Kishamer Sidhu, Director of Finance at North West London Hospital NHS Trust, explains how the Trust managed to dramatically reduce the overtime sessions spend while improving patient experience.
We are one of London’s largest NHS Trusts, and for us the national drive for efficiency savings together with a local budget shortfall meant that we had to identify £21 million worth of savings for the 2010-2011 financial year.
We used to spend £100,000 a month at two of our hospitals (Northwick Park and Central Middlesex Hospital) on overtime sessions (Waiting List Initiatives – WLIs) in theatres to ensure patients were treated within 18-week of referral for treatement.
We had previously successfully completed a project in Endoscopy, with consultancy Newton, through which WLI spend was reduced by £0.24 million. It was a pilot project to see whether the methodology would work. We didn’t want to invest a large amount of resources for nothing, both in terms of money and in terms of people time and effort. Could lean work? The pilot would test the results, and also help us to see whether practice at the Trust could change.
And it did: it proved that change could be achieved, while showing a general appreciation for the lean approach. Cost reduction and efficiency improvements were seen as spin-offs of quality improvements, of getting things right.
The pilot project is what had us engage Newton to work together on a bigger project, to increase theatre capacity and utilisation for elective surgery patients, while reducing WLI spend.
We concentrated on three project streams to achieve our goal: list availability; utilisation; and unnecessary WLI initiatives. Right away we realised that if we were to complete these projects, an effective information system that would allow for a rigorous pre-session allocation approval process had to be in place. It was a matter of gaining visibility of all the data we needed in order to make informed decisions.
Detailed analysis of the Trust’s existing theatre timetables revealed that the number of lists available to specialties could be increased to fulfill the required capacity. To achieve this, we focused on the use of cancelled theatre sessions and through a 25% increase in cancelled session utilisation, we were able to create an additional 4.9 lists per week.
Excess capacity was also identified in several specialties within the Trust, presenting opportunities to work with various theatre teams to reallocate sessions to those specialties and surgeons requiring additional lists.
Through a combination of improving the booking of theatre sessions and reducing on-the-day theatre delays, we were then able to increase theatre utilisation by 18%. We got there by providing enhanced visibility and the tools needed to ensure lists were booked appropriately.
We also moved to tackle issues before the day of surgery, by introducing a meeting structure that is designed to identify upcoming issues related to theatre lists in advance.
We implemented a customised theatre management system to address the most common issues that caused delays in theatres. The system records, measures and prioritises delays to ensure that all the patients booked on lists are operated on.
It is clear that we would not have achieved our results had it not been for our new IT infrastructure, which draws information from the Trust’s existing PAS system as well as from customised input screens in theatres.
The system played a key role in removing overtime spend by enabling a data-driven approach to be taken when allocating WLIs. It clearly highlights which theatre sessions were under or over booked and flags up last-minute cancelled sessions yet to be rebooked, which additionally gives clinical staff clearer ownership of their theatre lists.
In a single user-friendly interface, the system took booking data from PAS together with average consultant theatre times to provide the scheduling teams with a clear and easy-to-use view of which sessions had space available for additional operations.
The system has built-in reporting functionality which allows clinical staff to run reports showing past performance. This has ultimately enabled the allocation of WLIs to those specialties and consultants that have an agreed need for them.
The solution was off the shelf, but the way it was deployed was unique, to make sure that it would be used. For example WHO checklists, the metric by which clinical data is recorded, was built into the screen and completion improved significantly.
The primary project took four months, although the entire cycle span 10 months. There were many issues we had to solve: we are a complex organisation, both culturally and operationally. Our staff was very supportive from the very beginning: medical staff proved particularly receptive. They were the ones who would get to operate more, at the end of the day, but they were also the most sceptical because they were aware of the scale of the change we were requiring.
We have been able to significantly reduce our WLI spend from £1.25 million to £0.36 million. Theatre utilisation has been increased by 18%, delivering the extra capacity needed to treat elective surgery patients. WLI usage is now measured and reported on a daily basis and theatre efficiency can be measured by list, by theatre suite, by consultant, by day, by week, and by month.
A more streamlined patient pathway has been delivered, together with greater patient choice by creating those additional 4.9 lists per week and reducing cancelled sessions.
The project included a full handover stage, which involved transferring the knowledge and skills needed to sustain the improvement and drive it even further.
We also received the HSJ’s Efficiency in Information Technology award for this programme, which was a great accomplishment for the Trust. Mortality rate at the Trust is among the lowest in the UK, which this project was designed to ensure was continued.