MAIN management, anaesthesia, recovery, Information technology, Quality

MAINBODYTheconcept of quality and its improvement is essential to our clinical practiceand delivery of care within the health services. Quality initiatives areinevitable and necessary in today’s health care system, and nurses are in a primeposition to initiate and participate in this process. Change in health carerefers to the process of adjusting current practice in order to improve quality(Barr & Dowding 2012, Hewitt-Taylor 2013). Operating theatres are costlyresources in health care institutions, encompassing a stressful workenvironment where patient safety is paramount. Operating theatres can contribute to more than 40% of a hospital’s totalrevenue. (Ahmed et al.

, 2013). The NHS Institute for Innovation and Improvementlaunched The Productive Operating Theatre (building teams for safer care) inSeptember 2008. The programme has been designed to support organizations totest and implement significant improvements across four quality domains:Patient experience and outcomes, Team performance and staff wellbeing,  Safety and reliability, Efficiency and value.(Cronin et al., 2014).  The aim of theprogramme is to improve quality and safety in theatres by enabling frontlinestaff, with the support and commitment of the executive management team, tosystematically identify and resolve day to day issues and frustrations usingproven methodology and lean principles. (“Evaluation of The ProductiveOperating Theatre programme,” 2013).

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The Programme commenced in Ireland in 2010with the initial training of 5 pilot sites. The pilot theatres alone deliveredannual productivity savings of €3 million and inventory savings of €300,000.(“The Productive Operating Theatre (TPOT) Programme 2010-2016 – Royal CollegeSurgeons in Ireland,” n.d.)Variousquality improvement projects exist which perioperative nurses practice in orderto improve the quality of care they provide for patients. For example, surgicalsafety checklist, incident reports, fall risk assessment, prevention ofpressure ulcer, medical alarms, RFID for specimens, ISBAR, Early warning scoreetc. Change in practice is required, however careful planning andimplementation are also necessary to ensure that intended outcomes are achievedand factors which affect the sustainability of change are addressed. (Chard,2010) .

The Productive Operation Theatre, also called the TPOT was introducedin two operating rooms in November 2014. The operating list in both theatresincluded Colorectal, urology and Breast cases. A multidisciplinary team was formedwhich included managers from the nursing department, management, anaesthesia,recovery, Information technology, Quality and Surgical Consultant, Operatingtheatre, anaesthetic, post-operative recovery staff based around a clinicallyled management cycle of continuous improvement.

The project was accepted,supported and aligned to the hospital’s Surgery, Anesthesia, and Critical CareDirectorate aims. Implementingthe programme, began which consists of a series of progressive modules:foundation modules, enabler modules and process modules, called the TPOT house.Foundationmodules – Executive and programme leaders began to implement the programme bycommunicating with staff and trust boards. Enabler modules – Knowing how we aredoing. All members of staff are brought together to identify obstacles torunning the ideal operating list. Progress is reviewed through data collectionon agreed measures. Well organised theatre. Directly involves staff in thesorting and standardization of equipment, leading to increased efficiency andless time wasted searching for equipment.

Operational status at a glance. Usesvisual management processes and real-time tools to effectively manage and planthe theatre environment. Team working. Aims to tackle the problem of adverseevents resulting from communication failures by increasing team cohesivenessand introducing a brief/debrief checklist. Scheduling. Aims to increaseeffective utilisation of a theatre session by working across the silo andencouraging communication between executive leaders, booking staff and theatrestaff. Schedules are adapted to different procedures and different staffingneeds, taking into account demand and capacity. Process modules Deals with theentire surgical care pathway from start-up to recovery.

It involves thestandardisation of a prompt and effective startup process, effective patientpreparation, improving transitions between patients in the theatre (turnaround)and transition of patients from one service to the next (handover), planning theusage of stock and replenishing stock levels and effective management ofpatient recovery..As a first step of the TPOT project,  Ontime start was planned to launch. Before the launch meeting of 60 minutes washeld with all the team members. Baseline data was presented and the goalexplained and clarified.

The discussion was done on existing barriers andsuggestions to improve On time start and the target was agreed among all. Theproject On time start at 0830 hrs, commenced (do) on 13th to 20th November 2014in two operation theatres. A keen pathway mapping (study) was done along thepatient pathway from the holding bay, preoperative checklist and check in, intoanaesthesia room, safe surgery checklist, surgery, end anaesthesia, into therecovery room and issues or improvement opportunities were documented.

Firstteam discussion was held the following week where the existing barriers toon-time start identified over the 5 days implementation period were broughtinto consideration, team members were allowed to vent subjectively followed byobjective analysis. (act) Daily team briefing at 0750 hrs was introduced andearly afternoon Debrief. The nursing preoperative checklist was changedmodified more user-friendly according to the data analysis. Meeting of the TPOTteam after a month reported the action completed based upon the TPOT projectimplementation. the theatre dashboard design process was updated, discussed onprogress and practical adjustments, improvements were made in schedulingpatients and on pre-assessment to prevent cancellations and maximize theatreutilization.   the ideal operating list Recoverybed available when needed, Excellent team working/leadership Excellentenvironment, including patient and staff facilities, Efficient patientpreparation and pre-assessment, Patient experience as good as possible,Accurate, organised lists Scheduling, right case mix and capacity, Good communication and efficient handover,Excellent portering service, Keeping to start and finish times, Skilled staff,clear role identification, Equipment available when and where needed.

possibleAccurate organised lists Scheduling – right case mix and capacity Goodcommunication and efficient handover Excellent portering service Keeping tostart and finish times Skilled staff, clear role identification  (Rymaruk and Buch, 2015)Barriersto the ideal operating listRecoverybeds not available when needed Staff shortages, inflexibility Poor team workingInefficient patient transportation (i.e. from recovery to ward) Changes tooriginal list order Inefficient patient pre-assessment Difficulty instandardisation and location of equipment Poor environment in the surgicaladmissions lounge Patient location and ward issues Increased paperwork, dresscode, trust policies Inefficient patient turnaround time Poor staff facilitiesEquipment not  available when and whereneeded  Problems with IT systems


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