Elective surgery recovery
l Embed the 6/4/2 process*, scheduling and look back to improve utilisation and embed ownership of the lists, including reviewing utilisation at two weeks in advance.
l Include daily and regular meetings with key staff with firm agendas, ensuring there are agreed cut offs for Cancer/ P2, so elective can backfill where required from pools.
Admissions and theatre flow: Theatres should automatically send for the first on list / ‘golden patients’ to assist theatre lists to start on time. Day cases should be the default, with day cases identified as first on the list to assist flow. It is also important to make the best use
of the estate e.g. looking at different storage solutions to minimise cramped corridors; convert space from trollies to chairs, increasing day case flow; repurposing rooms to sterile prep to support flow, etc. IT systems that are used to admit patients should be standardised to ensure safe effective care can be delivered, without extraneous paperwork or duplication. List lockdown should also be in place prior to the surgery day to reduce list order changes on the day. Trusts should minimise patient transfer times/delays by preparing the next patient when the previous one is transferred to theatre, and consultants calling for the next patient. Bloods on the day could also be done by cannula instead of needle to reduce the turnaround for appropriate procedures.
Immediate post–op / discharge: The ‘TTO’ (to take out) is a form that should be completed for all patients being discharged from hospital. Trusts should create pre-packs for TTO to help discharge nurses. But it is also important to ensure there is regular feedback to clinical teams (surgeons/anaesthetists) where patients have a failed discharge due to nausea/dizziness etc, so that intraoperative processes can be reviewed to optimise post-operative discharge. Trusts should review the discharge letter process to understand the bottlenecks and take appropriate actions.
Wards: It is important to ensure that, one week prior to TCI, checks are embedded either in pre-assessment or admissions until a single pre-assessment for the site is introduced. It is also important to understand the frequency and patterns of patients converting from day case to inpatient. Trusts should consider a working group
including nursing, pre-op/anaesthetics to reduce length of stay if necessary. Furthermore, Trusts should understand if the system has the ability to include both an inpatient assessment
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form and a local anaesthetic/day case assessment form which can be used on the day of admission.
Staffing: Trusts should ensure all relevant staff attend daily huddles/team briefings etc. It is important to review staffing allocations to lists, including anaesthetic support, through development of pooled teams, to improve team working within theatre and consistency to drive productivity and throughput improvements. Trusts should also consider if the start time for the staff groups are conducive to theatre start times. They need to understand staffing constraints and the long-term staffing plan, as well as to consider alternative staffing models and where alternative staffing groups may fit into structures (e.g. nursing associates). Trusts may also consider alternative staff
to provide support, in place of out-of-hours teams – for example, for out-of-hours physio, the nursing team could be trained to mobilise patients for discharge. This may assist day case rates and ensure discharge is provided in a timely manner. Ultimately, Dan concluded that there is a need
to reset pathways; to “work smarter, not harder”. Instead of “crisis management at the end of the pathway”, we need to put the “right processes in at the start”, he asserted. Often the solutions are “already out there”, but silo working prevents them from being communicated. With this in mind, it is important to listen
to the voice of staff working in theatres, decontamination, on the wards and admissions – to ensure all stakeholders are involved in the decision-making and pathway design. If we
are to improve outcomes, increase efficiency and reduce waiting time, this will need to be a priority.
CSJ
Notes *6/4/2 process: Surgical staff must agree their annual leave six weeks in advance, agree their surgical lists four weeks in advance, and double check their plans two weeks ahead.
Reference 1 NHS England, 2022/23 priorities and operational planning guidance.
About NPAG
The National Performance Advisory Group (NPAG) was originally established and funded by the Department of Health in 1983 to provide advice and guidance regarding pay/ productivity issues for ambulance, ancillary and estates staff. In July 2006, it became a trading division of the East of England Ambulance Service NHS Trust. Over the years, NPAG has grown its portfolio to become a nationally-recognised provider of services to healthcare across the country, including: national best value and benchmarking groups; benchmarking exercises; training workshops and courses; management consultancy service; and conference organisation and event management. The organisation’s prime purpose is to provide consultancy services and other support to NHS and public sector managers in the continuous improvement of their services.
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