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DHF Presentations between 2004 and 2008 +44(0)1423 506 848 +44(0)789 907 4881 www.directhealthfirst.com Kent House 42 Duchy Rd Harrogate HG1 2ER.

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Presentation on theme: "DHF Presentations between 2004 and 2008 +44(0)1423 506 848 +44(0)789 907 4881 www.directhealthfirst.com Kent House 42 Duchy Rd Harrogate HG1 2ER."— Presentation transcript:

1 DHF Presentations between 2004 and (0) (0) Kent House 42 Duchy Rd Harrogate HG1 2ER

2 Entry Hurdles · UK visas · UK work permits · NCSC · CHI · Professional bodies · Clinical registration bodies · Other government initiatives

3 What is day surgery? Ambulatory care. Out-patient care. Short-stay. Minimally invasive surgery. Diagnostic procedures. Minor injuries. Non-surgical interventions. etc…

4 (50%) possible as day cases : Lasar prostatectomy Trans cervical resection endometrium (TCRE) Eyelid surgery inc tarsoplasty, blepharoplasty Hallux valgus ("bunion") operations Arthroscopic menisectomy Scope’ shoulder surgery (subacromial decomp) Subcutaneous mastectomy Rhinoplasty Dentoalveolar surgery Tympanoplasty

5 (50%) possible as day cases : Laparoscopic cholecystectomy interval appendicectomy Laparoscopic herniorrhaphy Thoracoscopic sympathectomy Submandibular gland excision Partial thyroidectomy Superficial parotidectomy Breast cancer wide axillary clearance Haemorrhoidectomy Urethrotomy Bladder neck incision

6 Possible as day cases : Tonsillectomy in children Correction squint Bat ears/minor plastic procedures SMR Reduction nasal fractures Cataract extraction Laparoscopy  sterilisation Termination pregnancy TUR/laser/diathermy/limited resection bladder Ts Pilonidal sinus excision and closure

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8 Waste from unplanned admissions

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10 “ if you’re a fit young man who needs a knee operation, you don’t want to go into a general hospital and lie next to somebody who has a bed-sore and MRSA” Hospital Doctor ( ) NHS Improvement Plan: Part Three, Treatment Centres are not a threat DHF

11 Scheduling ASC’s BLOCK SCHEDULING · CASES SCHEDULED BY TIME (15 MIN. INCREMENTS) MORE THAN 1 CONSULTANT/THEATRE WORK THROUGH THE DAY PAY - FEE FOR SERVICE TC’s BLOCK BY SESSION OR LIST MAJOR AND MINOR 1 CONSULTANT/LIST SCHEDULED DOWN-TIME BETWEEN LISTS PAY BY LIST OR SESSION. SOME FEE FOR SERVICE DHF

12 Pre-op Day of Surgery ASC’s ARRIVE 1 TO 1 1/2 HRS. PRIOR TO SURGERY ARRIVAL TIMES ARE STAGGERED PREOP TEACHING - CRUTCHES, EXERCISES PREOP MEDS GIVEN (ANTI-EMETICS, ANTI- INFLAMMATORIES) NURSES CANNULATE BLOCKS, SPINALS DONE IN PREOP AREA TC’s ARRIVE IN GROUPS AT 7:00AM, 11:00AM AND 5:00PM PATIENTS FREQUENTLY SEE THE CONSULTANT FOR THE FIRST TIME ANAESTHETIST OWNS THE PATIENT DHF

13 Perioperative Process Anaesthesia ASC’s PATIENTS WALK DIRECTLY INTO THEATRE CRNA’s WITH MD SUPERVISION MORE REGIONAL ANAESTHESIA OUTPATIENT ANAESTHESIA NHS TC’s ANAESTHETIC ROOM, TRANSFERRED TO THEATRE ODA’S LESS REGIONAL ANAESTHESIA (SITE SPECIFIC) DHF

14 Perioperative Process Theatres ASC’s STAFFING - 1 SURGICAL TECH., 1 CIRCULATING NURSE, 1 FLOAT NURSE SCHEDULING OF CASES ANAESTHESIA TECHNIQUES SURGICAL TECHNIQUES EQUIPMENT NHS TC’S STAFFING - 1 SCRUB NURSE, 2 CIRCULATING NURSES, 1 ODA ANAESTHETIC ROOMS SIMILAR SAME DHF

15 Recovery Process ASC’s NO LMA’s OR ENDO TUBES IN RECOVERY OUTPATIENT ANAESTHESIA THIS IS WHERE THE MEDS THAT ARE GIVEN UP FRONT MAKE A DIFFERENCE PATIENTS ARE SENT HOME, HOME READY NHS TC’s YES HOSPITAL ANAESTHESIA, PROLONGED RECOVERY TIME - ANAESTHETIST SPECIFIC DHF

16 Case Costing ASC’s CASE COSTING DECIDES WHETHER OR NOT YOU DO A PROCEDURE COST/CASE (BY CPT or DRG, SPECIALTY,CONSULTANT) SUPPLY MANAGER IT SYSTEM SUPPORT DETAILED INVENTORY SYSTEM EDUCATE STAFF AND CONSULTANTS HAVE TO CONTINUALLY WORK TO DRIVE DOWN COSTS NHS TC’s NO WAY TO CASE COST NEVER BEEN A NEED NO SYSTEM IN PLACE DHF

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19 Drivers Waiting times, lists & capacity Choice, Access and Quality Contestability, Plurality and VFM DHF

20 ISTCs NHS TCs OCTs [ ] NHS Capacity through Systems Redesign & other ways 7/27 43/46 DHF

21 PFI PPP Capacity Growth Services FM

22 Sick or well model: In business parks and shopping malls. Range of procedures away from hospital site. Age range. Investigations. Contraindication and risk factors. Length of stay.

23 Examples of Differences: Ownership of property. Quality of build. Teams: Small teams. Telephones not attendances. Sick or well model: · Responsibility · Roles

24 ElectiveEither WayCDM Total hipSquintAsthma CataractChemotherapyPsoriasis CholecystectomyClub footRheumatoid Arthritis HerniorrhaRadiotherapyExcema C.A.DReconstructionDepression T.O.P. PhyHair lipSchizophrenia Pain blocksExtreme obesityThyroid dysfunction DentalIncontinenceDialysis Chronic painAngina Osteo Arthritis Chronic pulmonary disease

25 When things go wrong Difficult to justify protocols which are contrary to UK best practice (without evidence base) which leads to unnecessary conflict with national standards organisations · when (not if) there are unacceptable fatalities · legal consistency across England (Clapham Omnibus)

26 Input and process specifications Some procedures require specific data for national registers and these have to be specified · e.g. NCEPOD · Cataract National Dataset · e.g. National Joint Registry

27 Outcomes The difficulty with outcome(s) is that the results should be attributable to the treatment

28 Measures KPIs · 25 ISTCs · NHS TCs Outcome Measures · NHS TCs · ISTCs

29 Differences Equipment & Facilities Buildings & Layouts Turnkey & Systems Health from Sickness Model (Pt walking) Changing Expectations (Drs pushing) Procedure innovation (i.e. blood conservation) Indicators Competencies VS. Apprenticeships

30 Fear of clinical incompatibility Personal habit Agreed team practice /SAgreed local customs P/SNationwide custom P/SNationwide best practice P/SInternational best practice P/SRobust evidence practice /SLegal requirement

31 Credentialing People Facilities Organisation GMC Specialist Register Training Buildings, equipment, consumables systems, information, registration HCC

32 Grow capacity VFM Delivered quickly Maintain quality Improve access TCs

33 On or Off NHS property Near or far away In their buildings With or without their staff NHS Trusts & PCTs

34 Movable leased refurbished (modular) Buildings

35 Types of Surgery Centres in the U.S. Hospital owned Joint Venture (Hospital & Physicians) Physician Owned Management Companies with or without physician ownership

36 Driving Forces behind the “Surgery Centre Movement” Physicians / Surgeons Hospitals Government / Insurance Industry Patients

37 What Procedures can be ‘safely’ performed in the setting? not associated w/ excessive blood loss &/or fluid shifts do not require higher specialized operating equipment or intensive post-op care; post-op pain manageable take a “reasonable period of predictable time” the‘ultimate’ determinant: clinician comfort level

38 What Patients? few standardized guidelines no multi-centre studies; paucity of large prospective studies Mayo Clinic Study 1984: ASA III no higher risk in a Surgery Centre FASA 1987: survey of 87,000 patients, questioned relationship between pre-existing disease and peri- operative complications There is some empiric evidence of certain “patients at risk”

39 Patients at Risk “complex morbid obesity/complex sleep apnoea” potential for airway problems, dysmorphic facial features, severe rheumatoid arthritis, extreme age (?) poor physiologic condition: ASA III+/IV history of problems with anaesthesia (MH history) Acute substance abuse

40 The goal of any pre-op system “Reduce the morbidity of surgery & return patient to normal functioning as quickly as possible.”

41 Risk Classification The Johns Hopkins Risk Classification System

42 Summary of the Model Goal: isolate the potential problem patients while minimizing testing on the healthy patient Integrated service; cooperation w/ Surgeons & Primary Care Anaesthesia consensus on pre-determined algorithms

43 Pre-Op Testing: a sample matrix for minimally invasive surgery

44 Surgery Centre Pre-Op Testing: On-Site Electrocardiogram Haemoglobin Glucometer Urine Pregnancy Test

45 The process of the screening process is a crucial first step that allows for the provision of safe, effective, and efficient medical care……The development of preoperative evaluation systems in response to outpatient and same day admission surgery provides the challenge of organizing services into formal systems with guidelines formulated on the basis of mutual agreement and established clinical practice……it is imperative that the anesthesia staff reach a consensus on significant preoperative evaluation issues and adhere to them in dealing with patients and surgeons and associated organizations. Conspicuous or consistent deviation from these practices will only serve to undermine the confidence of all the parties………Anesthesiologists, in setting up their systems, are well advised to allow for a measure of flexibility. While adhering to a strong standard of care, reasonable judgement in providing that care is preferable to unyielding policies. Ambulatory Anesthesiology: A problem oriented approach L. Reuven Pasternak, M.D., Chapter 1, Screening Patients: Strategies and Studies.

46 On-Time Performance Updated preference cards On-site Sterile Processing Standardize Case packs- supplies pulled day before Patients walked to OR – short distance, no porters Quick Prep & Anaesthesia Starts – minimize M.A.S.T. Rapid turn around time (less than 10 minutes) Simple Charting – report by exception, utilize checklists OR flow closely monitored by the OR charge nurse & the charge anaesthetist: “vigilance”

47 Example Anaesthesia Service Quality Indicators: Patient and surgeon satisfaction Accuracy rate on clinical records Same day cancellation and surgical cases delayed Cost per case benchmarking Prolonged post-op nausea/vomiting Taking longer than 30 minutes in phase I ‘Reportable incident’ rates

48 “Customized” Anaesthesia involvement: current techniques, continual presence, and provide in-servicing Quick recovery, fast-tracking experience, discharge not time based PACU process streamlined; standing orders Tailor patient recovery to individual needs and aggressive vigilance of patients’ recovery Construct an efficient physical layout Recovery Process

49 Opportunity: Automated system: · cost per case (by CPT, Specialty, Physician) · preference card integrated w/ inventory system Educate & involve surgeons in standardizing high-volume or high cost procedures; Provide Performance Reports Standardization/Product Formulary · Lower Case Supply Cost · Minimizing Supply Waste Use data in negotiating with vendors; Drive Better Product Pricing; ‘Just In-Time’ Inventory Examine reusable versus disposable Efficient Supply Utilization

50 The Medical Director: Key Characteristics Practicing Physician (Anaesthetist or Surgeon) Respected member of medical staff On-Site (majority of the time) Must have a strong understanding of the ASC culture and be able to work with management team

51 Summary: Success Characteristics of Ambulatory Surgery Facilities Strong Leadership & Teamwork (including leadership from the Anaesthetist) Physician Relationships Patient Convenience Streamlined Processes & Clinical Protocols Cost Management

52 The US ASC Challenges Reluctance of surgeons and anaesthesia Overly burdensome regulations or hospital meddling Reluctant patients Duplication of equipment and excess capacity Dilution of staff pool Decrease in staff morale at acute care hospital Poor coordination with Primary Care Physician – care tends to be incidental

53 Governance Simplified - management team autonomy Allowed to function as an independent unit Allowed to work as a separate business unit (with own budget)

54 Facility Design Is a smaller unit possible? Regulation issues (Health Care Commission) Sterile processing Design restrictions – Recovery Room arena – Anaesthetic Rooms

55 Medical Staff Relations Full-Time dedicated Clinical Director: anaesthetist Primary Care buy-in and cooperation Referral management Consultants · In-Put solicited · Aligned incentives? Productivity incentives Private Practice

56 Anaesthesia Care Team Dedicated core of providers: Contract limitations? Team approach: · Pre-op consensus · Anaesthetic pathways · Willingness to work outside assigned lists – Ex: pre-op blocks Aligned incentives? · Productivity incentives · Quality incentives Provider shortage · Contract limitations · Foreign providers

57 Patient Must manage expectations Potential for reluctance to be cared for in this model Tying in social services, rehabilitation

58 Staff Issues Cross-Training Staffing in Theatres: · National Association of Theatre Nurses recommended staffing levels · Anaesthetic Nurses Human Resources · Staff incentives · Customer service culture

59 Information Management Use Data to track efficiency · On-Time starts · Average case length · Turn around time Cost Capture: · Inventory Controls · Items used · Physician and Staff Education

60 Pre-Op Process Nurse led Phone call for certain surgeries Minimize paperwork– e.g: “Trust Notes’’ Reduce testing Primary care & Anaesthesia leadership

61 Challenge Traditional Thinking “We’ve always done it this way” Fears of being sued ‘Shotgun’ approach to patient care · Diabetics, Obesity, etc. · EKGs


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