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Technical Appendix

National Theatres ProjectReportNovember 2006

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Scottish Executive, Edinburgh 2007

Technical Appendix


National Theatres Projectii


ISBN: 978-0-7559-5322-6

Scottish ExecutiveSt Andrew’s HouseEdinburghEH1 3DG

Produced for the Scottish Executive by Astron B49732 1-07

Published by the Scottish Executive, January 2007


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Contents

INTRODUCTION 2

APPENDIX A: Glossary and Definitions 4

APPENDIX B: Balanced Scorecard 19

APPENDIX C: Mandatory Scorecard 22

APPENDIX D: Measure Definitions 23

APPENDIX E: Reporting Framework 25

APPENDIX F: Pilot Management Reports 26

APPENDIX G: Pilot Scorecard 29

APPENDIX H: Pilot Analysis - Hours Breakdown 30

APPENDIX I: Pilot Analysis - Session Duration 31

APPENDIX J: Pilot Analysis - Patient Pathway 32

APPENDIX K: Pilot Analysis - Surgical & Anaesthetic Times 33

APPENDIX L: Capability Scoping 35

APPENDIX M: Capability Template 45

Contents 1

National Theatres Project2

Introduction

The objective of the National Theatres Project (NTP)is to achieve Best Value for theatre services byappropriately increasing patient throughput, therebyusing resources more productively and efficiently.

The purpose of this Technical Appendix is to providefurther detail to the main report on the project workundertaken and to give examples of analysis andinvestigation of findings from the use of the balancedscorecard approach to comparative performance.

Summary of Supporting InformationIn June 2005 the National Theatres Project agreedthe following activities with the NationalBenchmarking Project Board:

• a national theatres glossary with agreed definitionsto be drawn up and implemented

• a minimum standard dataset to be agreed acrossScotland

• development of routes for ensuring localaccountability

• evaluation of existing/available theatre systems.

Glossary and Definitions

A draft Glossary and Definitions was produced inconjunction with the Service. Where there wasalready agreement from existing national bodies onspecific definitions, these were incorporated. Whereno such agreement existed, definitions were agreedby a wide group of theatre users and wherenecessary amended following consultation (nationalevents and Board visits).

This draft was progressed through the NationalClinical Dataset Development Programme Board andhas been subject to a full formal consultation processwith a view to implementation in 2007.

A summary of terms and definitions appears asAppendix A.

Minimum Dataset

A National Data Points Day was held in August 2005with stakeholders from across the Service todetermine the information required in order tomanage theatres effectively. A theatre servicesbalanced scorecard which covers strategic andoperational indicators was produced from the outputof the day. This scorecard has been subsequentlyrefined and further developed with a focus on patientoutcomes and clinical governance matters with awide range of Service input from across Scotland.

The latest draft balanced scorecard, and some noteson the potential application of the balancedscorecard in a theatres context can be found inAppendix B.

A subset of these indicators have been proposed asmandatory national indicators to be collected byBoards from 2007/08 onwards. These are shown inAppendix C, while Appendix D provides moredetailed definitions of the measures.

Scorecard Pilots

Following development of the balanced scorecard,two pilot implementations tested:

• the use of the balanced scorecard to monitor andmanage continuous improvement in theatres

• accountability and responsibility structures toachieve ownership and control of the theatrecapacity and improvement in theatre services.

Appendix E shows an outline reporting framework,and examples of the management reports developedduring the pilots can be found in Appendix F.

Data from the pilots was used to populate thebalanced scorecard as far as possible. Thispopulated scorecard forms Appendix G. Where datacould be extracted from an existing theatre system,much of the scorecard could be populated with

Introduction 3

relative ease. Where a manual system was in place itwas not possible to populate as much of thescorecard. Accordingly two full pilot site scorecardcomparisons were not able to be generated as onlyone site had a comprehensive electronic theatresystem with the other pilot site providing manualreturns for pilot reporting.

Following completion of the pilots, the data collectedwas analysed and effective ways of representing thisinformation were explored. Appendices H to Killustrate these.

Capability Scoping

During March to July 2006 visits were made to allmainland Health Boards. The purpose of these was to:

• carry out a detailed assessment of currentlyavailable local theatres information

• evaluate existing theatres system implementations

• validate and assess nationally collected theatresdata

• seek Board input to the National Theatres Projectand balanced scorecard development

• communicate the purpose and objectives of theNational Theatres Project to Health Boards andinterested staff.

The detailed findings from the capability scopingare contained in Appendix L and the templateused to structure the visits can be found inAppendix M.


GENERIC DATA ITEMS

CHI Number The Community Health Index (CHI) is a population register, which is used in Scotland for

health care purposes. The CHI number uniquely identifies a person on the index.

Person Birth Date The date on which a person was born or is officially deemed to have been born, as

recorded on the Birth Certificate.

Associated Associated Professionals are those individuals who are involved with the client/patient in

Professionals a professional capacity, e.g. consultant, social worker, occupational therapist, etc.

Associated The recognised professional group to which the care professional belongs and in which

Professional Group they are employed.

Health Record A Patient Health Record Identifier is a code (set of characters) used to uniquely identify a

Identifier patient within a health register or a health records system, e.g. PAS.

APPENDIX A: Glossary and Definitions

Operating Theatres Data Standards

PATIENT DETAILS

ASA status The ASA PS classification globally assesses the degree of “sickness” or “physical state”

prior to selecting the anaesthetic or prior to performing surgery.

Code P1: A normal healthy patient.

Code P2: A patient with mild systemic disease.

Code P3: A patient with severe systemic disease.

Code P4: A patient with severe systemic disease that is a constant threat to life.

Code P5: A moribund patient who is not expected to survive without the operation.

Code P6: A declared brain-dead patient whose organs are being removed for donor

purposes.

Appendix A: Glossary and Definitions 5

PATIENT DETAILS (Contd)

NCEPOD category NCEPOD classification categorizes the urgency of the patient’s intervention.

Code 01: Immediate: Life, limb or organ saving intervention. Resuscitation simultaneous

with surgical treatment. The target time to theatre is within minutes of decision taken to

operate. E.g. Rupture aortic aneurysm, major trauma to abdomen or thorax, fracture with

major neurovascular deficit, etc.

Code 02: Urgent: Acute onset or deterioration of conditions that threaten life, limb or

organ survival.

Sub code A: Intervention within 6 hours: the target time to theatre is within

6 hours of decision to operate and normally once resuscitation is complete.

Sub code B: Intervention within 24 hours: the target time to theatre is within

24 hours of decision to operate and normally once resuscitation is complete.

Code 03: Expedited: Stable patient requiring early intervention for a condition that is not

an immediate threat to life, limb or organ survival. Target time to theatre is within days of

decision to operate.

Code 04: Elective: Surgical procedure planned or booked in advance of routine

admission to hospital. Target time to theatre is planned. Encompasses all conditions not

classified as immediate, urgent or expedited.


OPERATING ENVIRONMENT

Operating room type The type and setting of the room in a hospital where an interventional procedure

codeable in OPCS4 takes place.

Code 01: Category 1: Main theatre suite Sub code A: Operating theatre

Sub code B: Anaesthetic room

Sub code C: Recovery room

Sub code D: Procedure room

Code 02: Category 2: Sub code A: Satellite or isolated theatre

Sub code B: Day theatres

Code 03: Category 3: Sub code A: Endoscopy Suite

Sub code B: Radiology

Sub code C: Cardiac Catheterisation Lab

Sub code D: Procedure room

Sub code E: Pain clinic

Code 04: Category 4: Sub code A: ICU

Sub code B: A & E

Sub code C: Wards

Code 98: Other: Any other location not included in the above.

Operating session type The type of period of operating time allocated to a consultant.

Code 01: Scheduled:

Sub code A: Planned: Periods of theatre time allocated to a consultant,

usually on a regular basis, in which the consultant or a member of the firm

can perform operations, the majority of which have been arranged

beforehand. The maximum duration of a scheduled session is a notional

half-day.

Sub code B: Emergency: Periods of time allocated to a consultant on a

regular basis for patients whose visit to the operating theatre were not

foreseen but take place as a result of illness or a complication requiring an

urgent operation. The maximum duration of a scheduled session is a notional

half-day, e.g. trauma sessions/sessions sometimes locally known as CEPOD

sessions.

Code 02: Unscheduled: Periods of time allocated to one or more consultants outside

scheduled sessions allocated to a consultant and used by that consultant or one of the

same main specialty, for specific Theatre Case, usually at short notice.

Operating list type The type of published list, which consists of a set of patients who are to be operated on

in a session. The list documents the patients and the details of their impending operation.

Code 01: Elective: An operating list that comprises solely elective cases.

Code 02: Emergency: An operating list that comprises solely emergency cases.


OPERATING ENVIRONMENT (Contd.)

Specialty of session The specialty of the consultant to whom the operating session has been allocated.

A specialty is defined as a division of medicine or dentistry covering a specific area of

clinical activity and identified within one of the Royal Colleges or Faculties.

Code A1: General Medicine

Code A2: Cardiology

Code A7: Dermatology

Code A9: Gastroenterology

Code AA: Genitourinary Medicine

Code AM: Palliative Medicine

Code AQ: Respiratory Medicine

Code C1: General Surgery

Code C12: Vascular Surgery

Code C3: Anaesthetics

Code C4: Cardiothoracic Surgery

Code C41: Cardiac Surgery

Code C42: Thoracic Surgery

Code C5: Ear, Nose & Throat

Code C6: Neurosurgery

Code C7: Ophthalmology

Code C8: Trauma and Orthopaedics

Code C9: Plastic Surgery

Code CA: Paediatric Surgery

Code CB: Urology

Code D3: Oral Surgery

Code F2: Gynaecology

Code F3: Obstetrics

Code G1: General Psychiatry

Code H1: Clinical Radiology

Code R11: Surgical Podiatry

Code 98: Other, specify

To be determined, no existing codes at present:Dental Surgery

Maxillofacial

Interventional Radiology



Operating hours The hours during which the procedure was performed.

Code 01: Office hours: 08:00 hrs to 17:59 hrs Monday to Friday.

Code 02: Out of hours: 18:00 hrs to 07:59 hrs Monday to Friday and all day Saturday

and Sunday.

Time of day/night The period during which the procedure was carried out.

Code 01: Daytime: 08:00 – 17:59 hours.

Code 02: Evening: 18:00 – 23:59 hours.

Code 03: Night: 00:00 – 07:59 hours.

Operating times The combined date and time of an event.

Allocated start time of list/session: Time when the anaesthetist is scheduled to take

charge of the (first) patient in preparation for anaesthesia.

Actual start time of list/session: Time when the anaesthetist actually takes charge of the

(first) patient in preparation for anaesthesia.

Allocated finish time of list/session: The time when the anaesthetist is scheduled to hand

over the care of the last patient to recovery staff.

Actual finish time of list/session: The time when the anaesthetist actually hands over the

care of the last patient to recovery staff.

Sub-data items - adapted from the National Theatres Project:

Planned hours of list/session: The difference between the allocated start time of

list/session and allocated finish time of list/session.

List run time: The time difference between the actual list/session start time and the actual

list/session finish time.

List under run: When the list run time is less than the planned hours of list/session. The

term, as used in the Acute Hospital Portfolio, does not necessarily mean the list finished

early, as it might have started late.

List over run: When the list run time exceeds the planned hours of list/session. The term,

as used in the Acute Hospital Portfolio, does not necessarily mean the list finished late,

as it might have started early.



Reason for An explanation of why an operating list or session did not take place as planned.

cancellation of Code 01: Public holidaylist/session Code 02: Cancelled by surgeon/main operator: Sub code A: Planned leave

Sub code B: Sick leave

Sub code C: On call

Sub code Z: Other reason

Code 03: Cancelled by anaesthetic department: Sub code A: Planned leave

Sub code B: Sick leave

Sub code C: Skill mix

Sub code Z: Other reason

Code 04: Theatre Staff: Sub code A: Sick leave

Sub code B: Skill mix

Sub code Z: Other

Code 05: Training/Continuing Professional Development

Code 06: Maintenance

Code 07: Equipment failure/unavailable

Code 08: Administrative error

Code 09: No ward beds

Code 10: No High Dependency Unit beds available

Code 11: No Intensive Care Unit beds available

Code 98: Other reason for cancellation

Code 99: Not known

Reason for late start An explanation for the theatre list/session starting later than its allocated start.

of list/session Late start: When the actual start time of list/session is later than the allocated start time

of list/session.

Code 01: Porter not available

Code 02: Patient arrived late to hospital

Code 03: Patient not fasted

Code 04: Patient not ready in ward

Code 05: Patient not consented

Code 06: Staff not available to accompany the patient

Code 07: Investigations or x-rays missing

Code 08: Blood not available

Code 09: Intrusion of other specialty or emergency

Code 10: Anaesthetist delayed



Reason for late startof list/session Code 11: Surgeon/main operator delayed

(Contd.) Code 12: Theatre staff delayed

Code 13: Anaesthetic assistant delayed

Code 14: Theatre not adequately staffed

Code 15: Theatre not ready


Code 98: Other

Code 99: Not known

Reason for late finish An explanation for the list finishing later than its allocated finish time.

of list/session Late finish: When the actual finish time of list/session is later than the allocated

finish time of list/session.

Code 01: Late start of list/session

Code 02: Unexpectedly difficult procedure

Code 03: Difficult or unexpected anaesthetic problem

Code 04: Intrusion of other specialty

Code 05: Intrusion of other emergency

Code 06: Delayed availability of recovery facilities

Code 07: Delayed availability of High Dependency Unit facilities

Code 08: Delayed availability of Intensive Care Unit facilities

Code 09: List overbooked


Code 98: Other

Code 99: Not known


THEATRE PROCESSES AND OPERATIVE PROCEDURES

Specialty of procedure The specialty of the consultant who is responsible for the patient’s care. A specialty is

defined as a division of medicine or dentistry covering a specific area of clinical activity

and identified within one of the Royal Colleges or Faculties.

Code A1: General Medicine

Code A2: Cardiology

Code A7: Dermatology

Code A9: Gastroenterology

Code AA: Genitourinary Medicine

Code AM: Palliative Medicine

Code AQ: Respiratory Medicine

Code C1: General Surgery

Code C12: Vascular Surgery

Code C3: Anaesthetics

Code C4: Cardiothoracic Surgery

Code C41: Cardiac Surgery

Code C42: Thoracic Surgery

Code C5: Ear, Nose & Throat

Code C6: Neurosurgery

Code C7: Ophthalmology

Code C8: Trauma and Orthopaedics

Code C9: Plastic Surgery

Code CA: Paediatric Surgery

Code CB: Urology

Code D3: Oral Surgery

Code F2: Gynaecology

Code F3: Obstetrics

Code G1: General Psychiatry

Code H1: Clinical Radiology

Code R11: Surgical Podiatry

Code 98: Other, specify

To be determined, no existing codes at present:Dental Surgery

Maxillofacial

Interventional Radiology


THEATRE PROCESSES AND OPERATIVE PROCEDURES (Contd.)

Type of theatre case An indication of the type of patient visit to the operating theatre to undergo one or more

operative procedures.

Code 01: Scheduled: Includes scheduled or elective cases where the operation was

planned in advance.

Code 02: Unscheduled: Where the operation was unexpected or could not be planned

in advance.

Sub code A: Emergency

Sub code B: Revisit to theatre: When it was necessary for the patient to be

referred to theatre for a further operation/procedure as a result of

complication(s) related to a previous operation/procedure undertaken during

the same episode of care.

Management intent Whether or not the patient's attending clinician expects, at the time of booking, that the

patient will be admitted and discharged on the same calendar day, or discharged on a

subsequent date.

Code 00: None: Where no decision has been taken.

Code 01: Inpatient: Where the patient is expected to be discharged on a subsequent

date following the procedure.

Code 02: Day case: Where the patient is expected to be discharged on the same

calendar day after the procedure.

Code 03: Extended recovery: Where patients are admitted, operated on and stay for one

night post-operatively in a hospital facility (overall stay up to 23 hours). (International

Association for Ambulatory Surgery.)

Code 99: Not known.

Dates and times of The combined date and time of an event.

theatre processes Date and time of booking: The combined date and time at which the theatre team were

and operative notified that the patient required a procedure in theatre.

procedures Time patient sent for: The time that the theatre team sent the request for the patient to

be brought to the operating theatre department.

Time patient arrived in theatre premises: The time that the patient actually arrived in the

operating theatre premises.

Time into anaesthetic room: The time at which the patient was brought into the

anaesthetic room.

Start time of anaesthesia: The time of start of the anaesthetic procedure where this takes

place either in the operating theatre or in the anaesthetic room.

Time into theatre: The time at which the patient is transferred from the anaesthetic room

into theatre.

Start time of procedure: The time of commencement of the procedure regardless of

whether an anaesthetic is given or not. This should be ‘knife to skin’ or equivalent.

It does not include positioning, with the exception of manipulation of fractures.



Dates and times of Finish time of procedure: The time at which the procedure was finished and any

theatre processes dressings applied.

and operative Time patient entered recovery: The time at which the patient was transferred into the

procedures (Contd.) recovery area.

Time patient ready to leave recovery: The time at which the patient was assessed as

meeting the discharge criteria of the recovery room.

Time patient actually left recovery: The time at which the patient actually left the recovery room.

Operative procedure An indication of whether or not the intended operative procedure was performed.

performed indicator Code 01: Procedure performed.

Code 02: Patient anaesthetised but procedure not performed.

Code 03: Procedure cancelled.

Code 99: Not known.

Reason operative An explanation for an operative procedure not having taken place as planned.procedure not Code 01: Secretarial error.performed Code 02: Cancelled by patient:

Sub code A: Unable to attend

Sub code B: No longer wishes procedure

Sub code C: Did not attend – reason not known

Sub code Z: Other

Code 03: Cancelled by surgeon/main operator:

Sub code A: procedure not required

Sub code B: Patient not prepared

Sub code C: Surgeon/main operator not available

Sub code Z: Other

Code 04: Cancelled by anaesthetist:

Sub code A: Patient not fit

Sub code B: Patient not prepared

Sub code C: Anaesthetist not available (Sickness)

Sub code D: Anaesthetist not available (Skill mix)

Sub code Z: Other



Reason operative Code 05: Cancelled by theatre management:

procedure not Sub code A: Staff not available (Sickness)

performed (Contd.) Sub code B: Staff not available (Skill mix)

Sub code C: Equipment not available

Sub code D: Intervention by emergency case

Sub code E: Intervention by priority case

Sub code F: Lack of theatre time

Sub code Z: Other

Code 06: Cancelled by hospital:

Sub code A: No ward bed bed available

Sub code C: No Intensive Care Unit bed available

Sub code D: Administrative error

Sub code Z: Other

Code 07: Preoperative guidance not followed.

Code 98: Other reason for cancellation.

Code 99: Not known.


HEALTHCARE PROFESSIONALS

Associated An indication of the role carried out by each professional. Professionals are those

Professional Role individuals who are involved with the client/patient in a professional capacity.

(Operating theatres)Code 01: Consultant responsible for care: Consultant who carries clinical responsibility

for a patient’s healthcare during an episode.

Code 02: Operating surgeon/main operator (Main operating clinician): Clinician

performing the procedure.

Code 03: Surgical first assistant (First operating assistant): An individual who assists

the operating surgeon in performing the procedure.

Code 04: Assistant surgeon (Additional operating assistant): Any other individual (in

addition to the first assistant) who assists the operating surgeon/clinician in

performing the procedure.

Code 05: Supervising surgeon/clinician: Surgeon/clinician supervising the procedure.

Code 06: Main anaesthetist: Medical practitioner responsible for the administration of

anaesthesia/sedation.

Code 07: Assistant anaesthetist: Medical practitioner assisting the main anaesthetist in

the administration of anaesthesia/sedation.

Sub Code A: Medical practitioner

Sub Code B: Non-medical practitioner

Code 08: Supervising anaesthetist: Anaesthetist supervising the anaesthetic procedure.

Code 09: Anaesthetic assistant: Non-medical person assisting the anaesthetist(s) in

the administration of anaesthesia/sedation.

Code 10: Scrub practitioner: Registered practitioner responsible for the preparation

and handling of instrumentation, swabs, needles, etc. during a surgical

procedure.

Code 11: Circulating practitioner: Practitioner assisting the scrub practitioner.

Code 12: Recovery room practitioner: Registered practitioner responsible for care of

patient during recovery from procedure.

Code 13: Radiographer

Code 98: Other: Includes medical and nursing students, medical trainees, medical

representatives, AHP trainees or any other observers.


HEALTHCARE PROFESSIONALS (Contd.)

Associated The grade of the associated professional in the operating theatre.

Professional Grade(Operating theatres) Attributes: Associated Professional Status - Permanent

Locum

Temporary

Agency

Bank

Code 01: Consultant

Code 02: Associate Specialist

Code 03: Staff Grade

Code 04: Seamless training grade

Sub code A: Year 1

Sub code B: Year 2

Sub code C: Year 3

Sub code D: Year 4

Sub code E: Year 5

Sub code F: Year 6

Sub code G: Year 7

Sub code H: Year 8

Code 05: Specialist Registrar year 1-4

Code 06: Senior House Officer

Code 07: Foundation Year 2 (Senior House Officer 1)

Code 08: Foundation Year 1 (Pre-Registration House Officer)

Code 09: Nurse: bands 2-8

Code 10: Operating Department Practitioner

Code 11: Operating Department Assistant

Code 12: Physicians assistant - anaesthesia

Code 13: Surgical Practitioner

Code 98: Other

Level of surgical/ Where a non-consultant is involved this indicates the level of supervision in place and

clinical supervision the location or whereabouts of the supervising consultant/clinician.

Code 00: No supervision

Code 01: Operating room environment:

Sub code A: Present in operating room - Scrubbed

Sub code B: Present in operating room - Not scrubbed

Sub code C: In operating department but not in operating room

Code 02: Office

Code 03: Home

Code 98: Other


HEALTHCARE PROFESSIONALS (Contd.)

Level of anaesthetic Where a non-consultant is involved this indicates the level of supervision in place and

supervision the location or whereabouts of the supervising consultant anaesthetist.

Code 00: No supervision

Code 01: Operating room environment:

Sub code A: Present in operating room

Sub code B: In operating department but not in operating room

Code 02: Office

Code 03: Home

Code 98: Other

SOURCE AND DESTINATION PATIENT

Source of admission The originating location within the hospital from where the patient was brought to theatre.

to operating theatreCode 01: Inpatient ward: Local identifiers may include ward numbers, names, etc.

Code 02: Day bed unit

Code 03: Emergency care unit

Code 04: A&E

Code 05: High Dependency Unit

Code 06: Intensive Care Unit: Synonyms include Critical Care Unit (Adult/Paediatric),

Intensive Therapy Unit, etc.

Code 07: Admissions unit

Code 98: Other source

Intended destination The planned or intended location to which the patient is to be sent from the operating

from operating theatre/recovery area.

theatre/recoveryCode 01: Inpatient ward: Local identifiers may include ward numbers, names etc.



Code 04: Extended recovery unit: Where patients are admitted, operated on and stay for

one night post-operatively in a hospital facility (overall stay up to 23 hours). (International





Code 07: Transfer to other hospital

Code 08: Home

Code 98: Other destination


SOURCE AND DESTINATION PATIENT (Contd.)

Actual destination The actual location to which the patient was sent from the operating theatre/recovery.

from operatingtheatre/recovery Code 01: Inpatient ward: Local identifiers may include ward numbers, names, etc.



Code 04: Extended recovery unit: Where patients are admitted, operated on and stay for

one night post-operatively in a hospital facility (overall stay up to 23 hours). (International





Code 07: Transfer to other hospital

Code 08: Home

Code 09: Mortuary

Code 98: Other destination

Appendix B 19

National• Cost of idle capacity• Direct cost per case (case mix adjusted)• Total cost per head population (adjusted for

cross-boundary flow) and by theatre level

LocalFinancial measures are currently thought to be lessuseful at local level

Financial

National• Deaths• Cancellations

Local• Cancellations• Complaints• Resource unavailability• Deaths• Critical Care• Time in recovery• Risk management episodes• Length of stay outliers• Surgical re-admissions• Waiting list efficiency ratio• Theatre delays• Re-operation within the same admission• Sickness abscence• % emergency procedures at night

Patient/Quality

National• Surgical theatre hours• Anaesthetic theatre hours• Downtime• Utilisation• Case-mix adjusted throughout• Elective/non-elective mix

Local• Available theatre time• Allocated theatre hours• Actual theatre hours• Procedural theatre hours• Surgical theatre hours• Anaesthetic theatre hours• Turnover time• Case-mix adjusted throughput• Elective/non-elective mix• Over-runs• Under-runs• Late-starts• Cancelled sessions• Delayed discharges (from Recovery)

Efficiency

National• Information capture

Local• Theatre staff compliance ratio• Development of new ways of working• PDPs (learning/development)• Utilisation of theatre information• Level of dataset capture• Role within capacity planning• Level of supervised training procedures• Level of unsupervised training procedures

Future/Capability

APPENDIX B: Balanced ScorecardNational Theatres Project – Balanced Scorecard3rd October 2006


A balanced scorecard can be produced for each(elliptical) interface on the diagram. As the scorecardbecomes more high level the level of detail and arequirement for individual identifiers becomes less.

1) At an individual level the scorecard should collateall the procedures carried out by one individual(nurse, surgeon or anaesthetist) to populate theindividual’s personal dataset. This information shouldbe in a format using the definitions for the nationaldataset and be exportable to existing operation logs,the scorecard forming the event log for the individual.Colleges (Anaesthesia and Surgical) have alreadydefined formats and datasets for these reports towhich can be added data about theatre utilisation,start, finish times, etc. from the collated personaldata. By providing feedback on the dataset availablethis will encourage local ownership and verificationthus ensuring buy-in and data quality at a local level.The information can be validated through use in theappraisal process and link in to any national auditprocesses. By incorporating all the items from thenational scorecard (and any specialty standards) theindividual will be able to set their performance incontext. This is key to any working system.

2) The theatre level scorecard will collate all datafor that theatre. This dataset will contain moremanagerial factors (start and finish times,utilisation, etc.) and will be used to managetheatre capacity. A typical dataset for managerialpurposes can be derived from the nationaltheatres audits by the Audit Commission andadvice and rules to utilise the data arising can befound in these reports. The top-level informationon utilisation, etc. can be used to comparetheatres within the suite.

3) The hospital level scorecard takes all of theindividual theatre datasets and distils the datatowards the Board dataset. In performing thisprocess local comparisons on critical incidents andperformance can be used to change practice locallyat an early stage if necessary.

4) The Board level scorecard has progressivelyfewer indicators however the basis of the scorecardis the detail contained in the local scorecards. Anyoutlying information can be tracked through thesystem.

Individual

Hospital

Board

Scotland

BoardScorecard

HospitalScorecard

TheatreScorecard

Individual Event Log(Nurse, Surgeon,Anaesthetist)

Specific condition/procedure review and standardSpecific

Condition/Operation

Application of the Balanced Scorecard

Appendix B 21

5) At a national level it is important that theinformation is easily understood by the public (whowill be seeking reassurance that the system isworking safely and efficiently) and is concise.Comparison of the Board data at a national level willset the standard for Scotland.

It is clear from previous attempts to produce a globalfigure for theatre activity that it is very case-mixdependant. Case-mix adjustment is complex and notalways accurate. Efficiency figures should beapplicable across the board and quality measuresunequivocal.

To provide performance data for individual specialtydepartments it is suggested that relevant professionaladvisory groups be asked to produce a basket ofprocedures that occur in sufficient numbers and haveconsistent profiles of care in terms of length ofanaesthetic, operation, grade of surgeon andanaesthetist, outcome and at a Board level populationbased incidence of procedure. This approach hasbeen in place and is successful for hip fractures.

Each specialty should identify one major procedureand one day case procedure together with a further“developing” procedure.


Mandatory Indicators

Opportunity cost of unused hours

Comparative cost of theatres activity

Financial

Risk management episodes

Surgical re-admissions

Theatre delays

Cancellations

Deaths/10,000 patients

% emergency procedures at night

Patient/Quality

Unutilised hours/Allocated hours

Over-runs/Allocated hours

Under-runs/Allocated hours

Procedural time/Actual hours

Operative time/Allocated hours

% cancelled sessions

Late start hours/Allocated hours

% emergency cases in planned sessions

Efficiency

Information quality

% dataset captured

Use of theatres information

Development of new ways of working

Future/Capability

APPENDIX C: Mandatory Scorecard

Appendix D: Measure Definitions 23

The contents of the square brackets within the textcross-reference these definitions with Appendix A.

Opportunity cost of unused hours: the costassociated with the number of patients who couldhave been operated upon during unutilised time:unutilised hours divided by 3.5, multiplied by theaverage number of patients per session for theBoard, multiplied by the average cost per patient.

Comparative cost of theatres activity: Cost pertheatre hour.

Allocated hours: total theatre time allocated to eachsession holder and specialty. Allocated hours are thedifference between the session allocated start timeand the session allocated finish time [Operatingtimes].

Unutilised hours: the difference between allocatedhours and actual hours as a percentage of allocatedhours. Actual hours are the difference between thesession actual start time and the session actual finishtime [Operating times].

Over-runs: the number of over-run hours as apercentage of allocated hours. An over-run occurswhen the actual session length exceeds the plannedsession length [Operating times]. Only over-runs ofmore than 30 minutes will be included.

Under-runs: the number of under-run hours as apercentage of allocated hours. An under-run occurswhen the planned session length exceeds actualsession length [Operating times]. Only under-runs ofmore than 45 minutes will be included.

Procedural time: procedural hours are the time fromstart of anaesthetic to time of exiting the operatingroom [Dates and times of theatre processes andoperative procedures].

Operative time: the difference between the starttime of the procedure and the finish time of theprocedure [Dates and times of theatre processes andoperative procedures].

Cancelled sessions: the percentage of allocatedsessions unused due to cancellation by the holder[Reason for cancellation of list/session].

Late starts: the number of hours lost due to latestarts as a percentage of allocated hours. A late startoccurs when the list actual start time exceeds theplanned start time [Reason for late start oflist/session]. Only late starts of more than 5 minuteswill be included.

Emergency cases: the number of emergency cases[NCEPOD category: 01, 02] carried out withinplanned sessions as a percentage of the totalnumber of cases carried out within planned sessions[Operating session type: 01A].

Risk management episodes: the number of riskmanagement episodes per 1000 procedures.

Surgical re-admissions: the number of surgicalpatients re-admitted for surgery within 28 days as apercentage of total number of patients.

Theatre delays: the average number of minutes lostper session due to delays, e.g. no porter, patient notready. Only delays of more than 5 minutes will beincluded.

Cancellations: percentage of elective patientswhose procedure is cancelled within 10 working daysof due date for operation [Reason operativeprocedure not performed].

Deaths: the number of deaths in theatre per 10,000patients [Actual destination from operating theatre/recovery: 09].

APPENDIX D: Measure Definitions


% emergency procedures at night: thepercentage of emergency [NCEPOD category: 01,02] procedures carried out between 00:00 and 07:59[Time of day/night].

Information quality: an assessment High, Mediumor Low of the quality of theatres information available.The criteria for assessment are shown in sections5.3, 5.4 and 5.5 of the main report.

Dataset capture: the proportion of the mandatoryindicators available.

Use of theatre information: an assessment High,Medium or Low as to the effective use of theatresinformation.

New ways of working: an assessment High,Medium or Low as to the degree of innovation andextent to which new ways of working are beingadopted. The criteria for assessment are shown insection 5.7 of the main report.

It is proposed to further develop and test RiskManagement and Quality Assurance measuresthrough the National Theatres Implementation Group(NTIG). This work will also include development oftraining measures:

Supervised training: the number of supervisedtraining procedures carried out as a percentage oftotal procedures. A supervised training procedureoccurs when the main operator [Associatedprofessional role: 02] is a trainee [Associatedprofessional grade: 04-06], and a consultant[Associated professional grade: 01] is present –scrubbed or not scrubbed [Level of surgical/clinicalsupervision: 01/A or 01/B].

Unsupervised training: the number ofunsupervised training procedures carried out as apercentage of total procedures. An unsupervisedtraining procedure occurs when the main operator[Associated professional role: 02] is a trainee[Associated professional grade: 04-06], and there isno consultant present [Level of surgical/clinicalsupervision: neither 01/A nor 01/B].

Efficiency and Patient/Quality indicators will bereported at session holder, specialty, hospitaland Board level. Indicators will be reported forscheduled (planned and emergency) andunscheduled sessions.

NTIG will produce a detailed specification foreach of the above measures prior tocommencement of data collection.

Appendix E: Reporting Framework 25A

PP

EN

DIX

E:R

epo

rtin

gF

ram

ewo

rk

By

Boa

rd/S

ite/T

heat

reTy

pe/T

eam

/Indi

vidu

al/C

linic

ian

Thea

tres

Vari

ance

Sp

ecia

lty

Vari

ance

Ana

lysi

s

Pro

ced

ural

Vari

ance

-C

ompa

rativ

eco

stof

thea

tres

activ

ity

-O

ppor

tuni

tyco

stof

unus

edho

urs

Cos

t

Mix

Volu

me

Cos

t

Pat

ient

Volu

me

-U

nutil

ised

hour

s/A

lloca

ted

hour

s-

Late

star

thou

rs/A

lloca

ted

hour

s-

%C

ance

lled

sess

ions

-Tu

rnov

ertim

e-

Ope

rativ

etim

e-

Ove

r-ru

ns/A

lloca

ted

hour

s-

Und

er-r

uns/

Allo

cate

dho

urs

-%

Em

erge

ncy

case

sin

plan

ned

sess

ions

-P

roce

dura

ltim

e-

Ana

esth

etic

time

-O

pera

tive

time

-Tu

rnov

ertim

e-

Rec

over

ytim

e

-P

roce

dura

ltim

e-

Ana

esth

etic

time

-O

pera

tive

time

-Tu

rnov

ertim

e-

Rec

over

ytim

e

-D

eath

spe

r10

,000

patie

nts

-C

ance

llatio

ns-

Thea

tre

dela

ys-

Sur

gica

lre-

adm

issi

ons

-R

isk

man

agem

ente

piso

des

-%

emer

genc

ypr

oced

ures

atni

ght

As

Leve

l1-

Dea

ths

per

10,0

00pa

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s-

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adm

issi

ons

-R

isk

man

agem

ente

piso

des

-In

form

atio

nqu

ality

-%

data

setc

aptu

red

-U

seof

thea

tre

info

rmat

ion

-D

evel

opm

ento

fnew

way

sof

wor

king

EFF

ICIE

NC

Y

PATI

EN

T/Q

UA

LITY

FUTU

RE

CO

ST

Leve

l1–

Ove

rall

The

atre

Ap

pen

dic

esF,

G,H

Leve

l2–

Sp

ecia

lty

Ap

pen

dic

esF,

ILe

vel3

–P

roce

dur

eA

pp

end

ices

J,K


Hours Breakdown

Actual Procdrl Surg Anaesth Turnover Procdrl

Percentage Breakdown

Surg Anaesth OtherOther Turnover

B+F C+D+E A-B H+I+JHospital AC8: Orthopaedics

Session holder: 92 66.4 88.2 33.5 11.8 42.9 -21.8 133 50 18 65 -33

Session holder: 96 53.6 51.0 31.4 11.0 8.6 2.6 95 59 20 16 5

Session holder: 155 54.7 51.6 33.2 9.5 8.9 3.1 94 61 17 16 6

Session holder: 227 33.2 30.9 20.7 5.4 4.8 2.3 93 62 16 15 7

Session holder: 242 42.0 41.0 26.8 6.4 7.8 0.9 98 64 15 19 2

Session holder: 254 52.6 49.7 33.6 10.1 6 2.9 95 64 19 12 5

Session holder: 306 26.7 26.8 13.7 6.4 6.7 -0.1 100 51 24 25 0

Session holder: 1136 99.8 107.0 61.7 15.1 30.2 -7.2 107 62 15 30 -7

Session holder: 1147 96.9 94.2 59.9 19.0 15.3 2.7 97 62 20 15 3

Session holder: 1228 97.2 94.4 59.6 20.8 14 2.8 97 61 21 15 3

Session holder: 1420 13.8 12.8 7.9 2.5 2.4 1.0 93 57 18 18 7

Session holder: 1857 9.4 9.5 6.3 2.2 1 -0.1 101 67 23 11 -1

Session holder: 2646 79.2 81.2 44.6 15.4 21.2 -2.0 103 56 19 28 -3

Total 725.4 738.3 432.7 135.5 170.1 -12.9 102 60 19 23 -2

C9: Plastic Surgery

Session holder: 52 6.5 7.1 3.5 0.0 3.6 -0.6 109 54 0 55 -9

Session holder: 63 4.8 3.1 2.9 0.0 0.2 1.8 64 61 0 3 36

Session holder: 200 18.8 25.3 12.6 1.6 11.1 -6.5 134 67 8 59 -34

Session holder: 1108 124.0 124.6 83.1 0.4 41.1 -0.6 101 67 0 34 -1

Total 154.2 160.1 102.1 2.0 56 -5.9 104 66 1 37 -4

CB: Urology

Session holder: 86 12.0 11.1 7.2 1.3 2.6 1.0 92 60 10 22 8

Session holder: 172 97.5 117.2 58.9 6.0 52.3 -19.7 120 60 6 54 -20

Session holder: 2409 6.6 11.8 4.8 0.6 6.4 -5.3 180 73 9 98 -80

Session holder: 2603 40.3 52.1 27.1 3.5 21.5 -11.8 129 67 9 53 -29

Total 156.3 192.1 98.0 11.3 82.8 -35.8 123 63 7 53 -23Report version 1.0 31 August 2006

APPENDIX F: Pilot Management ReportsNational Theatres Project – Benchmarking Pilot Board XHours Usage Analysis(Elective Sessions Only)Period: 01/02/2006 to 30/04/2006

A B C D E F G H I J K

Appendix F: Pilot Management Reports 27

Over-Runs

Sessions No. %AverageDuration(Hours)

No. %

Under-Runs

AverageDuration(Hours)

Hospital BUrology 72 18 25 1.5 45 63 1.5

Plastic Surgery 2 0 0 0.0 2 100 1.2

Minor Ops 7 0 0 0.0 7 100 1.3

Cardiology 5 0 0 0.0 5 100 2.0

Community Dental 7 1 14 1.0 6 86 1.3

Vascular 2 0 0 0.0 2 100 0.8

E N T 76 14 18 1.3 46 61 1.6

General Surgery 79 33 42 1.3 43 54 1.7

Gynaecology 10 0 0 0.0 9 90 1.6

Kids Dental 5 0 0 0.0 5 100 1.5

Max Fax 6 3 50 1.6 0 0 0.0

Oral Surgery 22 5 23 1.6 13 59 1.3

Orthopaedics 40 14 35 1.2 22 55 1.7

Renal 5 0 0 0.0 5 100 1.4

Total 338 88 26 1.3 210 62 1.6

National Theatres Project – Benchmarking Pilot Board YAnalysis of Actual Hours Usage versus Planned List Hours Usage(Elective Sessions Only)Period: 06/02/2006 to 30/04/2006

Report version 1.0 31 August 2006

Findings:

• 88% of sessions did not run to plan

• 114 hrs (32 sessions) of unplanned time was used

• 336 hrs (96 sessions) of planned theatre time was not used


Patient cancelled

PatientsNumber

Cancellations

%

Patientcancelled

PatientDNA

Theatrecancelled

Surgeon/anaesth

cancelled

Hospitalcancelled

Noreason

supplied

Hospital CA1 General Medicine 223 36 16 7 23 1 4 1 0

C1 General Surgery 257 23 9 5 8 0 4 2 4

C8 Orthopaedics 303 25 8 7 7 0 11 0 0

CB Urology 239 32 13 11 15 0 4 1 1

D3 Oral Surgery 6 1 17 0 0 0 1 0 0

Total 1,028 117 11 30 53 1 24 4 5

Cancellations Analysis

Period: 01/02/2006 to 30/04/2006

National Theatres Project – Benchmarking Pilot (Contd.) Board X

Report version 1.0 31 August 2006

Appendix G: Pilot Scorecard 29

APPENDIX G: Pilot Scorecard

Board X Hospital B

Patient/QualityCancellations % 13 7

Complaints No 2

Resource unavailability hrs lost

Deaths per 1000 pats 0.1 0.4

Critical care % 0.4 0.0

Time in recovery Avg (Mins) 38 –

Risk management episodes No 21

Length of stay outliers %

Surgical re-admissions per 1,000

Waiting list efficiency ratio

Theatre delays % 2 –

Re-operation within the same admission No

EfficiencyAvailable theatre time hrs 13,671 3,780

Allocated threatre hours hrs 11,767 –

Actual theatre hours hrs 8,601 1,098

Procedural theatre hours % 101 87

Surgical theatre hours % 59 65

Anaesthetic theatre hours % 14 21

Turnover time hours % -1 14

Case-mix adjusted throughput per theatre 1,136 1,180

Elective/emergency/unplanned mix % Elective 81 87

Over-runs (sessions) % 12 26

Under-runs (sessions) % 50 62

Late starts (sessions) % 79 71

Cancelled sessions % 14 21

Delayed discharges (from Recovery) No

Scheduled Utilisation = Allocated Hours

=11,767

X 100 = 86%Available Hours 13,671

Actual Utilisation =*Actual Theatre Hours Worked X 100

=8,601

= 73%Allocated Hours 11,767

*(Allocated Hours + Over-run Hours – Under-run Hours – Cancelled Sessions)

National Theatres Project30A

PP

EN

DIX

H:P

ilot

Ana

lysi

s–

Ho

urs

Bre

akd

ow

n

13,6

71

Ava

ilab

leH

ours

11,7

671,

904

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cate

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ours

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lloca

ted

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rs

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ualH

ours

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d

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Use

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8

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sed

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arly

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celle

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celle

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(572

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Turn

over

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(-99

)

572

Tim

esar

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sed

onth

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riod

1st

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thA

pril

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ese

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nson

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ious

one

goes

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over

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reth

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ard

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No

tes

Appendix I: Pilot Analysis – Session Duration 31

AP

PE

ND

IXI:

Pilo

tA

naly

sis

–S

essi

on

Dur

atio

nT

heat

reS

essi

ons

,Und

er-R

uns

and

Ove

rR

uns

Bo

ard

X,O

pht

halm

olo

gy,

01/0

2/20

06to

30/0

4/20

06

-100-80

-60

-40

-20020406080100

Session holder 43

Session holder 44

Session holder 97

Session holder 184

Session holder 264

Session holder 1033

Session holder 1983

%Under-Runs%Over-Runs

444

444

333

888

Not

es:

(1)–

Und

er-R

uns

are

only

calc

ulat

edif

they

are

over

45m

ins.

(2)–

Ove

r-R

uns

are

only

calc

ulat

edif

they

are

over

30m

ins.

Ove

r-R

uns

Ove

r-R

uns

Boa

rdX

Und

er-R

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Und

er-R

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Boa

rdX

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nder

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ated

ifth

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er45

min

utes

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Ove

r-R

uns

are

only

calc

ulat

edif

they

are

over

30m

inut

es.

3N

ote

that

the

sess

ion

hold

eris

not

nece

ssar

ilyth

ese

ssio

nus

er.

No

tes


AP

PE

ND

IXJ:

Pilo

tA

naly

sis

–P

atie

ntP

athw

ayP

atie

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athw

ay–

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arac

tS

urg

ery,

Bo

ard

X

Gra

de

of

Ana

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tn

%

No

Ana

esth

etis

t56

376

Ass

ocia

teS

pec

ialis

t66

9

Con

sulta

nt38

5

SP

R29

4

SH

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3

Med

ical

Stu

den

t11

1

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GR

D4

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PTG

DP

30

Not

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rded

10

HO

10

LCO

NS

10

Ca

nc

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ns

Th

ere

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en

oca

nce

llatio

ns

reco

rded

for

cata

ract

surg

ery.

Th

ere

wer

e7

37

case

sfo

rca

tara

ctsu

rger

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Des

tinat

ion

Th

ed

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atio

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ral

l73

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atie

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was

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tan

dar

dW

ard

De

lays

Th

ere

wer

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3ca

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cto

per

atio

ns

del

ayed

(3%

of

the

tota

l).

Re

aso

n

No

po

rter

avai

lab

le1

3P

atie

nt

no

tre

ady

10

Gra

de

of

Sur

geo

nn

%

Con

sulta

nt37

150

SP

R24

233

SH

O11

516

Med

ical

Stu

den

t4

1

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DO

C4

1

Not

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rded

10

Sen

tfo

r-

Arr

ival

An

aest

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art

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e

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rger

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art

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ery

end

Into

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-O

ut

of

reco

very

Me

an

tim

em

inu

tes

(Sta

nd

ard

De

via

tio

n)

05

10

15

20

25

30

35

40

45

50

55

60

65

8(4

)

8(8

)

18

(14

)

8(6

)

11

(7)

4(4

)

4(7

)

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ival

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nae

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etic

star

t

Into

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tre

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urg

ery

star

t

Find

ing

s

•30

%of

time

issu

rgic

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e•

26%

oftim

eis

pre

par

atio

nan

dan

aest

hesi

a

•38

%of

time

isd

own

time

•w

ide

varia

tion

inan

aest

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t-

into

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tre

•w

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e

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tion

intim

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rin

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dou

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very

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rger

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d-

Into

reco

very

Appendix K: Pilot Analysis 33

AP

PE

ND

IXK

:Pilo

tA

naly

sis

–S

urg

ical

&A

naes

thet

icT

imes

Sur

gic

alT

ime

for

Cat

arac

tO

per

atio

nsb

yS

urg

eon

Bo

ard

Y,30

/01/

2006

to28

/04/

2006

(Ele

ctiv

ep

roce

dur

eso

nly)

1C2C

3NC

5C6C

7NC

8NC

9NC

10C

11C

12N

C

Sur

geon

IDan

dgr

ade

(C=

Con

sulta

nt,N

C=

Non

-con

sulta

nt)

Sur

geon

IDan

dgr

ade

1C2C

3NC

5C6C

7NC

8NC

9NC

10C

11C

12N

C

No.

ofca

ses

5153

3755

523

1613

4052

10

70 60 50 40 30 20 10 0

Surgicaltime (mins)


Ana

esth

etic

Tim

efo

rH

ipR

epla

cem

ent

by

Ana

esth

etis

tB

oar

dX

,01/

02/2

006

to30

/04/

2006

(Ele

ctiv

ep

roce

dur

eso

nly)

Ana

esth

etis

tID

Ana

esth

etis

tID

and

grad

e(C

=C

onsu

ltant

,NC

=N

on-c

onsu

ltant

)38

C47

C48

C93

C12

3C12

9C15

2C18

1C22

1C29

1NC

293C

354N

C10

20C

1109

NC

No.

ofca

ses

91

102

27

35

44

43

141

1132

C11

39C

1140

NC

1143

C11

54C

1182

NC

1196

C12

22C

1226

C12

27C

1625

NC

1685

NC

1858

NC

2012

NC

No.

ofca

ses

63

54

21

52

77

92

11

2053

NC

2272

NC

2312

NC

2653

NC

2685

NC

2694

NC

2697

NC

2767

NC

2793

NC

2825

NC

2826

NC

No.

ofca

ses

11

31

11

12

19

1

80 60 40 20 0

38C

47C

48C

93C

123C

129C

152C

181C

221C

291NC

293C

354NC

1020C

1109NC

1132C

1139C

1140NC

1143C

1154C

1182NC

1196C

1222C

1226C

1227C

1625NC

1685NC

1858NC

2012NC

2053NC

2272NC

2312NC

2653NC

2685NC

2694NC

2697NC

2767NC

2793NC

2825NC

2826NC

Anaesthetic time (mins)AP

PE

ND

IXK

:(C

ont

d.)

Appendix L: Capability Scoping 35

Nationally Reported DataA number of common themes emerged regarding theinformation published in the annual Scottish HealthService Costs (Cost Book):

• In most Boards, theatres hours information iscollected either manually or through existingTheatre Management Systems and provided toFinance who combine with correspondingfinancial information.

• In a number of Boards, there was uncertainty asto how Finance sourced theatre hours statistics.

• There were general concerns over the quality ofthe published data, these primarily related toconsistency of definitions, inaccuracies in thenumbers of theatres per site, and capture of localprocedures.

• Cost book submissions prepared by Finance arenot validated by theatres personnel.

Other issues/concerns related to:

• the clarity of cost book definitions

• the prescriptive nature of cost bookrequirements

• the potential skewing of financial statistics bywaiting list initiative funding.

Comments on how to improve nationally reporteddata consisted of a mixture of common themes andmore detailed data-related suggestions. The mainthemes comprised:

• the need for clear and consistent definitions

• improved liaison with Finance, including validationof figures.

In some Boards, it was recognised that improvedlocal reporting capability was required.

There were a number of suggestions on how toimprove the value and accuracy of the data reported,as well as thoughts on potentially useful additionalinformation:

Improvement:

• separation of used/unused theatres

• separation of emergency and elective theatres

• reporting at site and specialty level

• identification of CEPOD, out of hours, etc.

• improvements in quality of coding

• a facility for local managers to provide asupporting commentary to identify assumptionsmade relating to their submissions.

Useful additional data:

• cost per case for standard procedures

• more robust utilisation statistics

• the extent to which pre-operative assessment isused

• use of capacity within the private sector

• available funded capacity by site and specialty

• education and training statistics

• staffing statistics.

National Theatres MetricsAn early piece of work by the National TheatresProject involved combining Cost Book informationwith SMR01 activity data to derive a number ofBoard level theatres metrics. These were reviewed aspart of the scoping visits.

On the whole Boards felt that the metrics derivedwould be potentially useful subject to the accuracy ofthe underlying Cost Book data. Again consistency ofdefinitions was a key issue.

APPENDIX L: Capability Scoping

Local InformationBoards across Scotland are moving towards real-time theatres information capture via a variety of TheatreManagement Systems, with several Boards implementing systems in recent months. There are however still anumber of mainland and island Boards which do not yet have systems.


A number of factors and concerns were raisedrelating to the use and interpretation of the metrics:

• Potential inconsistencies in the types of theatreincluded and their impact on utilisation, e.g.emergency theatres will reduce utilisation figuresand these should be excluded or reportedseparately

• The need to handle endoscopy activity on aconsistent basis

• Some Boards felt that the use of 41 hours pertheatre as a capacity measure was either too highor too blunt a statistic

• Cost book statistics assume a 52 week year,which will understate utilisation for theatresrun/funded for shorter periods

• Using SMR01 “Procedure not done” will under-report cancellations

• Figures would be more use by site and specialty

• Cost per procedure information would be betterby specialty

• The impact of teaching sessions on throughput

• Post-operative infection ratios would be moreuseful if based on inpatient activity only

• Grouping together DGH and Teaching hospitalswould be useful.

Systems in Use

Board System Vendor/In-house Updating Comments

(Former) Argyll and Clyde ORSOS* Per-Se Real-time Inverclyde RH using Galaxyas at March 2006

Ayrshire and Arran RES-Q RES-Q Real-timeBorders Sapphire Newgate Technology Real-time Expected to go live September 2006Dumfries and Galloway Sapphire Newgate Technology Real-timeFifeForth Valley Sapphire Newgate Technology Real-timeGolden JubileeGrampian Stopped using Galaxy in 2000

ORSOS Per-Se Real-timeGreater Glasgow TIS In-house Real-time

Meditech Real-time Meditech theatre moduleintegrated with HISS

Highland TheatreMan Tri-Soft Real-time Not BroadfordLanarkshire ORMIS iSOFT Real-time

ORSOS Per-SeLothian

Pets In-house St. John’s Hospital onlyTayside In-house Manual data capture

* Implementation ongoing at time of visit

Moving toreal-time

Appendix L 37

For Boards with systems, data is typically captured using a combination of touch screen and keyboard inputs. In one case, information is recorded manually and then entered into the Theatre Management System. It iscommon for surgeons and anaesthetists to add information to the system (operation note, procedure codes, ASAgrading information), but this does not happen in all Boards. Submitted information is usually verified, and can beamended if necessary. Within Boards without systems, manual data collection allows at least some key theatreperformance information to be provided, e.g. hours, cancelled sessions, cancelled patients, utilisation, etc.

Existing Systems – Support and Ease of Use

Board System Support Ease of Use

(Former) Argyll and Clyde ORSOS Standard upgrades. User group. Users confident about using in liveQuality - patchy to-date. environment.

Ayrshire and Arran RES-Q Annual license provides very basic System quite basic and lacksbasic support. validation facilities.

Borders Sapphire Standard upgrades. Very intuitive.Dumfries and Galloway Sapphire Two upgrades per year. User No major problems.

group. Quality – no problems.Forth Valley Sapphire Standard upgrades. Quality – Easy to use but some issues.

variable.ORSOS Periodic updates. Per-Se help desk.

Quality – pretty reliable.Greater Glasgow

TIS In-house. Quality – excellent.Meditech Major upgrades every two years. Relatively easy to use.

Highland TheatreMan Optional periodic upgrades. Fairly intuitive to use, few issues.Quality – okay.

Lanarkshire ORMIS Quarterly releases. User Group. No problems – easy to use.Quality – fine to-date.

Lothian ORSOS Input time consuming, user interfacePets requires improvement.

Tayside In-house support. Very happy with system.

On the whole, staff are happy with thesystems.


Existing Systems – Reporting and General Comments

Board System Reporting Other Comments

(Former) Argyll and Clyde ORSOS Standard reports, Crystal Reports Major potential benefits anticipatedAyrshire and Arran RES-Q System reports, exports to Recently upgraded

flat filesBorders Sapphire Standard reports Significant time savings envisagedDumfries and Galloway Sapphire 40 Standard Reports, Crystal Upgraded to SQL Server, new version

Reports, Exports to Excel due soonForth Valley Sapphire Crystal Reports, exports to Access System in place for 2-3 years

ORSOS Crystal Reports No current plans for upgrade forGreater Glasgow TIS Built-in reports, Crystal Reports replacement. Generally simple to use

and outputs considered usefulMeditech Able to provide a wide variety All relevant patient management

infomation collected in one placeHighland TheatreMan Business Objects and Crystal Minor developments planned only

ReportsLanarkshire ORMIS Standard reports, Crystal Reports Reporting framework based on NTP

outputsLothian ORSOS Flexible – relational database Moving towards real-time data capture:

Pets 2-3 month delay on average at presentTayside Wide range available, easy to add Very robust, no plans to upgrade or

replace

Appendix L 39

Reporting and AccountabilityThere are huge differences in the nature and level oftheatres performance reporting between Boards inScotland. This can vary from Boards where regularperformance reporting is not currently required, toBoards where reports covering a range of keyindicators are circulated widely around theatre usersand managers.

Reports produced include:

• utilisation reports

• cancelled sessions

• patient cancellations

• theatre activity

• over-runs, under-runs and late starts

• log books

• audit reports.

In addition, theatre information is used to:

• support ad hoc analyses

• provide baselines

• develop business cases

• report performance against specific targets

• provide comparisons

• support research activities

• validate data for national returns.

Reporting is typically a combination of weekly andmonthly outputs. Report distribution and theatreaccountability can include:

• Theatre Users

• Clinical Groups

• Anaesthetic Management Teams

• Surgical Management Teams

• Theatre Service Managers

• Clinical Service Managers

• Heads of Service

• Clinical Directors

• Medical Directors

• General Managers

• Performance Review/Management

• Specialty Management

• Directorate Managers

• Divisional Managers

• Senior Management Team

• Executive Directors

• Operating Division Chief Executives.

In at least one Board, Theatre Management Systemoutputs are displayed on notice-boards with plans toinclude the information on the intranet.


Minimum DatasetThe table below gives a high-level indication of the availability of the dataset required to produce the draftbalanced scorecard across Boards with Theatre Management Systems.

Sessional – by holder, specialty and siteAvailable theatre hoursAllocated sessions/hours:

- booked start time (first patient into anaesthesia)- actual start time- booked end time (last patient into recovery)- actual end time- cancellation - plus reason and notice period

ProceduralDate and locationSession holderOperating surgeonMain anaesthetistOperation type

- Emergency (usually within 1 hour) NCEPOD 1- Urgent (within 6 hours) NCEPOD 2a- Urgent (within 24 hours) NCEPOD 2b- Scheduled (within 3 weeks) NCEPOD 3- Elective NCEPOD 4

Time into anaestheticStart time of anaesthesiaTime into theatreStart time of procedureTime operation completedTime into exit roomTime into recoveryTime ready to leave recoveryTime out of recoveryDelays - reason and durationDestination (DSU, Ward, HDU, ICU, Mortuary, Transfer)Cancellation - plus reasonSpecialtyOPCS4 code(s)

Other information – by specialty and holder/surgeonAdvance hospital cancellation of procedure - date and reasonComplaintsTheatre hours lost to resource unavailability, e.g. equipment failure, staff shortageRisk management episodesSurgical re-admissions (within a specified period)Re-operation within the same admission

Dark Blue – high coverage Lilac – medium coverage Light Blue – low coverage

Appendix L 41

Glossary and DefinitionsFor terms relating to the derivation of the minimumdataset, relatively little disagreement was foundbetween the proposed national definitions andcurrent Board practice (for Boards where there was aTheatre Management System in use).

There were two notable exceptions:

• list finish time

• operating time

and in each of these cases at least several Boardswere working to different definitions.

Use of Theatres InformationThe final sections of the capability scoping visitslooked at the use of theatres information withinBoards (with or without an implemented system), inthree parts:

• What information is required?

• How is information used in capacity planning andoperations management?

• How do Boards manage theatres within thecontext of the “whole system”?

Required Information

As well as highlighting the “usual” theatres indicators,e.g. cancellations, utilisation of sessions, utilisationwithin sessions, throughput, start and finish times,etc., a number of other potential requirements werehighlighted. In particular, the need for individual datato support log books, job planning and appraisals.Other requirements included:

• surgical rates

• implant tracking

• costs per procedure

• times per procedure

• patient journey

• case-mix analysis

• bed utilisation

• re-operation rates

• surgical infection rates

• patient risk assessment

• operation records

• audit.

Capacity Planning and Operations Management

There was tremendous variety between Boards in theuse of theatres information to support these activities.In many Boards, such work tended to be restricted toone-off analyses for specific purposes, often as aconsequence of the limitations of the theatresinformation currently available.

Capacity reports, monthly capacity plans and/ormeetings were highlighted by a number of Boards,and the need to improve capability and awareness inthis area was also recognised. Several Boards areusing or developing capacity planning models. Theimpact of anaesthetist availability has also been thefocus of attention in a couple of Boards, and in oneinstance this has led to the development andsuccessful implementation of an anaesthetist rostersystem.

Whole System

Again, this is an area where the level of activity varieswidely. A significant number of Boards currentlyundertake little work in this area, but are seeking toaddress this. Much of the work that is undertaken isof an ad hoc nature and again effort has beenconstrained by data issues.

In some Boards, whole system issues are addressedthrough Performance Management, or throughrelevant stakeholder groups.

Of the whole system related activities currently takingplace, much of this is focussed on bed requirements.


Location Main Day Satellite Specialist Comments

Annex: Theatre Facilities by Site

Arran 12 Specialist

Ayr 5 3 2 Endoscopy2 Urology procedure roomsAnaesthetic procedure room

Ayrshire Central 2 ObstetricsCrosshouse 8 4 4 Endsocopy

Borders General 5 1 1 Endoscopy One main theatre is A&E, oneis exclusively Obstetrics

Dumfries 6 1 Ophthalmology One main theatre is dedicated1 Obstetric 24-hour emergency, two areEndoscopy designated day surgery

Garrick 1

Queen Margaret Hospital 8 1 Cataract1 Dental

Victoria Hospital 6 1 Dental One further main theatremothballed

Forth Park Maternity 1 Gynaecology1 Obstetrics

St. Andrews Memorial One main theatre mothballed

Falkirk 5 3 Endoscopy Main theatres include daysurgery, no emergency

Stirling 5 3 1 Endoscopy Main theatres include one forCEPOD and one for Trauma.One satellite theatre is forObstetrics

8 Endoscopy Six main theatres and twoOphthalmology treatment rooms in use. Main4 Treatment rooms theatres include day surgery

Ayrshire and Arran

Borders

Dumfries and Galloway

Fife

Forth Valley

Golden Jubilee

Appendix L 43


Aberdeen Royal Infirmary 15 3 1 UrologyEndoscopy suite

A&E 2Children’s Hospital 3 1 DentalElgin 4 Endoscopy roomMaternity Hospital 1 1 Procedure roomWoodend 4

ECT facility

Gartnavel General 8 4 1Glasgow Royal Infirmary 20 4 2RHSC Yorkhill 7 Endoscopy Imaging suite includes GA

coverStobhill General 8 2 2Southern General 10 2Victoria Infirmary 5 2Western Infirmary 6Inverclyde 6 1 1 EndoscopyRoyal Alexandra 9 2 2 Endoscopy

2 MaternityVale of Leven 3 1 1 Endoscopy

Inverness 9 2 Endoscopy One main theatre used1 Maternity exclusively for emergency

work Monday to FridayBelford 1 EndoscopyCaithness 2 EndoscopyMcKinnon 1 EndoscopyLawson 1 EndoscopyOban 1 1 Endoscopy

Wishaw 12 2 Endoscopy Main theatres include day surgeryone main theatre mothballed

Monklands 7 2 2 EndoscopyHairmyres 8 2 Endoscopy Main theatres include day

2 Cardiac surgery1 Dental1 Radiology

Grampian

Greater Glasgow and Clyde

Highland

Lanarkshire



New Royal Infirmary 12 4 8 Three mothballedEye Pavillion 3Western General 6 1 5Roodlands 2St. John’s 9 4Lauriston 1RHSC 5

Stracathro 3 2 EndoscopyPerth 5 2 2 Plus, one day surgery

treatment room. One satellitetheatre is mothballed

Ninewells 12 2 1 Ophthalmology Main theatres include 1 twin.Maternity theatre and Plust two day surgeryemergency room treatment rooms. Off-siteDental suite ECT facilities. Dental HospitalPaediatric theatre (sedation only)

Lothian

Tayside

Appendix M: Capability Template 45

APPENDIX M: Capability Template

CAPABILITY SCOPING

Board:

Primary Contact

Name:

Position:

Telephone/E-mail:

Planning

Extract baseline information:

Cost Book 2003/04 & 2004/05

National metrics 2003/04 & 2004/05

Identify specific data issues

Forward Requirements Summary to Primary Contact

Visits

Preliminary – NTP, introduction, background and information pack:

Datapoints Day Background Document

Draft Glossary and Definitions

Balanced Scorecard

Pilot Framework


Mechanism for Feedback

Number of Theatres

Site Main Day Satellite Specialist

Key Theatres Contacts (for inclusion in NTP distribution list)

Name Role e-mail

Appendix M 47

Nationally Held Data

Review of 2003/04 and 2004/05 baselines:

Are the figures reasonable, are the metrics potentially useful, general comments?

Specific data issues and resolution:

Sourcing of nationally reported data

Sources of activity and cost data

Issues and risks

Quality of data, ease to obtain, etc.


Potential improvement

(Including what information is useful, and what additional information would be useful)

Local information

1. Collection of local information

Process and issues, flowchart of process

Appendix M 49

Theatres System

For recent/ongoing implementations – request ITT and evaluation documents

System:

Vendor details (or in-house):

Software environment:

Purchase arrangements:

Support arrangements

Supported by, cost, SLA, quality of support, enhancements and upgrades

Ease of use

User comments on user-friendliness of system, like and dislikes

Reporting

Range and content of reports available, ability to define and configure reports


Implications of revised definitions and dataset

Ability to add and revise data fields, are there cost and operational implications

General comments

Existing plans for upgrade or replacement, major features and/or deficiencies, overall user assessment ofsystem.

2. Timeliness of information

Average delay between activity and recording:

Information added at a later date and average delay

Appendix M 51

3. Range and content of reports available

Reports if no Theatres System, or those produced outwith the Theatres Sytstem

Use of reports, who uses them and how are they used to drive improvement and/or corrective action

4. Data fields collected

Field list and definitions, input forms, etc.(Any source providing all fields available)

If not readily available, request and/or obtain contact details for provider


Minimum DatasetMany of the theatres scorecard measures can be calculated from the sessional and procedural datapointslisted below. The remaining measures have been detailed separately.

Avail (Y/N) SourceSessional – by holder, specialty and siteAvailable theatre hoursAllocated sessions/hours:

- booked start time (first patient into anaesthesia)- actual start time- booked end time (last patient into recovery)- actual end time- cancellation – plus reason and notice period

ProceduralDate and locationSession holderOperating surgeonMain anaesthetistOperation type

- Emergency (usually within 1 hour) NCEPOD 1- Urgent (within 6 hours) NCEPOD 2a- Urgent (within 24 hours) NCEPOD 2b- Scheduled (within 3 weeks) NCEPOD 3- Elective NCEPOD 4

Time into anaestheticStart time of anaesthesiaTime into theatreStart time of procedureTime operation completedTime into exit roomTime into recoveryTime ready to leave recoveryTime out of recoveryDelays - reason and durationDestination (DSU, Ward, HDU, ICU, Mortuary, Transfer)Cancellation - plus reasonSpecialtyOPCS4 code(s)

Other information - by specialty and holder/surgeonAdvance hospital cancellation of procedure - date and reasonComplaintsTheatre hours lost to resource unavailability, e.g. equipment failure, staff shortageRisk management episodesSurgical re-admissions (within a specified period)Re-operation within the same admission

OtherLength of stay outliers (see note 1)Waiting list efficiency ratio (see note 2)

Appendix M 53

Notes:

1. Individual cases compared with a historical analysis based on length of stay, specialty, and OPCS4 code(s).

2. Ratio of throughput to demand. Requires throughput and snapshots of opening and closing waiting list sizeover a period of time by specialty.

Definitions

For comparison against the draft Glossary and Definitions

Definition Description of any difference in definitionElective Emergency Operating theatreConsultant responsible for care Operating surgeon Supervising surgeon Surgical first assistant Assistant surgeons Main anaesthetist Supervising anaesthetist Assistant anaesthetist Specialty - consultant/patientDestination on leaving theatreList start time List finish timeList run timeList under-runList over-runPatient procedure hoursPlanned hoursOperating timeTurnover timeTime of bookingTime patient sent forTime patient arrived in theatre suiteTime into anaesthetic roomStart time of anaesthesia Time into theatreStart time of procedureTime operation completedTime into recoveryTime ready to leave recoveryTime actually left recovery


5. Data quality and issues

Comments on general quality of data, issues, data validation, matching data to costs, etc.

6. Health Board view on local theatres data

Information found to be useful, data gaps and information that would be useful

Extent to which theatres information is used in capacity planning (inc. demand and demand forecasting,e.g. OP referrals, emergency), decision making and operations management

Appendix M 55

7. Whole Systems View

How do Board anticipate/accommodate “whole system” two-way interactions:Consultant/Doctor sessions (e.g. theatre v. outpatients); Surgical beds; Length of stay;Occupancy; ICU beds; HDU beds

Visit Details

Location:

Date:

Board Representatives:

NTP Representatives:

Document History

Technical Appendix



This document is also available on the Scottish Executive website:www.scotland.gov.uk

Astron B49732 1/07


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