A northern trust created a role to identify the causes of same day cancellations – and possible methods for reducing them. By Buddhika Samarasinghe

Every day, thousands of planned operations are completed in the NHS but a small percentage are cancelled, for a number of reasons.

When they are cancelled due to hospital reasons – lack of bed, staff or equipment availability, problems with scheduling or administration, or to accommodate emergency operations – significant distress is caused to patients and carers.

Some patients may have already waited a number of weeks – and cancer and other high risk patients need their operations promptly.

The situation can be very costly due to the income lost. They also have a negative impact on other key NHS indicators such as the cancer waiting performance, two week waits and friends and family tests.

The challenge is how we address a fluid and complex problem when the issue is also fast changing

Like many other trusts, the University Hospital of Leicester Trust faced the continuous challenge of reducing their planned and elective cancellations on the day of surgery.

During the quarter ending 31 March 2015, 20,464 operations were cancelled on the day or the day before surgery. Some of these will have been last minute cancellations due to hospital reasons.

These, during the last quarter, represented 1.1 per cent of all elective activity, compared to 0.9 per cent in the same period in 2013-14.  

Exploring the problem

UHL created the role of “project manager – same day cancellations”. As the post holder, I explored the scale of the problem using quantitative methods followed by informal and formal discussions. The analysis helped to identify the key problem areas and some possible interventions.

The reason for on the day cancellations can vary tremendously from one week to another, even in the same specialty. Sometimes reasons are similar but the underlying causes are different.

For example, lack of theatre time can be caused by too many patients booked on an operation list. On another day, the same issue can be due to beds being allocated late or clinical complications arising during the surgery.

The challenge is how we address a fluid and complex problem when the issue is also fast changing. One of the effective ways to catch a moving target is to work as a team and adapt to the changes.

Keeping this in mind, the team came up with a number of strategies to reduce the risks of cancellations across all three sites.

The reason for on the day cancellations can vary tremendously from one week to another, even in the same specialty.

One of the initial steps was to engage with the wider frontline staff by highlighting the impact these disruptions have on patients. We used videos of patient stories and explanations to do this.  

We also did a number of things to deal with capacity pressures. Some of them involved collaborative working and better planning to accommodate constraints in bed capacities.

For some specialties, initiatives involved scheduling sessions in a flexible way to accommodate ad hoc emergencies. Other actions included working across the organisation to assess the bed status and making adjustments the day before to avoid cancellations on the day.

This helps us to prepare for pressures for ward beds or staffing issues in advance.

Another important approach was the Listening into Action (LIA) approach that UHL has adopted, encouraging staff to contribute their experience. All were invited to feed back events to capture “what can be done to reduce cancellations in your trust”, in line with the LIA process.

Around 70 staff provided their thoughts.

Key interventions include:

  • Educating all administrative staff about the relevant booking procedures and guidance.
  • Providing support to resolve any issues with medical records by making sure all checks are done and escalated to appropriate managers, the day before the operation.
  • Ensuring that the process for booking a critical care bed after the operation is transparent. A paediatric and adult critical care bed booking process on two sites using a shared electronic Outlook calendar viewable by anyone in the organisation. The booking process is managed by the critical care services.
  • Alerting a senior manager to any risks of cancellations on the day so they can find a solution or work with the relevant senior managers and clinicians to fix it.

This final intervention made a huge impact and provided an important solution to this challenge. There was active encouragement to raise the risk of cancelled operations to the specialty manager.

This was a huge change to the organisational culture. For example, when there is a risk of cancellation due to lack of an intensive care bed on site, the nurse in charge alerts the specialty manager, who then works with senior nurse leaders to provide staff or move them from other areas or sites to reduce the likelihood of cancellations.

The key to success of all these came from the support of the staff we included in the process, who formed a much bigger team than would be normal, to reduce cancellations and make significant savings to the local health economy

This escalation process provides clear roles and responsibilities to the relevant staff, and means senior managers get involved. Initially, this was very challenging to implement due to the size, and three-site nature of the organisation.

However, when staff realised the process was helping them and that specialty managers were taking action, this became normal practice.

Process escalation provided good intelligence about cancellations and their causes. These interventions have helped us to reduce hospital cancellations by 40 per cent in the last quarter of 2014-15 compared to the final quarter of 2013-14.

This reduction means we provided operations to an additional 276 patients and reduced patient complaints from 50 to 16 in the last quarter (2014-15) compared to 2013-14. In addition, we also reduced lost income by around £0.3m.  

In the last three quarters, UHL managed to achieve 0.8 per cent cancellations in line with the national standard. Before the project, UHL was not meeting this standard.

The key to success of all these came from the support of the staff we included in the process, who formed a much bigger team than would be normal, to reduce cancellations and make significant savings to the local health economy.

FIND OUT MORE: www.listeningintoaction.co.uk

Buddhika Samarasinghe is improvement programme manager at UHL trust