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2. 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
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3. 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
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4. 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
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5. 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
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6. 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
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7. 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
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8. 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
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9. 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
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10. 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
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11. 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
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12. 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
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13. 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
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14. 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
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15. 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
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16. 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 pm
Data
Resources
Diagnostics
and tools
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17. 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
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18. 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
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19. 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
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20. 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
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section
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21. 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
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22. 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
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section
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23. 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
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section
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