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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

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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

Ask Peter if he would like to say something as

Director of Surgical Services