theatre refurbishment programme city road 2 - meh board... · programme city road january 2015 ....

Theatre Refurbishment Programme City Road

January 2015

www.moorfields.nhs.uk

Theatre Improvement programme

Work streams Key actions

1 Theatre staffing • Review of structure, roles and responsibilities

2 Service teams • Developing service team leaders

3 Operating lists • Review of scheduling and planning of lists

4 Admitted pathway • Feasibility study, develop options for 1st floor

5 Operational/Equipment • Defined management of contracts & stock control

6 MEH private • Identify service developments for private

7 Emergency admitted • Improve the pathways to improve communication

8 Information Technology • Review of software, systems and metrics available

9 Governance • Review of policy, processes and information

10 Safety • Team Brief and WHO checklists

11 Education & research • Recruitment of Practice facilitator

12 Efficiency and Value • Improve utilisation of theatre capacity

13 Performance Metrics • Accurate reporting tools

14 Communication /Progress • Reports /updates /user groups


Work stream 1- Theatre Staffing Agreed structure, roles and responsibilities

Consultation undertaken with Clinical theatre teams

Significantly improved performance management processes,

absence management and appraisal management

Planned

Administrative consultation planned January 2016

Implementation of e-rostering programme

Identified Theatre Service Team Leader roles and job descriptions

agreed, banded and commenced January 2016

Planned

Each service team undertake a review of equipment and

instrumentation requirements

Each team leader attends service review meeting and service

Governance meetings to understand the needs of the services


Work stream 2- Introduction of Service Teams


Work stream 3- Ordering and Planning of Operating lists

Scheduling and planning of operating lists meeting held weekly

Pilot project with a Surgeon and anaesthetist from each service,

reviewing and ordering the operating list developed

Planned

Local safety standards finalised describing the agreed process for

scheduling and listing of procedures

Commence pilot of planned order of operating lists

Review current pathways and confirmation of key weaknesses or

non-compliances against guidance to admitted pathway

Developed an outline schedule of accommodation for facilities

Architect engaged to develop feasibility study and scope of service

Planned

Measured survey, structural survey, review of M&E infrastructure

Present feasibility study with option appraisal.


Work stream 4 – Pathway for admitted activity


Work stream 5- Operational + Equipment Identified all maintenance and service contracts for theatres

Introduction of material management processes in theatres with bar

coding – significant cost reduction in non-pay

Development of new operating theatre timetable

Planned

• Annual review of equipment and instrumentation

• Finalise the move of maintenance and service

Agreement for specific theatre to be made available to MEH private

Specific team leaders identified to lead MEH private

Reporting programme available for MEH private to review the utilisation

of their lists

Planned

New timetable developed and further discussions ongoing

Scoping programme to review capacity and demand requirements


Work stream 6- Moorfields Private


Work stream 7- Emergency Service A full service review and audit of the VRE service to establish the

current resources and future opportunities

Planned

Review of referral source to the VRE Clinic to ensure that referrals

are triaged and signposted effectively

Review of treatment and procedure options to ensure income

captured throughout the pathway.

Identified requirements for integration of PAS Silverlink and OpenEyes

Installation of ‘COW’ on wards to assist with communication and flow of

activity

Planned

Implementation of data and operational requirements for the successful

integration between PAS and OpenEyes


Work stream 8- Information Technology


Work stream 9- Governance

Review of all local procedures and standard operating processes

ensuring local safety standards are based on National Safety

Standards for Invasive Procedures (NATSSIP’S)

Weekly Theatre meeting to discuss the responsibility's of

adhering to the procedures and the impact on patients safety- all

staff encouraged to report safety incidents and/or near misses

Theatre representation to Infection control, Clinical Governance,

Risk Management and Health and safety meetings feeding back

to the theatre team

Significantly improved responsibility and accountability from

staff with clear job descriptions

Planned

Ongoing review of local safety standards to ensure compliance

against National Safety standards



Work stream 10- Safety Reinforce the use of the WHO checklist providing an accurate record

of checks being performed – delivers a written record of Procedural verification and site marking

Sign in, time out and sign out

Prosthesis verification

Conformity with the Pre-operative Team Brief encourages all staff to

express any concerns of planned procedures or patient safety

issues with a debriefing session at the end

Audit of Team brief undertaken, demonstrating improved compliance

Infection control audit

Health and safety audit

Medicines Management audit- all demonstrate compliance

Planned

Ongoing audit of Local safety standards

Continued discussion with staff of responsibilities for the

management of e.g. Prosthesis verification, equipment failure and

prevention of retained foreign objects



Work stream 12- Efficiency and Value Significant improvement in management of theatre budget both pay

and non pay

Open day being undertaken for recruitment of group of staff wishing

to work in theatres at City road- reduction of agency utilisation

Planned

• Programme to define reference costs per procedure

• Recruitment to fill staff vacancies via Open days

Introduction of programmes for monitoring and reporting of activity:

Theatre utilisation broken down by every session

Starting time of both am and pm sessions

Cancellation report for medical and non medical activity

Planned

Audit of cancellations and DNA’s to understand trends

Audit of activity between VR elective and VR emergency activity


Work stream 13- Performance Metrics


Work stream 14- Communications

Communications board in City Road theatres updated monthly

Monthly reports available for services and directorates of progress

and utilisation

Weekly scheduling and cancelation meeting at City Road including all

service managers and service admission co-ordinators with P&I

representative to discuss scheduling, utilisation and staffing issues

Update provided at Clinical Governance half days and clinical service

meetings

Planned

Develop a Moorfields Theatre group for all theatres leads from City

road and satellites to meet monthly to ensure consistency in

standards and resolution of concerns ensuring best practise initiatives

are communicated to all

Development of a Moorfields Medical Theatre user group


theatre refurbishment programme city road 2 - meh board... · programme city road january 2015 ....

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