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Surgical Day Case Cancellations in Opthalmology
Transcript of Surgical Day Case Cancellations in Opthalmology
Genna Davis & Mariya Kovalenko
Why is this a problem?
PLAN: data collection
The figures from York Hospital:
Cataract operations make up the majority of ophthalmic surgery carried out in York Hospital and they are also the most commonly cancelled.
York Hospital carries out 3000-3600 cataract operations per year .
From the 1st January 2013 - 15th August 2014 there were 200 cancellations of ophthalmology surgeries overall, and 94 of these were cataract operations .
The number one reason for cancellations is patient feeling unwell on the day.
Analysing the data:
Even though most of the patients contacted on the day were unable to attend, one patient was available to occupy an otherwise wasted theatre slot. Providing a very good outcome for that patient, who had his surgery early.
This demonstrates that the new process can work successfully and can avoid waste of time and resources.
Thanks for listening!
Act: Planning forward
How it affects the hospital
Cancellations put pressure on the 18 week maximum waiting time from referral to treatment - targets may not be met . Currently there are 370 patients on the waiting list in York .
Evidence from the RNIB shows over 80% said ophthalmology departments are already undertaking extra clinics at evenings and weekends to keep up with demand, which is also the case in York. 
Unused theater slots cost the hospital/CCG money.
How it affects patients
NHS patient's right to be seen within 18 weeks
Patients spend longer time on waiting list
If not met patients have to contact hospital, clinic or commissioner
to arrange an alternative 
Negative effect on health:
Vision 2020: The Right to Sight  but... evidence from a 2013 RNIB survey shows that 37% of a total of 172 ophthalmology workers across England agreed that "patients are 'sometimes' losing their sight unnecessarily due to delayed treatment" 
Problems that arose
The majority of patients called at short-notice were unable to come in.
Some nursing staff felt hesitant in scheduling new patients into theatre lists without the approval of the consultant first
Time pressures on nursing staff meant some failed to use the list when cancellations occurred
1 patient came in at short notice
Nursing staff used the short notice waiting list to contact patients earlier than the waiting list coordinator would have
Nursing staff and waiting list coordinator worked well together at implementing the procedure
Which issue to target?
Based on Jim Harvey's speech structures
Ophthalmology surgery is the most common surgery performed in the UK, with the majority of these being cataract operations .
From 2012-2013, 340,809 cataract procedures were carried out in the UK .
1. Did not attend
2. High BP/glucose/INR
3. Admin issues
4. Anxious patients
DO: The solution
York has already looked into and fixed most problems but one of the main remaining areas for improvement is to
patients who cancel on the day.
Patients already have the option of being placed on a list agreeing to be contacted at short notice
This list is used by the Waiting List Coordinator to try and occupy empty slots when patients cancel in advance
Our aim is to make this list available to nurses who are available at earlier hours than the Waiting List Coordinator and so will be able to contact patients sooner, on the day, to replace those that can not attend
The Nursing Manager has educated all ophthalmic nurses about the new procedure
Nurses receive a short notice list on Monday morning of each week
They will annotate the list as they use it and notify the Waiting List Coordinator to book a patient into theatre and remove them from the short-notice list
They will also notify him as to people who are contacted but refuse - to avoid them being called again
Who: MDT approach
Monitoring the impact
The short-notice waiting list will be updated by the Waiting List Coordinator daily and an up-to-date one generated for Monday of each week
We can monitor how many people are being removed from the short notice list and thus how many potentially empty theatre slots are being filled
In addition, we can collect data about why people refuse to attend on the day to aid us in developing
any future areas for improvement.
1 cataract surgery involves
5 members of staff - £ wages
1 cataract surgery can take anything from 15-45 minutes - £ of wasted time
1 cataract surgery uses ~£180 of consumables/equipment - £ of wasted resources
Other costs if patients cancel:
wasted resources if hospital transport booked
staff time spent rescheduling patients
Ophthalmology Surgery Overall in York
How appointments are managed
• Patient seen by consultant in clinic, initial visual acuity and BP measured
• Patient then sent an acknowledgment letter in the post 1-3 weeks later
• This contains an ‘available at short notice' tick box and slip that the patient can send back to ophthalmology via free post
of patients choose this, and thus are placed onto a short notice waiting list by the Waiting List Coordinator
• Patient receives the date of their actual appointment 3 weeks in advance
• Waiting time for a cataract operation in York is currently 12 weeks .
At York Hospital within 1 year (01.10.2013 - 09.10.2014) there were 76 cataract surgery cancellations 
That is ~6.33 cancellations per month
Speaking with ophthalmology;
waiting list manager
Which issue to target?
2. Did not attend
3. High BP/glucose/INR
4. Admin issues
5. Anxious patients
6. Surgeon unavailable
To reduce the number of on the day cancellations in cataract surgery in order to;
Reduce financial losses
Improve patient experience and health outcomes
Meet waiting time targets
PLAN: Brainstorming solutions
Successful methods for reducing cancellation rates include;
An appointment reminder service for patients
Improving the initial letter sent out to patients (redesign letter, easier to read)
Enabling patients to cancel appointments more easily
Giving patients ability to choose the date and time of their appointment
Carrying out an early pre-operative assessment
The involvement of front-line staff in any change
Redesign of work processes
Training of surgical staff
During 4 weeks that the short notice waiting list has been available to the nurses (15/12/2014 - 8/01/2015);
6 patients were cancelled on the day
3 - bed shortage, 3 - medically unfit
10 short-notice patients were called
1 patient agreed to come in
All consultants need to be briefed on the process.
Edit letter sent out to patients informing them that 'short notice' may be a few hours.
DNA awareness campaign for ophthalmology.
Conclusion, our QIP has been effective and should be continued forwards.
1. The Royal College of Ophthalmologists. Cataract Surgery Guidelines. London: September 2010; 5-6. http://www.rcophth.ac.uk/page.asp?section=451 (accessed 9 November 2014).
2. RNIB. Surgery deferred. Sight denied. Variation in cataract service provision across England. July 2013; 2-5. http://www.rnib.org.uk/sites/default/files/Surgery%20deferred%20sight%20denied%20executive%20summary.pdf (accessed 5 January 2015).
3. NHS Choices. Your rights in the NHS: Guide to NHS waiting times. May 2013. http://www.nhs.uk/choiceintheNHS/Rightsandpledges/Waitingtimes/Pages/Guide%20to%22waiting%20times.aspx (accessed 23 November 2014).
4. McGill, R. Ophthalmology Waiting List Coordinator. Personal communication. 1 December 2014.
5. RNIB. Don’t turn back the clock: Cataract surgery – the need for patient-centred care. June 2011; 3-19.
www.rcophth.ac.uk/core/core_picker/download.asp?id=953 (accessed 4 January 2015).
6. WHO. Vision 2020: The Right to Sight. Global Initiative for elimination of avoidable blindness. Action Plan 2006-2011. Geneva: 2007; 2-10. http://www.who.int/blindness/Vision2020_report.pdf (accessed 6 January 2015).
7. NHS Institute for Innovation and Improvement. Plan, Do, Study, Act (PDSA). 2008. http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html (accessed 28 October 2014).
8. Glowala, M. Ophthalmology Day Case Cancellations. Presented at York Hospital. York, 2013.
9. Glowala, M. Record of Cancellations in Cataract surgery. Received 19 December 2014.
10. Glowala, M. Ophthalmology Theatre Manager. Personal communication. 4 January 2015.
11. Hovlid, E., Bukve, O., Haug, K., et al. A new pathway for elective surgery to reduce cancellation rates. BMC Health Services Research. 2012; 12(154). doi:10.1186/1472-6963-12-154. (accessed 12 December 2014).