The Productive Operating Theatre
Dr Ramanathan Kasivisvanathan (ST7)
Dr Ahmed Chekari (Consultant and Clinical Director)
In these times of financial austerity significant savings need to be made whilst also maintaining the quality of healthcare delivered. This has resulted in the concept of Quality Improvement Productivity and Prevention otherwise known as QUIPP (1). One area that has been targeted is improving productivity in the operating theatre. A study from the Freeman Hospital in Newcastle in 2007 estimated that the total daily cost of running an average theatre was just under £5000 (2). To extrapolate this figure further a hospital with 10 operating theatres running over a year would amount to an expenditure of around £18 million. This considerable expenditure lead The National Health Service (NHS) Institute for Innovation and Improvement in 2009 to produce the QUIPP project called The Productive Operative Theatre (3). It is a range of strategies designed to provide a systematic way of delivering improvements in safety, efficiency and patient outcomes in the operating theatre whilst also reducing expenditure see Figure 1.
Whilst there are many important strategies in the ‘Productive Operating Theatre’ one key concept is that of Lean Methods. The remainder of this article discusses its importance in improving theatre productivity and furthermore its relevance to the anaesthetist.
The concept of Lean methods in healthcare is best understood by looking at its origins in manufacturing. Lean manufacturing, lean enterprise or lean production is a philosophy first popularized by Toyota: It considers the expenditure of resources for any goal other then the creation of value for the end customer to be wasteful and thus a target for elimination. The key concept in the ‘Lean’ theory is the steady identification and removal of waste or ‘Mudu’ (Japanese for waste) this in turn improves quality whilst reducing production times and costs (4). Many consider this principle to be one of the key drivers responsible for turning Toyota into one of the world’s largest car manufacturers.
Lean methods, The Productive Operating theatre and the Anaesthetist
Broadly speaking there are 7 types of ‘waste’ that need elimination in order to improve productivity in manufacturing. By considering each type of waste in relation to the operating theatre and analyzing our daily practice it is clear how we as anaesthetists can bring about improvements in theatre productivity. Let us consider an example of each:
1. Overproduction: processing an order before it is needed. Any process that is done on a routine schedule –regardless of current demand i.e. ’just in case’
Examples include: ordering certain preoperative tests on all patients on the basis that they may be cancelled or delayed if they do not have them, when in fact the majority of these tests do not change patient management.
Solution: Optimize pre-assessment so it is evidence based and provides clear easily available guidance on when certain tests should be ordered.
2. Inventory: purchasing before it is required to ensure an excess of stock is available.
Examples include purchasing and then stocking an excess of theatre equipment or anaesthetic drugs. Excess stock occupies space and makes other processes less efficient i.e. difficulty finding an emergency anaesthetic drug because it is hidden in a ‘sea’ of other drugs resulting in a delay of administration (see Figure 2A) Oversupply of stock can also provide the false impression a drug has run out and further supplies are then inappropriately ordered resulting in an overspend.
Solution: Streamlined drug cupboards (see Figure 2B) of only commonly used drugs stored in alphabetic order with only 1-2 boxes of each drug.
3. Waiting: any form of waiting which results in nothing productive being done by the worker.
Examples include waiting for a patient to come down to theatre and sitting in the coffee room doing nothing.
Solution: Employ and engage more porters so there are fewer delays in bringing patients to theatre.
4. Waste of transportation: movement of equipment, products or personnel to ensure work can done.
Examples include wastage in time transporting patients from the admitting ward to the theatre or vise versa.
Solution: Optimal geographic design of theatre complex to optimize patient flow.
5. Waste of over-processing – spending unnecessary resources to produce an equivalent product.
Examples include giving patients a nerve block, a spinal and a general anaesthetic for a joint replacement when a general anaesthetic and local infiltration may provides equivalent outcomes and be significantly quicker.
6. Defects – an error carried on downstream requiring intervention at a later stage resulting in a delay in the efficiency of the entire process, to the extent a significant resource saving could have occurred had the error been detected and acted upon early.
Examples include patients scheduled for surgery where the appropriate pre operative paperwork is not completed and this is only discovered once in theatre resulting in delays in the operating list whilst the paperwork is being completed and potentially cancellation of a later patient.
Solution: Robust checking systems before patients come to theatre.
7. Motion - when a worker needs to move repeatedly to perform their job.
Examples include constantly moving around theatre and the anaesthetic room to get drugs, equipment and or disposal of waste.
Solution: A motion efficient theatre where everything is easily available with minimal movement (see Figure 3)
With a £20 billion shortfall expected in NHS budgetting by 2020 (5) maximal productivity of our operating theatres is crucial. The concept of the productive operating theatre and ‘Lean Methodology’ are therefore vital and we as anaesthetists play a key role in leading in these areas.
(5) BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4507