Meghana Pandit, Chief Medical Officer and Hannah Iqbal, Director of Strategy and Partnerships, Oxford University Hospitals NHS Foundation Trust discus show they have transformed elective care in Oxford over the last 12 months, increasing operating usage to 87%, and reducing 104 week+ waiting lists by 75%.
Introduction
During the COVID-19 pandemic, clinical and academic teams in Oxford were at the centre of the response, from vaccine development, to identifying beneficial treatments through the RECOVERY trial, to pioneering work on long-COVID. As we have emerged from the more acute phases of the pandemic and shifted our focus towards recovery, we have sought to build on the agility, compassion and commitment our teams showed throughout the pandemic to explore how we might now meet the challenges of elective recovery – including through improving theatre productivity and utilisation.
The pandemic has had major ramifications for routine healthcare nationally, with emergency care under pressure, and over six million people waiting for elective care. The same is true for us in Oxford. During the pandemic, like many hospitals around the country, we, at times, had to postpone routine inpatient and day case elective surgery to prioritise urgent surgery including cancer, and urgent and emergency care pathways.
We describe in this blog some of the work we’ve done to improve our theatre productivity and utilisation – from c.65% in 2019 to c.87% in 2022 and in doing so have reduced our waiting list and the number of patients waiting over 104 weeks in the past 6 month period (October 2021 to March 22) by 75% to 26 patients.
What we did and what we learnt
To approach the challenge of improving our theatre productivity and utilisation, we have:
- Ensured dedicated clinical leadership – We appointed 3 new Clinical Directors for theatres and set up a cross-divisional theatre productivity steering group, chaired by the Chief Medical Officer and with the right people at the table.
- Supported by a culture of quality improvement – Six months before the pandemic, we set up a cross-divisional Theatre Productivity QI Programme to drive change. Through this, clinical teams were empowered to suggest and pilot changes to improve productivity, predominately focusing on processes, policies, and workforce. The programme included the creation of an organisation wide theatres dashboard. We set definitions for theatre utilisation, efficiency, and turnaround times. The dashboard was visible to all at theatre suite, specialty, and consultant level. Improved transparency of data meant more ability to apply QI methodology to metrics which were highlighted as needing improvement by the teams themselves
- Improved our results – Since then, our teams – led by the three Clinical Directors – have focused on improving utilisation, efficiency, cancellations, overruns, underruns and at the same time, ensuring improvement in pre-operative processes to reduce cancellations on the day (e.g. to 3.7% at the Nuffield Orthopaedic Centre, against Trust target of <5%), and following a 6/4/2 or 5/3/1 week template to ensure that theatres are fully utilised. Our improved scheduling emphasized the need to ascertain availability of surgical, anaesthetic and staff cover in theatre for each operating list, releasing the list at 2 weeks or 1 week in cancer work to other specialities. This ensured minimal theatre sessions were lost.
During the pandemic, we used the time where electives were cancelled to undertake emergency cases and we allowed multiple specialties to work in the same theatres, challenging traditional ‘one surgeon, one list’ models to improve utilisation and efficiency. - Making the most of cutting–edge technology – We were the first NHS Trust to purchase a comprehensive robotic navigation platform for spinal surgery at the John Radcliffe, as well as purchasing a further two surgical robots for use in the Oxford Cancer and Hematology Centre at the Churchill Hospital.This technology allows for more minimally invasive procedures that not only improve patient outcomes and decrease the time patients spend in hospital (with a reduction in length of stay of c.1 day in spinal surgery), but also decrease the amount of time spent in theatre. This allows our teams to be more productive with each list as well as supporting a significant decrease in the number of patients who need to return to theatre (a reduction of c.83% in spinal surgery).
- Supporting international recruitment and new roles – The OUH GMC Sponsorship Scheme has been established to enable international senior doctors in training, or at consultant-equivalent level, to work in the OUH. The doctors we appoint through the scheme will be senior trainees already working on a national training scheme or have completed equivalence in their own country, building on our strong track record of international recruitment. In 2021-22, the OUH had issued 14 GMC certificates of sponsorship.We have also established a strong focus on nursing recruitment, with over 900 internationally educated nurses being recruited to work at OUH, and 107 internationally educated nurses joining our theatres since the end of 2017.
- Ensuring we have the right digital enablers in place – In March 2022 we implemented digital pre-operative assessment, theatres scheduling and documentation at one of our hospital sites, the Nuffield Orthopedic Centre, via the OUH deployment of Cerner theatres. This has helped re-enforced Trust standards, improved data quality, reduced duplicated effort and transcription errors. We are now rolling this out across our remaining sites, and in conjunction with Anaesthesia-BMDI (a digital Anaesthetic Chart with automated real-time feeds from anaesthetic machines and patient devices), this will make the surgical pathway paperless, improving efficiency and productivity.
What’s next?
Internally, we will continue to focus on ensuring sustainable change, committed leadership, and embedding a culture of quality improvement across theatres. For example, a recent QI event at the Horton General Hospital has identified a need to create a dedicated Day Surgery Unit to facilitate High Volume Low Complexity (HLVC) work. In addition, we are rolling out the programme more widely across the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (BOB ICS).