Variations in care quality occurs across the health system, especially in hospital theatres. Nursing Times gathered a group of theatre nurses, and those interested in improving surgical care and reducing waste, to meet financial savings and improve quality
Unwanted variation in the perioperative environment holds back care-quality improvement and wastes resources when they’re more scarce than ever. The Nursing Times perioperative managers roundtable examined concerns with unwanted variation, and the steps panel members are taking to tackle this issue in the perioperative setting.
Three key themes arose repeatedly, giving insight into the practical solutions that could help reduce unwanted variation, including:
Collaborative working: Using hub frameworks, engaging surgeons, and democratising the suggestions-for-improvement process helps get the team working together and communicating about what is needed. One panel member used collaborative working to reduce instrument wastage and has saved £200,000.
Comprehensive training: You can have the most advanced equipment, but if staff don’t know how to use it, you’re not going to deliver safe, high-quality services. To improve patient care, it’s vital to provide clinical resources that help staff feel safe, skilled and confident.
Data-driven processes: More and better data is needed to improve benchmarking and measure the effects of change. Data drives surgeons to compete against one another to improve their metrics. However, it should not be used to punish outliers. Rather, every outlier or incident should be seen as an opportunity for improvement.
Bryn Davies is the general manager, Europe, at Syncera by Smith & Nephew.
Syncera is a strategic business unit of Smith and Nephew. Our unique digital solutions are designed to help reduce unwarranted perioperative variation and optimise operating theatre efficiency. Optionally linked with clinically proven hip and knee implants to deliver further cost efficiences.
“Theatre is the engine room of the hospital,” says Sarah Moppett of Nottingham University Hospitals Trust. “But it is so often overlooked.” The purpose of the event at which she spoke, however, was to focus on the theatre. And to highlight how, when savings need to be made and waste cut, surgical nurses can be pioneers in the process and often make significant savings – if they can overcome, as Ms Moppett says, being sidelined as can happen in some hospitals.
“One group last year looked at laparascopic consumable spending across sites, particularly at what general surgeons and gynaecologists were utilising in terms of laparascopic equipment,” says David Crosby from East and North Hertfordshire NHS Trust.
“They were using three different providers, but were able to narrow it down to one, which reduced costs by £150,000 per year. We made use of the hub frameworks to support this, but weren’t able to go through NHS Supply Chain (which might have helped save even more costs). But we were not focused on saving costs so much as this being a strong collaborative effort among surgeons, staff, theatre managers and so on. We don’t want to create too much of a ‘top-down’ approach – we want theatre teams to be able to come to managers and ask for support.”
Something similar has been happening at Nottingham University Hospitals Trust. Maria Shallow says an “evaluation product” group was set up at the trust, which has been running for the last three years and involves a senior clinician, a general manager and a host of other people.
“We used this to standardise [procurement] between hospitals, such as with laparascopic equipment, and we have been doing a lot of standardisation with these types of products that are widely used within different specialities,” says Ms Shallow.
“In one year they’ve saved more than £200,000 just by looking at equipment and shared governance around products. This is a good example of saving money but clinicians have to be involved in terms of the challenge around the benefits to patients and the savings that can be made.”
Chris Greaves at North Tees and Hartlepool FT says: “Another big thing has been transferring critical care patients. People found they were throwing a lot of equipment away at the end of a transfer, but by engaging with everyone in the critical care path they got it down to an agreed standardised transducer, which saved money and made the critical care transfer much safer, reducing the number of incidents linked into patient safety.
”We managed to achieve this across three big organisations, but only through the vehicle of network collectivity – managing theatres, critical care and A&E.”
But financial savings weren’t the only goal, Ms Moppett tells us: “Rather than saving money, our main aim was to improve patient safety. We found with the pumps that we were using different pieces of kit, which introduces risk We have completed a lot of standardisation around safety rather than saving money, such as with arterial line packs.
”Nationally there are incidents where the wrong bag of fluids can be used.. Now the trust provides standard arterial line packs with everything you need to put a line in, which has made a big difference.”
“The biggest turn off for consultants is if it’s all about money,” says Joann Morse of Morecambe Bay FT. “It must be safe, and you must show how standardisations are making things safer.”
Mick Dowling from King’s Hospital NHS FT, says: “The desire for quality drives patient safety – if staff don’t know what they’re doing or how to use products, then inefficiency and lack of safety start right there. But what’s the governance around that? It must be challenging for a lot of theatres right now.”
Ms Shallow says: “At Nottingham University Hospitals we ensure staff have gone through a specialist induction for both equipment and the theatre setting itself – Nottingham University Hospitals has six full days of training to provide competent and safe practitioners that are supported to work clinically by ensuring they are adequately trained in their new environment.
”This also helps with retention of staff, because if staff feel supported and can retain the information they’re given, they’ll be more willing to keep working as they know they are being supported properly and feel safe to work.”
Sarah Cullen of Morecambe Bay Hospitals FT says some theatre teams prefer to manage stock themselves as they know the kit clinically and can recognise when the wrong piece arrives.
“We have used the team’s suggestion to trial a group of clinical support workers sharing the responsibility of stock control and ordering, while maintaining clinical skills so they know their business and have some control,” she says.
“This will improve patient safety by ensuring the right kit is available when it is needed. It will also increase teams’ awareness of the cost of kit and reduce waste by increasing awareness.”
Recruitment and retention of staff
Attracting and keeping staff in theatres can prove just as difficult as elsewhere in a hospital, but there are methods through which nurses can be retained.
Minija Joseph, Cardiac theatre Clinical Co-ordinator at King’s College Hospital NHS FT, introduced a series of guidelines to teach theatre staff working in cardiac theatres exactly what they had to know before working there and what to use and how to use it, while trying to standardise the theatres.
“King’s Hospital has seven cardiac surgical consultants who all use different instruments, sutures and disposable items, so there was a need to standardise,” Ms Joseph says.
“We worked together with clinical lead and we have managed to standardise practice. We reviewed all instrument sets and removed all unnecessary instruments. Surgeons use the same items and sets in department, we have introduced rolling training and refresher programmes.
”To prepare patients for theatre, we introduced a patient preparation protocol for the wards so we have a clear surgical pathway for the patient journey to reduce risk of infection. We start with anatomy and physiology so it is not just theatre-based training, but an in-service education programme with competencies.
”All staff go through a comprehensive induction – everyone in this department gets three years of comprehensive training. Training staff thoroughly and treating them well helps them to give excellent patient care. I work very closely with the staff and teach them.”
Caroline Pilbeam, Western Sussex NHS Healthcare Trust, says: “Non-EU staff are more likely to stay because otherwise they’d have to reapply for their visa. It can be hard to retain other staff because they often want to move. There are lots of
opportunities for nurses everywhere, especially if they have a couple years of experience. If you can create development opportunities in their current role, they’ll be more likely to stay. Career progression and financial benefits make people more willing to take on more responsibilities.”
She continues: “One of the biggest challenges is getting people out to start with. One hospital has admitted all new people in the last year, but the negative side is having a lot of new starters, which take a lot of input and time to train. It is important to manage numbers with competency. Just keeping on top of everything is an investment – not even just financial investment, but time to balance workload and training.
”A six-day induction programme sounds fantastic but you’d need everyone to actually be able to put in that time, and staff tell us they find it hard to find that balance.”
Ms Shallow agrees that training your staff is what it takes to get them to do the job well and motivate them to stay: “We have separate induction programmes for different bands. We have a huge workforce – over 700 staff – so we need to make sure they keep staff updated to appropriate skill levels. Being a major trauma centre, we need to keep trauma skills up to date, and want staff to feel like they’re getting everything they need in terms of support and training.
“Specialised surgery, such as emer-gency surgery, is a challenge so we have looked at in-house rotation programmes among different hospitals to try to teach different levels of skill and keep staff up to date.
”One campus is predominantly emergency and another elective, so we encourage people to move between campuses – you therefore create a healthy workforce where people are encouraged to develop a diverse set of skills.
”Otherwise you can become so specialised that it is hard to recruit. It’s not healthy to have teams that are so specialised they can’t move around, even if they want to.”
Kay Wandless of East and North Hertfordshire NHS Trust says: “We’ve had more of a problem with merging – for example, orthopaedic staff came up to general theatre and it was like an invisible barrier.
“So there was one set of staff, very good at doing spines and implants, and at the other end there was another set doing vascular and triple-As. Even with trust inductions, staff inductions, mentorships and so on trying to merge two separate teams and getting them to engage was really difficult, because it was very much ‘us versus them’.
”It’s important to get a well-rounded experience because surgeons have to be able to work with different kinds of nurses and vice-versa. But it is hard to get that integration, especially with surgeons who have become more challenging when they don’t know the team they are working with.”
Krishna Kallianpur from Derby Teaching Hospitals NHS FT agrees: “We merged two hospitals and moved on-site in 2009, and I know from experience you have to work really hard to pull two different teams together.”
Panellists believe integration takes a long times and is complex. They also commented that you need integrated teams to be flexible to provide the level of service you need.
Ms Moppett says: “You need to simulate the environment, and if things go wrong work out what you would do and work together. We do a ‘team steps programme’, an in-depth simulation team training programme theatre teams can use. This simulates various scenarios in the theatre environment, and gets teams to think about having to work together to solve problems. It has been great for increasing multidisciplinary collaboration and everyone having a voice.
”Several multidisciplinary teams have completed it, and have found it helpful for improving team working. This is an ambitious programme to enable all multidisciplinary theatre teams to do the programme , but we do feel it’s important for everyone to complete it, as safety is our top priority.”
Many of the nurses highlighted mixing between the multi-disciplinary teams, and said when they had, the dynamic was interesting. One nurse commented that having the orthopaedic surgeons suggest training, arrange it, and then invite other staff to come had gone down well. It gave clinical support workers the opportunity to saw or drill a bone, and that exposure has developed an interest which had never been there before for some people.
Lesley Fowler of North Tees & Hartlepool NHS FT says: “On a small scale, just having meetings between surgeons and different levels of nurses has been eye-opening in terms of things that have caused major issues for the surgeons.
”Just having bands 5, 6 and 7 sitting around the table as a team has been really positive in moving things along. Very simple things come out and you understand better and it’s really changed the team dynamics, it’s been really positive.”
Using data and information
One of the main themes of the conversation was the variation in care, with some attendees feeling this is caused by the variation in supplies. Ms Joseph says: “In cardiac theatres, there are so many heart valves and devices manufactured by different companies. If you go to any cardiac theatre you will see 40 different cardiac valves and another 25 different repair devices. How do nurses, particularly junior nurses know which one is the right size and how to prepare it?
“Every valve is prepared in a different way and it’s hard to remember in our pressurised environment. King’s cardiac theatre has its own booklet with guidelines on what it looks like, how to prep it and other details. I worked with Liva Nova on this, creating the first book in the world on how to identify and prepare cardiac devices.”
There are other ways to ensure there are no ‘never’ events. Ms Fowler says:
“I know of an orthopaedics department in another hospital that has instruments with boxes, which you can just scan and they’ll tell you on the screen what you’re using, and if it is compatible with the procedure. It would be great to expand that software across all specialties.”
The roundtable panelists agreed that healthcare providers should not place so much emphasis on scrutinising or criticising small mistakes. They felt that nurses, other healthcare professionals and managers must put energy into actually making improvements. They pressed for a need to re-examine processes for potential mistakes that have been overlooked and use these mistakes to foster learning for staff. One nurse commented: “We’re only human and have to remember that when dealing with never events, no matter how hard it is.
“A recent study looking at never events across the UK found that the bigger you are, the more likely you are to have one, so it’s just a game of numbers – not really a good measure of safety.
“I want to make one more point about never events,” says Ms Joseph. “We need to focus on the good things – so much news gets published about never events and not so much about things nurses actually accomplish. We need to counterbalance the bad with the good.”
“It is very important for the junior nurses to get involved in new project in the theatres and implement the good practice, so that they get experience and if they need help, then senior nurses need to lead and support them.
“One of the statements in the Carter report declares a “quest for 80% compliance” on electronic ordering,” said Mr Crosby. “Some people don’t think it’s the best way forward because they think we are heading towards a monopoly, reducing competition/variety, which is not necessarily good. A number of products have been taken away due to contractual costs.”
“With the size of procurement, one hospital has done a direct cost comparison, which has been quite eye-opening. When it’s just a predetermined supply chain it does turn into a monopoly if they don’t challenge it.”
Ms Pilbeam says Western Sussex had introduced a clinical procurement lead in theatres who works between theatres, across sites: “Having someone managing supplies has been really successful and they’re much more invested in saving money because they’re part of a team of staff who are all being affected.”
Kimberley O’Hara of Western Sussex reinforced her colleague’s point: “Another hospital has a clinical support worker who will go through all materials each month, price them, then go back through procurement to tell them how much they are wasting – things that go out of date or never get used and so on. This really helps even though it can take a long time.”
The two nurses from Nottingham University Hospitals were keen to highlight how shared governance could be a tool used to empower ground floor staff in tackling waste. The process, which won a Nursing Times Award for the team in 2015, allows all employees to play a part in decision making around the trust.
“Shared governance is a powerful tool for staff, and it is important that teams sort out governance together,” says Ms Shallow. “It helps with standardisation to have everyone collaborating. It empowers staff to make shop floor changes. But leadership is key, with the right leadership you can help to unblock problems that are barriers to empowering others.
The feeling from the group about this event was summed up beautifully by Ms Moppett: “It has definitely served as a good reflection tool. Theatre can be such a hidden specialty, undervalued and misunderstood and yet we are the engine room of a hospital. It is nice to do a roundtable like this and hear passionate and interesting points from different theatre leaders with different perspectives.”