Rotamap

Improved theatre planning results in enhanced theatre delivery: A case study using Rotamap services for 6-4-2 theatre planning

Alexander Bones, February 2024

Introduction

Historically, theatre planning for elective operations has suffered from inefficiencies, with NHSi concluding the NHS loses 300,000 operations a year due to inefficient scheduling. Examples of inefficiencies include late starts, early finishes, and delays between operations; addressing these to deliver additional sessions would equate to a 17 % increase in productivity. We worked with an NHS Trust who observed issues around theatre planning, with certain surgical specialties struggling to assign staff in a timely manner. Without a single source of truth in the form of a live, shared rota, it was unclear if theatre lists had surgeon cover allocated and if the assignments being made were compliant with 6-4-2 theatre planning policy (Box 1).

The Trust worked with us to use Rotamap services to improve visibility of surgeons and anaesthetists covering a given theatre and maximise the use of these spaces. Rotamaps electronic rostering tools, Medirota and CLWRota, are able to communicate with each other, letting them share live information between departments using shared resources or spaces. This information can be viewed across multiple departments, divisions, or even entire Trusts with Overviews. Overviews provide a composite view of activity in real time by pulling together information from multiple departments Medirota and CLWRota rotas into a single live view.

The Trust also mandated:

• Medirota/CLWRota must be used for rostering all theatre activity
• Annual leave should be managed in CLWRota/Medirota and be approved at least six weeks ahead of time
• Departments automatically set up their rotas and close their leave books six weeks in advance, thus showing where sessions were uncovered and preventing leave from being automatically approved

This removed some of the ambiguity around assignments, as:

• If there was no surgeon or anaesthetist available for a given list, then this was flagged in advance. The Trust could then enforce the 6-4-2 planning process
• If no surgeon had been named at four weeks, then the theatre space was open for other specialties to pick up
• If no anaesthetist was available, the session was marked as “At risk”, and stood down if cover was not found

After making the above changes, the Trust saw improvements in theatre planning with staff being assigned earlier and seeing fewer cancellations. We offered to look into the data in depth to quantify this improvement. The findings are presented in this article.

What have we looked at?

We compared data from eleven surgical specialties, along with anaesthetics, all of which were using Medirota or CLWRota before and after the Overview was used for 6-4-2 theatre planning. The analysis was split over two periods: 'Pre-Overview', between January and July 2022; and 'Post-Overview', between January and July 2023. As the names imply, ‘Pre-Overview’ was before the Overview was being used for 6-4-2 theatre planning, and ‘Post-Overview’ was after the Overview was in use for theatre planning. We wanted to look at key metrics to see improvements based on the key points of the 6-4-2 theatre planning process. We looked at how far in advance surgeons had their leave approved; how far in advance theatre sessions were being ‘finalised’ (that being the last change in the surgeon and anaesthetist running the list), how many theatres were cancelled and how far in advance the cancellations occurred, and finally how theatre sessions were being delivered (i.e. using staff within the department, using more trainees/middle grade anaesthetists, or using locum staff). For surgeon and anaesthetist assignment times we will be looking at two chart types, histograms and cumulative density function plots - see Box 2 for an explanation of these.

What did we find?

Surgeon assignment

We looked at surgeon assignment times in pre-Overview and post-Overview. In the post-Overview reporting period, more theatre sessions had the surgeon finalised than in the pre-Overview reporting period at the majority of time points; there wasn’t a single time point where the pre-Overview sessions had more surgeons finalised than post-Overview. The data showing how far in advance theatre sessions were finalised is shown in Fig. 1. The post-Overview data had a large number of sessions finalised around 40 days in advance. In the pre-Overview time period the number of sessions being finalised around 40 days in advance was lower than in the post-Overview time period. In addition, there were more sessions being finalised less than 40 days in advance compared with the post-Overview reporting period. The data indicate that post-Overview, the theatre sessions are being finalised earlier in advance, and that there were fewer late changes.

Figure 1. Histogram of consultant surgeon assignment times in advance of a given theatre list. For each theatre list in both time periods, the time difference between the last change in consultant surgeon assigned to a given list and the date the list was due to start was calculated. This was determined to be the date the list was “finalised”. We then grouped the data into time intervals and plotted them as two histograms (above), with the bar position along the x-axis indicating how far in advance sessions were finalised, and the bar height along with y-axis indicating the number of theatre sessions finalised that many days in advance.

To compare a few key time points, in the post-Overview reporting period a quarter of sessions had the surgeon finalised 53 days in advance; this was 49 days in advance in the pre-Overview reporting period (Fig. 2). Post-Overview, half of all sessions had the surgeon finalised 40 days in advance, compared with 37 days pre-Overview. Finally, 75 % of sessions post-Overview had the surgeon finalised at 28 days compared with 18 days pre-Overview.

Figure 2. Empirical cumulative density function (eCDF) plot of consultant surgeon assignment times in advance of a given theatre list. Data is the same as figure 2. Each step on the graphs indicates the fraction of total sessions occurring within the time period that were finalised that many days in advance or earlier.

We can see that consultant surgeons were being assigned, earlier in advance across the Trust. By enforcing the points discussed earlier as part of the planning policy, departments could identify staff who were absent and make adjustments as appropriate, which fed back to the Trust-wide Overview, as where lists had no cover, these could be offered out to other specialties earlier in advance.

Anaesthetist assignment

In this Trust, the surgeons are generally assigned to a theatre list first, then anaesthetists are assigned. We compared when consultant anaesthetist assignments were finalised between the two time periods, and it is clear that in the post-Overview reporting period, anaesthetist assignments were finalised much earlier in advance compared with pre-Overview (Fig. 3). A large number of sessions had the anaesthetist finalised around 42 days in advance post-Overview, while no sessions had the anaesthetist finalised that far in advance pre-Overview.

Figure 3. Histogram of consultant anaesthetist assignment times in advance of a given theatre list. For each theatre list in both time periods, the time difference between the last change in consultant anaesthetist assigned to a given list and the date the list was due to start was calculated. This was determined to be the date the list was “finalised”. We then grouped the data into time intervals and plotted them as two histograms (above), with the bar position along the x-axis indicating how far in advance sessions were finalised, and the bar height along with y-axis indicating the number of theatre sessions finalised that many days in advance.

When it comes to the anaesthetists assigned to a theatre session, the differences in terms of finalisation are stark (Fig. 3). A quarter of theatre sessions post-Overview had the anaesthetist finalised 42 days in advance, compared to 22 days in advance pre-Overview. Post-Overview, half the sessions were finalised 31 days in advance, compared to just 15 post-Overview. Finally, three quarters of theatre sessions had the anaesthetist finalised seven days in advance post-Overview, compared with four days in advance pre-Overview.

Figure 4. Empirical cumulative density function (eCDF) plot of consultant anaesthetist assignment times in advance of a given theatre list. Data is the same as figure 3. Each step on the graphs indicates the fraction of total sessions occurring within the time period that were finalised that many days in advance or earlier.

Here, we can see that the post-Overview data has shown a dramatic improvement in terms of anaesthetists assignments being finalised compared with pre-Overview. The knock-on effects for anaesthetics of being able to see earlier in advance which specialty was going to run a given theatre list meant that they could assign the appropriate anaesthetist to the session earlier in advance.

Leave approval

This is the percentage of planned consultant surgeon leave that was approved at least six weeks ahead of time. Planned leave consists of annual leave and study leave, excluding sick leave and related unplanned absences.

While the increase is minor, departments may be approving leave which has no impact on planned activity as cross-cover has been organised, leave that doesn’t cross planned work, or time off in lieu may be granted. It may also be the case that departments are organising leave through other channels, and later uploading it to Medirota. It may also be that departments are simply not adhering to the policy. We decided to take a look at the number of planned theatre sessions that had planned leave approved over them. Pre-Overview there were 517 planned theatre sessions which had leave approved over them less than six weeks in advance; post Overview this reduced by 43 % to 293. This suggests that, although the proportion of leave being approved less than six weeks in advance is similar between the two time periods, fewer sessions were being approved over planned theatres, perhaps indicating stronger adherence to the policy where leave would impact planned theatres.

Cancellations

A major goal of the 6-4-2 theatre planning policy is to ensure that all relevant staff are assigned to cover theatre lists two weeks before they are due to happen. The aim here is to reduce theatre cancellations due to inadequate staffing as much as possible. As the central “hub” of theatre activity for the Trust, we looked at theatre cancellations in the anaesthetic department pre- and post-Overview.

Below we see the number of theatre session cancellations due to no surgeon:

This was a positive development and could be a result of the Trusts 6-4-2 policy combined with the Overview.

We wanted to look at all theatre session cancellations regardless of reason and identify how far in advance they were marked as cancelled. Cancellations further in advance allow staff to be reassigned as appropriate and theatre space to be used. We then looked at how far in advance these theatre sessions were being cancelled (Figure 5).

Figure 5. Heatmap of days theatre sessions were cancelled in advance. Here, we calculated the difference between how far in advance they were marked as cancelled and when the session was due to happen. Numbers and colour in the cell indicate the number of theatre sessions cancelled that many days in advance. 2022 data is across the top, 2023 data is across the bottom.

From the heatmap shown in Fig. 5 we can look at the cancellations that will likely have the most impact i.e. those late notice cancellations. Looking at on the day theatre cancellations:

Showing on the day theatre cancellations have nearly been halved. If we look at cancellations one day in advance:

These have also been reduced. If we look at the median time in advance theatre sessions were marked as cancelled, we can see that post-Overview cancellations occurred earlier on:

Theatre delivery

Finally, we wanted to look at how many theatre sessions were delivered across the Trust.

A modest increase, but we can then look at how this was achieved, i.e. was this achieved by increasing the use of locum bank staff? Looking at the use of extra theatre sessions, generally those that are performed by anaesthetists in return for additional payment, we found a decrease:

This could be a substantial cost-saving for the trust by reducing their use of locum-bank staff and instead using their anaesthetists in a more efficient manner.

Conclusions

In this article we have seen a Trust utilise our Overview service in order to improve their 6-4-2 theatre planning policy. After adopting the Overview, the Trust found that:

• More leave was approved at least six weeks in advance
• The surgeon covering a theatre list was finalised three days earlier on average
• The anaesthetist covering a theatre list was finalised sixteen days earlier on average
• On the day theatre cancellations were reduced by 46 %
• Theatre cancellations one day ahead were reduced by 27 %
• Extra anaesthetist sessions were reduced by 13 %

Through making various changes to their theatre planning policy the trust were able to design a more effective theatre utilisation policy. However, without a single live view of theatre usage, there was no way to confirm if there was actual cover. It was only once the Trust adopted our Overview service for their theatre planning that all theatre activity could be viewed in a single place, which resulted in more effective theatre delivery at a reduced cost. It is worth noting that there was not full compliance with 6-4-2 theatre policy as some surgical specialties were not using Medirota, meaning their activity was not visible on the Overview. As these specialties come on board, we may see further improvements.

Disclaimer

All data used within this article were extracted from Rotamap's services and collated in close partnership between Rotamap personnel and the trust.

Contact us

If you would like to work with us to implement the Overview for 6-4-2 theatre planning, please contact the Rotamap support team at support@rotamap.net or +44 (0) 20 7631 1555 if you are an existing user, or info@rotamap.net if you would like to learn more about our services.

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