THE theatre 11). Monthly overrun performance Measured by

 THE IDEAL OPERATING LISTRecovery bed available when needed, Excellent team working/leadership Excellent environment, including patient and staff facilities, Efficient patient preparation and pre-assessment, Patient experience as good as possible, Accurate, organised lists Scheduling,  right case mix and capacity, Good communication and efficient handover, Excellent portering service, Keeping to start and finish times, Skilled staff, clear role identification, Equipment available when and where needed. possible Accurate organised lists Scheduling – right case mix and capacity Good communication and efficient handover Excellent portering service Keeping to start and finish times Skilled staff, clear role identification  (Rymaruk and Buch, 2015)BARRIERS TO THE IDEAL OPERATING LISTRecovery beds not available when needed Staff shortages, inflexibility Poor team working Inefficient patient transportation (i.e. from recovery to ward) Changes to original list order Inefficient patient pre-assessment Difficulty in standardisation and location of equipment Poor environment in the surgical admissions lounge Patient location and ward issues Increased paperwork, dress code, trust policies Inefficient patient turnaround time Poor staff facilities Equipment not  available when and where needed  Problems with IT systemsSession starting time is one of the key factors of TPOT and represent a recognized measure of theatre efficiency as late start is associated with list overrunning and patient cancellationAUDITStart time Monitored from November 2014 to February 2015 during which —– patients underwent surgery. Defined by the start of anaesthetic administration and measured by the number of days starting by 8.30 a.m. in two theatres (theatre 10 and theatre 11). Monthly overrun performance Measured by the number of minutes in excess of 30 min past the standard finish time during the same period. The number of lists that finished more than 60 min early was also measured in one theatre to monitor whether a short procedure could be accommodated at this time. Recovery This was measured to further explore issues identified in vision meetings regarding delays in transfer from recovery. The delay in transfer from recovery to the ward was measured.LEAN PRINCIPLESLean is a structured way of continuously exposing and solving problems to eliminate waste that delivers value to customers, our patients. Elimination of waste and the productive operating theatre Lean thinking systems theorists describe 7 types of ‘waste’ that need elimination in order to improve productivity. first  Overproduction In lean thinking terms is defined as processing an order before it is needed, or any process that is done on a routine schedule regardless of current demand i.e. ‘just in case’ scenarios. Example: Ordering a broad range of preoperative investigations, such as a full set of laboratory blood tests and cardiac investigations on all patients scheduled for surgery. INITIATIVE should be taken to ensure that patients get the right test for the right condition and procedure at the right time.secondly, Inventory issues arise when the stock is purchased before it is required to ensure that an excess is available so stock never runs out. Example: Excess stock In the anaesthetic room occupies space and makes other processes less efficient. thirdly Waiting in lean thinking terms, is defined as any form of waiting which results in nothing productive being done by the worker. Example: OT staff are unable to do anything productive because the transfer of a patient to the OT has been delayed. If such delays are not communicated to the OT, staff remain poised in anticipation of the patient’s arrival and withhold from starting other duties. fourth Waste of transportation can occur where equipment, products or personnel are moved to ensure that work can be done. Example: The time spent in transporting patients from an admitting ward to the OT or vice versa. Solution Healthcare institutions should always consider the distances of the OT to the patient admission lounge or ward when planning new day case surgical units or theatre complexes. fifth Waste of over-processing is defined as spending unnecessary resources to produce an equivalent product. Example: Performing perioperative medical interventions routinely when there is actually no evidence of benefit to patient outcomes. An example of over-processing is routinely inserting nasogastric tubes intraoperatively in all patients having abdominal surgery. sixth  A defect is defined as an error carried downstream which then requires intervention at a later stage, resulting in a delay in the efficiency of the entire process. A significant resource saving could have occurred had the error been detected and acted upon early. Example: Absent or poorly Implemented checking processes Inadequate checking processes can result in the performance of the wrong operation on the wrong patient or the wrong site, resulting in catastrophic patient harm and further resource requirements. World Health Organization Surgical Safety Checklist (WHO 2008) that has been shown consistently to improve patient safety and to reduce errors in the OT (Haynes et al 2009)  seventh  Motion Inefficiency in motion occurs when a worker needs to move repeatedly in order to perform their job. Example: Multiple movements between the OT and the anaesthetic room to get drugs, equipment or dispose of waste Such movements result in inefficiency, obstruct other healthcare workers and potentially increase the introduction of pathogens by doors constantly being opened. ( R Kasivisvanathan and A Chekairi 2014)