Health Service Focus

Cultural shift pays off at Britain’s leading orthopaedic hospital

With the Royal National Orthopaedic Hospital NHS Trust (RNOH) moving from a CQC rating of ‘Requires Improvement’ to ‘Good’, John Bateson, senior improvement advisor, Jonathan Berry, deputy head of operations and Cynthia Rau, theatre business support manager, outline the improvements made at the organisation.

We are now seeing a burgeoning culture of improvement at RNOH, and finding that colleagues feel inspired to identify and make improvements to the care they deliver, the experience of patients and the daily experience of our teams. 

The change is fundamental, and it was clearly seen by the inspectors; after the 2018 CQC visit, the chief inspector of hospitals said: “Staff should be proud of the progress made…there was evidence of positive changes to organisational culture, quality improvement initiatives and innovative research projects.” 

The previous CQC inspection was in 2014 and changes seen by the inspection team were the result of a long-term focus on changing our organisational culture so that we are in a position to make improvements driven by delivery teams. This has been happening across the trust, in clinical and non-clinical settings, often led by the frontline delivery teams. To illustrate what we’ve been doing, we have some examples of the improvement activity in theatres that we think have made a big difference. 

Firstly, we wanted to make sure we had wide buy-in to the improvement work, so back in late 2017 we set out to deliver a ‘perfect week’ in theatres with wide engagement from all staff. Clinical and non-clinical staff collaboratively agreed a number of measures that could determine what a perfect week in theatre should look like. This included ambitious targets on prompt start times, reducing unwarranted cancellations and finish times. Then we concentrated the efforts of the whole trust on running one ideal week in theatres, gathering learning and improvement ideas as we went. 

This has been a whole-team effort with the fundamental involvement of frontline staff. The results have been seen in our data, which we have shared widely to help build confidence and commitment to ongoing improvements: 

• We set a target for the Booking Fill Rate of 90% and we have seen a 10% improvement and a shift to a median of 94%.
• Intra-session utilisation now has a median above 87%, which is an 8% improvement.
• Prompt starts now have a median measure of 72%, which is a 7% improvement, and is moving towards our shared target of 85%. 

The approach led to a series of immediate improvements, including a weekly multidisciplinary forward planning meeting that looks at the situation six weeks, four weeks and two weeks out from surgery; we call it 6-4-2. We have also introduced a daily ‘theatre huddle’, a 20-minute meeting to review the next day’s operating list in detail, to avoid on-the-day cancellations and delayed starts to lists. 

There are also some long-term improvement projects that have been identified, which include the need for a dedicated paediatric admissions nurse to prepare children for surgery on the day and the development of a dedicated Theatres Admissions and Day Case Unit (TADCU) to ease ward pressures. 

The approach has also led to an increased interest in improvement projects; two members of the team are currently undertaking a one-year improvement leadership programme, and staff are now identifying and driving new improvement ideas. 

One of the most exciting aspects of this work is that it has created energy for improvement, and a fund of ideas for the next steps. We are now working harder to understand the root causes for avoidable cancellations on the day of surgery. We are also in the process of developing cancellation avoidance strategies by closely reviewing all cancellations through a working group that includes a consultant surgeon and operational theatre staff. 

We have made a lot of improvements in our service recently, and we think that by all staff working closely together, we have managed to create an atmosphere of continuous positive engagement between front-line staff, both clinical and non-clinical, senior clinicians and senior management.

For more information

Tw: @RNOHnhs

W: www.rnoh.nhs.uk