How to Make the Operating Theatre
Run Smoothly

Overall, the program is designed to deliver a better hospital experience for patients by optimizing team working among staff, raising standards of care and reducing operational delays.

Devised and developed by the NHS Institute for Innovation and Improvement in co-operation with six hospital pilot sites, The Productive Operating Theatre (TPOT) draws on procedures used in the aviation industry and lean processes commonly seen in the automotive industry to enable operating room nurses, doctors and administrators to work more effectively.

The goal is to achieve the ‘perfect operating list’; not just on the occasional day when everything happens to run smoothly, but every day, week in and week out. It sets up the working processes to ensure that glitches are minimized.

Results from the pilot schemes over the last 12 months have shown significant improvements in theatre efficiency through operating lists running more smoothly with fewer hold-ups. And patients have shown improved rates of normothermia and pain control during recovery.

In many general hospitals, running and staffing an operating theatre is one of the most costly patient services provided. In England, the NHS Institute for Innovation and Improvement estimates that it costs between £14 (approx €15.70) and £20 (approx €22.50) per minute to run a single theatre. The TPOT program is unique in harnessing the ability of staff to make this expensive function run as efficiently as possible.

The program provides a complete support package to enable surgeons, anaesthetists, theatre nursing staff and management teams to work together successfully. It includes DVDs, web based resources, templates for working documents and supervised on-site training and workshop sessions with NHS Institute representatives.

TPOT starts with an introductory visit from an NHS Institute representative, who meets with senior hospital management, as well as medical staff, to ensure their support and commitment to the program’s aims, whether directly or indirectly involved in the work of the operating theatre.

‘Visioning’ workshop sessions are then held for senior management, clinicians and theatre staff. These workshops are designed to identify all the obstacles that stand in the way of achieving the perfect operating list. Such obstacles can vary from staff being late for theatre because of difficulty in finding a car parking space, to faulty operating theatre doors and frustrations over missing equipment. Some are housekeeping issues which can be solved by management straight away, while others become the focus of the TPOT program.

Staff are then invited to describe their vision and ambitions for the program. Champions are appointed to work alongside a program leader and a leader from the executive management.

An important part of the program is setting up measurement systems as tools to encourage continuous improvement. Theatre teams can see how they perform against agreed aims in areas such as start times and patient turnaround.

Using the practice of airline flight crews as an example, all members of the operating team gather together for briefing and debriefing sessions before the start and at the end of each day’s surgery.

These sessions, lasting five to ten minutes, allow planning and give everyone an opportunity to express any concerns they may have before the surgery list starts. And at the end of the day, the debriefing session provides an opportunity to review the day’s performance.

The use of WHO safe surgery checklist (detailed in a separate report in this issue of Exsero) is also an intrinsic part of the communication process. Real-time operational status boards are another means of improving communication within the theatre department. These are usually positioned in a central area and display information so that staff can see how the day’s lists are progressing.

An example of a lean process recommended by the TPOT program is day of surgery admission for patients. They should be accommodated in a dedicated pre-surgery unit as close as possible to the operating theatres. This reduces the possibility of delays in finding patients who may be moved between wards at short notice due to pressure on beds.

Day of surgery admission also reduces the lengths of stay for patients and reduces the number of staff involved in their care. Nursing staff in the pre-surgery unit are involved solely in preparing patients without being required for other duties elsewhere. Experience from the pilot schemes has shown that day of surgery admission reduces average patient transfer times from 18 minutes to just four minutes.

Once an operation has been completed, a quick turnaround is essential for the theatre schedule to run on time. Turnaround rates are measured from the time a patient leaves theatre to the time the next anaesthetic is applied. Reduced turnaround times mean less waiting for patients and staff, reduced staff over-time and more operations being completed in the day.

Experience from a theatre in one of the pilot schemes has shown that achieving a target turnaround time of 10 minutes during a two week period saved 251 minutes of ‘wasted’ theatre time, when staff were waiting between the end and start of procedures. Over a year, the increased productivity is worth about £85,000 (approx €95,500).

Post-operation, the patient’s recovery experience is also measured across four parameters: axillary temperature on arrival in the recovery suite, the level of pain experienced, the presence of any complications and any delays in being transferred to the ward.

Here the pilot schemes have reported the proportion of patients with a maximum pain score of less than 6 increased from 73% to 88%. And the percentage of patients with an axillary temperature on arrival above 35.4° rose from 91% to 98%. A reduction in patient safety incidents and complications through improved team working and communication was also reported.

Lean process principles are also applied to theatre store rooms, including how consumables and equipment should be stowed for easy access and how stock levels should be properly controlled.

TPOT applies the ‘5S’ principle – Sort, Set, Standardise, Shine and Sustain. Theatre supplies should be sorted to make the best use of available space; they should be set out on clearly labelled shelves; the same system should be standardised for all store rooms; the area should be kept clean and tidy; and stocks should be regularly audited to sustain the improvements made.

The use of pre-packed, instrument procedure trays is recommended to reduce picking times, and to eliminate the possibility of the wrong instruments being selected and staff finding items missing or unserviceable.

Supplies of consumables and equipment should be matched to demand, avoiding unnecessary expenditure on building up large stocks. The TPOT program requires an initial stock taking, with flow rates assessed and supplier delivery times logged. Stocks should then be aligned on a ‘just-in-time’ basis with their rate of use.

Experience from the pilot schemes has shown that an immediate saving of £5,000 (approx €5,600) can be expected per theatre in running down existing store room stocks. And an ongoing annual saving of £9,000 approx €10,100) can be anticipated in stocking consumables on a lean basis.

Feedback from medical teams involved in delivering the benefits of TPOT has shown increased morale through an enhanced sense of job satisfaction, says Amanda Fegan.

“Staff feel more empowered because they have been involved throughout the process, from conception to implementation,” she says. “They want to do a good job and this program removes barriers that can get in the way. They can go home on time knowing their efforts have been channelled in the right way.