Unlocking Hidden Capacity: A Practical Guide to Optimising Theatre Utilisation

Why this topic matters

Elective surgical waiting lists remain a significant challenge across the NHS. Optimising theatre utilisation is not just about financial efficiency; it has a direct impact on patient access, outcomes, and staff morale. Better use of existing theatre time can reduce waits for planned procedures, enhance patient experience, and create a more sustainable working environment for surgical teams.

Inefficiencies in theatre scheduling and management can manifest as:

• High rates of late starts and early finishes: Reducing available operating time.
• Inefficient turnover times: Delays between cases.
• Unused blocks of time: Sessions cancelled or not filled due to various reasons (e.g., patient cancellations, lack of beds, staffing issues).
• Suboptimal case mix: Not aligning cases to maximise throughput or speciality expertise.

Addressing these issues requires a systematic approach, involving multidisciplinary collaboration and good data.

Practical explanation: Understanding theatre utilisation

Theatre utilisation is a measure of how effectively operating theatre time is used. It’s often expressed as a percentage of 'actual operating time' compared to 'allocated time'. However, a nuanced understanding goes beyond a simple percentage.

Key metrics and definitions

• Allocated Session Time: The total scheduled time for a theatre session, e.g., 08:30 – 17:00.
• Actual Operating Time (Knife-to-Skin Time): The duration from the first incision to skin closure for a procedure. This is the 'productive' time.
• Total Occupancy Time (Room Occupancy): The time when the patient is in the theatre room, including anaesthesia, surgery, and immediate post-operative care in the room. This affects the availability for the next case.
• Turnover Time: The period from the previous patient leaving the theatre to the next patient entering. Efficient turnover is crucial for throughput.
• Lost Time: Time within an allocated session that is not used for patient care or preparation. This includes late starts, early finishes, extended turnover, and unscheduled breaks.

It’s important for trusts to agree on consistent definitions for these metrics to enable meaningful data collection and comparison.

Types of 'hidden capacity'

Hidden capacity refers to recoverable time or efficiency gains that aren't immediately obvious but can be unlocked through process improvements. Examples include:

1. Reduced Late Starts: Mitigating delays due to patient unreadiness, missing equipment, or staff handovers.
2. Optimised Turnover: Streamlining the patient exit, room cleaning, and next patient entry process.
3. Minimised Early Finishes: Better scheduling of cases to fill the entire session, or having a 'fill-in' list for shorter cases.
4. Effective Management of Cancellations: Proactive management of patient fitness and having robust plans for re-allocating cancelled theatre slots.
5. Data-driven Scheduling: Using historic data to accurately estimate case durations and better match cases to available slots and team expertise.

Common pitfalls in theatre utilisation

• Lack of Consistent Data Collection: Without accurate and granular data on start times, finish times, and reasons for delay, identifying patterns and root causes is difficult.
• Blaming Individuals, Not Systems: Often, inefficiencies are systemic, not due to individual performance. A blame culture hinders open discussion and improvement.
• Poor Communication & Siloed Working: Lack of coordination between surgical teams, anaesthetics, nursing, porters, and sterile services can cause significant delays.
• Inflexible Scheduling: Rigid theatre lists that don't account for variability in case length or allow for last-minute adjustments.
• Focusing Solely on 'Knife-to-Skin' Time: While important, it doesn't capture the entire efficiency picture. Total room occupancy and turnover are equally critical.
• Ignoring Patient Pathway Outside the Theatre: Delays in pre-assessment, ward readiness, or post-operative bed availability can nullify theatre efficiency gains.

Step-by-step approach: Unlocking hidden capacity

1. Define and Measure:

   • Establish clear, agreed-upon definitions for all theatre metrics (e.g., allocated time, actual operating time, turnover time).
   • Implement robust data collection. This might involve manual logging initially, but digital solutions offer greater accuracy and less burden.
   • Measure baseline utilisation for each theatre and surgical speciality over a representative period (e.g., 3-6 months).
   • Consider different types of theatre sessions (elective, emergency, day case) separately.

2. Analyse and Understand Variances:

   • Benchmark against national standards (e.g., GIRFT, NCEPOD) where available, and against internal targets.
   • Identify key areas of lost time (late starts, early finishes, extended turnovers, cancellations).
   • Conduct 'deep dives' or 'gemba walks' in theatres to observe processes and identify bottlenecks first-hand. Engage staff from all disciplines.
   • Use tools like Pareto charts to identify the 'vital few' causes that account for the majority of lost time.

3. Engage Multidisciplinary Teams:

   • Form a core theatre optimisation group including surgeons, anaesthetists, ODPs, nurses, theatre managers, porters, and managers from pre-assessment, wards, and sterile services.
   • Foster a non-punitive environment for discussing delays and challenges. Use quality improvement methodologies (e.g., PDSA cycles).
   • Educate staff on the impact of theatre efficiency on patient care and waiting lists.

4. Implement Targeted Interventions (Examples):

   • Pre-theatre Huddles: Short, daily meetings involving all relevant staff to review the upcoming list, identify potential issues, and allocate roles.
   • Patient Pathway Readiness: Standardise pre-assessment clinics and check-in processes. Ensure all necessary scans, results, and consent are in place well in advance.
   • Standardised Turnover Process: Develop and train staff on a clear, step-by-step process for patient transfer, cleaning, and setup for the next case.
   • Proactive Cancellation Management: Implement a robust system for patient communication, fitness checks, and a 'reserve list' of appropriate cases for short-notice slot filling.
   • Improved Scheduling Software/Practices: Use data to build more realistic lists. Consider 'surge lists' or 'flexible slots' for shorter or high-volume cases.
   • Dedicated Cleaning/Portering: Ensure timely availability of support staff.
   • Equipment Management: Ensure all necessary equipment is available, functional, and checked before the session starts.

5. Monitor, Evaluate, and Sustain:

   • Continue to collect and display key metrics regularly. Visual management boards in theatres can be very effective.
   • Review the impact of interventions on utilisation, patient flow, and staff satisfaction.
   • Celebrate successes and share learning. Embed changes into standard operating procedures.
   • Regularly revisit the process to identify new opportunities for improvement.

Example in clinical practice: Reducing late starts in Elective Orthopaedics

A large NHS Trust identified that its elective orthopaedic theatres consistently started 30-45 minutes late, adding up to significant lost time each week. An analysis showed the primary causes were:

• Patients arriving late to the ward or not being ready (e.g., missing consent, not fasted).
• Anaesthetic reviews taking place on the morning of surgery, leading to last-minute cancellations or delays.
• Missing x-rays or pre-operative scans.
• Operating Theatre Practitioners (OTPs) struggling to locate specific equipment or instrument sets.

The theatre optimisation group, involving orthopaedic surgeons, anaesthetists, ward nurses, and theatre staff, implemented the following interventions using PDSA cycles:

1. Pre-assessment Pathway Review: Enhanced the pre-assessment clinic process to ensure all investigations were complete and consent checked several days prior to surgery. A dedicated 'readiness check' nurse role was introduced on the ward the day before surgery.
2. Morning Huddle: A mandatory 15-minute huddle at 07:45 involving the anaesthetist, surgeon, theatre nurse, ODP, and ward nurse to confirm patient readiness, discuss the list order, and foresee potential issues.
3. Equipment Audit: Theatre team conducted a thorough audit of frequently used orthopaedic equipment, streamlining storage and creating 'preference cards' for common procedures ensuring all kits were available and prepped.

Outcome: Within six months, the average late start time reduced to less than 10 minutes, effectively 'finding' an extra one-third of a full theatre session per week for elective patients across the orthopaedic theatres. This led to a measurable reduction in the waiting list for hip and knee replacements.

How Lazomis can help

Lazomis provides a structured framework and tools to support your theatre optimisation journey. Our platform can assist with:

• Data Collection & Visualisation: Digital forms and dashboards to capture theatre start/finish times, turnover times, and reasons for delays, providing real-time insights into utilisation metrics.
• Quality Improvement Project Management: Structure your PDSA cycles, assign tasks, and track interventions related to improving theatre efficiency.
• Communication & Collaboration Tools: Facilitate multidisciplinary team discussions, share project updates, and disseminate best practice guides across your theatre teams.
• Stakeholder Engagement: Tools to survey staff on perceptions of efficiency and gather qualitative feedback to complement quantitative data.
• Reporting: Generate reports on progress and outcomes to share with clinical directors, operational managers, and trust boards.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.

Key takeaways

• Optimising theatre utilisation is crucial for reducing waiting lists and improving patient access.
• Hidden capacity can be unlocked by systematically addressing late starts, early finishes, and inefficient turnover times.
• Accurate, consistent data collection on theatre metrics is the foundation for effective improvement.
• Multidisciplinary collaboration and a non-punitive culture are essential for successful implementation of changes.
• Small, sustained improvements (e.g., early morning huddles, standardised pathways) can yield significant gains in capacity.