Improving efficiency of operating theatres

The NSW Agency for Clinical Innovation (ACI) Surgical Services Taskforce (SST) is working with clinicians and managers to improve the efficiency of operating theatres and access to emergency and elective surgery in NSW public hospitals, writes Professor Donald MacLellan.
In 2011-12, approximately 210,000 patients had elective surgery in more than 270 public hospital operating theatres in NSW. Across the system, 45 per cent of all admissions to operating theatres are for elective surgery, 27 per cent for emergency procedures and 28 per cent for non-surgical procedures such as endoscopies.
These procedures generally share the same resources, so if the demand for emergency surgery and non-surgical procedures exceeds what is available, scheduled elective surgeries may be delayed or cancelled. In July 2013, the NSW Auditor-General’s Office published the results of the Managing Operating Theatre Efficiency for Elective Surgery Performance Audit. The audit assessed how efficiently public hospital operating theatres are being managed to deliver elective surgery.

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“There is a need for Guidelines to address fair, logical and standardised efficiency measures that promote accuracy in data collection across the state. Standardised data allows for reasonable comparisons to be made between sites in order to identify any variance.”
PROFESSOR DONALD MACLELLAN

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Efficiency was chosen as the focus of the audit because it has been identified as a key factor in meeting national timeframes for elective surgery and activity based funding budgets. Two primary criteria were applied to collect performance information and audit evidence:

• Are public hospitals meeting appropriate operating theatre efficiency targets?


• Do managers have the information they need to manage operating theatres efficiently?

The audit showed that there is potential for operating theatres to be managed more efficiently and the opportunity for more surgery to be undertaken without increasing current funding or resources.
Three key elective surgery efficiency targets which are currently not being fully met under the current model were also identified, including:

• Theatre utilisation


• Cancellations on the day of surgery


• First case starting on time.

The audit concluded that the NSW Health statewide elective surgery targets alone are insufficient to drive theatre efficiency at a Local Health District (LHD) and hospital level. Those in charge of operating theatres need a wider range of efficiency indicators to drive performance, as well as access to tools and resources to monitor efficiency more effectively at a local level. A recommendation was made for the Agency for Clinical Innovation Surgical Services Taskforce (ACI SST) to work with the NSW Ministry of Health (MoH) to support LHDs in improving elective surgery efficiency through the development of practical guidelines, tools and resources.
In response to the audit findings and recommendations, the SST held an Operating Theatre Efficiency Workshop: Time In, Time Out, Time Over in Sydney in September 2013. The workshop brought together operating theatre managers and health professionals for a day of expert presentations and discussions on operating theatre efficiency in NSW.
Three key priority areas for surgical efficiency and management to inform the development of statewide Guidelines for Surgical Efficiency were identified through the facilitated discussion at the workshop, including:

• Efficiency measures


• Theatre costs


• Whole of surgery.

The ACI and MoH have established three working groups for each of the identified priority areas to progress the outcomes and discussions from the workshop. Each of the working groups will provide considered expert advice on specific topics relating to the core issues of the identified priority areas for inclusion in the Guidelines.
Efficiency Measures Working Group
The Efficiency Measures Working Group provides advice on operating theatre measures that reflect efficiency on process and responsibilities for data collection.
Measuring the efficiency of operating theatres is important to ensure that available resources are used effectively. Participants at the workshop indicated that current measures of efficiency, such as first case start on time, can be difficult to achieve due to inflexible parameters. It was suggested that these measures on their own do not accurately reflect efficiency in the complex team environment of the operating theatre.
There is a need for Guidelines to address fair, logical and standardised efficiency measures that promote accuracy in data collection across the state. Standardised data allows for reasonable comparisons to be made between sites in order to identify any variance.
Considerations for the working group include data definitions, data quality, processes for data collection and data interpretation and analysis.
Theatre Costing Working Group
The Theatre Costing Working Group provides advice on costs associated with the different elements of surgery, feasible costing measurements and responsibilities for data collection in operating theatres.
The average cost of a fully staffed operating theatre per hour of surgery in NSW has not previously been well defined. Accurate cost estimates should consider all elements of surgery such as staffing, consumables, wastage in the operating theatre and capital cost depreciation.
The Guidelines may provide an indication of the average cost of surgery in NSW to allow sites to monitor variance in their costs, and identify areas for efficiency. The Whole of Surgery Working Group provides advice on the responsibilities of managers from preadmission through to the operating theatre suite and discharge, effective structures for collaboration between management and clinical staff, and developing effective frameworks that promote efficiency in patient throughput and quality care.

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“Those in charge of operating theatres need a wider range of efficiency indicators to drive performance, as well as access to tools and resources to monitor efficiency more effectively at a local level.”
PROFESSOR DONALD MACLELLAN

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Whole of Surgery Working Group
While efficiency measures and cost estimates can be defined within the parameters of the perioperative environment, the overall efficiency of operating theatre throughput is influenced by external factors. Pre- and post-operative processes, the availability of staff and operating theatre infrastructure can all affect efficiency.
There is a need for the Guidelines to provide direction on processes that can be employed by leadership, managers and operating theatre staff to enhance efficiency.
Considerations for the working group include management/leadership, models of care, staffing, and theatre size.
The three working groups are overseen by an Operating Theatre Efficiencies Steering Committee and the ACI SST.
To date, a literature search has been completed to assist the Efficiency and Whole of Surgery working groups to identify best practice nationally and internationally. The Operating Theatre Costing working group has partnered with the Activity Based Funding Taskforce to undertake a costing project and work with a trial hospital to improve the accuracy of costing for operating theatres.
The work each of working groups is undertaking has provided the content for the Guidelines for Surgical Efficiency, which will be released for comment in the second half of 2014.
Professor Donald MacLellan
Professor Donald MacLellan completed his science and medical degrees at Glasgow University before training in General Surgery in Melbourne. Donald held the position of Professor of Surgery at the University of Melbourne for 6 years before becoming Professor of Surgery at the University of Sydney. Donald has worked as the NSW State-wide Program Director of Surgery from 2005 to 2012 before joining the ACI. He has worked extensively with the Surgical Services Taskforce, Local Health Districts, and other clinical Networks to make significant improvements in surgical service delivery over the past 10 years.
The Agency for Clinical Innovation (ACI) is the lead agency in NSW for promoting innovation, engaging clinicians and designing and implementing new models of care.
All ACI models of care are built on the needs of patients, and are underpinned by extensive research conducted in collaboration with leading researchers, universities and research institutions.
Clinical Networks, Taskforces and Institutes provide a forum for doctors, nurses, allied health professionals, managers and consumers to collaborate across the NSW health system. The ACI works closely with the Ministry of Health, Bureau of Health Information, Clinical Excellence Commission, Health Education and Training Institute, NSW Kids and Families and the Cancer Institute NSW.