mike davidge & anna lipp: the challenge of day case surgery
DESCRIPTION
In this slideshow, Mike Davidge, Head of Measurement, NHS Institute for Innovation and Improvement and Anna Lipp, President Elect for the British Association of Day Surgery, outline the challenges faced in improving performance in day case surgery, focusing on the strategies used at Norfolk and Norwich University Hospital to increase efficiency and productivity in this area. Mike Davidge and Anna Lipp presented at How can hospitals do more with less? in October 2012.TRANSCRIPT
British Association of Day Surgery www.bads.co.uk British Association of Day Surgery www.bads.co.uk
The challenge of day case surgery
Dr Anna Lipp Lead for Day Surgery, Norfolk and Norwich University Hospital President-elect British Association Day Surgery Mike Davidge Head of Measurement, NHS Institute for Innovation and Improvement Responsible for Better Care, Better Value indicators
British Association of Day Surgery www.bads.co.uk
Outline
• Identifying day surgery challenges locally • Case studies in different surgical
specialties – Orthopaedics – General surgery – Breast surgery
• What you can do • Recommendations
British Association of Day Surgery www.bads.co.uk
Do we have a problem with day surgery rates at NNUH ?
NHS Better Care, Better Value Indicators
British Association of Day Surgery www.bads.co.uk
NNUH rates vs. BADS targets Procedure NNUH day case
rate BADS Target day case rate 2011
Top 5% Hospitals 2011
Lap Chole 9%(2008) 60% 65%
Bunions 45% (2011) 85% 88%
Mastectomy 11% (2011) 30% 14%
British Association of Day Surgery www.bads.co.uk
Bunions Consultant % day case
2011 % day case 2012
BADS target %
Top 5%
A 67
B 25
C 33
D 100
E 20
Totals 45% 62% 85% 88%
British Association of Day Surgery www.bads.co.uk
Barriers to Bunions
• Scheduling on afternoon list • Physio gone home by time patients
mobilising • Plaster room shut 5pm- they supply boots
and crutches • Night staff on ward “don’t do discharges”
• “Dinosaur Consultant” • Patient information leaflets out of date
British Association of Day Surgery www.bads.co.uk
Strategies
• Multi-disciplinary bunion team • Updated information leaflets • Boots given out at pre-assessment • Crutches available on ward • Night staff trained in discharge process • Retirement of dinosaur, new, enlightened
consultant appointed!
British Association of Day Surgery www.bads.co.uk
Mastectomy rates
Consultant No. day cases
No. in-patients
% Day case 2011
% Day case 2012
BADS target
Top 5%
A 0 6 0% 15% 30%
B 2 7 29% 27% 30%
C 0 5 0% 33% 30%
D 1 7 11% 29% 30%
Totals 3 25 10% 26% 30% 14%
British Association of Day Surgery www.bads.co.uk
Barriers to mastectomy day case
• Pre conceptions of team • Major, cancer surgery, anxious patients,
thought to prefer to be in hospital • Painful • Drains
• Out of date patient information leaflets • Follow up for Friday discharges
British Association of Day Surgery www.bads.co.uk
Strategies
• Multi-disciplinary team discussion re merits of hospital vs. home
• Surgeons reviewed need for drains • Analgesia actually used on ward reviewed • Pain management at home information
leaflet developed • Ward staff acted as contact point for
Friday discharges
British Association of Day Surgery www.bads.co.uk
Lap cholecystectomy Consultant 2011 Day
case % 2012 Day Case %
BADS Target Top 5%
A 75% (21) 94%
B 25% (2) 100%
C 81% (38) 88%
D 40% (2) 100%
E 50% (2) 100%
F 74% (40) 71%
Totals 71% (105) 81% 60% 65%
British Association of Day Surgery www.bads.co.uk
Day Case lap cholecystectomy rates
0
10
20
30
40
50
60
70
80
2008 2009 2010 2011
Day case rate
Day case rate
British Association of Day Surgery www.bads.co.uk
Barriers to lap chole day cases
• Booking process • Recorded as in-patient if not operated on in
day unit, despite 0 length of stay • Belief that day cases could only be managed
in the “Day Unit”
• Scheduling after major cases, insufficient recovery time
• Inertia
British Association of Day Surgery www.bads.co.uk
Strategies for lap choles
• Importance of intended management day case explained
• Scheduling reviewed- lap–choles go first • Surgeons competitive tendency exploited!
British Association of Day Surgery www.bads.co.uk
Common barriers
• Preconceptions – Doctors, nurses, patients, carers
• Booking issues • Organisational and scheduling issues • Lack of awareness of benefits • Inertia
British Association of Day Surgery www.bads.co.uk
WHAT CAN YOU DO?
British Association of Day Surgery www.bads.co.uk
Day case rates for selected procedures
• Review day case rates for individual procedures
• Use BADS directory to compare rates with targets
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
National Dataset
• Data from CHKS • Outcomes for
England 2011 • Top 5%,25% and
50% of hospitals by procedure
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
How to access Better Care Better Value indicators
• Web address:
www.productivity.nhs.uk
British Association of Day Surgery www.bads.co.uk
Select your organisation
British Association of Day Surgery www.bads.co.uk
Summary for your organisation Click on indicator to drill down
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
British Association of Day Surgery www.bads.co.uk
Strategies for change
Post operative stay Yes: >1 day Yes: 1 day No
Pre-
oper
ativ
e st
ay
Yes
E Retain as
Inpatient but remove pre-
operative stay
D Convert
proportion to day case but remove all pre-operative
stay
B Easy win to convert to
a day case
No F
Retain as Inpatient
C Convert
proportion to day case
A Effectively
already a day case
British Association of Day Surgery www.bads.co.uk
Specialty level example
62%64%66%68%70%72%74%76%78%80%
ACurrent rate
BA + zero Inpatient
stays
CB + pre-op stays
only
DC + 1 day post-op
stays
Summary Day Case Rates for Urology
2005/06 activity (2482 Elective IP Adms)
Current DC rate Convert zero IP stays
Convert Pre-op only stays Convert 75% 1 day post-op stays
British Association of Day Surgery www.bads.co.uk
Estimate bed days savings
0
500
1000
1500
2000
2500
AConvert Pre-op stays
only
BA + 1 day post-op stays
CB + remove pre-op stays
on all cases
Summary Bed days saved for Urology
2005/06 activity
Convert Pre-op only stays Convert 75% 1 day post-op stays
Remove pre-op stay for longer stays
British Association of Day Surgery www.bads.co.uk
Top Tips for improving day case rates
• Analyse rates by procedure and compare to BADS target and top 5%
• Identify barriers specific for each specialty and procedure
• Exploit surgeons competitiveness! • Keep improving