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Foundation modules – Executive and programme leaders began to implement the programme by communicating with staff and trust boards. Enabler modules – Knowing how we are doing. All members of staff are brought together to identify obstacles to running the ideal operating list. Progress is reviewed through data collection on agreed measures. Well organised theatre. Directly involves staff in the sorting and standardization of equipment, leading to increased efficiency and less time wasted searching for equipment. Operational status at a glance. Uses visual management processes and real-time tools to effectively manage and plan the theatre environment. Team working. Aims to tackle the problem of adverse events resulting from communication failures by increasing team cohesiveness and introducing a brief/debrief checklist. Scheduling. Aims to increase effective utilisation of a theatre session by working across the silo and encouraging communication between executive leaders, booking staff and theatre staff. Schedules are adapted to different procedures and different staffing needs, taking into account demand and capacity. Process modules Deal with the entire surgical care pathway from start-up to recovery. It involves the standardisation of a prompt and effective startup process, effective patient preparation, improving transitions between patients in the theatre (turnaround) and transition of patients from one service to the next (handover), planning the usage of stock and replenishing stock levels and effective management of patient recovery.

. As a first step of the TPOT project,  On time start was planned to launch. Before the launch meeting of 60 minutes was held with all the team members. Baseline data was presented and the goal explained and clarified. The discussion was done on existing barriers and suggestions to improve On time start and the target was agreed among all. The project On time start at 0830 hrs, commenced (do) on 13th to 20th November 2014 in two operation theatres. A keen pathway mapping (study) was done along the patient pathway from the holding bay, preoperative checklist and check in, into anaesthesia room, safe surgery checklist, surgery, end anaesthesia, into the recovery room and issues or improvement opportunities were documented.

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First team discussion was held the following week where the existing barriers to on-time start identified over the 5 days implementation period were brought into consideration, team members were allowed to vent subjectively followed by objective analysis. (act) Daily team briefing at 0750 hrs was introduced and early afternoon Debrief. The nursing preoperative checklist was changed modified more user-friendly according to the data analysis. Meeting of the TPOT team after a month reported the action completed based upon the TPOT project implementation. the theatre dashboard design process was updated, discussed on progress and practical adjustments, improvements were made in scheduling patients and on pre-assessment to prevent cancellations and maximize theatre utilization.


Recovery bed available when needed, Excellent team working/leadership Excellent environment, including patient and staff facilities, Efficient patient preparation and pre-assessment, Patient experience as good as possible, Accurate, organised lists Scheduling,  right case mix and capacity, Good communication and efficient handover, Excellent portering service, Keeping to start and finish times, Skilled staff, clear role identification, Equipment available when and where needed. possible Accurate organised lists Scheduling – right case mix and capacity Good communication and efficient handover Excellent portering service Keeping to start and finish times Skilled staff, clear role identification  (Rymaruk and Buch, 2015)


Recovery beds not available when needed Staff shortages, inflexibility Poor team working Inefficient patient transportation (i.e. from recovery to ward) Changes to original list order Inefficient patient pre-assessment Difficulty in standardisation and location of equipment Poor environment in the surgical admissions lounge Patient location and ward issues Increased paperwork, dress code, trust policies Inefficient patient turnaround time Poor staff facilities Equipment not  available when and where needed  Problems with IT systems

Session starting time is one of the key factors of TPOT and represent a recognized measure of theatre efficiency as late start is associated with list overrunning and patient cancellation


Start time Monitored from November 2014 to February 2015 during which —– patients underwent surgery. Defined by the start of anaesthetic administration and measured by the number of days starting by 8.30 a.m. in two theatres (theatre 10 and theatre 11). Monthly overrun performance Measured by the number of minutes in excess of 30 min past the standard finish time during the same period. The number of lists that finished more than 60 min early was also measured in one theatre to monitor whether a short procedure could be accommodated at this time. Recovery This was measured to further explore issues identified in vision meetings regarding delays in transfer from recovery. The delay in transfer from recovery to the ward was measured.


Lean is a structured way of continuously exposing and solving problems to eliminate waste that delivers value to customers, our patients.


Elimination of waste and the productive operating theatre Lean thinking systems theorists describe 7 types of ‘waste’ that need elimination in order to improve productivity. first  Overproduction In lean thinking terms is defined as processing an order before it is needed, or any process that is done on a routine schedule regardless of current demand i.e. ‘just in case’ scenarios. Example: Ordering a broad range of preoperative investigations, such as a full set of laboratory blood tests and cardiac investigations on all patients scheduled for surgery. INITIATIVE should be taken to ensure that patients get the right test for the right condition and procedure at the right time.

secondly, Inventory issues arise when the stock is purchased before it is required to ensure that an excess is available so stock never runs out. Example: Excess stock In the anaesthetic room occupies space and makes other processes less efficient. thirdly Waiting in lean thinking terms, is defined as any form of waiting which results in nothing productive being done by the worker. Example: OT staff are unable to do anything productive because the transfer of a patient to the OT has been delayed. If such delays are not communicated to the OT, staff remain poised in anticipation of the patient’s arrival and withhold from starting other duties. fourth Waste of transportation can occur where equipment, products or personnel are moved to ensure that work can be done. Example: The time spent in transporting patients from an admitting ward to the OT or vice versa. Solution Healthcare institutions should always consider the distances of the OT to the patient admission lounge or ward when planning new day case surgical units or theatre complexes. fifth Waste of over-processing is defined as spending unnecessary resources to produce an equivalent product. Example: Performing perioperative medical interventions routinely when there is actually no evidence of benefit to patient outcomes. An example of over-processing is routinely inserting nasogastric tubes intraoperatively in all patients having abdominal surgery. sixth  A defect is defined as an error carried downstream which then requires intervention at a later stage, resulting in a delay in the efficiency of the entire process. A significant resource saving could have occurred had the error been detected and acted upon early. Example: Absent or poorly Implemented checking processes Inadequate checking processes can result in the performance of the wrong operation on the wrong patient or the wrong site, resulting in catastrophic patient harm and further resource requirements. World Health Organization Surgical Safety Checklist (WHO 2008) that has been shown consistently to improve patient safety and to reduce errors in the OT (Haynes et al 2009)  seventh  Motion Inefficiency in motion occurs when a worker needs to move repeatedly in order to perform their job. Example: Multiple movements between the OT and the anaesthetic room to get drugs, equipment or dispose of waste Such movements result in inefficiency, obstruct other healthcare workers and potentially increase the introduction of pathogens by doors constantly being opened. ( R Kasivisvanathan and A Chekairi 2014)


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