Title: A mixed methods study on Improving Productivity and Patient Experience in Elective care among NHS Acute Care Providers in England by Investigating Reduction of OTDO (On The Day of Operation) Cancellations.
Funder: Department of Health and Social Care

Abstract: The significant emotional impact that patients have experienced due to On The Day of Operation cancellations(OTDO) is clearly documented (Tait et al., 1997; Ivarsson et al., 2002; Schofield et al., 2005; Hovlid et al., 2013). Patients are directly affected by OTDO cancellations due to delays to their operation, which may be harmful (Ivarsson et al., 2002; Argo et al., 2009). OTDO cancellations create significant problems for the productivity of elective care, including the utilisation of theatres and clinical staff efficiencies (Schofield, Rubin et al. 2005; Souzdalnitski and Narouze, 2014). According to a study completed in 2007, around 70 million was claimed by NHS trusts due to the OTDO cancellations (McIntosh at al., 2012), but this can be argued to be an underestimation.In 2015/2016, there were 69,568 OTDO cancellations due to hospital reasons across 137 NHS acute care providers (www.england.nhs.uk). Analysing the national data on OTDO cancellations due to hospital-reasons [selecting for trusts with over 30,000 elective operations in financial year 15-16 (n=110)], we found that over the last five years (2011-12 to 2015-16) there is a great deal of consistency in the relative performance of trusts. The year-to-year rank correlations are very large (Spearman's rs >.75), and the trusts currently in the top and bottom deciles have fairly consistent patterns of very good or very poor performance (see Appendix A - Figure 1).This fairly consistent five-year variation provides a useful research opportunity to investigate what the high performing trusts are doing differently from the poorly performing trust to keep down the OTDO cancellations rates.OTDO cancellation rates exceeding 10% of all scheduled cases have been reported in hospitals in the United States (Argo et al., 2009; Lacqua et al., 1994) and in Europe (Sanjay et al., 2007; Mangan et al.,1992; Seim et al. 2009). The high percentage of the OTDO cancellations are avoidable: 80% (Rymaruk, 2011); 80% (Bamashmus et al., 2010); or 60% (Schofield, Rubin et al. 2005), 59.2 +/- 8.9% (Trentman et al., 2010).There is evidence that improving patient care pathways can reduce OTDO cancellations rates and improve the productivity of elective care (Samarasinghe, 2016; Mckendrick et al., 2014; Hovlid et al., 2013; Singhal, Warburton et al. 2014; Pratap et al., 2015; Westbury et al., 2009; Pandit et al., 2007). The theoretical basis for interventions to reduce OTDO cancellations is a very complex and fluid issue (Samarasinghe, 2106) due to the multifactorial nature of potential causes (Hovlid and Bukve, 2014).Despite the major impact on patients and NHS financials, there is very little understanding on what factors influence OTDO cancellations. Hence, using Operations Management theories, this exploratory research project aims to investigate how to improve the productivity and patient experience in elective care by investigating reduction of OTDO cancellations.The project consists of four work packages (WP) each with an objective as follows.1) A systematic review of the OTDO cancellations literature with a focus on strategies to reduce OTDO Cancellations and improve productivity of elective care. 2) A multi-centred retrospective observational study to understand the variations in the OTDO cancellation rates among a sample of six NHS acute care providers. 3) A multi-centred case studies at clinical speciality level to identify the factors influencing OTDO cancellations rates. 4) The development of recommendations and good practice guidance to reduce OTDO cancellations and improve the productivity of elective care.In summary, the research study aims to provide recommendations and good practice guidance on reduction of OTDO cancellations and improving productivity in elective care, with an emphasis on delivering significant benefit to patients and avoiding the current multi-million-pound waste due to low productivity in the elective care pathway.

Lay abstract: When a planned operation is cancelled on the scheduled date it is called an OTDO (On The Day of Operation) cancellation. These OTDO cancellations have a great negative impact on the patient's and carers' experience (emotional distress, disappointment and inconvenience). The OTDO cancellations create a lot of waste of NHS resources and provide a signal of potentially low productivity of planned care.According to a study completed in 2007, around 70 million were claimed by NHS trusts (McIntosh et al., 2012) due to OTDO cancellations, but it can be argued that this is an underestimate.In 2015/2016, there were 69,568 OTDO cancelled due to hospital reasons across 137 English NHS acute care providers, (www.england.nhs.uk); this was a 14.5% increase compared to 2013/14.A number of studies have highlighted that between 60% and 80% of the OTDO cancellations are avoidable (Rymaruk, 2011; Bamashmus et al., 2010; Schofield et al., 2005).There is evidence that there is a big difference in the OTDO cancellation rates among English NHS trusts (McIntosh at al., 2012). We analysed the hospital cancellations rates in English NHS trusts from 2011/12 to 2015/16 and found that the trusts currently in the top and bottom ranks have fairly consistent patterns of very good or very poor performance over these 5 years. This fairly-consistent performance provides an opportunity to investigate what the high performing trusts are consistently doing differently from the poorly performing trusts. Despite the huge importance of the area to patients and NHS organisations, there is are very few good quality studies completed to understand what factors influence OTDO cancellation rates and high elective productivity in some NHS trusts compared to others.There is research evidence that using a wide range of methods to improve patient care pathways can reduce the OTDO cancellations rates and improve productivity of planned care (Samarasinghe, 2016; Mckendrick et al., 2014; Pratap et al., 2015; Westbury et al., 2009; Pandit et al., 2007). Reducing the OTDO cancellations is a very complex and fluid issue (Samarasinghe, 2106) due to the multifactorial nature of the problem (Hovlid and Bukve, 2014).The main aim of this research project is to complete an in-depth analysis of OTDO cancellations, and understand the factors that influence tem in order to improve elective productivity by learning from the NHS trusts that have lower cancellation rates.Firstly, by carefully understanding the published studies on OTDO cancellation, the proposed work intends to understand the ways of reducing the cancellations and improving the productivity of planned care.Secondly, the proposed work aims to study the differences in the OTDO cancellation rates within selected six NHS acute trusts (case study sites) and their related clinical specialities to understand the differences and similarities in OTDO cancellation rates. The six NHS acute care trusts will include three high- performing and three poorly-performing trusts, selected by studying data for all NHS trusts. This will be done by working collaboratively and using relevant data from the NHS trusts. These NHS trusts will be studied further in the third, fourth parts of the study.Thirdly, detailed case studies will be developed in the six trusts focusing on an identified clinical speciality to understand factors that influence the cancellation rates. Operations Management theories will be used to understand how patient flow and management practices influence the productivity of planned care and OTDO cancellations in the identified clinical speciality. The case study development will be based on field work collecting information by reviewing OTDO cancellation incidents and conducting interviews with managers and clinicians by the researcher as part of the.Finally, after completing the stages of the proposed work, and after considering the findings carefully, the study aims to make actionable recommendations and good practices to reduce the OTDO cancellations and improve the productivity of planned care.The study is expected to publish a minimum of one peer-reviewed article for each objective and findings will be shared with NHS organisations to improve services to patients.The study also has a potentially great benefit to patients by avoiding the disappointment of cancellation of OTDO. Further, this study also has a potentially great benefit to NHS organisations, as OTDO cancellations waste millions of pounds. Hence, the findings of this study aim to inform how the effective use of resources can make substantial savings at an organisational level which is vital for all NHS organisations in the current economic climate.

Research activity codes: 8.2 HEALTH AND WELFARE ECONOMICS
Health categories: GENERIC HEALTH RELEVANCE