operating theatres and day surgery - cvuhb w… · modelling bed capacity against service...

Operating Theatres and Day Surgery

Cardiff and Vale University Health Board

Audit year: 2010

Issued: February 2013

Document reference: 388A2011

Status of report

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.

mailto:[email protected]

Contents


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


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.


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.


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.


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.


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


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.


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


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.


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


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).


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


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.


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


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.


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


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



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


7 Comparative group includes all day theatres in England and Wales, with a sub-comparator group of

all day theatres in Wales.


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%


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.


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


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


8 We have used the total British Association of Day Surgery (BADS) basket of 188 procedures.


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.


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.


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.


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.


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


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%)


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.


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


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.


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’


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



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.


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).


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.


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.


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.


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.


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.


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).


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


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.


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)


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%


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.


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‟



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‟


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.


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%)


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:


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:


‒ 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


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‟.


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



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.


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.


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.


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


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.


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


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;


‒ 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.


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.


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.


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


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


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


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


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



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



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



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



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



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



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



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



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



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



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



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



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



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

operating theatres and day surgery - cvuhb w… · modelling bed capacity against service...

Documents