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DHF

DHF. Presentations between 2004 and 2008. +44(0)1423 506 848 +44(0)789 907 4881. Kent House 42 Duchy Rd Harrogate HG1 2ER. www.directhealthfirst.com. Entry Hurdles. UK visas UK work permits NCSC CHI Professional bodies Clinical registration bodies Other government initiatives.

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DHF

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  1. DHF Presentations between 2004 and 2008 +44(0)1423 506 848 +44(0)789 907 4881 Kent House 42 Duchy Rd Harrogate HG1 2ER www.directhealthfirst.com

  2. Entry Hurdles • UK visas • UK work permits • NCSC • CHI • Professional bodies • Clinical registration bodies • Other government initiatives

  3. What is day surgery? • Ambulatory care. • Out-patient care. • Short-stay. • Minimally invasive surgery. • Diagnostic procedures. • Minor injuries. • Non-surgical interventions. etc…

  4. (50%) possible as day cases: • Lasar prostatectomy • Trans cervical resection endometrium (TCRE) • Eyelid surgery inc tarsoplasty, blepharoplasty • Hallux valgus ("bunion") operations • Arthroscopic menisectomy • Scope’ shoulder surgery (subacromial decomp) • Subcutaneous mastectomy • Rhinoplasty • Dentoalveolar surgery • Tympanoplasty

  5. (50%) possible as day cases: • Laparoscopic cholecystectomy • interval appendicectomy • Laparoscopic herniorrhaphy • Thoracoscopic sympathectomy • Submandibular gland excision • Partial thyroidectomy • Superficial parotidectomy • Breast cancer wide axillary clearance • Haemorrhoidectomy • Urethrotomy • Bladder neck incision

  6. Possible as day cases: • Tonsillectomy in children • Correction squint • Bat ears/minor plastic procedures • SMR • Reduction nasal fractures • Cataract extraction • Laparoscopy  sterilisation • Termination pregnancy • TUR/laser/diathermy/limited resection bladder Ts • Pilonidal sinus excision and closure

  7. Waste from unplanned admissions

  8. “if you’re a fit young man who needs a knee operation, you don’t want to go into a general hospital and lie next to somebody who has a bed-sore and MRSA” Hospital Doctor (09-09-2004) NHS Improvement Plan: Part Three, Treatment Centres are not a threat DHF

  9. ASC’s BLOCK SCHEDULING CASES SCHEDULED BY TIME (15 MIN. INCREMENTS) MORE THAN 1 CONSULTANT/THEATRE WORK THROUGH THE DAY PAY - FEE FOR SERVICE TC’s BLOCK BY SESSION OR LIST MAJOR AND MINOR 1 CONSULTANT/LIST SCHEDULED DOWN-TIME BETWEEN LISTS PAY BY LIST OR SESSION. SOME FEE FOR SERVICE Scheduling DHF

  10. ASC’s ARRIVE 1 TO 1 1/2 HRS. PRIOR TO SURGERY ARRIVAL TIMES ARE STAGGERED PREOP TEACHING - CRUTCHES, EXERCISES PREOP MEDS GIVEN (ANTI-EMETICS, ANTI-INFLAMMATORIES) NURSES CANNULATE BLOCKS, SPINALS DONE IN PREOP AREA TC’s ARRIVE IN GROUPS AT 7:00AM, 11:00AM AND 5:00PM PATIENTS FREQUENTLY SEE THE CONSULTANT FOR THE FIRST TIME ANAESTHETIST OWNS THE PATIENT Pre-op Day of Surgery DHF

  11. ASC’s PATIENTS WALK DIRECTLY INTO THEATRE CRNA’s WITH MD SUPERVISION MORE REGIONAL ANAESTHESIA OUTPATIENT ANAESTHESIA NHS TC’s ANAESTHETIC ROOM, TRANSFERRED TO THEATRE ODA’S LESS REGIONAL ANAESTHESIA (SITE SPECIFIC) Perioperative ProcessAnaesthesia DHF

  12. ASC’s STAFFING - 1 SURGICAL TECH., 1 CIRCULATING NURSE, 1 FLOAT NURSE SCHEDULING OF CASES ANAESTHESIA TECHNIQUES SURGICAL TECHNIQUES EQUIPMENT NHS TC’S STAFFING - 1 SCRUB NURSE, 2 CIRCULATING NURSES, 1 ODA ANAESTHETIC ROOMS SIMILAR SAME SAME Perioperative ProcessTheatres DHF

  13. ASC’s NO LMA’s OR ENDO TUBES IN RECOVERY OUTPATIENT ANAESTHESIA THIS IS WHERE THE MEDS THAT ARE GIVEN UP FRONT MAKE A DIFFERENCE PATIENTS ARE SENT HOME, HOME READY NHS TC’s YES HOSPITAL ANAESTHESIA, PROLONGED RECOVERY TIME -ANAESTHETIST SPECIFIC Recovery Process DHF

  14. ASC’s CASE COSTING DECIDES WHETHER OR NOT YOU DO A PROCEDURE COST/CASE (BY CPT or DRG, SPECIALTY,CONSULTANT) SUPPLY MANAGER IT SYSTEM SUPPORT DETAILED INVENTORY SYSTEM EDUCATE STAFF AND CONSULTANTS HAVE TO CONTINUALLY WORK TO DRIVE DOWN COSTS NHS TC’s NO WAY TO CASE COST NEVER BEEN A NEED NO SYSTEM IN PLACE Case Costing DHF

  15. DHF

  16. Drivers • Waiting times, lists & capacity • Choice, Access and Quality • Contestability, Plurality and VFM DHF

  17. ISTCs OCTs [2000-2005] 7/27 43/46 NHS TCs NHS Capacity through Systems Redesign & other ways DHF

  18. PPP PFI Capacity Growth Services FM

  19. Sick or well model: • In business parks and shopping malls. • Range of procedures away from hospital site. • Age range. • Investigations. • Contraindication and risk factors. • Length of stay.

  20. Examples of Differences: • Ownership of property. • Quality of build. • Teams: Small teams. • Telephones not attendances. • Sick or well model: • Responsibility • Roles

  21. When things go wrong Difficult to justify protocols which are contrary to UK best practice (without evidence base) which leads to unnecessary conflict with national standards organisations • when (not if) there are unacceptable fatalities • legal consistency across England (Clapham Omnibus)

  22. Input and process specifications • Some procedures require specific data for national registers and these have to be specified • e.g. NCEPOD • Cataract National Dataset • e.g. National Joint Registry

  23. Outcomes The difficulty with outcome(s) is that the results should be attributable to the treatment

  24. Measures • KPIs • 25 ISTCs • NHS TCs • Outcome Measures • NHS TCs • ISTCs

  25. Differences • Equipment & Facilities • Buildings & Layouts • Turnkey & Systems • Health from Sickness Model (Pt walking) • Changing Expectations (Drs pushing) • Procedure innovation (i.e. blood conservation) • Indicators • Competencies VS. Apprenticeships

  26. Fear of clinical incompatibility

  27. Credentialing • GMC • People • Specialist Register • Training • Buildings, equipment, consumables • Facilities • HCC • Organisation • systems, information, registration

  28. VFM • Growcapacity • Delivered quickly • TCs • Improve access • Maintain quality

  29. In their buildings • On or Off NHS property • NHS Trusts& PCTs • With or without their staff • Near orfar away

  30. refurbished • Movable • Buildings • (modular) • leased

  31. Types of Surgery Centres in the U.S. • Hospital owned • Joint Venture (Hospital & Physicians) • Physician Owned • Management Companies with or without physician ownership

  32. Driving Forces behind the “Surgery Centre Movement” • Physicians / Surgeons • Hospitals • Government / Insurance Industry • Patients

  33. What Procedures can be ‘safely’ performed in the setting? not associated w/ excessive blood loss &/or fluid shifts do not require higher specialized operating equipment or intensive post-op care; post-op pain manageable take a “reasonable period of predictable time” the‘ultimate’ determinant: clinician comfort level

  34. What Patients? • few standardized guidelines • no multi-centre studies; paucity of large prospective studies • Mayo Clinic Study 1984: ASA III no higher risk in a Surgery Centre • FASA 1987: survey of 87,000 patients, questioned relationship between pre-existing disease and peri-operative complications • There is some empiric evidence of certain “patients at risk”

  35. Patients at Risk • “complex morbid obesity/complex sleep apnoea” • potential for airway problems, dysmorphic facial features, severe rheumatoid arthritis, • extreme age (?) • poor physiologic condition: ASA III+/IV • history of problems with anaesthesia (MH history) • Acute substance abuse

  36. The goal of any pre-op system “Reduce the morbidity of surgery & return patient to normal functioning as quickly as possible.”

  37. Risk Classification The Johns Hopkins Risk Classification System

  38. Summary of the Model • Goal: isolate the potential problem patients while minimizing testing on the healthy patient • Integrated service; cooperation w/ Surgeons & Primary Care • Anaesthesia consensus on pre-determined algorithms

  39. Pre-Op Testing: a sample matrix for minimally invasive surgery

  40. Surgery CentrePre-Op Testing: On-Site • Electrocardiogram • Haemoglobin • Glucometer • Urine Pregnancy Test

  41. The process of the screening process is a crucial first step that allows for the provision of safe, effective, and efficient medical care……The development of preoperative evaluation systems in response to outpatient and same day admission surgery provides the challenge of organizing services into formal systems with guidelines formulated on the basis of mutual agreement and established clinical practice……it is imperative that the anesthesia staff reach a consensus on significant preoperative evaluation issues and adhere to them in dealing with patients and surgeons and associated organizations. Conspicuous or consistent deviation from these practices will only serve to undermine the confidence of all the parties………Anesthesiologists, in setting up their systems, are well advised to allow for a measure of flexibility. While adhering to a strong standard of care, reasonable judgement in providing that care is preferable to unyielding policies. Ambulatory Anesthesiology: A problem oriented approach L. Reuven Pasternak, M.D., Chapter 1, Screening Patients: Strategies and Studies.

  42. On-Time Performance • Updated preference cards • On-site Sterile Processing • Standardize Case packs- supplies pulled day before • Patients walked to OR – short distance, no porters • Quick Prep & Anaesthesia Starts – minimize M.A.S.T. • Rapid turn around time (less than 10 minutes) • Simple Charting – report by exception, utilize checklists • OR flow closely monitored by the OR charge nurse & the charge anaesthetist: “vigilance”

  43. Example Anaesthesia Service Quality Indicators: • Patient and surgeon satisfaction • Accuracy rate on clinical records • Same day cancellation and surgical cases delayed • Cost per case benchmarking • Prolonged post-op nausea/vomiting • Taking longer than 30 minutes in phase I • ‘Reportable incident’ rates

  44. “Customized” Anaesthesia involvement: current techniques, continual presence, and provide in-servicing Quick recovery, fast-tracking experience, discharge not time based PACU process streamlined; standing orders Tailor patient recovery to individual needs and aggressive vigilance of patients’ recovery Construct an efficient physical layout Recovery Process

  45. Opportunity: Efficient Supply Utilization • Automated system: • cost per case (by CPT, Specialty, Physician) • preference card integrated w/ inventory system • Educate & involve surgeons in standardizing high-volume or high cost procedures; Provide Performance Reports • Standardization/Product Formulary • Lower Case Supply Cost • Minimizing Supply Waste • Use data in negotiating with vendors; Drive Better Product Pricing; ‘Just In-Time’ Inventory • Examine reusable versus disposable

  46. The Medical Director: Key Characteristics • Practicing Physician (Anaesthetist or Surgeon) • Respected member of medical staff • On-Site (majority of the time) • Must have a strong understanding of the ASC culture and be able to work with management team

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