Click here to continue

Introduction What is the operating theatre toolkit for? The operating theatre toolkit has been designed to develop organisation wide strategic management of current operating theatre services and promote best practice.   Who should use the toolkit? The toolkit will promote discussion and innovate solutions around possible present constraints. Anyone with responsibility for effective theatre utilisation will benefit from this tool. What are the aims of the toolkit? The patient flow collaborative aims to remove unnecessary constraints or delays in the patient process. It is recognised that operating theatre utilisation will deliver effective and efficient service to aid patient flow.   How should the concepts be implemented from this toolkit? Local theatre innovation teams should discuss tools and concepts adapting these to their local context. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools End of section Back to menu

Goals of the toolkit Introduction The operating theatre toolkit is based on whole system thinking and includes a whole of hospital perspective on effective and efficient theatre utilisation.   Goals Key elements to efficient use of operating theatres are: Effective management Good communication Well trained staff Appropriate facilities and equipment Operational layout that allows flow of patients. Support services play a large part in maximising efficiency by providing: Pre-operative preparation and assessment Available beds Sterile theatre equipment Portering, cleaning and maintenance staff. Effective planning and scheduling systems will enable smooth patient flow thus increasing capacity, improving patient and carer experience, improved employee satisfaction and morale.   Your feedback Feedback on this first version of the operating theatre toolkit is welcome and will be used to update subsequent versions. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools End of section Back to menu

Overview and strategy Key elements Planning patient pathways Theatre Introduction Planning patient pathways Key elements Theatre Management structure Goals of the toolkit Overview and strategy Staffing Postponements Health service team Processes Operating list management Data Trauma and emergencies Effective use of theatre time Resources Diagnostics and tools Theatre design Click to continue Page 1 of 9 Back to menu

Overview and strategy Theatre management structure Introduction Theatre Management structure Theatre management structure Theatre management structure should be clearly defined with accountability for: Full budgetary authority Adequate sessional allowance Information systems Utilisation Administrative, medical and nursing staff. Goals of the toolkit Overview and strategy Health service team Day to day management should be provided by an experienced trained and skilled theatre manager, who is responsible for clear communication, ensuring competent staffing and suitable equipping of all theatres.   Suitable systems for planning activity should be available to allow allocation of staff, and to respond safely and flexibly when changes take place to routines. Policies should be developed to deal effectively with changes to operating lists. Operating lists should be clearly posted well in advance and in suitable locations. Theatre management team should regularly review utilisation, cancellations, list overruns, late starts and waiting lists. Processes Data Resources Diagnostics and tools Click to continue Page 2 of 9 Back to menu

Overview and strategy Planning patients pathways Introduction Planning patient pathways Goals of the toolkit Overview and strategy Health service team Planning patients pathways Patients pathways should take into account ways to maximise use of theatres and bed availability. Patients admitted to pre-operative units can be transferred to wards following surgery allowing time for discharge of previous patients. Integration of pre-operative assessment and day case recovery area located adjacent to theatres provides an efficient use of space, skilled staff and may aid patient transport to and from theatres. This scheme also reduces time on ward rounds for surgeons and anaesthetist as patients are in one place. Processes Data Resources Diagnostics and tools Click to continue Page 3 of 9 Back to menu

Overview and strategy Staffing Staffing Introduction Goals of the toolkit Staffing Overview and strategy Health service team Staffing Anaesthetic departments should provide a system of staffing that works locally and is acceptable to staff Department staffing should match clinical activity, with sufficient cover for elective and emergencies Robust systems for booking leave must be in place and owned by all, with an advertised leave policy A lead anaesthetic consultant should be identified to support the theatre management team and trainees Adequate orientation of new or locum staff should be made a priority Adequate staffing should be available to cover governance tasks of note recording and data entry. Processes Data Resources Diagnostics and tools Click to continue Page 4 of 9 Back to menu

Overview and strategy Operating list management Introduction Goals of the toolkit Operating list management Overview and strategy Health service team Operating list management Close communication and coordination between pre-op area and theatre using agreed procedures is essential A nominated person should liaise with wards and transport staff from theatres A suitable holding area staffed and equipped will assist with smooth flow Agreement should be made for preparation and transport of patients to and from theatres Policies on fasting, anticoagulation, shaving, dentures, jewellery, appropriate underwear and removal of make-up should be developed Units should agree the level of training needed to escort patients to and from theatres A documented system of handover and identification of patient should be in place A system to book critical care beds for elective admissions should be in place and booking confirmed before anaesthesia for surgery. Processes Data Resources Diagnostics and tools Click to continue Page 5 of 9 Back to menu

Overview and strategy Effective use of theatre time Introduction Goals of the toolkit Overview and strategy Effective use of theatre time Health service team Effective use of theatre time It is important that all theatre lists start and finish at the agreed time. Agreement should be made to make this possible.   Realistic scheduling of theatres will prevent cancellations All day theatre lists have proven efficient, within the synchronising of surgical and anaesthetic time and staffing Good time keeping principles should be adopted and monitored by the theatre management team Pro-active re-allocation of cancelled theatre lists. Processes Data Resources Diagnostics and tools Click to continue Page 6 of 9 Back to menu

Overview and strategy Theatre design and operational layout Introduction Goals of the toolkit Overview and strategy Theatre design Health service team Theatre design and operational layout Design of operating theatres is essential for maximising patient flow, consideration needs to be made for: Large multi-purpose accommodation to enable increase in complexity and equipment Transport routes that flow through stages of theatre care Internal communication IT systems that facilitate appropriate communication and supervision. Processes Data Resources Diagnostics and tools Click to continue Page 7 of 9 Back to menu

Overview and strategy Trauma and emergency surgery Introduction Goals of the toolkit Trauma and emergencies Overview and strategy Trauma and emergency surgery Effective planning for emergency and trauma surgery is needed to prevent cancellation of elective surgery. Provision of exclusive emergency list will assist in preventing cancelled elective surgery. Health service team Processes   Good communication enables clinical decisions to be made rapidly, increasing the number of surgical procedures carried out in a safe time and environment. Time should be allowed for the Anaesthetist to assess emergency patients to their satisfaction. Experienced surgical staff should prepare patients who have multiple and complex medical problems, this can prevent cancellation at anaesthetic assessment. Pre-operative assessment for patients who are elderly, have multiple and complex medical problems can benefit from a team approach between anaesthetist, surgeon and physician. Data Resources Diagnostics and tools Click to continue Page 8 of 9 Back to menu

Overview and strategy Cancellations of surgery Introduction Postponements Goals of the toolkit Overview and strategy Health service team Cancellations of surgery It is extremely distressing and stressful to patients who are postponed surgery, many cancellations can be prevented by assisting patient flow with good planning in: Bed management Pre-operative assessment Increased communication Regular review of cancellation can assist with target areas for redesign and innovation. Cancellation data should be collected and reviewed weekly with agreed action plans. Processes Data Resources Diagnostics and tools End of section Back to menu

Health service team Introduction Goals of the toolkit Overview and strategy Health service team Processes It is essential for operating theatre innovation to have a skilled, trained and committed innovation team. The team should consist of representatives of all theatre staff groups.   Management – clinical/non clinical Nursing – Pre op and theatres, including operating department practitioners Clinical – Anaesthetist/Surgeons Administration – Admin and Portering Data Resources Diagnostics and tools End of section Back to menu

Processes Receive patient to Admission ward following operation Introduction Goals of the toolkit Initial recording of overall patient processes should be made covering: Admission Receive patient to ward following operation Overview and strategy Health service team Processes    Administration Processes will also need to map demonstrating process from: Data Allocation to theatre list Theatre reception on day of operation Resources Diagnostics and tools Click to continue Page 1 of 7 Back to menu

Processes Theatre Theatre Bed ICU Theatre Recovery Recovery Theatre Introduction Process map groups Goals of the toolkit Theatre Theatre Bed ICU Theatre Overview and strategy Recovery Recovery Theatre Theatre ICU Health service team Processes Home Bed HDU/ITU ICU Bed Data Home Bed Bed Home Resources Home Home Diagnostics and tools Mapping tip Map high level group first Click to continue Page 2 of 7 Back to menu

Processes Introduction Goals of the toolkit Scheduling The realistic building of theatre lists start in processes outside of theatre environment, essential validation of how ‘lists’ are made needs to be undertaken to maintain effective and efficient operating theatres.   Agreement can be made on average time per procedure to enable effective booking of theatre lists. Average time per operation can be agreed and used to assist building theatre templates. Overview and strategy Health service team Processes Case 1 Case 2 Case 3 9.00 am 12.30pm Data Resources Diagnostics and tools Click to continue Page 3 of 7 Back to menu

Processes Step Time per step Process steps examples Introduction Process steps examples Goals of the toolkit Step Time per step Patient transported from ward 5 Patient checked in to theatre Patient taken to anaesthetic room 2 Anaesthetic given 10 Patient positioned onto theatre table Surgery completed 40 Patient taken to recovery area Patient in post op 20 Patient taken to ward Theatre hands over patient to ward Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 4 of 7 Back to menu

Processes Step Time per step Colour code Process steps examples Introduction Process steps examples Goals of the toolkit Step Time per step Colour code Patient transported from ward 5 Patient checked in to theatre Patient taken to anaesthetic room 2 Anaesthetic given 10 Patient positioned onto theatre table Surgery completed 40 Patient taken to recovery area Patient in post op 20 Patient taken to ward Theatre hands over patient to ward Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 5 of 7 Back to menu

Processes Build your schedule Introduction Build your schedule Goals of the toolkit Use graph paper with one square per minute to sequence time scales per procedure. Overview and strategy Health service team 1 MINUTE 102 MINUTES Processes Data Resources Diagnostics and tools Click to continue Page 6 of 7 Back to menu

Processes Build your schedule 9.00 am start 1.30 pm end Introduction Build your schedule Goals of the toolkit Transfer graph sequence timescales to chart clinic time. Overview and strategy 9.00 am start 1.30 pm end Health service team Processes Data Resources Diagnostics and tools End of section Back to menu

Data Core data set End of section Introduction Goals of the   Suggested Measures Late Starts (e.g. >15mins) / Early Finishes (e.g. >60mins) / Overruns (e.g. >30mins) Example – For ten Orthopaedic sessions with a scheduled start time of 8:30am the sample showed four (or 40%) started >15mins late. Number of Major Procedures (>1hr) v Minor Procedures (<1hr) by Specialty Average time in theatre by specialty / procedure Lost time due by Cancellation reasons e.g. no beds, patient unfit Number of patients arriving in theatre with consents not completed by week Delays Monitor theatre delays for one week to agree on the top 10 reasons for delays. When this is agreed, 4 weeks data will be collected against the top 10 delays. Once 4 weeks of 10 delays have been gathered SPC charts will need to be produced. Time needs to be collected against each reason(s) per day, as the top ten offenders may not amount to the longest waste in time. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools End of section Back to menu

Resources Introduction Aim: To increase the utilisation and quality of care within operating theatres.   Change Concepts Review operating theatre utilisation (see tool kit) Scheduling Identify system to report delays daily via agreed criteria Remove delays, complexity and hand offs within administration process Smooth process from Emergency Department / Inpatient wards to Operating Room and back to ward Review stages of Transfer from ward /Emergency Department, recovery to ward Review capacity and demand for emergency and elective theatre Review role of theatre coordinator and joint work with Pre-Operative and bed management Review equipment turn around times via Central Sterilising Services Department and booking of equipment Review recovery and transfer procedures – develop appropriate ‘pull’ process to theatre/wards Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools End of section Back to menu

Diagnostics and tools Operating theatre checklist Delay proforma Introduction Operating theatre checklist Delay proforma Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools End of section Back to menu