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Creating an efficient operating theatre

Matthew Lowry 
Chief, Rotherham Hospital,
Rotherham NHS Trust, UK
Operating theatres are often described as the ‘heart’ or even ‘engine room’ of a hospital. Theatres are a complex, high-risk, multi-professional (sometimes tribal) area of work and in them we see a microcosm of many of the current challenges facing healthcare providers across Europe. 
European countries spend a significant part of their GDP on healthcare.(1) This reflects a commitment to the health of the nation, yet, alongside that commitment sits increasing financial pressure to improve performance and efficiency. We live in an era of budget deficit, increasing numbers of elderly people and rapidly changing technology.
In the operating theatre, these issues are distilled. Theatre has been found to account for up to 40% of total hospital costs(2) yet it also generates income. There is a need to increase throughput but patient safety cannot be compromised. Technology is available that can improve efficiency if we can show it to be cost efficient and within our budget. 
An approach needs to be adopted that addresses these challenges in an area where many top-down improvement efforts have historically failed, or at best delivered short-term, mostly transient benefits.
Productivity and beyond
Clearly there is a need for process optimisation in the operating theatre. Theatres are often a key limiting factor in patient pathways. Healthcare professionals working in operating theatres continue to examine options such as administering anaesthesia in the induction room while the OR is being prepared(3) or developing staff schedules that maximise use of teams and rooms.(4)
One question is the extent of change required. Small changes in theatre can be of limited value and are often not converted into increased activity: saving a surgeon an extra 15 minutes does not equate to an extra case going on a list. On the other hand, building a new theatre is an expensive option, costing well over a million euros.
Theatre time has been estimated to cost over £30 per minute according to some studies or, in a 2005 study of 100 US hospitals, operating room charges were found to average $62 per minute.(5) In this environment, time cannot be wasted looking for missing materials, waiting for staff to arrive or for the patient to be prepared for surgery. A theatre needs to be productive with procedures being carried out for as great a percentage of the working week as possible. Furthermore, time-saving equipment or procedures, along with the training and support to ensure their effective use, become an important part of improving efficiency. For example, using a single-use custom procedure tray has been shown not only to improve efficiency in theatre but also to minimise storage space, require less stock and give faster access to stock when needed.(6) 
The issues at stake here are broader than productivity, with most healthcare systems now faced with a number of concurrent challenges. Variations in outcome need to be ironed out. 
In the UK, for example, mortality rates following emergency surgery vary twofold between hospitals.(7) Constant effort is needed to improve patient experience, especially with patients able to increasingly choose between ‘willing providers’ for elective surgery. Access, or waiting times, remain close to politicians’ hearts, and in the UK, NHS patients are now given a legal right to treatment within 18 weeks of initial referral. There is increasing demand due to the aging population – a quick look at demand predictions for joint replacement surgery or cataracts illustrates this. And all of this is required within increasingly limited resources. 
Rotherham’s experience 
In 2009 Rotherham Hospital in the north of England became part of a pilot for ‘The Productive Operating Theatre Programme’ (TPOT), led by the NHS Institute for Innovation and Improvement (NHSIII). The programme became the catalyst for a wide-ranging and systematic improvement in the way operating theatres are run in Rotherham. 
TPOT is a modular programme looking at both the processes in theatres and the foundations and enablers that underpin them. Attention can be focused on one area before moving on to explore the opportunities in another. At the programme’s heart is an emphasis on teamwork, quality and giving healthcare professionals working in theatres the mandate to challenge and solve the problems they are experiencing.
Rotherham was typical of the NHS, with most surgeons having two or three operating lists per week, each scheduled to take around three and a half hours. Thus managers expect surgeons to spend eight to 10 hours per week operating. However, in reality, lists take only two and a half to three hours (starting late and finishing early) and only around half of that is knife-to-skin time, which means the total operating time for a surgeon is typically only four hours a week. In addition, international studies show that the average nurse working in theatre spends three hours each day just waiting or looking for things.(8) These figures suggest that the scale of opportunity for improvement is huge.
In 2009, ‘reported’ theatre utilisation in Rotherham was 95%. Most theatres in the UK run for up to nine sessions per week, each scheduled for three and a half hours. However, they typically start 15 minutes late and many finish 30 minutes early, with at least five percent of sessions cancelled and often not backfilled.(9) 
The effect of this time loss means each theatre is actually used for less than 25 hours per week or less than 50% of a normal working week of 8am to 6pm, Monday to Friday. 
At Rotherham, we applied a human factors approach, which is used in the aviation industry to examine the interaction between human and machine in order to improve safety, to our operating theatres. Our aim was to foster effective teams, with our surgeons and anaesthetists working alongside one other to understand what makes a safer team.
Through applying standardisation, ‘lean’ techniques and focusing on patient flow, significant opportunities to improve quality and productivity were identified. 
The results 
After systematically reviewing the way we worked in a number of areas included in the TPOT programme, the impact was assessed.
There was a reduction in the number of ‘glitches’ or issues that could have an impact on safety or productivity, such as the order of patients in the list, or the availability of specific equipment from 3.5 to 1.1 per theatre session. The staff sickness rate was reduced by 30%, with staff surveys showing attitudes to change, teamwork and the wider organisation all improved.
Our stock levels were reduced by £60,000 and our theatres better organised, with standard items (for example, drugs, dressings) in standard places in every theatre and anaesthetic room. 
In addition to making the theatre a better place to work, changes like this can have a real impact on patient safety. When the Whittington Hospital in London, UK did similar work, they found the average time taken by non-anaesthetic staff to find an emergency drug fell from 46 seconds to less than 10 seconds.
In Rotherham, a theatre admissions unit was developed that has reduced the time from call of next patient to their arrival in theatre from fourteen minutes to four. Preoperative assessment services were also reviewed, and now 100% of patients in most specialties are offered the opportunity to have their assessment on the day they are listed for surgery, rather than on a separate hospital visit.
The changes resulted in huge increases in productivity, with the average theatre list now lasting almost four hours from start to finish, compared to the previous average of less than three in 2009. Theatre sessions are no longer cancelled owing to surgeons’ or anaesthetists’ annual leave; instead, the theatre is kept in use by backfilling flexibly with other staff sometimes from other specialties. As a consequence of this we have been able to increase numbers of patients seen in theatre by more than 30%. Waiting times for surgery have fallen dramatically, with around 80% of patients getting to surgery within nine weeks of referral (half the national waiting-time target). 
All our standard operating now takes place within the standard working week, which has saved the organisation a considerable amount of money previously paid for additional sessions.
Perhaps the most important achievement, which is more difficult to quantify, is a change in culture. Theatre staff are now leading the improvement efforts in theatres, sorting one problem and moving on to the next. This culture of a self-sustaining improvement process in the very heart of the organisation will hopefully be the lasting legacy of the changes we have implemented during the past three years.
Next steps
There are further substantial opportunities yet to be fully realised. Staff in theatres are now analysing patient scheduling and the booking rules for each session to try to improve patient tessellation in order to minimise lost time at the end of sessions. We are also looking at the types of anaesthetics used, presurgical carbohydrate loading and early postoperative mobilisation, as part of the NHS Enhanced Recovery Programme which aims to improve patient outcomes and reduce length of stay. It may eventually be an option to stagger patient arrivals, so that the patient due to be operated on late morning does not need to arrive at the same time as the first patient on the list, and then wait for several hours. 
The challenge across Europe
The experience outlined here may be from the UK, but the same challenges are being confronted in operating theatres across Europe, whether it is the need for better scheduling or for more efficient stock controls. And solutions are being explored; from an IT solution to theatre scheduling in Belgium(10) to saving time by using custom procedure packs for operations in Germany, France and Sweden.(6) It would appear that examining all aspects of operating theatre processes is valuable in bringing about changes in efficiency and that, as was the case in Rotherham, standardisation of processes has a significant impact on saving time and money while maintaining clinical standards. The development of standardisation procedures, from efficient storage of theatre equipment to making sure the right patient is in the right place at the right time, creates a framework which enables repeated high performance. 
Managed care in Europe is seen as the joint responsibility of policy makers, commissioners, providers, and the people who receive the healthcare. The initiative for change may come from any of these quarters: from guidelines introduced by policy makers through to patient preference. 
In terms of the operating theatre, shared responsibility for improving both efficiency and patient outcomes and ensuring safety is also needed. Top-down change alone is not always successful. As Edgar Schein, the great guru of organisational culture, said: “You can’t impose anything on anyone and expect them to be committed to it”. By contrast, bottom-up culture can often mean that the initiators of change lack formal authority. In the case of Rotherham, we found that top-down change worked only because it swiftly became a project that involved everyone. We achieved a cultural shift by giving ownership to the multidisciplinary team who work in the operating theatre.
The development will need to continue, of course, but in Rotherham, at least, we see that it is achievable to keep the hospital’s beating heart running efficiently, with positive results for patients, staff and management.
This article was supported by a grant 
from Mölnlycke Health Care.
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