Lower Limb Arthroplasty Improvement Project Summary – January 2016

Project Team

 
Wassim Tomouk (Clinical Lead), Richard Marx, Paul Ashton, Matt Wragg, Beccy Callan, Chris Vickers, Andrea Menzel, Steven Staniland, Sue Lake, Lynn Skelton, Jill Lomas (Managerial Lead) Paul Griffiths, (Service Improvement Lead).
 

Background

The Orthopaedic RHH theatre team made a 33% increase in throughput on Mr Wassim Tomouk’s Monday list. Four Hip or Knee replacement operations now regularly take place on this list; before the norm was three.
 

Assessment

In November 2012, the Surgeon, Anaesthetist, ODP and Theatre Nurses, with support from Service Improvement took time to meet, analyse data and discuss how they could reduce the time between cases to plan an extra patient. Using the Clinical Microsystem improvement method the team used the data to identify themes for improvement.
 

Diagnosis

They generated ideas for a new process of overlapping cases - which required two extra staff costing £400 per list – allowing one more case to be planned, with additional income of approximately £5500.
 

Treatment

The team tested this process over several weeks and gaps between cases reduced from 60 to 25 minutes, creating time for the fourth case. The new process is now standardised and four operations have been performed on the list since February 2013. As a result, the income per list has risen from £15,000 to over £20,000 with a cost increase of £400. 34 patient surveys demonstrated high satisfaction with the RHH Orthopaedic experience and this new process allows more patients to access this service.
 
The following charts demonstrate the improvement outcomes achieved during the initial implementation phase, in terms of increased cases per list and income per list:
 
Patient and Staff Feedback: Throughout the improvement process, feedback was sought from patients and staff about the improvements to practice, some comments were as follows:
 

 

Patients
Staff
“The team were excellent on all shifts day and night - couldn't fault them”
“We have improved team working and efficiency”
“The friendliness and professional approach to patient care and the food was very good”
“I think we have now got the staffing exactly right and every one in our team seems to know what they are doing”.
 
“Some of the staff were exceptionally caring”
 
Benefits to date and future progress: This improvement project has led to increased throughput helping reduce waiting times and making the list more cost effective. During a full year, the new process allowed an additional 34 patients to be operated on with net income to STHFT of approximately £156k (full year projections are 34 patients with net income of £156k). From November 2013 the process was rolled out to further hip and knee lists. The new process enables an additional 87 primary joint procedures to be undertaken each year. This will enable patients from the waiting list to be treated more quickly. The projected gross income to STHFT of this increased activity is £488k, with income of £335k when costs of implants are accounted for.
 
Key risks: There are several risks to the success of this work. Scheduling of patients on to the lists can be difficult due to the number of pre-operative appointments a patient has to have once added to the waiting list. Plans are being made for some tests of change to reduce the number of appointments. A further key risk is the availability of critical care beds for some patients, which may lead to on-day cancellations. Discussions are underway with the Anaesthetic team regarding this. A further risk is general bed availability due to increased throughput. To mitigate this, work is underway to ensure the principles of Enhanced Recovery are implemented on the Ward.
 
Latest progress: During 2014, the Orthopaedic Theatres at RHH underwent refurbishment, which meant that the lists returned to NGH, which reduced the ability to run the four joint lists. The re-furbished theatres were opened again in January 2015 and then the process was gradually re-stablished during 2015 and onto 2016. The work is complemented by improvement work taking place on Ward F1, where all the hip and knee replacement patients recover. This ward are using microsystem improvement methods to make improvements to process, focus on Enhanced recovery and support a smooth patient pathway for Orthopaedic patients.
 
Further Information: Please contact the Service Improvement Facilitator Paul Griffiths on x62108 or paul.griffiths3@sth.nhs.uk for more information on this work.

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