectomy (including bilateral)
(see note)
-120 69 29% 6% 1.71 3.17
Gynae07: Therapeutic laparoscopic procedures including laser,
diathermy and destruction eg endometriosis, adhesiolysis, tubal
surgery
51 181 45% 63% 1.37 1.21
Gynae08: Operations to manage female incontinence -3 84 33% 34% 1.18 1.35
Gynae09: Colposcopy (+ biopsy) 0 5 80% 99% 0.00 0.5
Gynae10: Destruction of lesion of cervix uteri (including loop
diathermy and laser)
24 150 60% 94% 0.50 0.67
Gynae11: Cone biopsy of cervix uteri (including laser) 10 24 13% 89% 0.52 0.83
Gynae12: Posterior colporrhaphy -39 60 8% 0% 1.58 2.16
Gynae13: Anterior colporrhaphy -3 116 3% 0% 2.46 2.48
Gynae14: Anterior and posterior colporrhaphy -17 64 3% 0% 2.56 2.76
Gynae15: Repair of enterocele (+/- posterior colporrhaphy) 2 4 0% 0% 2.75 2.24
Gynae16: Marsupialisation of Bartholin cyst 1 7 86% 96% 1.00 0.5
Gynae17: Termination of Pregnancy 33 172 77% 94% 1.00 0.54
Page 62 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Gynae18: Laparoscopic sterilisation 0 85 76% 88% 0.45 0.86
Head01: Excision of lesion of lip 8 82 94% 100% 1.60 0.5
Head02: Frenotomy / frenectomy of tongue 3 30 90% 100% 1.00 0
Head03: Excision/destruction of lesion of mouth 76 16 44% 100% 8.44 1
Head04: Excision of parotid gland 58 34 0% 0% 3.06 1.38
Head05: Excision of submandibular gland 14 12 0% 4% 2.17 1
Head06: Excision of sublingual gland 0 0% 1
Head07: Surgical removal of impacted/ buried tooth/teeth 54 1026 93% 99% 0.83 0.67
Head08: Exposure of buried teeth 0 66 97% 100% 0.00 0
Head09: Enucleation of cyst of jaw 6 24 79% 98% 1.20 0.67
Head10: Apicectomy 2 10 80% 100% 1.00 0.5
Head11: Sampling of cervical lymph nodes (see note) 50 37 22% 0% 1.93 1
Head12: Operations on branchial cyst 13 10 30% 12% 2.57 1
Head13: Total/Subtotal thyroidectomy -34 45 0% 0% 1.36 2.1
Head14: Hemithyroidectomy, lobectomy, partial thyroidectomy -29 62 0% 0% 0.85 1.36
Page 63 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Head15: Excision of lesion of parathyroids 11 96 0% 0% 1.36 1.25
Medical01: Liver biopsy 26 19 21% 77% 2.13 1
Medical02: Renal biopsy -10 66 94% 50% 1.00 1
Medical03: Bone marrow biopsy 194 214 88% 96% 9.16 3.78
Medical04: ERCP 299 135 6% 72% 2.87 1.41
Medical05: Implantation of cardiac pacemaker 172 223 48% 37% 2.66 1.15
Medical06: Elective Cardioversion 52 149 93% 96% 5.70 0.75
Ophth01: Excision of lesion of eyebrow 2 38 97% 100% 2.00 0
Ophth02: Excision of lesion of canthus 24 75 97% 100% 0.74
Ophth03: Excision lesion of eyelid 4 376 99% 100% 1.00 0.67
Ophth04: Biopsy/Cauterisation/Curettage of lesion of eyelid 2 64 97% 100% 1.00 0
Ophth05: Correction of ectropion 5 51 92% 100% 1.25 0.8
Ophth06: Correction of entropion 1 63 97% 100% 0.50 0.67
Ophth07: Correction of ptosis of eyelid 8 83 92% 100% 1.14 0.75
Ophth08: Blepharoplasty 5 46 89% 100% 1.00 0.85
Page 64 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Ophth09: Dacrocystorhinostomy including insertion of tube 23 64 34% 66% 0.79 0.85
Ophth10: Enlargement of lacrimal punctum 0 15 100% 100% 0
Ophth11: Correction of squint 39 222 78% 97% 0.88 0.67
Ophth12: Biopsy/Sampling of conjunctival lesion 2 23 91% 100% 1.00 0.5
Ophth13: Surgical trabeculectomy or other penetrating glaucoma
procedures
4 50 94% 96% 1.33 0.92
Ophth14: Laser iridotomy 0 45% 0.17
Ophth15: Laser photocoagulation of ciliary body 6 35 80% 95% 0.86 0.5
Ophth16: Extraction of cataract + implant 95 2300 95% 99% 0.95 0.87
Ophth17: Vitrectomy using pars plana approach 73 444 10% 97% 0.18 1
Orth01: Excision of ganglion 4 84 83% 96% 0.43 0.6
Orth02: Lengthening / shortening of tendon(s) 63 71 13% 68% 1.40 1.07
Orth03: Exploration of sheath of tendon (eg trigger finger) 2 102 92% 94% 0.75 0.69
Orth04: Excision of nail / nailbed 4 75 84% 96% 0.42 0.43
Orth05: Removal of internal fixation from bone/joint, excluding K-
wires
205 280 40% 73% 2.01 1.44
Page 65 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Orth06: Excision of lesion of peripheral nerve 8 35 40% 91% 0.48 1
Orth07: Carpal tunnel release -5 556 97% 98% 0.25 0.67
Orth08: Neurolysis and transposition of peripheral nerve eg ulnar
nerve at elbow
-1 45 84% 88% 0.43 0.76
Orth09: Examination/manipulation of joint under anaesthetic +
injection
26 171 11% 93% 0.24 0.86
Orth10: Dupuytren's fasciectomy -4 140 89% 88% 0.40 0.71
Orth11: Interpositional silastic arthroplasty of MCP/PIP joint (see
note)
0 0% 1
Orth12: Therapeutic arthroscopy of shoulder - subacromial
decompression, cuff repair (see note)
-159 492 24% 39% 0.36 1.04
Orth13: Diagnostic arthroscopic examination of shoulder joint (see
note)
1 9 11% 76% 0.25 0.5
Orth14: Arthroscopy of knee including meniscectomy, meniscal or
other repair (see note)
16 1195 72% 85% 0.55 0.92
Orth15: Autograft anterior cruciate ligament reconstruction -152 238 41% 12% 0.44 1.06
Orth16: Bunion operations with or without internal fixation and soft
tissue correction
16 234 3% 61% 0.51 1.08
Page 66 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Orth17: Posterior excision of lumbar disc prolapse including
microdiscectomy
58 60 0% 0% 2.47 1.56
Orth18: Minimally invasive hip replacement (2 incisions) 7 6 0% 0% 6.17 5
Orth19: Minimally invasive hip resurfacing 50 49 0% 0% 4.53 3.56
Orth20: Minimally invasive knee replacement 327 22 0% 0% 19.55 4.68
Paed01: Antral Washout (Maxillary) 0 1 100% 0% 1
Paed02: Herniotomy / Ligation of patent processus vaginalis 73 154 49% 96% 0.94 0.38
Paed03: Orchidopexy 34 144 67% 94% 0.71 0.35
Paed04: Orchidopexy - bilateral 14 24 38% 100% 0.93 0.58
Paed05: EUA Anus / Fibreoptic Sigmoidoscopy 163 2001 3% 98% 0.13 1.29
Paed06: Simple extraction of teeth 63 1414 64% 98% 0.16 0.67
Paed07: Syringing & probing of nasolacrimal ducts 7 28 68% 100% 0.78 0.5
Paed08: Repair of hypospadias 16 51 22% 0% 1.08 0.91
Urol01: Ureteroscopic extraction of calculus of ureter -7 31 23% 16% 0.83 1.09
Urol02: Endoscopic insertion of prosthesis into ureter 15 35 29% 34% 2.12 1.64
Urol03: Removal of prosthesis from ureter 38 171 74% 89% 1.31 1
Page 67 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Urol04: Endoscopic retrograde pyelography 0 8 13% 39% 0.71 1
Urol05: Other endoscopic procedures on ureter 20 24 29% 42% 2.18 1.33
Urol06: Cystotomy and insertion of suprapubic tube into bladder 10 17 6% 33% 2.00 1.89
Urol07: Endoscopic resection/destruction of lesion of bladder 85 352 37% 33% 2.18 1.82
Urol08: Endoscopic extraction of calculus of bladder -2 28 18% 15% 1.78 1.92
Urol09: Diagnostic endoscopic examination of bladder (including any
biopsy)
22 2511 85% 94% 0.61 1.21
Urol10: Dilatation of outlet of female bladder 1 1 0% 50% 1.00 0.5
Urol11: Endoscopic incision of outlet of male bladder -4 8 0% 0% 1.13 1.71
Urol12: Endoscopic examination of urethra + biopsy 7 50 92% 93% 1.75 1
Urol13: Endoscopic resection of prostate (TUR) 0 67 0% 1% 2.63 2.7
Urol14: Resection of prostate (see note) -2 9 0% 0% 1.00 1.4
Urol15: Prostate destruction by other means 3 2 0% 0% 2.50 1.4
Urol16: Operations on urethral orifice 6 25 48% 75% 1.00 1
Urol17: Orchidectomy 16 40 28% 55% 1.21 1
Urol18: Excision of lesion of testis 11 4 0% 100% 2.75 0.5
Page 68 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Urol19: Correction of hydrocele 3 112 77% 80% 0.85 0.94
Urol20: Excision of epididymal lesion 4 23 65% 87% 0.75 0.73
Urol21: Operation(s) on varicocele 3 6 17% 90% 0.60 0.46
Urol22: Excision of lesion of penis 0 38 97% 100% 0.00 0.8
Urol23: Frenuloplasty of penis 2 19 84% 100% 0.67 0
Urol24: Operations on foreskin - circumcision, division of adhesions 31 450 79% 91% 0.72 0.88
Urol25: Optical Urethrotomy 21 33 3% 27% 1.56 1.3
Urol26: Vasectomy 0 8 100% 100% 0.4
Urol27: Nephrectomy (see note) -13 42 0% 0% 4.62 4.95
Urol28: Pyeloplasty (see note) 0 0% 3
Urol29: Radical prostatectomy (see note) 0 0% 3.49
Vasc01: Carotid endarterectomy 28 43 0% 0% 2.91 2.26
Vasc02: Transluminal operations on iliac artery 92 51 4% 14% 2.69 1
Vasc03: Transluminal operations on femoral artery 90 66 0% 21% 2.24 1.15
Vasc04: Biopsy of artery (including temporal) 18 35 91% 6.00
Page 69 of 70 - Operating Theatres and Day Surgery - Cardiff and Vale University Health Board
Procedure Code and Name Potential
bed day
savings
(based on
best
quartiles)
CVU HB
Total
episodes
CVU HB
DC rate
(%)
National
UQ DC
rate (%)
CVU HB
LOS (days)
National
LQ LOS
(days)
Vasc06: Varicose vein surgery 10 301 79% 85% 0.81 0.86
Vasc07: Radiofrequency ablation of varicose veins (VNUS) 0 80% 0.67
Vasc08: Endovenous laser treatment (EVLT) of long saphenous vein 0 1 100% 97% 0.76
Vasc09: Varicose vein injection sclerotherapy 0 100% 0
Vasc10: Foam sclerotherapy of varicose veins 0 1 100% 100% 0.13
Vasc11: Subfascial endoscopic perforator surgery (SEPS) 0 0% 0
Vasc12: Thorascopic Sympathectomy (see note) 0 0% 1