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Focusing on ophthalmology waiting lists

Why was the initiative launched?
What was done?
Problems
Solutions
Ringing the changes
Is it working?
Tips for success
For more information contact

Using the 'Theory of Constraints' methodology to increase improve services to patients.


Why was the initiative launched?


In 1998, the NHS Executive Office for the Anglia and Oxford Region organised a workshop to explore whether the 'Theory of Constraints' (TOC) methodology could be used to help NHS Trusts manage their waiting lists. The workshop was part of the regional waiting list initiative and involved the National Patients' Access Team and Ashridge Management Consultancy.

The Radcliffe Infirmary, in common with many other organisations, was seeking innovative ways to tackle a long standing problem: how to reduce waiting lists in ways that did not sacrifice the quality of care provided to patients. Following the regional workshop the Trust decided to set up a Trust-wide programme to check out the TOC ideas. Two specialities, ophthalmology and neurosurgery, were chosen as the initial targets. Could the TOC approach really work in the NHS?

What was done?


Two workshops were arranged locally to help people involved understand the principles of the TOC approach. A programme of projects was designed to promote shared learning across the organisation, with three key objectives:


A review team consisting of Mr Paul Rosen, consultant ophthalmic surgeon, Barbara Cripps and Rebecca Turner, senior nurses, Meg Dale, waiting list administrator and Kathy Hulcup, Directorate Manager, was charged with leading and co-ordinating the work within ophthalmology.

Problems


A series of meetings were held with clinical team and managers to explore the optimum operating theatre capacity. A realistic profile specific to individual theatre lists was produced to establish the optimum number of cases per list and to reflect case mix and acknowledge individual surgeon's operating speeds. The discussions quickly confirmed that even working to absolute capacity it would not be possible to meet target levels of activity. Using the TOC approach surgical time was identified as the constraint within the system: a bottleneck that had to be eliminated.

Solutions


A number of ideas for extending theatre time were considered and the team chose to organise a trial to test twilight operating. Sessions were planned for three days per week, starting at 5pm and operating on five patients per session. There was some initial concern about how the idea would be received by patients. In the event it soon became evident that for some patients these sessions were much more convenient. It was easier for working members of families to escort patients to and from hospital, for instance. It also provided a calmer environment than the normal busy hubbub of hospital activity.

Phasing the workload throughout the day and evening was using theatre time more effectively and in ways that suited patients. This approach to increasing workload used ward staff more evenly during the working day. Progress was being made but the team was keen to explore other ways to ensure that sessions were used effectively.

Session start times and intervals between patients seemed to offer promising ways to speed the process. Other obstacles had already been removed. Patients no longer changed their clothing for surgery and where possible they walked from the clinic to the theatre. Traditionally the hospital had provided a chair to transport patients to theatre but it was clear that for most patients this was not needed. This change of policy released a good deal of porter time.

Ringing the changes


The team's discussions with staff suggested that further improvement might be possible if a buffer system was set up to ensure that surgeons would not have any wasted time between patients. Instead of calling patients one at a time it was suggested that two patients were called to ensure that a surgeon never waits for a patient to be brought. A small room close to the theatre was provided as a waiting area. Over time the practice fell out of use, yet productivity remained high. It was felt that the heightened appreciation of the issue of surgeons waiting for patients to be brought created by focussing on efficiency negated the need for such a buffer. Creation of a buffer follows a basic TOC principle that constraints should not be starved.


Radcliffe Infirmary: Ophthalmology Department
Waiting Lists Average list Reduction
March to August 1998 2250  
March to August 1999 1950 13%
Elective activity levels Average FCEs Increase
January to June 1998 325  
January to June 1999 450 38%

Is it working?


In designing the work programme the team wanted to be clear about how they would measure success. Measurement would be both quantitative and qualitative. Data would be available continuously to demonstrate both success and the need for further improvement. The views and experience of staff would be shared to promote learning across the Trust.

The work started in earnest in the summer of 1998 and within a matter of months good progress was being made. Between March 1998 and March 1999 the waiting list was reduced by about 10% with an increase in activity overall of about 900 cases. Activity increased overall by about 24%. Over eighteen months:


There is a real sense of success within the ophthalmic team overall. As one nurse said ' the most valuable thing was to work with management to do what is best in meeting the Department's clinical objectives'. This was reflected by the Ophthalmology Department's achieving Beacon status in May 1999.

There has been similar success with work in neurosurgery with reductions in elective cancellations and increased throughput. Taken together these projects have enabled staff in the Trust to make real progress in exploring how TOC can help them improve efficiency and the quality of care to patients. The need for flexibility is evident. Overcoming the main constraint in the system by supporting it and using buffer management often means the creation of others - that will require attention in the continuous quality cycle. The Trust has now set in hand a further programme to extend the approach into other specialities.

Tips for success



For more information contact


Sally Reid
TOC Project Manager
The Radcliffe Infirmary, c/o Administration
Woodstock Road, Oxford OX2 6HE
Telephone 01865 224195
Email Sally.Reid2@orh.anglox.nhs.uk

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