No waste

Waste is an ongoing problem in the NHS: money, time, resources – it can all be used better. We know this. Working more efficiently means working safer, thinking differently. Everyone knows that there is less money about so it’s vital that we explore new ways to improve what we do and how we do it.

Here our programme to improve flow through our Operating Theatres is described.

Since 2011, a Trust-wide project to increase and maintain our flow through theatres to a mean utilisation of 77 per cent has been underway. Our operating theatres are one of our most valuable resources. A funded operating theatre standing empty can cost up to £20 per minute. As such, GOSH needs to make the best use we can of every session. GOSH set up an improvement group, with representatives from all clinical units, to understand the issues and develop an improvement programme.

The aim is to sustain a mean utilisation of 70 per cent during 2011 and 77 per cent by the end of 2012/3 for all surgical specialties. This will bring us into line with the utilisation rate recommended by the Audit Commission. Utilisation above this presents a significant increased risk of ‘on the day’ cancellations and overruns, plus the additional pressure on clinical teams increases the risk of error therefore compromising patient safety.

Changes implemented

A dashboard with a wide range of measures was set up to include:

  • time lost to late starts,

  • cancellations

  • turnaround between cases and early finishes

  • time taken to bring a patient from ward to theatre

  • time taken for a nurse to arrive to collect a patient ready to leave recovery.

These enabled every team to drill down to the fine detail to identify their challenges.

We have used a whole raft of methodologies, each team focusing on the issue having the biggest impact on their own service. In one specialty, the use of After Action Review (AAR) huddles at the end of every list to identify exactly what happened and why, while it is still fresh, and agree the changes for next week’s PDSA cycle was very successful.

In another specialty, it became clear that time was being ‘saved’ for urgent cases, and as such, often going to waste if nothing materialised. The team looked back at the previous year’s activity and worked out what proportion of time was actually used by this cohort of patients. Once this was a known quantity, and they had a feeling for frequency, they were able to introduce firebreaks into the scheduling, and review each week how well these were being used. This continued until they came to a point where deadlines could be set for the time to be ‘released’ and filled with an elective case from the waiting list.

Other specialties have changed the way they plan their lists, such as putting an inpatient rather than a same-day admit patient first on the list, and moving from halfday to all-day operating. The admissions teams are also working with theatre teams to understand limits on case mix due to number of instrument sets available at any one time.


Results have been variable between specialties and units, and to fully understand what has happened and is happening, a range of measures need to be considered in the context of each other and the wider environment. In the Surgery Unit , it appears that we have been steadily decreasing until recent weeks. Further investigation shows that we have made more operating hours available, and are completing more procedures than ever before with a 10 per cent increased throughput and 4.5 per cent increase in hours operating.

The drop seen in end utilisation of original planned theatre hours relates to the opening of additional sessions in the summer. The break down into individual specialties shows that three specialties achieve greater than 77 per cent, four more achieving over 70 per cent and two specialties below 70 per cent utilisation.

Page last updated - 17 June 2013