Improvement cycles
| PDSA cycle | Plan/prediction | Do | Study | Act |
| A1 | If cases planned and leave dept at 8:30 (instead of waiting to be contacted) then will have time to attend team briefing (PM1). This will improve PM2 and OMs. | 10 May 2021. Next 10 cases.Plan case at least 24 hours before, prepare consumables and equipment. Leave dept at 08:30 for theatre, attend team brief. | OM1: ☒ 30% of cases finished on time (worse!). OM2: ☒ Mean around 0 (on-time only on average), with wide variation (±>1 hour); no material change. PM1: ☒ 0% (no team briefs attended) (no change). PM2: ☒ Mean=70 min, with high variation (±9 min), all CC (no material change). PM3: ☒ Mean 10:56 (no material change), 1 potential SC identified—linked to anaesthesia delay time. BM: S:3/5, M:0/2, L:0/3. | OM1: ‘Long’ case consistently finish after their planned finish time. PM1: Conclude: leaving at 8:30 had no impact on PM1 (attending brief), PM2 or PM3. Unsuccessful: refine. Leave earlier, move head measurement task from WA. Tentative pattern emerging: PM2 delay important factor in delaying surgical start time. |
| A2 | If have done head measurement on the ward and leave earlier (08:15) then will have time to attend team briefing (PM1). | 1 June 2021. Next 10 cases. As above PLUS. Measure the patient’s head on the ward. And leave department at 08:15. | OM1: ☒ 70% finished on time. OM2: ☒ Mean around 0 (on-time); no material change, but reduced variation (±50 min). PM1: ☑ 100% (all 10 team briefs attended: target met). PM2: ☒ No material change: mean=70 min. PM3: ☒ Mean 10:50 (small improvement), reduced variation. Consistent pattern emerging due to NP having to wait for anaesthesia to finish. BM: S:3/3, M:4/4, L:0/3. | Conclude: attendance may have some impact on ‘Short’ and ‘Medium’ cases; ‘Long’ still problematic. Little impact on PM2 and PM3, but prerequisite for B and C: retain. Anaesthesia delay continues to impact PM3. Conclude: next focus on NP impact on pre-surgery prep duration. |
| B1 | If simultaneous NP set-up with anaesthesia, then reduce pre-surgery delays, so PM2, PM3 and OMs. | 24 June 2021. Next 10 cases. As above PLUS. Do set-up simultaneously with anaesthesia (after intubation). | OM1: ☒ 60% finished on time. OM2: ☒ No material change. PM1: ☑ 100% (all 10 team briefs attended). PM2: ☒ No material change. PM3: ☒ Mean 10:44 (small improvement): All 10 cases started before 10:50. All CC. BM: S:2/2, M:4/4, L:0/4. | Long cases still problematic. No change to PM2 likely linked to NP theatre duration sometimes > anaesthesia duration. Conclude: want NP duration ≤ anaesthesia duration to avoid delays to surgical start. |
| B2 | If NP set-up in pairs then NP duration ≤anaesthesia duration: PM2 reduced, so PM3 and OM1 reduced. | 20 July 2021. Next 10 cases. As above PLUS. Do set-up in pairs. | OM1: ☑ 100%. All cases finished within planned finish time. OM2: (☑) Mean = –24 min (ie, early);~capable PM1: ☑ 100% (all 10 team briefs attended). PM2: ☒ Mean=55 min (process range 50–60 min). Material reduction in mean and variation (±4 min), all CC PM3: ☒ Mean=10:30 (=target) but above on ~50% of occasions! So not capable. BM: S:5/5, M:4/4, L:1/1. | Setting up in pairs has a significant impact on PM2: 40% cases within target, but still >target (45 min). Conclude: needs further reduction in NP time. Possible impact on ‘Long’ cases, BUT limited data in this cycle (one case). |
| C | If we only perform prone intraoperative baselines, we can remove duplication from the system. | 11August 2021. Next 10 cases. As above PLUS. Cease supine baseline recordings. | OM1: ☑ 100%. All cases finished on time again. OM2: (☑) Mean = −29 min (early); ~capable. PM1: ☑ 100% (all 10 team briefs attended). PM2: ☒ Mean=49 min. Low variation (±3 min). One case (of these last 10) within the 45-min target. PM3: ☑ Mean=10:20. All 10 cases were within the 10:30 target, UPL within target. BM: S:6/6, M:1/1, L:3/3. | Removing baseline duplication within the system significantly improved PM2 and PM3 (now capable of meeting target). Three-session cases now consistently finish before their planned finish times, even ‘Long’ cases. |
☑: Target met; ☒: Target not met.
BM, balancing metric; CC, common cause (ie, random) variation; L, long; M, medium-length; NP, neurophysiology; OM, outcome metric; PM, process metric; S, planned (relatively) short duration operations; SC, special cause variation; UPL, upper process limit (also known as upper control limit); WA, theatre waiting area.