The Planned Care Improvement Programme: Day Surgery in Scotland

Transcription

The Planned Care
Improvement Programme
Day Surgery in Scotland
© Crown copyright 2006
This document is also available on the Scottish Executive website:
www.scotland.gov.uk
Astron B48618 11/06
Further copies are available from
Blackwell's Bookshop
53 South Bridge
Edinburgh
EH1 1YS
ISBN 0-7559-5246-4
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The Planned Care
Scottish Executive, Edinburgh 2006
ISBN: 0-7559-5246-4
Scottish Executive
St Andrew’s House
Edinburgh
EH1 3DG
Produced for the Scottish Executive by Astron B48618 11/06
Published by the Scottish Executive, October, 2006
Blackwell’s Bookshop
53 South Bridge
Edinburgh
EH1 1YS
100% of this document is printed on recycled paper and is 100% recyclable
ii
Page
Executive summary
1
1. Introduction – a concensus that improvement is necessary
2
2. Background
4
3. The benefits of day surgery
5
4. Improving day surgery performance
7
5. Understanding and measuring current performance
8
6. British Association of Day Surgery – Directory of Procedures
10
7. Understanding the patient pathway
14
8. Good practice model
15
9. Identifying obstacles to improvement
17
10. Programme actions
19
11. NHS board actions
21
12. Measures
23
13. References
26
THE PLANNED CARE IMPROVEMENT PROGRAMME
CONTENTS
iii
iv
It is generally held that around 75% of surgical procedures can be conducted as ‘day surgery’.
Audit Scotland conducted a review of day case surgery in 2004 and concluded that, in general,
Scotland has lower day surgery rates than England and there is potential to increase day surgery
rates. From analysis to date it is clear that in Scotland there is considerable variation across
procedures, hospitals and boards.
Executive Summary
The increase in day surgery rates for appropriate procedures has the potential to improve the
service for patients by achieving shorter waiting times, allowing patient choice and making best use
of NHSScotland capacity.
• Treating day surgery as the norm for elective procedures was identified in ‘Delivering for Health’
as a high impact change and is being championed by the Planned Care Improvement
Programme;
• The programme promotes the measurement of same day care, made up of all procedures
performed in surgical specialties in a day surgery or outpatient setting;
• On 29 September 2006 the Minister restated our commitment to a 75% same day care target
across Scotland;
• Currently in Scotland around 66% of all procedures performed in surgical specialities are carried
out as day case or outpatient (with a surgical procedure);
• To reach an overall 75% same day care target, approximately 40,000 elective inpatient
procedures would need to be converted to day cases or outpatients each year;
• ISD estimate the cost of overnight accommodation to be £237. A reduction of 40,000 elective
inpatients would result in efficiency savings of £9.5m per annum based on overnight
accommodation savings alone;
• The British Association of Day Surgery has produced a directory of procedures containing
aspirational targets for day surgery and outpatient surgery. This will form the basis of aspirational
targets for NHSScotland;
• The Planned Care Improvement Programme will work with NHS boards to identify stretch goals
based on the local capacity to improve same day case rates in identified procedures.
1
1. Introduction – a consensus
that improvement is necessary
There is consensus amongst clinicians (such as the British Association of Day Surgery), NHS
Managers, improvement functions and audit/regulatory bodies that the amount of surgery
performed on a day case basis is sub optimal and could be increased.
Delivering for Health, the strategy for the NHS in Scotland published in 2005, highlights the
benefits that increased rates of day surgery can offer to patients and to the NHS and stresses the
belief that day surgery rates can and should be increased. It also identifies the need for variation in
day surgery rates across the country to be robustly examined and managed out of the system.
In common with the NHS Institute for Innovation and Improvement, Delivering for Health suggests
a fundamental shift in patient and NHS culture so that day surgery is regarded as the norm for
elective surgery.
The basis for this consensus is borne out of the following:
• The desire to improve clinical outcomes. Care can be provided through an evidence based
pathway, which in turn is likely to produce better outcomes with reduced rates of healthcare
acquired infection;
• Patients prefer it. It is less disruptive to patients and their families and there is a high preference if
this option is made available;
• It can be provided locally in many cases. It is likely to enable the care to be provided in a local
hospital;
• It can improve working lives. Staff who are involved in day surgery areas are able to work flexibly
with more family friendly rotas;
• It can develop professional practice. Nursing staff may have a greater level of autonomy and
patient contact as they can be responsible for nurse led pre-admission assessment, post
operative care and discharge;
• There is data which highlights a performance gap. Comparisons of Scottish targets with English
performance demonstrates that there is still potential to increase day surgery rates, which vary
across NHS Boards (Audit Scotland 2004);
• There is unexplained variation. The variation in day case rates cannot be solely explained by
differences in case mix. Evidence suggests that a sizeable proportion is due to differences in
clinical practice;
• There has already been incremental growth in the amount of day surgery performed over the last
20 years due to technological and medical innovations such as less invasive surgery and
improved anaesthesia.
2
The Programme will audit progress by adopting a basket of 25 procedures, again drawn from each
subspecialty and consistent with the recommendations of the Audit Commission’s basket of 25
procedures (Audit Commission 2000). We will support the NHS in Scotland to measure, expose and
act on day case variation.
The Planned Care Improvement Programme will support NHS boards across Scotland to reach the
overall target for same day care of 75%, supported across the surgical subspecialties by a
‘directory’ of procedures with individual targets for what can be achieved.
Overall Target 75%
BADS Directory
Basket
3
2. Background
The Planned Care Improvement Programme is a key element in the national Delivering for Health
Planned Care Work-stream, it is a national level action and in common with other national
improvement programmes, all Health Boards are expected to participate.
The vision of the programme is to optimise the flow of patients along their healthcare journey by
improving their experience of assessment, diagnosis and treatment based on augmented,
expanded, safe and reliable clinical systems.
The programme has a number of overarching goals that impact on day surgery:
• To support activities that increase whole system working and support the concept of FLOW across
healthcare systems;
• To support activities that reduce overall length of stay for patients;
• To support activities that lead to improvements in day case rates;
• To build NHS capacity in Clinical Systems Improvement, Clinical Systems Management and the
application of FLOW based thinking;
• Creating a culture of data measurement and rationality, where decisions are driven by the
collection, access to and use of good meaningful data.
The Planned Care Improvement Programme will support NHS Boards to raise their performance to
the standard of the best and ensure that they systematically implement the five simple changes
described in Delivering for Health as well as further spreading the use of support processes such as
Patient Focussed Booking and Referral Management Services to support the changes in the
healthcare delivery process in Scotland.
The increase in day surgery rates for appropriate procedures has the potential to improve the
service for patients by achieving shorter waiting times, allowing patient choice and making best use
of NHS Scotland capacity. This is one of the five simple changes outlined in Delivering for Health.
NHS Boards should be working on plans to improve their rates and the Planned Care Improvement
Programme will provide support for this improvement to be realised.
This approach to the use of day surgery is part of the overall drive to shift the balance of care and
deliver a healthcare system that ensures that the time our patients spend in hospital adds value to
them.
The programme is underway and work to identify improvement in day case rates is ongoing.
4
Evidence from the Healthcare Commission and the Modernisation Agency indicates that increasing
day surgery rates generates numerous benefits.
3. The benefits of day surgery
System Benefits
• Greater theatre utilisation as day surgery is planned well in advance and has a high proportion
of ‘standard’ cases;
• Reduction in cost as no overnight stay is required. This has been estimated at £237;
• Frees up inpatient beds;
• Reduced waiting lists;
• Improved utilisation of operating lists;
• Reduced cancellations;
• Increased capacity (more bed days available).
Clinical Outcomes
• Speedier recovery is promoted;
• Better outcomes as patients are more likely to follow an evidence-based pathway of care;
• Risk of hospital acquired infection reduced (lower infection rates in day case units).
Patient Experience
• Patients have a preference to be treated on a day case basis with minimum disruption to their
lives;
• Waiting times reduced due to better utilisation of hospital capacity;
• Care provided through a patient focussed pathway;
• Minimally invasive procedures;
• Much lower risk of hospital cancellations and guaranteed admission dates;
• Increased patient satisfaction.
5
Benefits for Staff
• Flexible working;
• Improved training opportunities;
• Involvement in all aspects of the patient pathways;
• Enhanced roles in pre-operative assessment and nurse-led discharge;
• Improved job satisfaction;
• Clear start and finish times for shifts;
• Organised operating lists in advance;
• Reduced delays and cancellations due to lack of beds.
6
As improvement science is applied to healthcare systems internationally, consistent themes are
emerging including demand, capacity and queue management, process improvement based on
added value, reducing variation, and identifying and then optimising patient flow.
4. Improving day surgery
performance
The variation present in day case rates cannot be solely explained by differences in case mix.
Evidence suggests that a sizeable proportion may be due to differences in clinical practice,
geography and demography. Furthermore, research by the NHS Modernisation Agency suggests
that a major reason for the slow growth in day case surgery is that hospitals predominantly
organise themselves as providers of inpatient care.
Delivering for Health and The 10 High Impact Changes (NHSMA) and latterly work by the Institute
for Innovation and Improvement describe ‘what’ needs to happen to improve the provision of
planned care. For example in their high impact changes the NHS Modernisation Agency states that
inpatient care should be the exception rather than the rule. This will obviously have significant
implications in a healthcare system that is focussed on inpatient care as the default position.
The key steps to effecting a change in performance can be summarised as follows:
• Understanding and measuring current performance;
• Understanding the patient pathway;
• Understanding the structures to support improvement;
• Understanding the obstacles to improvement.
This document, and its accompanying data pack, form a baseline to measuring day case
performance in Scotland and identifying opportunities to increase the amount of day surgery
carried out in Scotland.
7
5. Understanding and measuring
current performance
England
The English Department of Health’s NHS Plan (2000) set a target that 75% of elective admissions
should be day cases, and there has been substantial support via the Department for Health and
Modernisation Agency which promoted the substitution of day surgery for inpatient stays as one of
its 10 High Impact Changes.
The English Department of Health 2000/01 figure for the percentage of elective operations
performed as day surgery was 68%, but this contains large numbers of procedures performed in
day surgery units which do not need operating theatre facilities and that could be undertaken in
other parts of the hospital or in primary care. The percentage of ‘true day surgery’ is much less,
and no hospital was found to be performing at uniformly high levels across all specialties. (DH Day
Surgery Operational Guide 2002.)
The percentage of day surgery is not rising for all suitable procedures and has declined for some
procedures. Hospitals that have comparatively high day surgery rates for one procedure do not
have high rates for all, though there is a greater degree of consistency by the same specialty. The
Healthcare Commission recommends that if all appropriate procedures were treated as day cases,
Trusts should be able to achieve overall day case rates of 75%.
Scotland
The Audit Scotland Report of 2004 investigated Scottish day surgery performance and the key
messages that emerged were as follows:
• In general, Scotland has lower day surgery rates than England and comparison of Scottish targets
with English performance demonstrated that there is still potential to increase day surgery rates;
• There is considerable variation overall across both board and hospital. The Scotland-wide
position disguises a large variation among boards in achieving day case targets;
• In 2002/2003 the SEHD 1998 targets were only achieved in seven procedures out of the existing
basket of 19;
• The general trend is slowing in the rate of increase in day surgery, this may be because some
boards have reached the optimum level of day surgery, or because some boards are paying less
attention to developing day surgery as an alternative to inpatient care;
• As surgery continues to develop and new procedures become appropriate for day surgery or
outpatient treatment, there will be more opportunities to move away from inpatient care. Some
procedures had moved to an outpatient setting, e.g. cystoscopies;
• Targets for day surgery need to be used flexibly to avoid constraining further change in the
future.
8
Year ending 31/03/05
Day Case+
Outpatient
Outpatients
rate
Elective Day
Cases
Elective
Inpatients
Day Case
Rate*
183,236
141,819
0.56
94,800
0.66
Argyll and Clyde
15,271
9,717
0.61
2,081
0.64
Ayrshire
15,780
9,057
0.64
13,339
0.76
Borders
3,119
2,075
0.60
2,460
0.73
Dumfries and Galloway
5,020
2,883
0.64
6,194
0.80
11,101
6,157
0.64
13,085
0.80
Forth Valley
8,513
5,348
0.61
5,422
0.72
Golden Jubilee
2,438
3,450
0.41
37
0.42
Grampian
11,145
17,255
0.39
12,369
0.58
Greater Glasgow
40,193
36,974
0.52
11,775
0.58
8,973
6,922
0.56
4,462
0.66
Lanarkshire
17,200
9,975
0.63
11,199
0.74
Lothian
29,045
19,104
0.60
6,698
0.65
980
249
0.80
496
0.86
1,496
362
0.81
582
0.85
11,690
11,494
0.50
4,601
0.59
1,272
797
0.61
0
0.61
NHS board
Scotland
Fife
Highland
Orkney Islands
Shetland Islands
Tayside
Western Isles
Table 1
Day case rate by NHS board of treatment
All procedures perfomed in surgical specialities
Overall Scottish Day Case Performance
Table 1 illustrates the overall system performance across Scotland for all procedures performed in
surgical specialties.
Currently in Scotland around 66% of all ‘procedures performed in surgical specialities’ are carried
out as day case or outpatient.
9
6. British Association of Day
Surgery – Directory of
Procedures
The British Association of Day Surgery has published a Directory of Procedures (2006) covering 160
procedures across nine surgical sub specialities which set challenging aspirational targets for surgical
teams. The Planned Care Improvement Programme will use this directory as the basis for setting
aspirational targets for NHSScotland and to stimulate performance improvement.
The Directory of Procedures, if implemented in full would achieve the increase of 40,000 procedures
required to achieve a national target of 75%. However, the Directory is recognised as aspirational and
stretching and analysis of variation, cultural change and performance improvement needs to be promoted
across all surgery. The Directory and overall performance can be monitored by applying a small audit
basket approach as recommended by Audit Scotland. The Audit Scotland basket (expanded to 25
procedures) can be easily drawn from the BADS Directory as illustrated in table 2.
The key features of the BADS Directory of Procedures (2006) are:
• A wider range of procedures than existing audit baskets;
• Owned by the professions;
• The basket approach for audit can be easily drawn from the Directory;
• A set of aspirational performance goals that will encourage excellence and improvement;
• Targets quoted on the basis of real data and on real performance. Though it notes that the achievement
may require reconfiguration of day surgery lists, redesign of clinical pathways and investment in
appropriate technology;
• The aspirational targets may not be achievable by all, but should be used in tandem with the basket as
a series of stretch goals that promote the concept of short stay surgery and time based patient flows.
Analysis of current performance and the use of the audit basket:
It is commonly accepted that an effective audit tool to gain a deeper understanding of the overall system
performance is the use of a ‘Basket’ of procedures. There have been a number of baskets previously
proposed by organisations and professional bodies within and out with of NHSScotland. The basket
currently in use in Scotland is the Audit Scotland (2004) basket of 19 procedures and accounts for
approximately 30% of the procedures performed in Scotland.
A basket can help to focus activity on procedures or specialties where increases could be achieved, it is
not, however, the definitive measure of overall performance which must always be the main focus of
system improvement. The basket should be drawn from a number of sub specialties, that will be indicative
of the overall direction of travel, but will not cover the whole system. Inclusion in the basket should not be
a ‘competitive process’ and the importance of the basket must not be over played or it will detract from
wider system performance improvement.
10
Procedure
Combined
BADS
Scottish Day
England
HSJ
aspirational Advisory
Case and
best in
Stretch
targets
Outpatient rate 2004 day
case rates class 2006
goals
2006
2004/05
Orchidopexy
0.69
0.72
Circumcision
0.72
0.55
0.894
Inguinal hernia repair
0.35
0.78
0.646
Excision of breast lump
0.59
0.81
0.95
0.95
Anal fissure
0.57
0.48
0.4
0.4
Haemorroidectomy
0.60
0.56
0.65
0.65
0.50
0.50
0.75
0.75
0.50
0.50
Laparascopic cholecystectomy
Varicose veins
0.41
0.82
0.903
TUR
0.75
0.75
0.9
0.9
0.80
Depuytren’s excision
0.46
0.76
0.95
0.95
Carpal tunnel decompression
0.88
0.9
0.99
0.99
Ganglion
0.85
0.42
0.95
0.95
Arthroscopy
0.66
0.76
0.95
0.95
Bunion operations/halux valgus
0.24
0.85
0.85
Removal of metalware
0.51
Cataract extraction
0.88
0.93
Squint correction
0.74
0.23
Myringotomy
0.86
0.76
Tonsillectomy
0.04
Submucous resection
0.68
0.979
Table 2
Daycase and Outpatient rate for expanded basket of procedures
0.7
0.95
0.95
0.9
0.9
0.921
0.99
0.99
0.07
0.92
0.8
0.8
0.32
0.85
0.818
0.6
0.6
Nasal fracture
0.86
0.62
0.95
0.95
Correction of bat ears
0.52
0.64
H&C
0.71
0.45
Termination of pregnancy
0.87
0.82
Laparoscopy
0.76
0.62
Surgical removal of impacted
wisdom teeth
0.87
0.88
0.65
0.682
0.95
0.75
0.95
0.90
0.95
0.97
0.95
Source - ISD, SMR01 04/05; HES; HSJ; BADS Directory of Procedures
11
Table 3 provides a summary of this focussed analysis of the figures illustrated in Table 1. It shows a
performance across Scotland of 75% for the 19 procedures in the current audit basket; however, we
know that across Scotland the overall performance is in fact only 66%. Relying exclusively on the
procedures in the basket will not guarantee achievement of overall system performance.
The detailed analysis in the accompanying data pack further investigates the variation by Health
Board which will allow:
• Understanding trends in day case activity in each specialty.
>
Have day case rates increased or decreased in each specialty and what are the reasons?
• Benchmarking day case activity against national average and upper quartile performance to
identify where increases could be made and identifying where.
>
Simply reaching the national average in a relatively small group of procedures could bring
significant benefits.
>
How many extra procedures need to be performed to reach upper quartile performance?
• Identifying best performers and share ideas and in turn, get feedback and ideas from innovators.
• Focussing on local areas of maximum return, i.e. identify the small number of procedures where
big increases could be obtained and determine where local priorities should lie. These are most
likely to be those with a reasonably large volume and ‘middling’ day case rates – i.e. possible to
improve but not too complex.
12
Year ending 31/03/05
Day Case+
Outpatient
rate
Outpatients
Elective Day
Cases
Elective
Inpatients
Day Case
Rate*
England
904,296
268,230
0.77
Scotland
74,991
30,998
0.71
16,448
0.75
Argyll and Clyde
5,616
3,143
0.64
57
0.64
Ayrshire and Arran
4,713
2,249
0.68
2,843
0.77
Borders
1,693
690
0.71
397
0.75
Dumfries and Galloway
1,684
618
0.73
1,393
0.83
Fife
4,211
1,214
0.78
2,244
0.84
Forth Valley
4,832
1,536
0.76
98
0.76
Golden Jubilee
1,437
867
0.62
30
0.63
Grampian
4,391
3,710
0.54
2,770
0.66
15,123
6,964
0.68
1,523
0.71
Highland
3,228
1,451
0.69
1,169
0.75
Lanarkshire
7,455
2,194
0.77
827
0.79
13,788
3,284
0.81
948
0.82
Orkney Islands
270
74
0.78
0
0.78
Shetland Islands
353
95
0.79
3
0.79
5,833
2,685
0.68
2,146
0.75
364
224
0.62
0
0.62
NHS board
Greater Glasgow
Lothian
Tayside
Western Isles
Table 3
Daycase rate by NHS board of treatment for the Audit of Scotland basket of
procedures
Source - ISD, SMR01, SMR00; HES
13
7. Understanding the patient
pathway
A key step to identifying improvements in day case rates is to identify improvements to the patient
pathway. Health Boards should benchmark against good practice patient pathways for each
specialty and identify key evidence such as:
• Pooled waiting lists;
• Preoperative assessment and information for day surgery patients;
• Pain protocols for day surgery patients;
• Discharge criteria for nurse led discharge.
Data has a part to play and key reports should be in place that flag up the following:
• High cancellations and high DNA rates;
• Patients staying the night before and the night after;
• Poor patient feedback.
Health boards should understand their theatre utilisation data and identify any potential spare
capacity due to:
• Under runs and wasted time in theatre;
• Number of cases on lists;
• Poor weekly operating profile.
Patient Pathway
• Generic Referrals
• Call patients close
to appointment to
remind them and
confirm medication
details
• Stagger lists
• Stream patients
flows
• Lower patient
wait time
• Screen patients
at referral
i
Adm
• Pool waiting lists
where possible
tp
Ou
-A
Pre
nd
a
nts
atie
• Within 13 weeks
of referral
• One Stop shop –
one nurse-led
pre assessment
for all elective surgery,
partial booking,
consent begun
• Patient fully
briefed and prepared
14
ssion
• Introduce scheduling to get the
right people and right equipment in
the right place at the right time
• Live, real-time data/systems for
theatres
• Post op information
inc pain management
• Nurse-led discharges –
Discharge Lounge
Pre - Peri - Post
Dis
ch
arg
e
ss
sse
• Streamline process
Pre assess then list
for surgery
Pre assess facilities
could be based in OP
• Agree patient selection
criteria for DS based
on National Guidance
• IT to support staff
• Performance
management
information to be
communicated
to all staff
• Patient and Staff
Surveys feed
back ideas and
suggestions into
patient pathway
Fo
ll
• Stagger
admissions
• Dedicated
admissions area –
changing, locker
facilities
consulting rooms
• All patients
admitted on
day of surgery
ow
• All DS patients should walk to
theatre
• Dedicated day surgery lists
where possible – if not
schedule day cases first
• Mixed lists (IP, DC) can cause
problems with productivity and
cancellations
• LAs often before GAs: does
not accommodate recovery
time for same day discharge
• Flexible opening
hours supported by
an operational
policy
• Post-op
information
• Ensure quality
and consistency
of information
Management of
Post-Operative
Pain
• Follow up
telephone call
• Emergency
contact details
The Modernisation Agency Theatres Programme good practice model has a number of key
components that should be examined:
8. Good practice model
• Using pre-operative assessment to identify patients who:
>
have potential anaesthetic difficulties;
>
have pre-existing medical conditions;
>
report a change in their medical condition following their outpatient appointment;
>
no longer wish to have the operation, or are unsure.
• Implementing pre-operative assessment to:
>
plan pre-operative care, e.g. any special requirements;
>
provide the opportunity for explanation and discussion;
>
allay fear and anxiety;
>
provide an opportunity to discuss with patients any self-help matters to improve the outcome
of their urgency of their surgery (e.g. stopping smoking or losing weight);
>
start planning for discharge.
• Validating waiting lists to:
>
identify patients who no longer require their operations;
>
telephone patients near to the date of admission to confirm attendance;
>
provide surgical teams with reports on the number of patients removed from the list without
having treatment;
>
contact patients who did not attend pre-operative assessment to ensure that they still require
their operations;
>
produce and analyse cancellation reports to ascertain where improvements should be made;
>
produce and analyse theatre utilisation reports to identify where there is spare/potential
additional capacity and why cancellations are made.
15
• Develop partnerships with local primary and community care organisations to:
16
>
identify where delays and unnecessary overnight admissions occur – e.g. ordering of transport;
>
develop benchmarking information, and incentivising the move towards increased day case
and day surgery rates through commissioning;
>
publish a local benchmark of best and worst performers to kick start action planning to
improve and provide regular reports to ensure momentum continues;
>
develop pilots to provide for recovery at home and other primary care follow up processes
in the patient pathway, transport facilities, patient hotel facilities;
>
co-ordinate an examination of the skills mix implications for moving to increased day-case
work for each professional group;
>
clarify which procedures could move to outpatients and primary care.
There are generally areas where a change in practice could achieve an increase in day surgery
rates such as those illustrated below and the Planned Care Improvement Programme will support
boards as they work to improve their performance.
9. Identifying obstacles to
improvement
Incorrectly coded day case patients
• Incorrect classification of a patient can lead to day case patient being incorrectly recorded as an
inpatient – once this has happened it cannot be changed;
• Incorrect classification to zero day stay can impact on patient care as patients are often planned
as an inpatient, managed on an inpatient ward and sent home without adequate planning,
preparation or analgesia.
Changes required:
• Focus on this area needs to ensure that good practice patient pathways are adopted, booking
these patients through a day unit wherever possible, or through a discrete, modified section on
an inpatient ward;
• Set certain specialities with an average day case rate over 50% to be booked as a day case by
default, or at least all ‘basket’ procedures. Even if the patient then has to stay overnight the
system will recognise this and change to an inpatient.
Patients who are discharged on the day of their procedure, but are admitted
the night before.
The reasons given for this are pre-operative testing needed the night before and bed protection to
ensure that a bed is available on the day of surgery.
Changes required:
• Implementation of a Board wide policy on night before elective admissions;
• Pre-operative testing the night before can be eliminated by replacing it with pre operative
assessment in the week before;
• Introducing day case trolleys or dedicated day case beds where feasible, or elective surgery
admissions wards to reassure surgical specialities;
• Admission lounges to ensure that there is somewhere for the patient to wait;
• Nurse-led discharge will help to ensure that beds are available for all surgical admissions.
17
Patients who are admitted as day case patient – but who stay the night
Often day case patients are given the option to stay the night on mixed elective wards, but this is
often due to social rather than clinical reasons.
Changes required:
• Introduction of day case wards where safe nurse-led discharge can be carried out to agreed
protocols;
• Check and benchmark pre and post operative analgesia to ensure pain and nausea protocols
are specifically focussed towards same day discharge;
• Admit to a day unit where possible, or convert beds in an inpatient ward, staffing with day case
nurses using day case principles, rather than ward nurses on an inpatient ward;
• Ensure there are sufficient dedicated day surgery lists in the morning to facilitate recovery time
before discharge.
18
The Planned Care Improvement Programme will support NHS boards to raise their performance to
the standard of the best. From the analysis of the information contained in the accompanying
datapack it can be seen that there is variation across Scotland which may be due to a variety of
reasons such as geography, demography or actual physical facilities.
10. Programme actions
The Planned Care Improvement Programme will promote day surgery as the norm and will drive
improvement towards the 75% overall Scottish target for same day care that Health Boards should
aim to reach.
Currently in Scotland around 66% of all ‘procedures performed in surgical specialities’ are carried
out as day case or outpatient. To reach a 75% target, approximately 40,000 elective inpatient
procedures would need to be converted to day cases or outpatients in a year.
The benefits of this are clear, ISD estimate the cost of overnight accommodation to be £237. A
reduction of 40,000 elective inpatients would result in efficiency savings of £9.5m per annum
based on overnight accommodation savings alone.
The report by Scottish Medical and Scientific Advisory Committee SMASC (June 2005) highlighted
that the existing definitions of day case procedure and outpatient procedure are unhelpful and in
some instances are a cause of confusion resulting in some cases being coded in different ways. The
relevant distinction should be between in patient care and same day care.
The Planned Care Improvement Programme will promote gathering information on outpatient, day
case and inpatient treatment on a consistent basis to allow monitoring of how boards are
progressing the shift from inpatient to day case and from day case to outpatient care, and the
programme promotes the measurement of SAME DAY CARE made up from the combined day case
and outpatient rates as illustrated in Tables 1 and 3 above.
The programme will work with NHS boards to ensure that they are able to maximise performance
according to their own local circumstances and contribute to the overall Scottish performance goal,
for example:
• The programme will identify the upper quartile performance of all boards across Scotland. For all
boards sitting below this we will expect a plan to move performance to this rate, i.e. to raise
performance to that of ‘the best’.
• For boards sitting above the upper quartile performance the programme will expect a plan to
move to a series of ‘aspirational’ targets based on the information contained in the new BADS
Directory of Procedures.
19
Key Programme level activities:
Measurement and benchmarking
• Provide baseline data to all NHS boards in the form of a datapack issued with this document;
• Aggregate national daycase data on a monthly basis and make available to all NHS boards;
• Agree national targets;
• Agree local stretch goals for locally targeted procedures taking into account local capacity for
improvement.
Spreading good practice
• Provide opportunities for clinical and management teams to spread and share good practice;
• Hold national events showcasing best practice from around Scotland;
• Hold regional events to promote inter-board working.
Support
• Provide targeted support for NHS Boards where required;
• Provide project teams with the tools and techniques for making positive change;
• Provide dedicated information management time to assist in gathering performance data;
• Provide support targeted at improving theatre efficiency;
• Work with the British Association of Day Surgery to update daycase procedure lists for Scotland.
20
Audit Scotland (2004) said that NHS boards should monitor the levels of day surgery by procedure
and specialty, to establish where day case rates are low and take appropriate action. They should
also monitor levels of outpatient endoscopy and day surgery to ensure that procedures more
appropriately dealt with in an outpatient or endoscopy setting are not inappropriately using day
case facilities.
11. NHS board actions
Delivering for Health says:
“We need to introduce in Scotland a list of suitable day case procedures, such as the Audit
Commission’s basket of 25 procedures (Audit Commission 2001) OR that approved by the British
Association of Day Surgery. We then need to measure and act on variation.”
The Planned Care Improvement Programme has worked closely with the British Association of Day
Surgery to promote their new 2006 Directory of Procedures and recommends that boards use this
directory as the basis for setting performance targets, identifying where to get started and where the
quick wins may exist to boost day surgery performance.
Having identified where opportunities exist for increasing day case rates, the steps required locally
to achieve the goal are often far less clear. The Planned Improvement Programme will assist boards
by focussing on understanding whole patient pathways, sharing good practice and identifying the
obstacles that may prevent progress along the way.
Key Board level Activities:
Measurement and Benchmarking
> Identify procedures where greatest gains can be made;
> Measure current performance, including underlying demand and service capacity;
> Provide monthly update on locally targeted procedures and the overall board rate;
> Improve accuracy of clinical coding.
21
Process
> Identify a local clinical champion for day case surgery to provide clear clinical leadership for day
surgery services;
> Understand the local barriers to increased professional uptake of short stay pathways;
> Make day case and short stay surgery the default position for elective surgery;
> Use day surgery and short stay surgery to reduce overall hospital length of stay;
> Maximise the use of short stay pathways to support movement towards 18 week patient
pathways;
> Pool day surgery waiting lists;
> Introduce multidisciplinary pre-assessment for day surgery;
> Introduce patient focussed booking and primary targeting lists to minimise cancellations for non
clinical reasons;
> Improve theatre efficiency (85%) to improve the flow of patients through the systems;
> Reduce the number of cancelled or poorly utilised operating sessions;
> Introduce nurse-led discharge and explore options for rebalancing teams utilising new roles in
surgery;
> Adopt new ways of working and shift towards team based service delivery;
> Understand capacity and demand in order to properly balance key resources such as staff,
recovery facilities and theatre sessions;
> Ensure that patient are properly streamed to ensure that elective inpatients and day cases are not
mixed to the detriment of lists;
> Ensure that day surgery units are used appropriately;
> Develop and promote specific programmes of short stay and day surgery training for surgeons
and other clinicians.
Patients
> Introduce patient pathways for targeted procedures that clearly define the patient’s journey
through the 4 key stages of preoperative assessment, the operation, discharge and
post-operative support;
> Identify and map the flow of patients through the unit;
> Adopt a day case surgery strategy and address operational issues such as ending admission of
patients the night before and patients kept in overnight for non clinical reasons;
> Provide patients and their carers, where appropriate, with all necessary information in the most
suitable medium throughout the day surgery journey;
> A Did Not Attend (DNA) rate of not higher than 2% should be achieved or bettered.
22
Day Case Measurement
Essential to increasing the day case rate in Scotland to 75% is the ability to demonstrate the
improvements that have taken place and where these improvements have been made. ISD have
published data from 1998 and the attached data pack gives the most current benchmarking data
available. However, measurement throughout the life of the programme is essential to demonstrate
the effect improvement work has had on overall rates and locally targeted procedures.
12. Measures
National Rates
The fundamental programme measure for day case improvement will be the national rate. NHS
boards will be asked to report the three measures indicated below on a monthly basis. This data
will be used to track NHSScotland against the 75% day case rate target and NHS boards against
locally agreed targets.
• The total number of surgical procedures performed in an inpatient setting;
• The total number of surgical procedures performed in a daycase setting;
• The total number of surgical procedures performed in an outpatient setting.
Local Rates
Local project teams will be required to report data on the surgical procedures that have been
identified for improvement. These measurements will need to consist of the overall procedural rate
and the supporting measures that demonstrate changes in performance and how the improvement
has been delivered. Typical supporting measures are given below.
Supporting Measures:
Demand
When understanding the process it is essential to identify where the demand for the service is
originating from. This will allow you to set the capacity to remove a backlog or maintain a strong
position and identify patients who should be on a different pathway of care.
• The total number of patients referred for a surgical procedure;
• The total number of emergency surgical referrals from A&E;
• How long patients had to wait to be admitted for surgical procedures commonly done as day case.
23
Pre-assessment
The introduction of a pre-assessment service should help to reduce the number of clinical and
patient led cancellations and DNAs for surgical procedures.
• The number of patients booked for pre-assessment then % booked for surgery;
• The number of patients who did not attend their pre-assessment;
• The number of patients who had their pre-assessment cancelled by the hospital;
• The number of patients not offered pre-assessment.
Surgical Intervention
Correct measurement of the below will identify your activity and show where improvements to the
process are being converted into an increase in the number of patients seen.
• The total number of surgical procedures performed;
• The number of patients for each surgical procedure where it was cancelled by the hospital;
• The number of patients admitted as a daycase but treated as an inpatient;
• The number of patients admitted as an inpatient but treated as a daycase;
• The number of patients who DNA their surgical procedure but had been pre-assessed;
• The number of patients who DNA their surgical procedure and had been pre-assessed;
• The number of patients cancelled by the hospital who had been pre-assessed;
• The number of patients cancelled by the hospital who had not been pre-assessed;
• The reason for clinical cancellation of patients;
• Patient follow-up scores to review surgical outcomes.
24
An indication of an efficiently run theatre is to achieve 85% utilisation and NHS Boards should
attempt to reach this. The measurements below will identify areas that can be improved but will
also give the overall capacity of available theatre time. The programme recommends that the
below are gathered and recorded but it will not be necessary to report these to the programme.
• Number of operating theatres;
• Number of theatre sessions;
Theatre utilisation
• Number of consultants;
• Number of anaesthetists;
• Number of nurses (or nurse teams);
• The length of theatre sessions;
• The average length of an operation;
• The amount of time theatres are potentially available for use (opening hours);
• The amount of time that theatres are in use;
• The number of surgical procedures carried out;
• Short running sessions;
• Gaps between patients.
25
13. References
Accounts Commission for Scotland (1997) – Better by the day.
Accounts Commission for Scotland (1998) – Better by the day – update.
Association of Anaesthetists of Great Britain and Ireland (2005) – Day Surgery, revised edition.
Audit Scotland (2004) – Day surgery in Scotland – reviewing progress.
British Association of Day Surgery (2005-06) – Directory of Procedures.
Department of Health (2002) – Day Surgery: Operation guide – Waiting, booking and choice.
Healthcare Commission (2004) – Acute hospital portfolio, Guide to Topic 2004 – Day Surgery.
Healthcare Commission (2005) – Acute hospital portfolio review – Day Surgery.
Heath Service Journal (09, 2005) – Remains of the day.
Journal of One-Day Surgery (Volume 14, No 3) – What can we evict for the Day Unit.
Modernisation Agency (2004) – 10 High Impact Changes for Service Improvement and Delivery.
National Leadership and Innovation Agency for Healthcare (2006) – Day Surgery Programme, Final
report.
Scottish Executive Health Department (2005) – Scottish Medical and Scientific Advisory Group – Day
Surgery.
Scottish Executive Health Department (2005) – Delivering for Health.
Wales Audit Office (2006) – Making better use of NHS day surgery in Wales.
26
The Planned Care
This document is also available on the Scottish Executive website:
www.scotland.gov.uk
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The Planned Care Improvement Programme: Day Surgery in Scotland

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