M. HEMADRI MBBS (Madras) FRCS (Edinburgh) MBA (Leicester)

1. Challenging and Changing Every Step of the Surgical Pathway in an NHS HospitalEHMA Annual Conference, Athens, June 2008 M. HEMADRI MBBS (Madras) FRCS (Edinburgh) MBA (Leicester)

2. In this presentation • Conventional surgical pathway • Challenge each step • Single Visit pathway & results • People versus structure • Leadership from the ground and Feed-forward techniques • Problems • Lessons

3. Present/Traditional Model GP REFERS PATIENT Up to 13 weeks 2 1 Specialist Consultation 2 Other specialists, anaesthetic assessment +/- 2 to 8 weeks Bloods & review 6 weeks 2 Radiology Endoscopy +/- 13 Weeks 3 Review and place on waiting list 4 Nurse pre-assessment Up to 6 months Surgical operation 5 2 to 12 weeks 31/62 Impact 18 WDP Impact Routine post operative visit/visits 6

4. Business Process Re-engineering"... the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance, such as cost, quality, service, and speed.“Hammer & Champy (1993) • Time compression • Process re-design The shortest distance between two points is a straight line

5. Time compression of Traditional Model GP REFERS PATIENT 6 weeks 2 1 Specialist Consultation 2 Other specialists, anaesthetic assessment 6 weeks Bloods & review 6 weeks 2 Radiology Endoscopy 6 Weeks 3 Review and place on waiting list 4 Nurse pre-assessment 6 Weeks Surgical operation 5 6 weeks 18 WDP Impact Routine post operative visit/visits 6

6. How useful is a post-operative follow up visit? • 70% of patients felt that they would not benefit from a routine outpatient appointment.

7. Re-engineering of Traditional Model GP REFERS PATIENT 6 weeks 2 1 Specialist Consultation 2 Other specialists, anaesthetic assessment 6 weeks Bloods & review 6 weeks 2 Radiology Endoscopy 6 Weeks 3 Review and place on waiting list 4 Nurse pre-assessment 6 Weeks Surgical operation 5

8. Strong and abundant evidence for effectiveness of telephone pre-assessment Especially for day case surgery

9. Re-engineering of Model GP REFERS PATIENT 6 weeks 2 1 Specialist Consultation 2 Other specialists, anaesthetic assessment 6 weeks Bloods & review 6 weeks 2 Radiology Endoscopy 6 Weeks 3 Review and place on waiting list Telephone pre-assessment 6 Weeks Lets look at Visit 2 & 3 Surgical operation 4

10. Re-design: Emerging new model GP REFERS PATIENT 6 weeks 1 1 Specialist Consultation 1 Other specialists, anaesthetic assessment Radiology Endoscopy 1 Bloods 6 weeks Telephone pre-assessment Lets look at Visit 1 & 2 Surgical operation 2 Dissatisfaction was due to waiting times between admission operation and discharge.

11. Single Visit Model Structured GP Referral Standard pathway Unsuitable Suitable Communication – Negotiation with patient 1 Telephone Pre-assessment Surgical Consultation, Investigations, Nurse Assessment, Anaesthetist Assessment, Admission and Operative Surgery ALL ON THE SAME DAY NO ROUTINE FOLLOW UP Discharge when stable Guarantee to see in 48 hours at request

12. New model performance • Age range 20 to 83 years (M:F 2:1) • Minor (small lesions, vasectomy): Intermediate (hernia, varicose veins): Major (gall bladder, incisional hernia): • LA:GA=1:1 • No mortality, one unplanned admission, no 30 day readmissions. • Reduced DNA rates. • No cancellation due to hospital reasons. • 20 declined due to lack of indication/complexity/fit with exclusion criteria) • Referral to treatment time: Average 4 weeks • No major complications • No significant complaints • COST

13. Patient Feedback ‘BETTER THAN PRIVATE’

14. Conventional Projects 18 WDP Hospital at night 2/52 & 31/62 Conventional Teams Chairman, Vice Chairman, Project Manager, Appointed/deputed multi-discipline members Modernisation/Service Development sponsorship/supervision Regular formal meetings, reports Recipe books ‘‘Assured success’’ Unconventional project Spontaneously emerging, self selected teams No hierarchical structure No titles Self-monitoring No budget Very rare formal meetings Continuous informal contact Never produced a formal report Action first – discussion and documentation later. Why are we different?

15. Rigid infrastructure • Flex/alter structure to get people in line • Use people to get around rigid structure • Example our patient admin IT system • Emotional appeal one at a time builds up to a change

16. Sharing the glory is an investment • Financial – forget it? • Co-authoring • Award applications • Exclusive day outs • Appreciation letters • Press exposure Some of our team enjoying at the racecourse with a Brazilian theme!! FEED FORWARD TECHNIQUES

17. The Rewards Network Prestige Self worth Emotional satisfaction Soft skills enhancement Promotion Pay Rise Better Appraisals CV improvement ACTIVITY Authorship Awards Press citing Letters of appreciation Other FEED FORWARD TECHNIQUES

18. Doctors Hospital OPD Ward Back office staff Busy surgeons have long waiting lists Genuine belief in the old linear sequential process Not invented here Losers Resistors Turkeys will not vote for Christmas

19. LEADERSHIP FROM THE GROUND • Goole District Hospital • Accepting fluidity • Accepting asymmetrical progress • Saying ‘Yes’ more often than ‘no’ • Using the power of non-agenda • Short term micro feedback • Long term macro feed forward

20. Current Status • Radiology/Ultrasound and out patient predictive synchronisation • Radiology/USS + OPD + Pre-Assessment synchronised • Radiology/USS + OPD + Pre-Assessment + Anaesthetist Assessment synchronised NATURAL EXPANSION OF THE CONCEPT AND GENERIC GROWTH OF THE TEAM

21. So what is the problem? • Transformational change but…………… • Small scale • Roll out WHAT IS THE SOLUTION? Optimism. Strength of the model. Getting more political?

22. Conclusions • Change programmes not centrally defined can be done with equal or better success • People can be used to overcome rigid infrastructure • Loose alliance of normal employees can achieve the same effects as formal teams • The impact of small informal teams & their projects could be local and limited but…..

23. Lessons learnt • Feed-forward is a useful tool not only for hard and soft career progression but also a good political tool for enabling change. • Leadership from the ground is definitely possible and perhaps should be used more often

24. THANK YOU Acknowledgement to our small core team which apart from myself includes Peter Moore, Consultant Surgeon Jeanette Heaven-Terry, Surgical Secretary Jane Hopkins, Sister Day Surgery Unit Theatre floor in-charge of the day Anaesthetist of the day (usually Dr. M Thant, Associate Specialist or Dr S Jha, Staff Grade) AND An increasing band of extended team members and supporters