Surgical Services 2020 and Beyond - Kenneth Mealy National Clinical Programme in Surgery Charter Day Meeting February 9th 2017 - RCSI Dublin
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RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Surgical Services 2020 and Beyond. Kenneth Mealy National Clinical Programme in Surgery Charter Day Meeting February 9th 2017
Demographic changes
2031
1m > 65 yrs, 86% increase
136,000 > 85 yrs, 133% increase
Demographic Implications for Surgery Operation >65 >65 (2031) Total (2031) # neck of femur 2741 5098 5490 Cataract 7697 14,316 16,127 Cystoscopy 8074 15,017 23,168 TURP 550 1023 1191 Lap choley 774 1440 5375 Unilat hernia 597 1110 3060
Challenges for Surgery
• Hospital groups • Measuring
o Effective administrative Individual/Institutional
structures
Performance
• Capacity groups
o Beds
o Theatres • Governance and
• Manpower Quality Improvement
o Consultant numbers
o Non-consultant staff • Leadership
o Nursing
• Funding
General Surgeon discharged from All Model types in 2015 (Both those who had surgery & did not have
surgery)
(All)
HIPE 2015 – Clinician specialty 2600 - General Surgery, 2602 - Gastro Intestinal Surgery, 2603 - Hepatobiliary Surgery, 2604 - Vascular Surgery, 2605 -
Breast Surgery
Nationally Inpat # 69,391 DC # 121,053 Total # 190,444 % DC 63.6% Pop: 4,588,252
Dublin North East % of Nat 17.0%
West & NW % of Nat 18.1% Inpat 10,187 AvLOS 6.10
Inpat 13,596 AvLOS 5.13 DC 22,182 %DC 68.5%
DC 20,798 %DC 60.5% All 32,369 Pop: 889,126
All 34,394 Pop: 745,379
Dublin Midlands % of Nat 15.3%
Inpat 11,027 AvLOS 6.88
DC 18,194 %DC 62.3%
All 29,221 Pop: 737,527
Mid West % of Nat 6.7%
Inpat 4,908 AvLOS 5.69 Dublin East % of Nat 21.5%
DC 7,912 %DC 61.7% Inpat 15,460 AvLOS 5.97
All 12,820 Pop: 330,315 DC 25,437 %DC 62.2%
All 40,897 Pop: 974,514
South & SW % of Nat 20.1%
Inpat 13,098 AvLOS 5.66
DC 25,185 %DC 65.8% Peadiatric Group % of Nat 1.3%
All 38,283 Pop: 911,381 Inpat 1,115 AvLOS 6.14
DC 1,345 %DC 54.7%
All 2,460 5
NCPS use HIPE data for reports
Surgical Hospital metrics performance notes – recent example month end data
M4 : Highest AvLOS (10.4), Lowest DoSA (25.3%), ReAdmit of Target (3.1%) - off target
5th highest IP/DC WL (4,027) & 11th highest OP WL (9,000)
LapChole DC % much improved (59.1%),
M4 : 3rd Highest AvLOS (7.9), 6th Lowest DoSA (63.5%), ReAdmit of Target (3.4%) – off target
16th highest IP/DC WL (1,531) & 4th highest OP WL (14,522)
LapChole DC % (32.2%),
M4 : 5th Highest AvLOS (6.5), DoSA (58.4%), ReAdmit on Target (2.2%) – off target
3rd highest IP/DC WL (4,408) & 7th highest OP WL (12,835)
Low LapChole DC % (11.4%),
M4 : 2nd Highest AvLOS (8.2), DoSA (75%), ReAdmit on Target (2.3%) – near target
2nd highest IP/DC WL (4,493) & 3rd highest OP WL (15,094)
LapChole DC % (32.9%),
M4 : 4th Highest AvLOS (7.8), DoSA (80.1%), ReAdmit on Target (2.0%) – near target!
18th highest IP/DC WL (1,427) & 13th highest OP WL (7,962)
LapChole DC % (62.4%),
M4: : Waiting list issue (OP: 18,580 / IPDC:9,785) , Off target AvLOS (6.6 days)
M3: : Highest Readmission rate (4.6%) … AvLOS ahead of target (4.9 days)
M3 : Off target AvLOS (6.4 days)
M4 : Waiting list issue (OP: 21,200 / IPDC: 4,251) , AvLOS just over Target (5.1 days)
M4 : Wait list issue (OP: 13,762) , AvLOS off Target (5.1 days)
M4 : AvLOS near to Target (5.9 days) , Wait list (IPDC: 3,961)
NQAIS – Cholecystectomy Data
NQAIS – Acute colorectal Surgery
#####
FUNNEL PLOT: Precision (no. of cases)
Your hospital
All hospitals
Lower Precision: Fewer cases Greater Precision: More cases
(not as reliable) (more reliable)Hospital Mortality
Challenges for Surgery • Measuring Individual/Institutional Performance • Governance and Quality Improvement • Leadership
Models of Care
Improving Elective Improving Acute
Practice Practice
• Pre-admission Assessment
• Day Surgery • Separate stream
• Day of Surgery admissions • Early access to Senior
• Discharge planning Decision Makers
• Acute Surgical
2010 Assessment
Units/Diagnostics
• Emergency theatres
2013
17Healthcare Transformation
• Top-management
structural change
• Local operational
design
o Clinical and administrative
leadership
o Data and measurement
systems
o QI/process design
o Empowerment
o StandardsIP/DC waiting list for all Surgery Specialties – 16% increase in 1 year (as at 31
Jan’17)
Day Case & 0-3 3-6 6-8 8-12 12-15 15-18 18-24 24-36 36-48 48+ Grand
Inpat Wait Months Months Months Months Months Months Months Months Months Months Total
2017-01-31 25,724 16,469 7,516 11,425 5,819 4,202 1,992 589 19 3 73,758
2016-02-04 24,510 15,124 7,442 10,128 4,238 1,273 685 236 46 5 63,687
% 1 Yr change 5% 9% 1% 13% 37% 230% 191% 150% -59% -40% 16%
31/1/2017
04/02/2016
Galway UH ( 8,947 ) Galway UH ( 10,016 )
Beaumont ( 4,941 ) UH Waterford ( 4,827 )
UH Waterford ( 4,449 ) Beaumont ( 4,363 )
Mater ( 3,995 ) Mater ( 4,323 )
St James's ( 3,805 ) Tallaght Adult ( 3,951 )
Tallaght Adult ( 3,141 ) St James's ( 3,912 )
UH Limerick ( 2,608 ) Sligo ( 3,190 )
Tullamore ( 2,440 ) UH Limerick ( 3,057 )
Royal Vic ( 2,412 ) Royal Vic ( 2,821 )
Sligo ( 2,376 ) Tullamore ( 2,796 )
Cappagh ( 2,221 ) Roscommon ( 2,710 )
Crumlin ( 1,980 ) SIVUH ( 2,310 )
Letterkenny ( 1,728 ) Letterkenny ( 2,084 )
SIVUH ( 1,648 ) Cappagh ( 2,009 )
Roscommon ( 1,634 ) Crumlin ( 1,955 )
St Vincent's ( 1,392 ) St Vincent's ( 1,673 )
Cork UH ( 1,159 ) Cork UH ( 1,512 )
Kilkenny ( 1,102 ) Connolly ( 1,406 )
Drogheda ( 991 ) Drogheda ( 1,133 )
Louth ( 975 ) Louth ( 1,122 )Waiting list reduction • Waiting list validation • Demand/capacity analysis and planning • Subspecialty engagement • Performance metrics and analysis (TPOT/TQIP) • Sustainable infrastructural and operational investment.
Theatre Utilisation
Surgery Discharges in 2015 (including Acute and Elective admissions for surgery or surgical care)
Surgical Specialty split in
2015 Had Not Had
Surgery Surgery
AvLOS AvLOS
Acute 9.75 5.17
Elective 4.53 6.43
Total 6.93 5.33
NCPS use HIPE data for reports
23 -Acute Surgery
• Institutional • Individual
o 26 acute units o Model 4 Hospitals
o Acute Model of Care – • Emergency care
not implemented o Sub-specialty
• ASAUs interests
• Emergency theatres o No incentive to
• Senior Decision contribute
Makers o Model 3 Hospitals
o Model 3 Hospitals – • Staffing issues
better metrics • RotasAppendicectomy
Model 3 Model 4
No. 2499/757 2247/416
AvLOS 2.3/3.0 3.0/4.0
DOSA 61/62% 52/56%
PreAvLOS 0.5/0.5 0.7/0.6
PreAvLOS 0.3 – 1.2 spread nationally
HIPE 2015Acute General and Colorectal
Surgery - Mortality
Operation Model 3 Model 4
No Mortality (%) No Mortality (%)
Hartmanns 74 9.5 61 9.8
Right Hemi 72 9.7 96 6.3
Total Colorectal 366 9.2 622 8.3
Laparatomy 38 7.9 44 6.8
SB resection 86 10.5 129 9.3
Perf DU 52 3.9 72 9.7
Total General 6189 0.8 6216 1.4
2015 HIPEAcute Surgical Assessment Units • Business case • Design • Governance/Leadership • Sustainable staffing o Consultant o Non-Consultant • Integration with the ‘acute floor’ • Metrics and outcome analysis
Surgical Performance –
what does good look like?
• Good outcomes
• Good process
o What governance structures do you have?
o Are the Models of Care functioning and monitored?
o Does your hospital have a QI office?
o Do you regularly review surgical metrics, KPI’s and waiting
list data, NQAIS, NOCA audits?
o Do you regularly review all complaints and adverse
events?
o Do you carry out patient and staff satisfaction surveys and
exit surveys for trainees?
o What QI initiatives do you monitor?
o What is on your risk register?DEFINING PERFORMANCE
• Hospital admin engagement and clear institutional strategic goals
• Sound governance structures
• Deep institutional penetrance of sustainable performance improvement
• Greater oversight of internal professional and operational standards (appraisal)
• Greater consultant engagement, corporate responsibility and alignment
• More senior decision making early in the patient journey
• Better defined and co-ordinated flow optimisation SOPs between and within:
EDs, AMAUs, SSU, ASAU and Admissions
• Better ambulatory care pathways and appropriate procedure settings
• Better older person pathways
• Greater in-patient ward cohorting, rounding, and discharge rigor
• Greater use of effective continuous information management hubs and
dashboards
• Greater weekend working
• More patient experience metrics
• Better staff management to meet declining resilience – staff/resource shortages
• Greater HSE drive on integration and process improvement at the coal face*Challenges for Surgery • Measuring Individual/Institutional Performance • Governance and Quality Improvement • Leadership
Institutional Leadership
Mayo Clinic
• Audit Committee • All major committes • Compensation Committee chaired by a Medical • Conflict of Interest and Managing Innovations graduate Committee • Development Committee • Finance Committee • Governance Committee • Government and Community Relations Committee • Research and Education Committee • Quality, Safety and Patient Experience
Medical Leadership
• US NWR • Reasons
o Medical CEO led hospitals o Peer to peer credibility
show 25% increase in
o Continued focus on
quality scores
patient care
• % of managers with a o Employee satisfaction
clinical degree o Know what ‘good looks
• Size, private ownership like’
and competition • Healthcare balance:
o Quality vs cost
o Technology vs humanity
Bloom N, Sadum R, Van Reman J 2014 dmn.health.pdfMedical Leadership
• Yale Medical • Cleveland Clinic
o Two tier approach o Management Training
• Training in the • Emotional
principles of intelligence
healthcare delivery • 360 feedback
• Emergency leaders • Team building,
selected for MBA executive coaching,
training conflict resolution
and situational
leadershipSurgical Services 2020 and Beyond
• Process Measurement
o Individual and Institutional outcome reporting
• Quality Improvement Initiatives
o Models of Care
o Value added care
• Leadership
o Training in Management and Health Care
EconomicsSurgery Discharges between 2010 and 2015 (including Acute and Elective admissions for surgery or surgical care
excludes obstetrics, maternity hospitals, hospices and rehab units)
National Acute & Elective surgical volumes comparing 2010 to 2015
Surgical volume ↑ X 12.4%
Bed day usage ↓ X 10.9% Without improvments
Bed day savings 87,561 Extra BDUs at 242,372
Marginal cost saving of €16,549,029 a cost of €197,048,221
Day Cases rate ↑ X 12.4%
Based on HIPE discharges in 2010 & 2014 for model 4, 3 & 2 Hospitals
excluding maternity & neonates discharges.
Marginal saving in direct costs is € 189 per BDU.
Fully loaded cost is € 813 per BDU.
Without the improvements would have
required
2 fully staffed Model 3 Hospitals (738 beds)
to cope with increase surgical workload
NCPS use HIPE data for reports - 38yearly analysis 2010 … 2015
Note: New 2015 surgical procedure map table reapplied to allNOCA Audit Portfolio
National Total
# Audit Report Hospita Live 2016 2017 2018 TBC
Since ls
National Audit of Hospital
1 2016 44 44
Mortality (NAHM)
2 Major Trauma Audit (MTA) 2016 26 26
Irish Hip Fracture Database
3 2013 16 16
(IHFD)
4 NPEC Severe Maternal Morbidity 2011 19 19
5 NPEC Perinatal Mortality 2008 19 19
6 NPEC Planned Home Births 2013 20 20
7 Intensive Care Unit Audit (ICU) TBC 22 5 4 7 6
Irish National Orthopedic
8 TBC 27 1 1 4 7 15*
Register (INOR)
*Private HospitalsEmergency General Surgery
• Measured Standards
o Organisational change
o Consultant involvement
o Risk assessment
o Emergency theatre capacity
o Post-operative critical care
o Data collection and audit
• Mortality
o 30 day – 11.1%
o 90 day – 15.5%Acute Colorectal Surgery
Model 3 and 4 Hospitals
Model 3 Model 4 Total
Colostomy 29 67 96
Ileostomy 14 65 79
Resection and anastomosis 122 148 270
Total colectomy 18 60 78
Anterior Resection 4 39 43
Hartmanns 74 69 143
TOTAL 261 448 709
HIPE 2015You can also read
