Table 1

Improvement cycles

PDSA cyclePlan/predictionDoStudyAct
A1If 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.
A2If 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.
B1If 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.
B2If 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).
CIf 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.