Welcome to the Surgery Newsletter.
The Ministry of Health supports local health districts and health networks to develop and implement local improvement strategies, monitors performance against key indicators and shares knowledge regarding elective surgical services.
There is great work happening across NSW to improve on-time access to elective surgery.
In this edition
Message from the Executive Director, System Purchasing Branch
December can be a very busy time in our hospitals, ensuring our elective surgery patients are receiving their surgery before the planned service modifications, when many of our staff in surgical services take the opportunity for some well-deserved leave and to spend time with their families over the festive season.
As we approach the end of the year, it is a good time to reflect on the achievements of 2017.
NSW continues to be the best performing jurisdiction nationally. This is supported by the most recent Bureau of Health Information (BHI) Report - July to September 2017 quarter, which showed that:
- There was a total of 58 289 elective surgical procedures performed. This is an increase of 243 (0.4%) compared to the same quarter last year.
- Almost all (97.9%) of procedures were performed within the clinically recommended timeframes.
- Median waiting times were 10, 43 and 213 days for urgent, semi-urgent and non –urgent surgery, respectively. These results are unchanged for urgent surgery and shorter than the same time last year for semi-urgent (minus 1 day) and non –urgent surgery (- 7 days).
The Ministry of Health Surgery Team held its inaugural Professional Development Day for Waitlist Managers and Booking Officers on 10 March 2017. This event was tailored to encourage excellence and inspire opportunities for networking and growth. It covered everything from performance and elective surgery data collection, presentations from other local health districts, an update on what’s happening from a state-wide perspective and a session on conflict resolution and negotiation skills using real Booking Office scenarios. The evaluation report found that participants were happy to learn about redesign projects happening in other local health districts and were grateful for the networking opportunity. 51% of participants rated the event as very good and 33% rated it as excellent.
The Surgery Access Line received over 400 calls for assistance from patients and carers, General Practitioners and other health entities.
Congratulations! Working hard together as a team with one vision truly wins in the end. Excellent work everyone. Your hard work is truly appreciated.
I wish you all a wonderful, safe Christmas, and look forward to continuing to work with you all in 2018!
Executive Director, System Purchasing
Hospital initiated elective surgery postponements
As per the NSW Health Waiting Time and Elective Surgery Policy, hospital initiated postponements of elective surgery procedures should be avoided, and only occur when all options are exhausted.
Category 1 patients who have arrived must not be postponed without the authorisation of a senior member of management, and the treating doctor or delegate e.g. registrar.
In addition, any patient regardless of their clinical category who has been postponed by the hospital or doctor on the day of their planned admission date after arrival to the hospital must be reported to relevant senior personnel (to be determined by the Chief Executive).
Consistent with the policy, if a postponement is unavoidable, the following steps must be taken:
- The patient is to be rescheduled on the next available list according to clinical priority category
- A new planned admission date must be allocated and advised to the patient within five working days of the postponement.
Additionally, the following support options should be offered to the patient (where relevant):
- Contact made to a family member or friend
- Arrangement of, and payment for, transport home, accommodation and meals
- Contact details for counseling services and the local patient liaison service
Postponed patients must have priority over others not previously postponed, and are to be placed on the next available procedure/treatment list, appropriate to the patient’s clinical priority category,
Where possible, postponed patients should be prioritised on the procedure/treatment list to minimise the chance of delay (e.g. first on list where appropriate).
In the unfortunate event that a patient has been postponed twice and cannot be treated within appropriate clinical priority timeframes, the District/Network must actively investigate options for procedure/treatment to be undertaken at another facility (public or private). The cost is to be borne by the originating local health district or health network.
NSW Health funding boost for elective surgery performance
In 2017/18 the NSW Ministry of Health has provided an additional $3 million dollars to further improve access to elective surgery services in NSW. Through a formal Expression of Interest (EOI) process, funding was provided to Districts and Networks to undertake additional elective surgeries.
The initiative was open to all Districts and Networks with median waiting times greater than the NSW state average as detailed in the Bureau of Health Information (BHI) Healthcare Quarterly, January to March 2017:
- Cataract extraction (Category 3, median wait time 230 days)
- Total knee replacement (Category 3, median wait time 291 days)
- Total hip replacement (Category 3, median wait time 223 days)
The extra surgeries must be completed in addition to the agreed ‘Admissions off the Elective Surgery Waiting List’ target within the 2017/18 Service Agreement.
A Request for Proposal (RFP) was emailed to all Districts and Networks and we had a strong response from across the state including from rural and regional NSW. Responses were reviewed by an Evaluation Panel comprising representatives from the Ministry of Health and the Agency for Clinical Innovation.
The Evaluation Panel endorsed a recommendation that advised the Deputy Secretary, System Purchasing and Performance Division. Successful Districts and Networks were notified in November 2017.
The local health districts that were successful in their applications for additional funding were:
- Illawarra Shoalhaven
- Mid North Coast
- South Eastern Sydney
- South Western Sydney
- Western NSW
NSW has the best on-time elective surgery performance in the country. During 2016/17 NSW maintained or improved on-time performance in all clinical priority categories, sustained or reduced median wait times across all categories, and delivered in excess of 5,000 additional elective surgeries.
The volume of overdue patients remained low throughout 2016/17, with 210 patients overdue at the end of June 2017. Considering the additional patient presentations experienced across NSW, the ability for the system to deliver these performance results for elective surgery is exceptional.
Can I accept recommendations for admission (RFAs) from patients who don’t live in my local health district (out of area patients)?
Are varicose veins on the list of cosmetic procedures in the Waiting Time and Elective Surgery Policy?
Varicose veins are considered cosmetic surgery unless the Referring Doctor has provided information that the CEAP (Clinical, Etiology, Anatomy, Pathophysiology) Grade is > 3. Additional information on the classification of venous disease is available on page 57 of the Policy
For how long does patient consent remain valid?
The general rule is that consent will remain valid until it is withdrawn by the patient or until the patient’s circumstances change in a material respect.
Hospitals and practitioners should bear in mind, however, that a change in patient’s circumstances could encompass a number of situations. This would include a change in the patient’s condition which would affect treatment, the development of alternative treatments to the recommended procedure or the identification of new risks or side effects associated with the recommended procedure.
It is suggested, therefore, that a new consent form be obtained or the patient be asked to affirm their previous consent if a significant period of time has lapsed since the original consent was obtained. What constitutes a “significant amount of time” will depend on the individual circumstances of the case.
How long can a Not Ready For Care (NRFC) patient stay in NRFC?
If a patient is classified as "NRFC: deferred" where they are not ready for personal reasons such as holidays, work or home support, the maximum time a patient can defer their surgery for is:
- Cat 1: 15 days (referring doctor MUST be made consulted first)
- Cat 2: 45 days
- Cat 3: 180 days
Where a patient is classified as "NRFC: staged" (they are unfit due to co-morbidity such as ongoing Cancer treatment or their treatment is planned, such as a check cystoscopy). the hospital is required to actively mange the patient to ensure that they become ready for care.
If a patient is staged when the RFA is submitted, the staged timeframe should be identified by the treating doctor on the RFA at the time of being placed on the waitlist. Once this time frame is completed, the patient returns to the RFC category (1, 2 or 3) as indicated by the treating doctor.
Integrated surgical care for older and complex patients
Dr Ming Loh presenting key themes, innovations and challenges
Panel discussion on appropriatness of surgery: Prof Ken Hillman, Prof Jacqui Close, Mr David Gray, Mr Matt Jennings
Facilitator: Prof Michael Cox
The Agency for Clinical Innovation (ACI) Integrated Surgical Care project aims to add to the evidence base about how to improve outcomes following surgery for older people and those with complex comorbidities, from referral and pre-admission processes through to follow up care in the community and support services at home.
Exploration of how surgical care for older people is currently planned and managed in eight hospitals across NSW uncovered a number of innovative care models currently in use, identified barriers to integration of care across the patient journey and provided opportunity to review how existing toolkits are applied to support integration.
Consultations with clinical, administrative and management teams identified a number of considerations to better coordinate and deliver surgical care for older, complex patients, including:
- Appropriateness of surgical interventions and non-beneficial surgery
- Managing patient experience and expectations, particularly communication with family and carers
- Deconditioning of patients between referral and admission
- Management of post-operative delirium
- Optimising pre-admission and post-operative recovery pathways
- Variation in management of high-care patients in critical care services
- Discharge planning, including home and aged health support assistance
- Integration with primary and community care
The Integrated Surgical Care Forum was held on 24th November, bringing together health professionals from across NSW. The forum drew on themes identified through these consultations to discuss some of the challenges and solutions to delivering an integrated and coordinated approach to the management of care for older people having surgery in NSW. Showcase presentations highlighted examples of how services are working to identify and address the needs of complex surgical patients. Workshops also allowed participants to discuss priority areas for action, and how local improvement activity and state-level action could help to address current challenges.
The ACI is currently working to consolidate information provided by Forum and consultation participants into a report on current practices in NSW. The next steps in this project will be to map Integrated Surgical Care priorities against existing programs and initiatives, and consider broader, cross-network activities to further influence improvement in care. he ACI is currently working to consolidate information provided by Forum and consultation participants into a report on current practices in NSW. The next steps in this project will be to map Integrated Surgical Care priorities against existing programs and initiatives, and consider broader, cross-network activities to further influence improvement in care.
National Surgical Quality Improvement Program
The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a risk adjusted, internationally benchmarked and peer-controlled program to measure and improve the quality of surgical care. It allows hospitals to collect and compare 30-day patient outcomes and benchmark performance with local and international peer facilities. This leads to better information, improved care and better outcomes for patients.
NSQIP is sponsored by the Agency for Clinical Innovation Surgical Services Taskforce and uses clinical data collected by surgical clinical reviewers. The Program has been implemented in five hospitals across NSW from 2015 and is continuing to expand to new sites.
On the 26 October, the NSW NSQIP Collaborative came together to share their experiences of the program, profile clinical improvement projects and discuss the future of NSQIP in NSW. The Collaborative also welcomed new participants from Sydney Children’s Hospitals Network and Prince of Wales Hospital, who have recently joined NSW NSQIP.
Participating sites provided updates on their local quality improvement projects, and an overview of the NSW NSQIP data.
- Dr Tony Shakeshaft and Ms Kate Scanlon presented their work on reducing urinary tract infections at Nepean Hospital
- Dr Bruce Hodge and Ms Robyn Austin’s spoke about the colorectal surgical site infections (SSI) project at Port Macquarie Hospital
- Ms Ming Zeng presented on the SSI reduction project in gastrointestinal surgery at Westmead Hospital
- Ms Ashma Dawadi presented on the reducing SSI at Coffs Harbour Hospital
A project comparing hospital administrative data sets and NSQIP data collections was also discussed, along with potential application of NSQIP data for a National Emergency Laparotomy Audit, and the role of NSQIP in morbidity and mortality meetings to drive quality and safety improvement.
NSQIP is also trialing a patient reported outcomes module and NSW is investigating options for participation in the beta version of the module.
Spotlight: Melinda Pascoe, Principal Policy Officer for Surgery reaches a milestone!
In November, Melinda Pascoe was honoured for reaching the milestone of 35 years of service with NSW Health and was celebrated for her dedication.
Melinda is the Principal Policy Officer for Surgery, NSW Ministry of Health with responsibility for surgical access and services in NSW Public Hospitals. She has been working with the Ministry since April 2012, initially working in the patient flow arena before commencing her current role in January 2016.
Melinda’s experience includes many years of Perioperative Nursing experience, in both clinical and management roles. She has worked in several senior Nursing management roles with responsibility for diverse portfolios including Emergency Departments, Critical Care and Medical Specialties.
She has her Masters in Health Management, a Bachelor of Science in Nursing and a Certificate in Anaesthetic and Recovery Room Nursing.
Melinda is passionate about ensuring that surgical patients in NSW Public Hospitals receive timely, accessible and high quality patient centred services.
DASO means data at Royal North Shore Hospital
Data is a powerful tool in health, and the newly created Data Analysis and Surgical Outcomes (DASO) Unit is proving productive at Royal North Shore Hospital.
The DASO Unit connected data managers from across the Division of Surgery & Anaesthesia on 21 November at the first networking event and although it's early in the piece, it is hoped the data will eventually be used to improve patient outcomes such as helping shorten length of stay and reducing incidence of infection.
Maria Albania heads up the DASO Unit as manager and she believes it's a great opportunity for data managers and their corresponding departments to get the most out of their numbers.
"We're trying to connect and share ideas and resources," she said.
"Hopefully this unit can give them a voice; it's a central HUB where they can go if they need support or feedback on something they're working on."
"It's a really important resource to help make decisions and monitor activity and outcomes."
The DASO Unit was formed after a review of surgical data services was performed in 2015 by Professor Tom Hugh, Chair of Surgery, Northern Clinical School, University of Sydney. The unit's key objectives are to:
- Develop a collaborative approach to surgical audit and data activities by establishing key networks and links with already existing data sets, and data management and governance bodies both internally and externally
- Ensure that audit processes for all surgical departments meet RACS models of Best Practice for Surgical Audit
- Overcome barriers to surgeons participating in data and audit activities by providing appropriate and relevant support and increasing access to resources at all levels throughout the Division of Surgery
- Develop processes for reviewing surgical audit and data management needs, and establish criteria for allocating DASO Unit resources (e.g. part time financial support for data managers)
- Coordinate surgical data management and audit staff so that there is consistency, where possible across the Division, ensuring the same quality data service is being received by all departments
- Develop and standardise systems used for analysis and reporting of data management and audit processes and outcomes
- Develop special data support and audit capability for focused surgical audits that will foster clinical research
- Identify through surgical audit some of the educational and training requirements and professional development opportunities for surgical staff at RNSH.
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Preoperative patient blood management
In June 2015, Lismore Base Hospital, St Vincent’s Hospital Lismore and the North Coast Primary Health Network joined as a team to participate in the National Patient Blood Management Collaborative conducted by the Australian Commission on Safety and Quality in Health Care.
The overall aim was to increase the percentage of patients who had their haemoglobin and iron stores optimised prior to major elective surgery.
The project concentrated around three surgical streams: gastrointestinal surgery, gynaecological surgery and orthopaedic surgery, namely hip and knee joint replacements. The final report of the National Patient Blood Management Collaborative gives detail of the methodology used and the findings of the project.
Christmas recipe: Dark chocolate pretzel peppermint bark
And now for a helpful suggestion to use all those leftover Christmas candy canes and pretzels..... Try this easy recipe.
Serves 4 - 6, Time: 25 min
280grams dark chocolate chips
1 cup crushed pretzel sticks
1/3 cup crushed peppermint candy pieces
Melt chocolate in microwave in 30 second intervals stirring after each interval until melted.
Line baking sheet with baking paper
Spread melted chocolate in a thin layer over the baking paper. Sprinkle pretzels and crushed peppermint candies over the top. Gently press so they stick to the chocolate. Allow to harden, about 20 minutes. You can also refrigerate it until hardened.
Once the bark has hardened, break into pieces
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The Ministry will be closed, except for urgent matters, from December 23 and re-open on January 8.
The Surgery Access Line (SAL) will be unattended during this period and patients will be directed to contact their local hospitals for information and advice. Services will resume on Monday 8 January 2018.
Chrissie Crawford and Melinda Pascoe will be in touch in the New Year to update contact details and distribution lists.
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Tell us what you think
What did you think of this edition of the Surgery Newsletter?
Do you have some feedback on one of our stories, or do you have a story idea? We would love to hear from you.
Email the Editors at:
Ms Melinda Pascoe
Phone: (02) 9391 9557
Ms Chrissie Crawford
Phone: (02) 9391 9394