1. Rapid change in Orthopaedics ACC Friday 30 April 2010 Seabridge House Robert Middleton The Royal Bournemouth Hospital NHS Institute for Innovation and Improvement

2. What were the issues?  Waiting times  Balancing demand with capacity  Reduce costs  Competition  Outcomes

3. Why do our solutions fail?  We treat the symptoms of the problem  The end result doesn’t change because we don’t change the whole system Every system is perfectly designed to get the results it gets (Deming)

4. Variability Operating times

5. Variability There was huge variability in outcomes. Mean length of stay = 7.8 days and St Dev = 5.5 days

6. Deming  Understanding variation is the most important aspect when trying to understand a system How do we go about this in healthcare when so many factors vary from patient to patient?

7. What were the issues?  Approx 6000 procedures per year  10 procedures = approx 70% of the workload  Hip and knee replacement  Approx 25% of the workload  7.8 day average length of stay  Many pathways

8. What did we do?  We analysed the issues  Assessed the variability  Recognised what we could change and what we couldn’t  Provided a framework which accounted for variability  Kept it patient centred

9. Focused on what we could change  Non-confrontational  SDSA (standardise-do-study-act)  Single pathway  Introduced daily and weekly outcome measures  Ongoing audit/performance management

10. Framework Freedom and responsibility to work within a framework Manage the system and not the people

11. Patient-centred  The reason we are here  Galvanises professional groups  Evidence base for orthopaedics isn’t controversial  NHS Institute for Innovation and Improvement  There is no single magic bullet

12. Results – First 1200 patients 100% of operation dates are mutually agreed Over 90% attendance at pre-op education class 100% of patients admitted on day of surgery 99% of patients waited less than 4 hours between admission and operation (Mean = 2hrs 43mins) 100% of patients received physiotherapy within 18 hours of surgery

13. Length of Stay Before Change

14. Length of Stay After Change

15. Average length of stay by NHS trust TKR(H04) July 2007/08 – June 2008/09 THR(H80) July 2007/08 – June 2008/09 TKR(H04) July 2006/07 – June 2007/08 THR(H80) July 2006/07 – June 2007/08 Data from Dr Foster Intelligence – October 2008

16. Performance against case-mix adjusted expected length of stay by NHS trust TKR(H04) July 2007/08 – June 2008/09 THR(H80) July 2007/08 – June 2008/09 TKR(H04) July 2006/07 – June 2007/08 THR(H80) July 2006/07 – June 2007/08 Data from Dr Foster Intelligence – October 2008

17. Results – First 1200 patients No cases of deep infection Complications rates below 1%. Re-admission rate decreased by 50% Patient satisfaction is extremely high Length of stay dramatically decreased

18. Results - Length of stay Mean LOS = 4.1 days St Dev LOS = 1.7 48% decrease on previous mean LOS (7.8 days) Approx 4000 extra bed days

19. Results – Operative times

20. Results - Variability Example - Operative times

21. Using knowledge of variability to plan ahead We have developed a forward looking model Informed by real data and consistent with principles from other industries and leading thought leaders

22. Predicting variability

23. Sequential vs staggered operating lists  Same distributions  Sequential compounds error (difference from mean) through all cases  Staggered softens errors through all cases

24. Operative Time

25. Benefiting the NHS DOH 18 week workshops Dorset Gold Award 2009 Redesign of Orthopaedic services in Scotland National and International Presentations and Papers to Orthopaedic and Health Management meetings NHS Institute for Innovation and Improvement

26. The 6 key characteristics of organisations providing high quality care and value for money in patients with hip and knee replacement Patients’ expectations are consistently managed Patients are admitted on the day of surgery Patients are admitted on the day of surgery Patients’ planned procedures are not cancelled Patients’ planned procedures are not cancelled Patients are mobilised within 12–18 hours of surgery Patients are mobilised within 12–18 hours of surgery Patients are discharged using a criteria- based process Patients are discharged using a criteria- based process The decision to change your service

27. NHS Institute for Innovation and Improvement Focus on series Rapid Improvement Programme Regional Meetings National Meetings

28. Summary  Change the system  Standardise  Stream  Variability is predictable and controllable

29. Thank you