Quality Improvement to Address Surgical Burden of Disease at a Large Tertiary Public Hospital in Peru.
Journal
World journal of surgery
ISSN: 1432-2323
Titre abrégé: World J Surg
Pays: United States
ID NLM: 7704052
Informations de publication
Date de publication:
08 2021
08 2021
Historique:
accepted:
03
04
2021
pubmed:
27
4
2021
medline:
17
8
2021
entrez:
26
4
2021
Statut:
ppublish
Résumé
In resource-limited settings, there is a unique opportunity for using process improvement strategies to address the lack of access to surgical care. By implementing organizational changes in the surgical admission process, we aimed to decrease wait times, increase surgical volume, and improve patient satisfaction for elective general surgery procedures at a public tertiary hospital in Lima, Peru. During the first phase of the intervention, Plan-Do-Study-Act (PDSA) cycles were performed to ensure the surgery waitlist included up-to-date clinical information. In the second phase, Lean Six Sigma methodology was used to adapt the admission and scheduling process for elective general surgery patients. After six months, outcomes were compared to baseline data using Wilcoxon rank-sum test. At the conclusion of phase one, 87.0% (488/561) of patients on the new waitlist had all relevant clinical data documented, improved from 13.3% (2/15) for the pre-existing list. Time from admission to discharge for all surgeries improved from 5 to 4 days (p<0.05) after the intervention. Median wait times from admission to operation for elective surgeries were unchanged at 4 days (p=0.076) pre- and post-intervention. There was a trend toward increased weekly elective surgical volume from a median of 9 to 13 cases (p=0.24) and increased patient satisfaction rates for elective surgery from 80.5 to 83.8% (p=0.62), although these were not statistically significant. The process for scheduling and admitting elective surgical patients became more efficient after our intervention. Time from admission to discharge for all surgical patients improved significantly. Other measured outcomes improved, though not with statistical significance. Main challenges included gaining buy-in from all participants and disruptions in surgical services from bed shortages.
Sections du résumé
BACKGROUND
In resource-limited settings, there is a unique opportunity for using process improvement strategies to address the lack of access to surgical care. By implementing organizational changes in the surgical admission process, we aimed to decrease wait times, increase surgical volume, and improve patient satisfaction for elective general surgery procedures at a public tertiary hospital in Lima, Peru.
METHODS
During the first phase of the intervention, Plan-Do-Study-Act (PDSA) cycles were performed to ensure the surgery waitlist included up-to-date clinical information. In the second phase, Lean Six Sigma methodology was used to adapt the admission and scheduling process for elective general surgery patients. After six months, outcomes were compared to baseline data using Wilcoxon rank-sum test.
RESULTS
At the conclusion of phase one, 87.0% (488/561) of patients on the new waitlist had all relevant clinical data documented, improved from 13.3% (2/15) for the pre-existing list. Time from admission to discharge for all surgeries improved from 5 to 4 days (p<0.05) after the intervention. Median wait times from admission to operation for elective surgeries were unchanged at 4 days (p=0.076) pre- and post-intervention. There was a trend toward increased weekly elective surgical volume from a median of 9 to 13 cases (p=0.24) and increased patient satisfaction rates for elective surgery from 80.5 to 83.8% (p=0.62), although these were not statistically significant.
CONCLUSION
The process for scheduling and admitting elective surgical patients became more efficient after our intervention. Time from admission to discharge for all surgical patients improved significantly. Other measured outcomes improved, though not with statistical significance. Main challenges included gaining buy-in from all participants and disruptions in surgical services from bed shortages.
Identifiants
pubmed: 33900420
doi: 10.1007/s00268-021-06118-z
pii: 10.1007/s00268-021-06118-z
doi:
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
2357-2369Références
Mock CN, Donkor P, Gawande A et al (2015) Essential surgery: key messages from disease control priorities. Lancet 385(9983):2209–2219
doi: 10.1016/S0140-6736(15)60091-5
Raykar NP, Ng-Kamstra JS, Bickler S et al (2017) New global surgical and anaesthesia indicators in the World Development Indicators dataset. BMJ Glob Health 2(2):e000265. https://doi.org/10.1136/bmjgh-2016-000265
doi: 10.1136/bmjgh-2016-000265
pubmed: 29225929
pmcid: 5717956
Meara JG, Leather AJM, Hagander L et al (2015) Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386(9993):569–624
doi: 10.1016/S0140-6736(15)60160-X
Tsai TC, Orav EJ, Jha AK (2015) Patient satisfaction and quality of surgical care in US hospitals. Ann Surg 261(1):2–8
doi: 10.1097/SLA.0000000000000765
Citron I, Saluja S, Amundson J et al (2018) Surgical quality indicators in low-resource settings: a new evidence-based tool. Surgery 164(5):946–952
doi: 10.1016/j.surg.2018.05.016
Nicolay CR, Purkayastha S, Greenhalgh A et al (2012) Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg 99(3):324–335
doi: 10.1002/bjs.7803
Cofie LE, Barrington C, Akaligaung A et al (2014) Integrating community outreach into a quality improvement project to promote maternal and child health in Ghana. Glob Public Health 9(10):1184–1197
doi: 10.1080/17441692.2014.952656
Taylor MJ, McNicholas C, Nicolay C et al (2014) Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf 23(4):290–298
doi: 10.1136/bmjqs-2013-001862
Barker PM, Reid A, Schall MW (2016) A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implement Sci 11:12. https://doi.org/10.1186/s13012-016-0374-x
doi: 10.1186/s13012-016-0374-x
pubmed: 26821910
pmcid: 4731989
Mason SE, Nicolay CR, Darzi AJ (2015) The use of Lean and Six Sigma methodologies in surgery: a systematic review. Surgeon 13(2):91–100
doi: 10.1016/j.surge.2014.08.002
Six Sigma definition - What is Lean Six Sigma? (2020) | ASQ [Internet]. Available from: https://asq.org/quality-resources/six-sigma
Cima RR, Brown MJ, Hebl JR, et al (2011) Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg 213(1):83–92, Discussion 93–94
Valsangkar NP, Eppstein AC, Lawson RA et al (2017) Effect of Lean processes on surgical wait times and efficiency in a tertiary care veterans affairs medical center. JAMA Surg 152(1):42–47
doi: 10.1001/jamasurg.2016.2808
Rook JM, Wood E, Boeck MA et al (2021) The Bolivian trauma patient’s experience: a qualitative needs assessment. Injury 52(2):167–174
doi: 10.1016/j.injury.2020.12.014
Weinberg M, Fuentes JM, Ruiz AI et al (2001) Reducing infections among women undergoing cesarean section in Colombia by means of continuous quality improvement methods. Arch Intern Med 161(19):2357–2365
doi: 10.1001/archinte.161.19.2357
Shiraishi-Zapata CJ (2017) Monitoring of national surgical care indicators in the Peruvian health system. Colomb J Anestesiol 45(3):210–215
LaGrone LN, Fuhs AK, Egoavil EH et al (2017) Mixed-methods assessment of trauma and acute care surgical quality improvement programs in Peru. World J Surg 41(4):963–969. https://doi.org/10.1007/s00268-016-3832-3
doi: 10.1007/s00268-016-3832-3
pubmed: 27896407
Ruiz (2017) Análisis Situacional de Salud del Hospital Sergio Bernales [Internet], MINSA Peru. Available from: https://hnseb.gob.pe/repositorio-portal-transparencia/planeamiento-y-organizacion/IAPLAN06.pdf
Eguiluz W, Zapata T, Samaritano R, et al (2018) Análisis de Situación de Salud 2018 Lima Norte [Internet], MINSA Peru. Available from: http://www.dirislimanorte.gob.pe/wp-content/uploads/2019/01/asis-2018.pdf
Costa F, Sánchez A, Vakis R (2018) Evolución de la pobreza monetaria 2007–2017 [Internet], Peruvian Government. Available from: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1533/cap02.pdf
Mezones-Holguín E, Amaya E, Bellido-Boza L, Mougenot B, Murillo JP, Villegas-Ortega J, Sara JCDC (2019) Cobertura de aseguramiento en salud: el caso peruano desde la Ley de Aseguramiento Universal [Health insurance coverage: the peruvian case since the universal insurance act]. Rev Peru Med Exp Salud Publica 36(2):196–206. https://doi.org/10.17843/rpmesp.2019.362.3998 . PMID: 31460630
Peru Poverty Rate (1997–2021) [Internet] Available from: https://www.macrotrends.net/countries/PER/peru/poverty-rate ' www.macrotrends.net . Accessed 28 Mar2021
Bertolaccini L, Viti A, Terzi A (2015) The statistical point of view of quality: the Lean Six Sigma methodology. J Thorac Dis 7(4):E66–E68
pubmed: 25973253
pmcid: 4419289
Improta G, Balato G, Romano M et al (2017) Improving performances of the knee replacement surgery process by applying DMAIC principles. J Eval Clin Pract 23(6):1401–1407
doi: 10.1111/jep.12810
Babakus E, Mangold WG (1992) Adapting the SERVQUAL scale to hospital services: an empirical investigation. Health Serv Res 26(6):767–786
pubmed: 1737708
pmcid: 1069855
LaGrone LN, Romaní Pozo DA, Figueroa JF et al (2017) Status of trauma quality improvement programs in the Andean region: what foundation do we have to build on. Injury 48(9):1985–1993
doi: 10.1016/j.injury.2017.03.003
Stelfox HT, Joshipura M, Chadbunchachai W et al (2012) Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study. World J Surg 36(8):1978–1992. https://doi.org/10.1007/s00268-012-1593-1
doi: 10.1007/s00268-012-1593-1
pubmed: 22526038
Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360(5):491–499
doi: 10.1056/NEJMsa0810119
Weiser TG, Haynes AB (2018) Ten years of the surgical safety checklist. Br J Surg 105(8):927–929
doi: 10.1002/bjs.10907
White MC, Baxter LS, Close KL et al (2018) Evaluation of a countrywide implementation of the world health organisation surgical safety checklist in Madagascar. PLoS ONE 13(2):e0191849
doi: 10.1371/journal.pone.0191849
Ministerio de Salud del Perú. Resolución Ministerial N° 1021-2010-MINSA [Internet]. [cited 2020 Apr 16]. Available from: https://www.gob.pe/institucion/minsa/normas-legales/244453-1021-2010-minsa
Lacassie HJ, Ferdinand C, Guzmán S, et al (2016) World Health Organization (WHO) surgical safety checklist implementation and its impact on perioperative morbidity and mortality in an academic medical center in Chile. Medicine (Baltimore) [Internet]. [cited 2020 Mar 15];95(23). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907670/
Bosse G, Abels W, Mtatifikolo F et al (2015) Perioperative care and the importance of continuous quality improvement—a controlled intervention study in three Tanzanian hospitals. PLoS ONE 10(9):e0136156. https://doi.org/10.1371/journal.pone.0136156
doi: 10.1371/journal.pone.0136156
pubmed: 26327392
pmcid: 4556680
Gyedu A, Baah EG, Boakye G et al (2015) Quality of referrals for elective surgery at a tertiary care hospital in a developing country: an opportunity for improving timely access to and cost-effectiveness of surgical care. Int J Surg 15:74–78
doi: 10.1016/j.ijsu.2015.01.033
Forrester JA, Koritsanszky LA, Amenu D et al (2018) Developing process maps as a tool for a surgical infection prevention quality improvement initiative in resource-constrained settings. J Am Coll Surg 226(6):1103-1116.e3
doi: 10.1016/j.jamcollsurg.2018.03.020
Dunsch F, Evans DK, Macis M, et al (2018) Bias in patient satisfaction surveys: a threat to measuring healthcare quality. BMJ Glob Health [Internet]. Apr 12 [cited 2020 Mar 15];3(2). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898299/
Collar RM, Shuman AG, Feiner S et al (2012) Lean management in academic surgery. J Am Coll Surg 214(6):928–936
doi: 10.1016/j.jamcollsurg.2012.03.002
Larson E, Mbaruku GM, Cohen J, Kruk ME (2020) Did a quality improvement intervention improve quality of maternal health care? Implementation evaluation from a cluster-randomized controlled study. Int J Qual Health Care 32(1):54–63. https://doi.org/10.1093/intqhc/mzz126.PMID:31829427;PMCID:PMC7172021
doi: 10.1093/intqhc/mzz126.PMID:31829427;PMCID:PMC7172021
pubmed: 31829427