NEWSLETTER FOR NATIONAL CLINICAL PROGRAMME IN SURGERY

Issue 01 | Sept 2013

Models of Care for  

Elec.ve Surgery 

Models of Care for  

Acute Surgery 

Hosp

itals N

etw

ork

ed 

Audits…..NOCA(IASM,INOR,ICU,Trauma)

 Be=er Pa.ent Access, 

Quality Surgical Care &  

Cost Effec.veness 

Pre

‐Ad

mis

sio

n

Ass

ess

me

nt

 Ho

spit

alN

etw

ork

s

Acu

teC

are

Sp

eci

alt

y‐

Sp

eci

fic

Pa

thw

ays

Overarching Peri‐Opera.ve  Hospital Governance Structure 

Surg

ery

 Pro

gra

mm

e 

Pillars 

Ach

ieving 

Succ

ess

 Outcom

es 

Manpower/Workforce(Consultants,NCHDs,Nurses,AHPs,OtherGrades)

Resources(Beds,Theatres,Out‐PaMentFaciliMes)ICT,NQAIS

Founda.on 

Infrastru

cture

 

 Co

nsu

lta

nt

De

live

red

Se

rvic

e

Th

eP

rod

ucM

ve

Op

era

Mn

gT

he

atr

e

Da

yS

urg

ery

Da

yo

fS

urg

ery

Ad

mis

sio

n 

Ele

cMve

Ca

re

Pa

thw

ays

Targets&Metrics….(AvLOS..,DOSA…,Re‐AdmissionRates….)

Dis

cha

rge

Pla

nn

ing

Acu

teS

urg

ica

l

Ass

ess

me

nt

Un

it

Se

pa

rate

Ele

cMve

&

Acu

teP

ath

wa

ys

Planning&ChangeManagement

Welcome from the Clinical Leads

“Enabling access to high-quality surgical care through optimum resource utilisation (value)”We are delighted to welcome you to the first edition of the quarterly newsletter of the National Clinical Programme in Surgery (NCPS).

The National Clinical Programmes represent a strategic initiative between Clinical Strategy and Programmes Directorate of the Health Service Executive (HSE), led by Dr Áine Carroll, and the various post-graduate training bodies. The role of the National Clinical Programmes is to define how service will be delivered, measured and resourced and to provide clinical leadership. The Objectives are to:

• ImproveQuality

• ImprovePatient/ServiceUserAccess

• ImproveValue

The NCPS, a joint initiative between the HSEs Clinical Strategy and Programmes Directorate and the Royal College of Surgeons inIreland,specificallyaimstoprovideaframeworkforthedeliveryof safer, more timely, more cost-effective and efficient care, as well as greater accessibility for all surgical patients.

Itcommencedin2010withaninitialfocusonthedeliveryoftheModel of Care for Elective Surgery. This Model of Care, published in2011,hasalreadyhadsignificantpositiveimpactontheefficientdelivery of surgical care in Ireland. The Productive OperatingTheatreProgramme(TPOT),theNationalOfficeofClinicalAudit(NOCA)arealsosomeoftheprogrammesthatwereinitiatedbyNCPS prior to the commencement of the development of the ModelofCareforAcuteSurgery,whichwassuccessfullylaunchedbytheMinisterforHealthinJuly2013.

Prof.FrankKeane Mr.KenMealy

TheNCPSworkscloselywithotherNationalClinicalProgrammes,notablytheProgrammeinAnaesthesia,aswellasSpecialDeliveryUnit(SDU),patientadvocacygroupsandallrelevantstakeholdersacrossthehealthsystem.

WesincerelythankyouforyourcontinuedsupporttotheNCPSand do hope you will enjoy this newsletter.

ProfessorFrankKeane MrKenMealy Joint Lead, NCPS Joint Lead, NCPS

National Clinical Programme in Surgery at a glance

Each box shown in the ‘house’ above describes the important elementsoftheprogramme.Aswithanyhouse,thefoundationsstart on the ground and the elements are built in an orderly and sequential manner. The same has to be done in the Surgery Programme for it to be a success.

ABBREVIATIONS:

AHP - AlliedHealthProfessional;

AvLOS–AverageLengthofStay;

DOSA–DayofSurgeryAdmission

IASM–IrishAuditofSurgicalMortality

ICT–InformationandCommunicationTechnology;

ICU–IntensiveCareUnit;

INOR–IrishNationalOrthopaedicRegister;

NCHD–Non-consultantHospitalDoctor;

NOCA–NationalOfficeofClinicalAudit;

NQAIS–NationalQualityAssuranceIntelligenceSystem.

THE MODEL OF CARE FOR ELECTIVE SURGERY The development of a Model of Care for Elective Surgery was the initial focus of the National Clinical Programme in Surgery and the document was published in 2011. Since then, it hasbeen adopted by most surgical departments across the country, with measurable positive outcomes. The Elective Model of Care advocatesPre-AdmissionAssessmentclinics,Daysurgery,Day-of-SurgeryadmissionsandDischargeplanning.Italsosetshospitalandspeciality targets forAverage lengthofstay,aswellasDaysurgery.

Between 2010 and 2011, surgical volumes increased by 2.5%andbeddayusagedecreasedby5%.Thisamountstotruebedsavingsof91,662(net60,007).Therehasalsobeenanincreaseof 7.4% in day cases. This achievement is a direct reflection ofthecommitmentandhardworkofstaffandmanagementofacutehospitals across the country.

Withtherealisationthatupto60%ofhospital’ssurgicalworkloadrequireacutesurgicalcare,theModelofCareforAcuteSurgerywas launched this July. This Model of Care sets out best practice principles and strategies necessary to ensure the provision of high-qualityacutecareforpatientsinIreland.Itrecognisesthat,timelyaccess toaseniordecisionmaker, todiagnostics,and totheatres are important factors. Traditionally, emergency medicine has been second place to elective surgery, so the Model of Care forAcuteSurgeryalsorecognisestheneedtoseparatetheacutefrom the elective patient journeys and that, by better defining a clear pathway, this will lead to improved quality of care that is both safer and more cost effective. The success of the Model of Care hinges on the establishment of strong surgical and peri-operative governance structures and operational teams, as well as the provision of access to designated, protected beds.

PROGRAMME PILLARS• Day Surgery Guidelines

• Discharge Planning Process

• Pre-AdmissionAssessmentProcess

• NationalOfficeofClinicalAudit(NOCA)

• AverageLengthofStay(AvLOS)Targets

• DayofSurgeryAdmission(DOSA)Process

• The Productive Operating Theatre (TPOT) Programme

• Standardised,ValidatedDataAnalysis(HIPE)(NQAIS)

• Elective Care Pathways & Enhanced Recovery

PROGRAMME PILLARS• AConsultantLedService

• HospitalGroupsandNetworks

• AcuteSurgicalAssessmentUnits

• Surgical Teams and their Governance

• Capacity Planning Recommendations

• TheSeparationofAcutefromElective Streams

• Designated Beds and Theatre Recommendations

• WorkingwithotherProgrammesinUnscheduledCare

• Generic and Speciality Specific Standards of Care guidelines

• AcuteCarePathwaysandEnhancedRecovery

THE LAUNCH OF THE MODEL OF CARE FOR ACUTE SURGERYIn the development of theModel of Care for Elective Surgery,publishedin2011,itbecameclearthatacutesurgeryconstituted60%of theworkloadofmany surgical departments, and so theModelofCareforAcuteSurgerywasborn.

OnJuly17th2013,TheMinisterforHealth,DrJamesReillyTD,officially launchedtheModelofCareforAcuteSurgeryandtheNational Policy and Procedure for Safe Surgery at the Royal CollegeofSurgeonsinIreland(RCSI).Thereweremanyesteemedspeakerson theday, includingProfessorPatrickBroe,PresidentoftheRCSI,MrTonyO’Brien,CEO/DirectorGeneralDesignateof the Health Service Executive (HSE) and Dr Ellen O’ Sullivan, PresidentoftheCollegeofAnaesthetistsofIreland(CAI).ProfessorBroestatedtheModelofCareforAcuteSurgerywasatestamentto the determination of RCSI and HSE to the improvement ofsafety and quality of care for surgical patients presenting in the emergency or acute setting. Mr O’ Brien ‘hopes the principles contained in the document will guide all hospitals and groups of hospitals in their efforts to provide the best care possible for their patients’. During her speech, Dr O Sullivan congratulated the National Clinical Programme in Surgery for their achievements sofarandhighlightedtheneedforcontinuedteamworkingandbroadstakeholderengagement.

TheModels of Care for Acute Surgery and theNational Policyand Procedure for Safe Surgery is available for download from the RCSIandHSEwebsites.

Both Models of Care are available for download on the HSE and RCSIwebsites.Clickontheimagesaboveformoreinformation.

TRAUMA AND ORTHOPAEDICS PROGRAMMEThe Trauma and Orthopaedic Clinical Programme(TOP) is lead by MrDavidMooreandMrPaddyKennyasClinicalLeadsandCatherineFarrell,appointedinMay2013,asProgrammeManager.TheIrishInstitute of Trauma and Orthopaedic Surgery are the AdvisoryBody for the Programme. The Programme also has 5 RegionalLeads, Mr Bill Curtin, Mr Brian Lenihan, Mr Hannan Mullett, Mr EoinSheehanandMrMarkDolan.Theprogrammeiscurrentlyverybusyworkingonanumberofprojects,includingthedevelopmentof a Trauma and Orthopaedic Model of Care document, setting up a National Spine Service Plan group, encouraging Hospitals to contributedatatotheIrishHipFractureDatabase,co-ordinatingthe contribution of Trauma and Orthopaedic consultants to the HIQAHealthTechnologyAssessmentProcessandco-ordinatingthepublicationofagreedDVTprophylaxisguidelines.TheTraumaandOrthopaedicsProgrammehasalsoformedaworkinggroupwith the NCPS office and HSE procurement to launch National TendersforTraumaandOrthopaedicImplants,thefirstTenderwillbeforHipandKneeImplantsandwillbepublishedinNovember.

The programme has also been involved in forming a Cross programme Group to advance the publishing of guideline IntegratedCarePathway(ICP)forfracturedNeckofFemurpatients.AgroupwithrepresentativesfromAnaesthesia,Geriatrics,EDand

TOPmeton20thAugust2013andDrEmerAhern,waselectedas chair of the group. The group agreed that a template ICPwould be issued as a guideline and that the document will be sent for consultation prior to publication. Ms Louise Brent CNS inWaterfordRegionalHospitalhaskindlyagreedtoactasNurseLead for this Guideline.

For more information about the Trauma and Orthopaedics Programme, please contact Catherine Farrell, Programme Manager, catherinefarrell@rcsi.ie.

THE PRODUCTIVE OPERATING THEATRE PROGRAMME

‘Enabling and empowering theatre teams to transform the way they work’The Productive Operating Theatre (TPOT) programme is a continuous improvement programme to improve patient outcomes and operating theatre performance. It provides asystematic proven methodology, Lean, to enable theatre teams transformthewaytheyworktodeliversignificantimprovementsto quality of patient care, clinical outcomes and theatre utilisation. The Productive Operating Theatre Programme commenced in Irelandin2010,withtheinitialtrainingof5pilotsites.Thepilottheatresalonedeliveredannualproductivity savingsof €3millionand inventory savings of €300,000. Today there are 13 sitesactive within the Programme, whose 4 main objectives are tocontinuouslyimproveacross4qualitydomains:

1. Patient experience and outcomes

2. Safety and reliability of care

3. Team performance and staff well being

4. Valueandefficiency.

BENEFITS TO YOU AND YOUR PATIENTS• Improvequalityofpatientcareandclinicaloutcomes

- Improvedmulti-disciplinaryteamcommunication

- Increasedawarenessofpotentialissuesthatmay impact patient safety

- Improvedschedulingandpatientflow

- Increasedadherencetocarebundles

• Improvestaffmoraleandmulti-disciplinaryteamwork

• Empower staff to identify and resolve day to day issues

• Achievesubstantialgainsinproductivityandefficiency

- Extra theatre sessions

- Increasedpatientthroughput

- Reduction in cancellations

- Improvedturn-aroundtime

• Reduced errors, cancellations, avoid costs of harm through error

• Improvedschedulingandutilisation,stockcontrol.

Lean is a structured way of continuously exposing and solving problems to eliminate waste that delivers value to customers, our patients.

COLLABORATIONS

Winner of the TPOT Poster Competition at the Model of Care for Acute Surgery Launch was Alison Smith, TPOT Lead, Sligo Regional Hospital Team. Through the TPOT Programme, their start times significantly improved with the introduction of a Theatre Admission Area.

EDUCATIONAL EXCELLENCE IN SURGERY MEDICINE PHARMACY PHYSIOTHERAPY NURSING & MIDWIFERYRESEARCH LEADERSHIP POSTGRADUATE STUDIES SPORTS & EXERCISE MEDICINE DENTISTRY RADIOLOGY

If you require additional information regarding the Models of Care, hospital site visits, surgical activity analysis, The ProductiveOperatingTheatre(TPOT)oranyotherissuesarisingoftheNationalClinicalProgrammeinSurgery(NCPS),pleasekindlye-mailusatsurgeryprogramme@rcsi.ie.

The office of the National Clinical Programmes in Surgery is situated at the following address:

RoyalCollegeofSurgeonsinIreland,No.2Proud’sLane,Dublin2

Tel:014028502 E-mail:surgeryprogramme@rcsi.ie

Patient Arrives in hospital

at 7.00 hrs

PRE THEATRE

ADMISSION AREA

POST THEATRE

ADMISSION AREA

Efficient one

to one

admission

More

direct

route

Patients are waiting up to 60

minutes to be seen and

admitted by the

Multidisciplinary Team (MDT)

in the treatment room, LEVEL

5

Delays

experienced

include pre op

nebuliser

Delays due to the

geographical location of

the ward and transfer

from level 5 to level 8

Not all patients have had a

telephone assessment or

attended a Pre Assessment

Clinic

AS A RESULT 26%

ON TIME STARTS IN

APRIL 2012

All patients have had a telephone or

attended a PAC

appointment

Transferred to anaesthetic room

for cannulation at 08.30hrs

NOW 73% ON

TIME STARTS IN

JUNE 2013

81% say TAA

has improved

patients

outcomes

96% of MDT

state that

TAA has

been

effective

Staff Satisfaction Audit Patient Satisfaction

Audit

Timely admission

by the MDT

The Patient Pathway Pre and Post The Introduction

of The Theatre Admission Area (TAA)

Sligo Regional Hospital

Alison Smith Programme Leader TPOT

Direct

admission to

Level 8

We use T.P.O.T. to achieveultimate BREWS

Highest Quality GuaranteedWhen Served Combined

Safetyand reliability

of care

Patient’sexperience

and outcomes

T

B

A G S

S

B RE W

Theatre

overruns

Budget

overspend

Absenceof goodcommunication

Greatermanagement

and teamworkrequired

Satisfaction

& Safety of

patient care

Value and efficiency

Team performanceand staff wellbeing

Portiuncula Hospital

Operating Theatres

Portiuncula HospitalGalway / Roscommon University Hospital Group

Theatre over runs Better delivery of careBudget overspend Realistic and achievable lists

Absence of good communication Efficient spending & budgetingGreater management & teamwork required Workforce listened to and involved

Satisfaction & Safety of patient care SBARS (communication tool)

GalwayUniversityHospitalsOsppidéil na h-Ollscoile Gaillimh

UNIVERSITY HOSPITAL GALWAYMERLIN PARK UNIVERSITY HOSPITAL

Portiuncula Hospital Roscommon Hospital

B RE W

SBetter

deliveryof care

Realistic &achievable

lists Efficientspending &budgeting

SBARS(Communic-ation tool)

Workforcelistened to & involved

THE NCPS TEAMSurgery Leads – ProfessorFrankKeane,MrKenMealyPerformance Improvement Executive, SDU Scheduled Care – Ms Therese Dalchan Senior Project Manager, RCSI – Ms Mary FlynnProgramme Manager–MrEmekaOkerekeBusiness Intelligence–MrGerryKelliherTPOT Programme Manager – Ms Martha Ní ChuanaighTrauma & Orthopaedic Programme Manager – Ms Catherine FarrellAllied Health Professional Lead – Ms Caitriona CaulfieldAdministrator–MsNiamhKeane

Runner up of the TPOT Poster Competition at the Model of Care for Acute Surgery Launch was Marie Sinclair Portiuncula Hospital for their creative poster on the benefits of TPOT.

SHOULD YOU HAVE ANY QUESTIONS IN RELATION TO TPOT, PLEASE CONTACT

Martha Ní Chuanaigh The Productive Operating Theatre (TPOT) Programme Manager

Telephone +353(0)14022506

Email mnichuanaigh@rcsi.ie

For further information, click here and here