Driving effective theatre performance

It has been said that theatres are the heart of any hospital and that effective theatre performance is key to the success of the overall hospital. However, focusing on theatres alone ignores the fact that they do not exist in isolation, and focusing on fixing “single point” issues (such as changing the layout or tackling one specific team behaviour) ignores the complex interactions between processes, people and the organisational culture as a whole. In this short article we explore the key success factors that can improve theatre performance, quality and safety, and that can convert high theatre occupation into effective theatre utilisation. The benefit of this is not only seen in improved theatre performance, but in a better end-to-end process for both patients and staff.

Drivers of effective theatres

As mentioned in the introduction, theatres do not exist in isolation and are not an end in their own right. For example, patients who are not pre-assessed and are then found to be unfit for surgery, or those who cannot be found a bed on the day of admission are among the many sources of poor performance at the theatre “front door”, while problems with outcomes, discharge and transfers of care can create demands and bottlenecks at the back door. Due to the complexity in the end-to-end process and a general fear of “bringing down the house of cards”, it can often be left until there is a serious incident or until quality or performance drops to a completely unacceptable level before a material programme of change is initiated. In the absence of serious problems, the improvements attempted can be so minor as to warrant being classified as irrelevant. These include doing “tidy ups”, labelling shelves or poorly structured team building days to improve theatre team interactions, often with key players missing. While these latter examples may be worthy actions they are hardly likely to lead to a fundamental change in the way theatres run and often result in small improvements that have a very short “half life”. On the other hand, a knee-jerk reaction, when a significant issue does arise, is liable to disengage the teams and can actually leave a legacy that reinforces a blame culture. Effective theatre performance is achieved through a process of continuous review and improvement where managers and front line teams have the courage to tackle big issues. This is easy to outline but is normally hampered in reality by three problems: • A mentality of “competing tribes” – this is often a legacy of the organisational culture and previous events that have reinforced beliefs that “our team is better or more important than yours” or that “they do not know what they are doing” (whoever “they” are). • Broken pathways and processes – processes tend to break down over time through a combination of staff changes, new legislation, changes in practice, span of authority etc. The result is that performance drops and this increases the pressure to escalate activity through the already broken process. This creates a self-defeating cycle where productivity drops sharply but the release of resources to fix problems is resisted because of the need to tackle the growing backlog that has been caused because productivity is low. In this environment quality and safety suffer too. • Ineffective environment – a combination of poor information, poor relationships, leadership behaviours that support the status quo and the wrong measures of performance can create an environment that neither tackles the “tribal” behaviour or invests in fixing processes. Poor theatre performance can be driven by a mix of one or more of these elements and in Table 1 we have summarised how these three different issues interact and the outcomes they create. Effective theatre performance is about tackling all three issues – not just when problems occur, but on a continuous basis. In the following sections we explore some of the more practical things that can be implemented to improve theatre performance.