Challenging and Changing Challenging and Changing Every Step of the Surgical Every Step of the Surgical

Pathway in an NHS HospitalPathway in an NHS HospitalEHMA Annual Conference, Athens, June 2008EHMA Annual Conference, Athens, June 2008

M. HEMADRIM. HEMADRIMBBS (Madras) FRCS (Edinburgh) MBA (Leicester)MBBS (Madras) FRCS (Edinburgh) MBA (Leicester)

In this presentationIn this presentation

Conventional surgical pathwayConventional surgical pathway Challenge each stepChallenge each step Single Visit pathway & resultsSingle Visit pathway & results People versus structurePeople versus structure Leadership from the ground and Leadership from the ground and

Feed-forward techniquesFeed-forward techniques ProblemsProblems LessonsLessons

Present/Traditional ModelPresent/Traditional ModelGP REFERS PATIENT

Up to 13 weeks

Specialist Consultation

Radiology Endoscopy +/- 13 Weeks

Other specialists, anaesthetic assessment

+/- 2 to 8 weeks

Bloods & review 6 weeks

Review and place on waiting list

Surgical operation

Nurse pre-assessmentUp to 6 months

Routine post operative visit/visits

2 to 12 weeks

18 WDP Impact31/62 Impact

12

2

2

34

5

6

Business Process Re-engineeringBusiness Process Re-engineering"... the fundamental rethinking and radical redesign of "... the fundamental rethinking and radical redesign of

business processes to achieve dramatic improvements in business processes to achieve dramatic improvements in critical contemporary measures of performance, such as critical contemporary measures of performance, such as

cost, quality, service, and speed.“cost, quality, service, and speed.“Hammer & Champy (1993)Hammer & Champy (1993)

Time compressionTime compression Process re-designProcess re-design

The shortest distance between two points is a straight lineThe shortest distance between two points is a straight line

Time compression of Traditional ModelTime compression of Traditional Model

GP REFERS PATIENT

6 weeks

Specialist Consultation

Radiology Endoscopy 6 Weeks

Other specialists, anaesthetic assessment

6 weeks

Bloods & review 6 weeks

Review and place on waiting list

Surgical operation

Nurse pre-assessment6 Weeks

Routine post operative visit/visits

6 weeks

18 WDP Impact

12

2

2

34

5

6

How useful is a post-operative follow up visit?How useful is a post-operative follow up visit?

70% of patients felt that they would 70% of patients felt that they would not benefit from a routine outpatient not benefit from a routine outpatient appointment.appointment.

Re-engineering of Traditional ModelRe-engineering of Traditional Model

GP REFERS PATIENT

6 weeks

Specialist Consultation

Radiology Endoscopy 6 Weeks

Other specialists, anaesthetic assessment

6 weeks

Bloods & review 6 weeks

Review and place on waiting list

Surgical operation

Nurse pre-assessment6 Weeks

12

2

2

34

5

Strong and abundant Strong and abundant evidence for effectiveness of evidence for effectiveness of telephone pre-assessment telephone pre-assessment

Especially for day case surgeryEspecially for day case surgery

Re-engineering of ModelRe-engineering of Model

GP REFERS PATIENT

6 weeks

Specialist Consultation

Radiology Endoscopy 6 Weeks

Other specialists, anaesthetic assessment

6 weeks

Bloods & review 6 weeks

Review and place on waiting list

Surgical operation

Telephone pre-assessment6 Weeks

12

2

2

3

4Lets look atVisit 2 & 3

Re-design: Emerging new modelRe-design: Emerging new model

GP REFERS PATIENT

6 weeks

Specialist Consultation

Radiology EndoscopyOther specialists,

anaesthetic assessment

Bloods

Surgical operation

Telephone pre-assessment

11

1

1

2Lets look atVisit 1 & 2

6 weeks

Dissatisfaction was due to waiting times between admission operation and discharge.

Single Visit ModelSingle Visit Model

Structured GP Referral Standard pathwayUnsuitable

Communication – Negotiation with patient

Suitable

Telephone Pre-assessment

Surgical Consultation, Investigations, Nurse Assessment, Anaesthetist Assessment, Admission and Operative Surgery

ALL ON THE SAME DAY

Discharge when stable

NO ROUTINE FOLLOW UP

Guarantee to see in 48 hours at request

1

New model performanceNew model performance Age range 20 to 83 years (M:F 2:1)Age range 20 to 83 years (M:F 2:1) Minor (small lesions, vasectomy): Intermediate (hernia, Minor (small lesions, vasectomy): Intermediate (hernia,

varicose veins): Major (gall bladder, incisional hernia):varicose veins): Major (gall bladder, incisional hernia): LA:GA=1:1LA:GA=1:1 No mortality, one unplanned admission, no 30 day No mortality, one unplanned admission, no 30 day

readmissions. readmissions. Reduced DNA rates. Reduced DNA rates. No cancellation due to hospital reasons. No cancellation due to hospital reasons. 20 declined due to lack of indication/complexity/fit with 20 declined due to lack of indication/complexity/fit with

exclusion criteria)exclusion criteria) Referral to treatment time: Average 4 weeksReferral to treatment time: Average 4 weeks No major complicationsNo major complications No significant complaintsNo significant complaints

COSTCOST

Patient FeedbackPatient Feedback

‘‘BETTER THAN PRIVATE’BETTER THAN PRIVATE’

Why are we different?Why are we different? Conventional ProjectsConventional Projects 18 WDP18 WDP Hospital at nightHospital at night 2/52 & 31/622/52 & 31/62

Conventional TeamsConventional Teams Chairman, Vice Chairman, Chairman, Vice Chairman,

Project Manager, Project Manager, Appointed/deputed multi-Appointed/deputed multi-discipline membersdiscipline members

Modernisation/Service Modernisation/Service Development Development sponsorship/supervisionsponsorship/supervision

Regular formal meetings, Regular formal meetings, reportsreports

Recipe booksRecipe books ‘‘‘‘Assured success’’Assured success’’

Unconventional projectUnconventional project

Spontaneously emerging, self Spontaneously emerging, self selected teamsselected teams

No hierarchical structureNo hierarchical structure No titlesNo titles

Self-monitoringSelf-monitoring

No budgetNo budget Very rare formal meetingsVery rare formal meetings Continuous informal contactContinuous informal contact Never produced a formal Never produced a formal

reportreport Action first – discussion and Action first – discussion and

documentation later.documentation later.

Rigid infrastructureRigid infrastructure

Flex/alter structure to get people in lineFlex/alter structure to get people in line

Use people to get around rigid structureUse people to get around rigid structure Example our patient admin IT systemExample our patient admin IT system

Emotional appeal one at a time builds up Emotional appeal one at a time builds up to a changeto a change

Sharing the glory is an investmentSharing the glory is an investment

Financial – forget it?Financial – forget it? Co-authoringCo-authoring Award applicationsAward applications Exclusive day outsExclusive day outs Appreciation lettersAppreciation letters Press exposurePress exposure

FEED FORWARD TECHNIQUES

Some of our team enjoying at the racecourse with a Brazilian

theme!!

The Rewards NetworkThe Rewards Network

ACTIVITY

CV

improvem

ent

Better A

ppraisals

PayRise

Promotion

AuthorshipAwards

Press citingLetters of appreciation

Other

PrestigeSelf worth

Emotional satisfactionSoft skills enhancement

FEED FORWARD TECHNIQUES

LosersLosers ResistorsResistors

DoctorsDoctors HospitalHospital OPDOPD WardWard Back office staffBack office staff

Busy surgeons Busy surgeons have long waiting have long waiting listslists

Genuine belief in Genuine belief in the old linear the old linear sequential process sequential process

Not invented hereNot invented here

Turkeys will not vote for Christmas

LEADERSHIP FROM THE GROUNDLEADERSHIP FROM THE GROUND

Goole District HospitalGoole District Hospital Accepting fluidityAccepting fluidity Accepting asymmetrical progressAccepting asymmetrical progress Saying ‘Yes’ more often than ‘no’Saying ‘Yes’ more often than ‘no’ Using the power of non-agendaUsing the power of non-agenda Short term micro feedbackShort term micro feedback Long term macro feed forwardLong term macro feed forward

Current StatusCurrent Status

Radiology/Ultrasound and out patient Radiology/Ultrasound and out patient predictive synchronisationpredictive synchronisation

Radiology/USS + OPD + Pre-Radiology/USS + OPD + Pre-Assessment synchronisedAssessment synchronised

Radiology/USS + OPD + Pre-Radiology/USS + OPD + Pre-Assessment + Anaesthetist Assessment + Anaesthetist Assessment synchronisedAssessment synchronised

NATURAL EXPANSION OF THE CONCEPT AND

GENERIC GROWTH OF THE TEAM

So what is the problem?So what is the problem?

Transformational change Transformational change but……………but……………

Small scaleSmall scale Roll outRoll out

WHAT IS THE SOLUTION?

Optimism.Strength of the model.Getting more political?

ConclusionsConclusions

Change programmes not centrally defined Change programmes not centrally defined can be done with equal or better successcan be done with equal or better success

People can be used to overcome rigid People can be used to overcome rigid infrastructureinfrastructure

Loose alliance of normal employees can Loose alliance of normal employees can achieve the same effects as formal teamsachieve the same effects as formal teams

The impact of small informal teams & their The impact of small informal teams & their projects could be local and limited but…..projects could be local and limited but…..

Lessons learntLessons learnt

Feed-forward is a useful tool not only Feed-forward is a useful tool not only for hard and soft career progression for hard and soft career progression but also a good political tool for but also a good political tool for enabling change.enabling change.

Leadership from the ground is Leadership from the ground is definitely possible and perhaps definitely possible and perhaps should be used more oftenshould be used more often

THANK YOUTHANK YOUAcknowledgement to our small core team which apart Acknowledgement to our small core team which apart

from myself includesfrom myself includes

Peter Moore, Consultant SurgeonPeter Moore, Consultant SurgeonJeanette Heaven-Terry, Surgical SecretaryJeanette Heaven-Terry, Surgical SecretaryJane Hopkins, Sister Day Surgery UnitJane Hopkins, Sister Day Surgery UnitTheatre floor in-charge of the dayTheatre floor in-charge of the dayAnaesthetist of the day (usually Dr. M Thant, Associate Anaesthetist of the day (usually Dr. M Thant, Associate Specialist or Dr S Jha, Staff Grade)Specialist or Dr S Jha, Staff Grade)

ANDANDAn increasing band of extended team members and An increasing band of extended team members and supporterssupporters