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My Role
as a
Surgery Services
Data Analyst
Surgery Services
Data Analyst
Data that Describes the Surgical Journey
Working Data File
Data
Patient
Demographics
ED
Data
Referral
Theatre Coding
DataDataTheatre
Data
Admission
Discharge
Outcome
Data
Data
Linkage Tool
Pivot Tables
Linkage Tool
Pivot Tables
Reports
&
Improvement ActivitiesImprovement Activities
Narratives
BARWON HEALTH THEATRE
SCHEDULE
KPI WEEKLY REPORTKPI WEEKLY REPORT
Week beginning 10-6-13
• Theatre contact hour = ‘anaesthesia start time’ to ‘out of theatre time’
• Time period = calculated from ‘Into anos room time’
CONTACT HOURS PER WEEK Monday - Friday
MAIN
New schedule
commenced
14/1/13
* Includes off the floor procedures
2012 average contact hours per week = 443hrs
(median = 449hrs)
Week beginning 10/6 = 401hrs (10/6 public holiday)
CONTACT HOURS PER WEEK
GVC
New schedule
commenced
14/1/13
*Includes GVC Ward
2012 average contact hours per week = 130hrs
(median = 131hrs)
Week beginning 10/6 = 112hrs
*This slide has been updated 3/6/13 to includes GVC Ward
CONTACT HOURS PER WEEK (Mon – Fri)
ELECTIVE V EMERGENCY SURGERY
0700-1700
MAIN THEATRE
New schedule
commenced
14/1/13
* Excludes off the floor procedures
• 2012 average emergency contact hours per week = 112hrs (median 113hrs)
• 2012 average elective contact hours per week = 227hrs (median 235hrs)
Week beginning 10/6 = 126hr (emerg) 208hrs (elect)
Goal : Increase emergency contact hours (in hours) per week whilst not
decreasing elective surgery contact hours
CONTACT HOURS PER WEEK (Mon – Fri)
ELECTIVE V EMERGENCY SURGERY
0700-1700
MAIN THEATRE * Includes off the floor procedures
New schedule
commenced
14/1/13
• 2012 average emergency contact hours per week = 118hrs (median 120hrs)
• 2012 average elective contact hours per week = 233hrs (median 242hrs)
Week beginning 10/6 = 133hrs (emerg) 208hrs (elect)
Goal : Increase emergency contact hours (in hours) per week whilst not decreasing
elective surgery contact hours
CONTACT HOURS PER WEEK (Mon – Fri)
BY TIME PERIOD
1700-2400
MAIN THEATRE * Includes off the floor procedures
Contact hours week beginning 10-6-13 = 49hrs
2012 average contact hours per week = 34hrs (median 34hours)
Goal : Decrease out of hours emergency contact hours per week
PROCEDURES DONE w/b 10-6-13
1700-2400
Specialty CMBS Description Surgeon Start date and Time
Theatre
Hours
Anaesthesia EPIDURAL INJECTION (<= 1 HOUR) 0.8
Anaesthesia EPIDURAL INJECTION (<= 1 HOUR) 1.0
Urology
Prostate, transrectal needle biopsy of, using transrectal prostatic ultrasound
techniques and obtaining 1 or more prostatic specimens, being a service associate 14/06/2013 17:26 0.5
Orthopaedic RADIUS;DISTAL END;(COLLES/SMITH'S)OPEN REDUCTION FRACTURE 14/06/2013 21:17 1.8
General Surgery LAPAROTOMY INVOLVING ABDOMINAL VISCERA 14/06/2013 20:55 2.8
General Surgery HAEMORRHAGE-CONTROL OF POSTOP. 14/06/2013 22:30 4.2
Gastroenterology GASTROSCOPY + / - BIOPSY 14/06/2013 19:35 1.4
General Surgery ABSCESS/HAEMATOMA - LARGE -DRAINAGE UNDER G.A. 14/06/2013 0:25 1.2
Cardio -Thoracic PERICARDIUM-SUB-XYPHOID DRAINAGE 13/06/2013 19:25 1.4
Gynaecology CAESAREAN - LOWER UTERINE SEGMENT 13/06/2013 17:17 1.7
Obstetrics CAESAREAN - LOWER UTERINE SEGMENT 13/06/2013 22:10 1.5
Urology TESTIS-EXPLORATION OF +/- BIOPSY 13/06/2013 23:20 0.9
Ophthalmology EYE - EXAMINATION UNDER ANAESTHETIC 13/06/2013 21:15 2.0Ophthalmology EYE - EXAMINATION UNDER ANAESTHETIC 13/06/2013 21:15 2.0
Ophthalmology VITRECTOMY 13/06/2013 19:56 1.4
General Surgery COLECTOMY-SUBTOTAL WITH ANASTOMOSIS 13/06/2013 20:30 2.3
Orthopaedic RADIUS;DISTAL END;(COLLES/SMITH'S)OPEN REDUCTION FRACTURE 12/06/2013 19:45 1.8
Obstetrics CAESAREAN SECTION 12/06/2013 22:50 1.3
General Surgery HERNIA - UMBILICAL/MIDLINE/EPIGASTRIC - OVER 10 12/06/2013 21:02 1.9
General Surgery APPENDICECTOMY VIA LAPAROSCOPE 12/06/2013 19:46 1.1
Gastroenterology GASTROSCOPY + / - BIOPSY 12/06/2013 19:01 0.7
General Surgery LAPAROTOMY & MISCELLANEOUS BOWEL OPERATION 11/06/2013 21:50 2.8
Gynaecology DILATATION & CURETTAGE 11/06/2013 20:40 0.6
Obstetrics CAESAREAN - LOWER UTERINE SEGMENT 11/06/2013 21:50 1.1
Urology CYSTOSCOPY-INSERTION URETERIC STENT 11/06/2013 20:14 1.0
Urology
PYELOSCOPY,RETROGRADE-CYSTOSCOPY/URETERIC MEATOMY / OR URETERIC
DILATATION 11/06/2013 18:35 1.8
Orthopaedic RADIUS;DISTAL END;(COLLES/SMITH'S)OPEN REDUCTION FRACTURE 10/06/2013 20:48 1.9
Orthopaedic RADIUS;DISTAL END;(COLLES/SMITH'S)OPEN REDUCTION FRACTURE 10/06/2013 18:50 1.7
General Surgery DEBRIDEMENT &/- SUTURE OF CONTAMINATED WOUND (SOFT TISSUE) 10/06/2013 22:57 2.1
Plastic Surgery MICROVASCULAR REPAIR - ARTERY OR VEIN - DIGIT OR LIMB 10/06/2013 19:31 3.2
Plastic Surgery METACARPAL FRACTURE; CLOSED REDUCTION 10/06/2013 18:45 2.0
CONTACT HOURS PER WEEK (Mon – Fri)
BY SPECIALITY
2200-2400
MAIN THEATRE
New schedule
commenced
14/1/13
* Includes off the floor procedures
Goal: A decrease in contact hours 2200-2400
2012 weekly average = 5hrs (median = 5hrs)
Week beginning 10-6-13 = 13hrs
CONTACT HOURS PER WEEK
BY TIME PERIOD
0000-0700
MAIN THEATRE * Includes off the floor procedures
New schedule
commenced
14/1/13
Contact hours week beginning 3-6-13 = 18hrs
2012 average contact hours per week = 5hrs (median 4hrs)
Goal : Decrease emergency contact hours per week 0000-0700
PROCEDURES DONE PER WEEK (w/b 10/6/13)
BY TIME PERIOD
0000-0700 Including cases commenced before 2400
MAIN THEATRE
In Theatre (into Anos
Rm) Consultant CMBS Description
Dressing done date and
Time
Sum of Theatre
Hours
10/06/2013 22:21 Douraid Abbas
DEBRIDEMENT &/- SUTURE OF
CONTAMINATED WOUND (SOFT TISSUE) 11/06/2013 0:10 2.1
12/06/2013 0:20
Michael
Borschmann
TONSILS - POST OP HAEMORRHAGE - RE-
OPERATION 12/06/2013 1:10 1.0
13/06/2013 0:30 Douraid Abbas
SEPSIS-GROSS INTRA-PERITONEAL-
LAPAROTOMY 13/06/2013 2:45 2.5
ABSCESS/HAEMATOMA - LARGE -
13/06/2013 23:55 Douraid Abbas
ABSCESS/HAEMATOMA - LARGE -
DRAINAGE UNDER G.A. 14/06/2013 1:00 1.2
14/06/2013 5:05 Sam Sabary CAESAREAN - LOWER UTERINE SEGMENT 14/06/2013 6:50 1.9
14/06/2013 4:00 David Wardill
HEMICOLECTOMY-RIGHT - WITH
ANASTOMOSIS 14/06/2013 6:05 3.2
15/06/2013 22:50 Marilla Druitt CAESAREAN - LOWER UTERINE SEGMENT 16/06/2013 0:12 1.4
17/06/2013 0:17 Cheng-Hon Yap
ASCENDING THORACIC
AORTA,REPAIR/REPLACE+AORT.VALVE
+IMPLANT COR.ARTERIES 17/06/2013 7:55 7.9
12/06/2013 3:30 Heather Butler EPIDURAL INJECTION (<= 1 HOUR) (blank) 0.5
12/06/2013 17:40 Heather Butler EPIDURAL INJECTION (<= 1 HOUR) (blank) 1.0
13/06/2013 3:20 Colin Gordon EPIDURAL INJECTION (<= 1 HOUR) (blank) 0.3
13/06/2013 6:30 Colin Gordon EPIDURAL INJECTION (<= 1 HOUR) (blank) 0.8
13/06/2013 18:30 Simon Tomlinson EPIDURAL INJECTION (<= 1 HOUR) (blank) 0.8
Grand Total 24.5
ORTHOPAEDIC CONTACT HOURS PER WEEK MONDAY - FRIDAY
EMERGENCY SURGERY
MAIN THEATRE
1700 - 0700
New schedule
commenced
14/1/13
Contact hours week beginning:
10-6-13 = 7hrs
2012 average contact hours per week = 3.9 hrs (median 8.5hrs)
Goal : A decrease in contact hours for orthopaedic surgery
(emergency only) Monday to Friday after hours
ELECTIVE COLONOSCOPY CASES PER WEEK
(CMBS 32084, 32087, 32090, 32093)
Week beginning;
10-6-13 = 40
Goal: An increase in colonoscopies up to June 30th 2013
Current activity: July – Dec 2012 = 48 cases per week (average)
(based on 6 sessions per week with an average of 6 -7 cases per session)
TARGET = 40 cases per week
ELECTIVE COLONOSCOPY CASES PER WEEK GASTRO V GENERAL SURGERY
(CMBS 32084, 32087, 32090, 32093)
ELECTIVE AND EMERGENCY O&G DONE IN ALL LISTS EXCLUDING O&G LISTS MON -FRI
0700-1700
New schedule
commenced
14/1/13
Goal: Reduction of emergency O&G cases done in non O&G lists
(CMBS codes: 16519, 16520, 16522, 16564)
Orthopaedic Flow – June 2013
Orthopaedic Waiting List
All categories
Orthopaedic Waiting List
Cat 2 Overdue and Ready for Care
Monthly Totals
Total number of Cat 2 patients ready for care and have been waiting over 90 daysJune 2013 = 219
(data gathered on 30th every month excluding Feb which was gathered on 28th)
Orthopaedic Waiting List
Cat 2 Over threshold
Overdue and Ready for Care by timeframe
*Includes patients that have been given a date but not yet had surgery * Excludes patients NRFC
June 2013 Average days overdue = 129 Median days overdue = 119
Orthopaedic Waiting List
Monthly Medians (over threshold days only) for Cat 2
Overdue and Ready for Care
ORTHOPAEDIC ON TIME STARTS
Mon- Fri (AM, AD and PM lists)
Excludes SMUG and GSTR Lists June 2013
June = 12/52 lists started on time
Average number of lists per month – 52
Average % on time starts per month – 17%
ON TIME STARTS BY SPECIALITY – June 2013
Mon- Fri (AM, AD and PM lists)
Excludes SMUG and GSTR Lists
23%
LATE START REASONS
Mon- Fri (AM, AD and PM lists)
Excludes SMUG and GSTR Lists
JUNE 2013
Orthopaedic Theatre Contact Hours Monday - Friday
per month by time period
January 2012 - June 2013
Orthopaedic Theatre Contact Hours Monday - Friday 0700 – 1700
Elective v’s emergency
Elective
Emergency
ORTHOPAEDIC CONTACT HOURS PER MONTH
MONDAY - FRIDAY
EMERGENCY SURGERY
MAIN THEATRE
1700 - 0700
June 2013 contact hours = 26hrs
2012 average contact hours per month = 37hrs (median 37hrs)
Goal : A decrease in contact hours for orthopaedic surgery (emergency only) Monday to Friday after hours
Indicators
for
Emergency SurgeryEmergency Surgery
Hip Fracture
HIP Fracture - DRG I08A &IO8B
ED to OP by timeframe May 2013
May = 14 cases
Time from ED presentation to Surgery Start Average hrs Median hrs
May 97 45
Hip # data is one month behind due to coding
HIP Fracture - DRG I08A &IO8B
Operated by Time Period
Hip # data is one month behind due to coding
01224364860728496
108120132144156168
Hours Hip Fracture Barwon Health Jun 2011 - May 2013
12
11
1
1
44
444
444
4
23232
1 1
4
11
80th percentile 43 hrs
Project
Summary
Segment Start Finish Mean Sigma Count LCL UCL Stable Capable
1 00:00 00:00 27.95 17.31 361 -24.0 79.87 No
12/03/11
13/06/11
24/06/11
19/07/11
14/08/11
14/09/11
15/10/11
17/11/11
15/12/11
03/01/12
19/01/12
31/01/12
15/02/12
11/03/12
24/03/12
09/04/12
02/05/12
19/05/12
10/06/12
29/06/12
14/07/12
22/07/12
26/08/12
12/09/12
27/09/12
16/10/12
05/11/12
24/11/12
21/12/12
13/01/13
02/02/13
26/02/13
21/03/13
20/04/13
05/07/13
05/10/13
Date
0
BaseLine 1.00.018
Hip Fracture Mortality
30/03/2012
13/01/2013
13/06/2011
08/10/2011
24/01/2012
18/03/2012
14/07/2012
24/10/2012
01/06/2011
01/07/2011
08/08/2011
12/10/2011
08/12/2011
10/01/2012
02/02/2012
14/03/2012
14/04/2012
30/05/2012
14/06/2012
14/07/2012
27/08/2012
12/10/2012
16/11/2012
10/01/2013
09/02/2013
08/04/2013
02/08/2011
03/12/2011
12/06/2012
02/09/2012
29/01/2013
29/03/2013
07/09/2011
29/03/2012
18/07/2012
03/11/2012
-20.0
-10.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Days Hip Fracture - Acute Length of Stay - ASA Score1
1
21
4
1
32
12
1 2
1
1
44 44 444 4
44
4
11
Not
1
30/03/2012
13/01/2013
13/06/2011
08/10/2011
24/01/2012
18/03/2012
14/07/2012
24/10/2012
01/06/2011
01/07/2011
08/08/2011
12/10/2011
08/12/2011
10/01/2012
02/02/2012
14/03/2012
14/04/2012
30/05/2012
14/06/2012
14/07/2012
27/08/2012
12/10/2012
16/11/2012
10/01/2013
09/02/2013
08/04/2013
02/08/2011
03/12/2011
12/06/2012
02/09/2012
29/01/2013
29/03/2013
07/09/2011
29/03/2012
18/07/2012
03/11/2012
DateBaseLine 1.00.018
Project
Date 09/06/2013 16:45:07
Summary
Group Start Finish Mean Sigma Count LCL UCL Stable
1 17/06/2011 17/05/2013 4.667 2.046 27 -1.47 10.80 No
2 02/06/2011 06/04/2013 8.113 5.043 62 -7.02 23.24 No
3 01/06/2011 29/04/2013 9.455 4.772 176 -4.86 23.77 No
4 19/06/2011 18/05/2013 9.262 5.230 61 -6.43 24.95 No
Not 08/06/2011 10/05/2013 9.419 5.024 43 -5.65 24.49 No
Patients with an ASA Score of over 1 have a
longer LOS - in acute
30/03/2012
20/01/2013
19/06/2011
14/10/2011
28/01/2012
16/04/2012
21/07/2012
26/11/2012
02/06/2011
07/07/2011
11/08/2011
15/10/2011
08/12/2011
11/01/2012
05/02/2012
21/03/2012
08/05/2012
31/05/2012
23/06/2012
21/07/2012
17/09/2012
03/11/2012
24/12/2012
02/02/2013
04/04/2013
19/07/2011
01/12/2011
05/06/2012
02/09/2012
29/01/2013
08/04/2013
12/11/2011
26/04/2012
04/09/2012
14/02/2013
-20.0-15.0-10.0-5.00.05.0
10.015.020.025.030.035.040.045.050.0
Days Hip Fracture - Sub-- Acute Length of Stay - ASA Score12
1 1
3
1
12
1
1
4 44 44
4
11
Not
1
30/03/2012
20/01/2013
19/06/2011
14/10/2011
28/01/2012
16/04/2012
21/07/2012
26/11/2012
02/06/2011
07/07/2011
11/08/2011
15/10/2011
08/12/2011
11/01/2012
05/02/2012
21/03/2012
08/05/2012
31/05/2012
23/06/2012
21/07/2012
17/09/2012
03/11/2012
24/12/2012
02/02/2013
04/04/2013
19/07/2011
01/12/2011
05/06/2012
02/09/2012
29/01/2013
08/04/2013
12/11/2011
26/04/2012
04/09/2012
14/02/2013
DateBaseLine 1.00.018
Summary
Group Start Finish Mean Sigma Count LCL UCL Stable
1 17/06/2011 17/05/2013 3.654 1.809 26 -1.77 9.079 Yes
2 02/06/2011 06/04/2013 6.952 4.999 62 -8.05 21.95 No
3 01/06/2011 29/04/2013 8.310 4.656 168 -5.66 22.28 No
4 19/06/2011 18/05/2013 7.948 5.459 58 -8.43 24.33 No
Not 08/06/2011 10/05/2013 8.333 5.436 39 -7.97 24.64 No
Patients with an ASA Score of over 1 have a
longer LOS - in sub-acute
Ankle, Humerus, Tibia & Fibula
24
48
72
96
120
144
168
Hours Ankle - ASA Score Time to Surgery 1
1
1
1
44
1
4
1
1
4
1
12
4444
1
2
1
1
1
4
111
1
44
2
1
44
3
11 1
4
Not
4
4
44
4
11/Jun/1131/Jul/1110/S
ep/1120/O
ct/1112/D
ec/1114/Jan/1216/F
eb/1221/A
pr/1218/M
ay/1218/Jun/1225/Jul/1212/S
ep/1227/O
ct/1208/D
ec/1228/Jan/1305/M
ar/1305/M
ay/1310/Jan/1125/Jun/1118/A
ug/1127/S
ep/1120/N
ov/1105/Jan/1212/F
eb/1225/A
pr/1223/M
ay/1209/Jul/1206/A
ug/1218/O
ct/1226/N
ov/1217/Jan/1329/M
ar/1303/M
ay/1302/D
ec/1324/S
ep/1116/A
pr/1221/N
ov/1226/D
ec/1225/N
ov/1101/M
ay/1228/D
ec/12
Date
0
BaseLine 1.00.018Summary
Group Start Finish Mean Sigma Count LCL UCL Stable Capable
1 08/Jan/11 05/Dec/13 21.46 21.51 179 -43.1 85.98 No No
2 10/Jan/11 03/Dec/13 24.18 19.80 163 -35.2 83.59 No No
3 11/Mar/11 22/Apr/13 36.08 36.10 37 -72.2 144.4 No No
4 26/Dec/12 01/Apr/13 54.00 28.37 2 -31.1 139.1 Yes No
Not 06/Mar/11 04/Oct/13 36.32 44.03 34 -95.8 168.4 No No
04/07/2011
20/08/2011
27/09/2011
31/10/2011
28/12/2011
25/01/2012
29/02/2012
02/04/2012
05/05/2012
13/06/2012
27/07/2012
16/08/2012
20/09/2012
20/10/2012
17/11/2012
05/12/2012
10/01/2013
20/02/2013
25/03/2013
18/04/2013
26/05/2013
27/10/2011
02/03/2012
24/05/2012
22/08/2012
08/11/2012
04/02/2013
05/05/2013
03/02/2013
22/05/2012
09/04/2013
0
12
24
36
48
60
72
84
96
108
120
Hours Appendicectomy - Time to Surgery - ASA Score1
11 1
4
1
23
12
2
11 1
1
4
33
1
44
2121 2
2
12
1
21 1
2
1
4
3
14
Not 1
04/07/2011
20/08/2011
27/09/2011
31/10/2011
28/12/2011
25/01/2012
29/02/2012
02/04/2012
05/05/2012
13/06/2012
27/07/2012
16/08/2012
20/09/2012
20/10/2012
17/11/2012
05/12/2012
10/01/2013
20/02/2013
25/03/2013
18/04/2013
26/05/2013
27/10/2011
02/03/2012
24/05/2012
22/08/2012
08/11/2012
04/02/2013
05/05/2013
03/02/2013
22/05/2012
09/04/2013
DateBaseLine 1.00.018
Project Ankle Fracture Time to Surgery.bpf
Date 10/06/2013 07:43:23
Summary
Group Start Finish Mean Sigma Count LCL UCL Stable Capable
1 01/06/2011 26/05/2013 16.33 11.41 420 -17.9 50.57 No
2 05/06/2011 30/05/2013 18.67 12.04 144 -17.4 54.79 No
3 22/06/2011 12/04/2013 16.22 9.80 18 -13.2 45.63 No
4 08/08/2011 23/03/2013 7.333 0.887 3 4.674 9.99 Yes Yes
Not 03/07/2011 09/04/2013 16.57 7.848 35 -6.97 40.12 No
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Director of Surgical Services
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