ELECTIVE SURGICAL

TARGETS

Audrey Hauraki

Auckland’s District Health Boards

Greater Auckland has a total population of 1.5 million people and is divided into three district health boards comprising four major hospitals. • Auckland City Hospital ( ADHB )

• North Shore Hospital and Waitakere City Hospital ( WDHB )

• Counties Manukau District Health Board ( CMDHB )

CMDHB Population

Population 490,000

Diverse ethnicity

– Maaori 17%

– Pacific 19%

– Asian 21%

– European 40%

Middlemore

CMDHB is divided into two major sites Middlemore Hospital • This is a major hospital and includes:

– 920 beds – Emergency department - one of the busiest in Australasia – Department of Critical Care – Burns Unit - Regional & National service – Medicine, General Surgery, Orthopaedics, Plastic Surgery, Women’s

Health wards – Children’s Hospital - Kidz First – Rehabilitation Unit - Healthcare of Older People – Maternity – Mental Health

Middlemore Hospital

Manukau Health Park

• Manukau Health Park is 9km from Middlemore

• Manukau SuperClinic - opened in 1997 • Expanded with additional modules in 2000 & 2009

– Now consists of 10 Modules with 114 clinic rooms and 15 procedure rooms

• Manukau Surgery Centre – extended in 2001 and now

– 74 beds – 4 HDU beds – 10 operating theatres – 2 procedure rooms – 40 chair dialysis unit

Manukau Health Park

Model of Care

• Dedicated elective facility

• Started with Manukau SuperClinic built in 1997 as an

Ambulatory Care facility - transferring majority of outpatients and day surgery from the Middlemore campus

• In the late 1990s the Government identified elective surgery

as a priority with “Waiting Time” funding and Middlemore was at maximum capacity for theatres and beds

• Decision to build Manukau Surgery Centre

Manukau Surgery Centre

• Separation of elective service from acute service to protect the elective service performance

• Phased approach to commissioning

– October 2001 started as an overnight 5.5 day facility – July 2002 Orthopaedic Surgery all elective surgery except of spine and

joint revisions – July 2003 General Surgery moved medium acuity cases – Confidence quickly developed and access was given to higher acuity cases – 2005 a second floor was fitted out to manage the volume

Services Today

• 220,000 outpatient attendances in the past year • 14,456 elective surgical cases in the past year • Specialties include:

– Orthopaedic Surgery - including joint revisions – General Surgery - including Bariatric, Oesophageal & Colorectal – Vascular - cases not requiring ICU – Renal - for tunnel lines – Plastic Surgery - including Breast Reconstruction – Hand and Upper Limb joint replacement – Gynaecology – Ophthalmology - including corneal transplants – ENT - including secondary Head & Neck and Thyroidectomy,

Sialendoscopy – Urology - currently day cases with regional service (expanding to become

CMDHB based service with inpatient beds)

Achievements - Manukau Surgery Centre

• Purpose designed to support elective surgical patients

• 85% of CMDHB elective surgery performed uninterrupted by acute services

• General Surgery recognised the benefits for patient recovery

and started a research programme on why patients recover faster when operated on at MSC

• Staff are rostered separately for each site therefore elective surgery lists are not impacted on by the acute workload

• Decreased length of stay

Achievements

• Innovative health delivery by the Manukau Surgery Centre offers the opportunity to work in an elective environment in a public hospital setting

• 38 additional elective beds plus a 4 bed HDU added to meet demand and increased acuity

• Decreased complications

• High level of patient satisfaction

Elective Surgery Targets

• A dedicated elective facility enabled CMDHB to meet the elective targets set by the organisation and Government

– Initially the targets were total contracted volumes (CWD)

– Waiting lists were managed by highest score/longest waiting

– Then in 2007 Government set volume targets for Total Joint

replacements and Cataract surgery

– Introduction of Government mandated Elective Surgery Targets

– Then notification of a future target of no one waiting longer than 6 months

– Target had to be achieved by 30th June 2012

New Zealand Government Targets

From 2001 the aim has been to provide clarity, timeliness and equity of care on a national basis

The current National Government set targets of:

– No patient waiting over 6 months for First Specialist Assessment (FSA) by 30th June 2012

– No patient waiting over 6 months for treatment by 30th June 2012

Targets met and then

– No patient waiting for FSA or treatment over 5 months by 30th June 2013

– No patient waiting for FSA or treatment over 4 months by 31st December 2014

Achieving no one waiting over 6 months

• Target was not negotiable

• Financial penalty if not achieved

• Need for accurate waiting lists - housekeeping

• Led to improved processes e.g. ensuring patients needing surgery were fit to proceed before being added to the waiting list

• Led to improved customer service - need to negotiate appointments in a timely way

Targets - Achieving 6 months

• All services needed to take responsibility

• Can not remove patients without seeing / treating – once on the list service is committed to seeing that patient

• Maximising the use of all available theatre lists

• Outsourcing surgery to private providers (publicly funded)

Results

• All Services at CMDHB achieved no patient waiting over 6 months by 30th June 2012

• Services are now tracking well to achieving the 5 month target by 30th June 2013

• Some services on target to achieve the 5 month target by 31st December 2012

Case Study

Ophthalmology

• Issue - low number of cataract procedures on each theatre list

• Needed to increase number as only one Ophthalmology theatre available

• To increase 06/07 internal production to achieve annual target of 1037 procedures set by Ministry 05/06 only achieved 855

If Private can do it why can’t we?

Was it an equipment issue?

• Aging microscope

• Only five cataract sets

• 5 phaco hand pieces

• 3 operating beds

• A stool with limited function

Was it a staff issue?

• Aging workforce

• Skill mix

Would Equipment alone solve the issue?

• Needed to understand how the private sector achieve their throughput

• Set up a project for streamlining the Surgical Pathway

Objective:

• To observe the differences between a private provider and compare to Manukau Surgery Centre processes

Model of Care Comparison

MSC Private Provider

Reception 2 receptionists 4 receptionists

Pre-op Nurse allocated to block area

May help in pre-op

Distance between

pre-op and theatre

Special room for theatre check and eye drops

Pre-op wait opposite the theatre

Theatre 2 RNs & HCA ORL/Ophthalmology

3-4 RNs experienced in ophthalmic surgery

MSC Private Provider

Theatre Pre-op checking

Computer entries

Very little paper work

No computer

Lens checked by surgeon day before

Microscope Mobile

Nurses set up

Ceiling mounted and surgeons helps set up

Session 8.30 -12

1.30 - 5

8-12/until list finishes

1-5/until the list finishes

MSC Private Provider

Lens Surgeon loads Nurse loads

Anaesthesia Different Anaesthetist depending on roster

Same Anaesthetist every week

Helped with positioning, monitoring set up

Post Op Theatre nurse takes patient to second stage

Nurse comes into theatre to collect patient

MSC Private Provider

SSU 0 dedicated

12 theatres working multi specialty

1 dedicated tech for cleaning, sterilising & repacking

Recommendations for MSC

• Preop nurse to be dedicated to eye list so the theatre nurse does not leave OR

• Theatre model to be 3 RNs & 1 HCA

• Anaesthetists to be encouraged to be part of team to streamline flow

• 2 RNS allocated to 2nd stage to manage volume - allows the theatre nurse to handover

Request for Equipment

• New microscope

• 2 new Stryker beds

• New surgical stool

• Increase in cataract sets to 10

• 5 extra phaco hand pieces

• Development of customised procedure pack

• Introduction of Ozil technology

Outcome of redesign for Cataract lists

• It is standard to have 5 - 6 patients on all lists

• New equipment, customised packs and increased instruments have all helped to improve throughput

• Staffing model of dedicated preop staff, 3 RNs & HCA in theatre and 2 RNs in 2nd stage has improved the work flow

• Stable workforce

• A purpose built Ophthalmology suite would give additional gains

Where are we now?

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TOWL

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Ophthalmology - Managing the volume

• Keep dedicated appointment slots for new patients - not used for follow ups

• Look for alternative clinics to free up SMOs

– Technician led stable post Avastin

– Technician led Anterior Segment photo clinic

– Nurse led post op Cataract clinic

– Stable Glaucoma clinics

• Saturday clinics

• Recruitment

Surgery Waiting List

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Ophthalmology - Managing the volume waiting for surgery

• Development of a procedure room in clinic

• 1992 procedures performed 2011/12 that used to be done in theatre

• Maximising the available theatre lists - 5-6 cataract on each list

• Flexible rostering for lists covering leave

• Reducing cancellations and DNA on day of surgery

• Outsourcing

– 600 Cataract patients outsourced 2011/12 year

CONGRATULATIONS

Local MP visits CMDHB to recognise and congratulate the achievement

Next Challenge - Now working on achieving 5 months

• Target of 5 months is non negotiable • FSA

– constant monitoring – Still working on sustainability of 6 months – Saturday custom clinics as required – outsourcing to private sector 100 FSA for Occular Plastic

• Surgery – Streamlining preadmission processes – Very close to achieving this target – Still outsourcing 600 Cataract procedures

Future Challenges - Achieving the 4 month targets

• Target of 4 months is non negotiable • 5 months will be achieved due to additional clinics and

theatre lists

• Achieving 4 months needs a new way of managing patients across the continuum

– Teamwork at scheduling meetings to maximise theatre use – Currently looking at treatment pathways – Discharge from follow up clinics – What can be managed in the community – Alternative workforce roles

Points to Take Away

• You only need to go from good to better

• Find your natural leaders

• Education

• Reward good performance

• Ignore dinosaurs

Acknowledgements

• My team for staying at work while I present

• Kathie Smith - Service Manager for ORL, Ophthalmology & Audiology, MSC Operational Manager

• Catherine Larsen - Service Manager of Theatres

• Sue Shipperlee - Elective Services Manager

• Photographic Department CMDHB

• Conference Organising Committee