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Lucey Á, Kennedy S, Hussey A, McInerney N, Kelly JL, Joyce KM. The application of human reliability analysis to carpal tunnel decompression. Ann R Coll Surg Engl 2024; 106:432-438. [PMID: 37381781 PMCID: PMC11060861 DOI: 10.1308/rcsann.2023.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/30/2023] Open
Abstract
INTRODUCTION Many surgical procedures are prone to human error, particularly in the learning phase of skills acquisition. Task standardisation has been suggested as an approach to reducing errors, but it fails to account for the human factors associated with learning. Human reliability analysis (HRA) is a structured approach to assess human error during surgery. This study used HRA methodologies to examine skills acquisition associated with carpal tunnel decompression. METHODS The individual steps or subtasks required to complete a carpal tunnel decompression were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was carried out by consensus of subject matter experts. This identified the potential human errors at each subgoal, the level of risk associated with each task and how these potential errors could be prevented. RESULTS Carpal tunnel decompression was broken down into 46 subtasks, of which 21 (45%) were medium risk and 25 (55%) were low risk. Of the 46 subtasks, 4 (9%) were assigned high probability and 18 (39%) were assigned medium probability. High probability errors (>1/50 cases) included selecting incorrect tourniquet size, failure to infiltrate local anaesthetic in a proximal-to-distal direction and completion of the World Health Organization (WHO) surgical sign-out. Three (6%) of the subtasks were assigned high criticality, which included failure to aspirate before anaesthetic injection, whereas 21 (45%) were assigned medium criticality. Remedial strategies for each potential error were devised. CONCLUSIONS The use of HRA techniques provides surgeons with a platform to identify critical steps that are prone to error. This approach may improve surgical training and enhance patient safety.
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Affiliation(s)
- Á Lucey
- Galway University Hospital, Ireland
| | | | - A Hussey
- Galway University Hospital, Ireland
| | | | - JL Kelly
- Galway University Hospital, Ireland
| | - KM Joyce
- Galway University Hospital, Ireland
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von Schudnat C, Schoeneberg KP, Albors-Garrigos J, Lahmann B, De-Miguel-Molina M. The Economic Impact of Standardization and Digitalization in the Operating Room: A Systematic Literature Review. J Med Syst 2023; 47:55. [PMID: 37129717 DOI: 10.1007/s10916-023-01945-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 03/29/2023] [Indexed: 05/03/2023]
Abstract
Hospital face increased resource constraints and competition. This escalates the need for efficiency optimization especially in resource-intense areas, such as the Operating Room (OR). Efficiency cannot happen at expenses of patient outcomes. Innovative digital support systems (DSS) have been introduced into the market to support established standardization methods of intraoperative workflows further. This review aimed to analyze whether applied standardization methods and implemented DSS of intraoperative surgical workflows lead to increasing efficiency and demonstrate economic improvements. A systematic review of intraoperative surgical workflows standardization and digitalization was performed. Journal articles and reviews from 2000 to 2023 were retrieved from EBSCO, PubMed, and Scopus databases, as well as the internal database of Johnson & Johnson. 17 articles showed a significant increase in efficiency through standardization, which led to cost reductions between $70.20 to $3,516 per case without negatively impacting quality. Five additional articles on DSS demonstrated a significant positive impact on efficiency and quality. Reduction in OR-time between 6 to 22% per case was one main contributor. No literature on DSS revealed any correlated economic impact. Selected standardization methods and introduced DSS for intraoperative surgical workflows effectively increase efficiency while maintaining or even improving quality. Demonstrated cost-effectiveness of non-digital standardization methods across surgical areas requires more research on complex and resource-intensive procedures and the economic value of DSS to support hospital management's strategic decisions to overcome the increasing economic burden.
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Affiliation(s)
- Christian von Schudnat
- Department of Business Organization, Faculty of Business Management, Universitat Politecnica de Valencia, Cami de Vera, s/n, 46022, Valencia, Spain.
| | - Klaus-Peter Schoeneberg
- Department of Economic and Social Sciences, Berliner Hochschule für Technik, Berlin, Luxemburger Str. 10, 13353, Berlin, Germany
| | - Jose Albors-Garrigos
- Department of Business Organization, Faculty of Business Management, Universitat Politecnica de Valencia, Cami de Vera, s/n, 46022, Valencia, Spain
| | - Benjamin Lahmann
- Department of Statistics and Operation Analysis, Faculty of Business and Economics, Mendel University Brno, Zemědělská 1, 61300, Brno, Czech Republic
| | - María De-Miguel-Molina
- Department of Business Organization, Faculty of Business Management, Universitat Politecnica de Valencia, Cami de Vera, s/n, 46022, Valencia, Spain
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von Schudnat C, Lahmann B, Schoeneberg KP, Albors-Garrigos J, De-Miguel-Molina M. Impact of a digitized workflow for knee endoprothesis implantations on hospital-specific ratios. Technol Health Care 2022; 31:955-968. [PMID: 36442162 DOI: 10.3233/thc-220395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND: The continuous decrease of healthcare resources requires hospitals to improve efficiency while striving to improve quality standards that deliver better patient outcomes. OBJECTIVE: The objective of this study was to analyze whether the implementation of digital support systems during orthopedic surgery positively affected clinical processes and quality ratios. METHODS: A retrospective case-control study of 297 knee joint replacement procedures was conducted between 2015 and 2020. Thirty-five patients were allocated to the treatment and control groups after they were identified with exact matching and estimation of the propensity score. Both groups were balanced regarding the selected covariates. The effect of the surgical procedure manager (SPM) on the incidence of acute haemorrhagic anaemia between the two groups was evaluated with a t-test, and the odds ratio was calculated. RESULTS: SPM-supported surgery has no significant influence on the incidence of acute haemorrhagic anaemia but leads to significantly shorter hospital stay (1.93 days), changeover (4.14 minutes) and recovery room time (20.20 minutes). In addition, it reduces the standard deviation of operation room times. CONCLUSIONS: The study concludes that SPM enhances surgical efficiency and maintains quality outcomes. To overcome their increasing financial pressure hospital management should commercially evaluate the implementation of digital support systems.
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Affiliation(s)
- Christian von Schudnat
- Department of Business Organization, Faculty of Business Management, Universitat Politecnica de Valencia, Valencia, Spain
| | - Benjamin Lahmann
- Department of Statistics and Operation Analysis, Faculty of Business and Economics, Mendel University in Brno, Brno, Czech Republic
| | - Klaus-Peter Schoeneberg
- Department of Economic and Social Sciences, Berliner Hochschule für Technik, Berlin, Germany
| | - Jose Albors-Garrigos
- Department of Business Organization, Faculty of Business Management, Universitat Politecnica de Valencia, Valencia, Spain
| | - María De-Miguel-Molina
- Department of Business Organization, Faculty of Business Management, Universitat Politecnica de Valencia, Valencia, Spain
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Abstract
PURPOSE OF REVIEW Operating rooms are critical financial centers for hospital systems, with surgical care representing about a third of all health care spending. However, not all of the costs are appropriate or necessary, as there are sometimes significant inefficiencies in how operating rooms are utilized. RECENT FINDINGS Recent innovations utilizing patient-centered data, systems principles from manufacturing industries, and enhanced communication processes have made significant improvements in improving operating room efficiency. By focusing on improving communication, standardizing processes, and embracing a learning health system with innovations, significant improvements in operating room efficiency can be seen to improve outcomes and costs for the health system and patient.
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Affiliation(s)
- Daniel J Lee
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, West Pavilion 3rd Floor, Philadelphia, PA, 19104, USA.
| | - James Ding
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas J Guzzo
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Davidson SJ, Rojnica M, Matthews JB, Langerman AJ. Variation and Acquisition of Complex Techniques. Surg Innov 2016; 23:586-592. [DOI: 10.1177/1553350616663322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background. Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between techniques. We used pancreaticoduodenectomy as a model to catalogue variability between surgeons and investigate factors that affect fellows’ acquisition of techniques. Materials and methods. Semistructured interviews and operative note analysis were conducted to determine techniques of 5 attending surgeons, and these data were mapped to identify variations. Identical interviews and questioning were completed with 4 fellowship graduates whose practice includes pancreaticoduodenectomy. Results. All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were 21 surgical step data points that differed. Of 5 surgeons, 4 were unable to identify colleagues’ techniques. Fellows reported adopting techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Residency training did not strongly influence their choice of technique; however, senior partners after fellowship did influence technique. Conclusions. The number of variants of pancreaticoduodenectomy based on granular, step-by-step differences is larger than previously described. Results hint that variation may be furthered by the fact that surgeons are not aware of the techniques used by colleagues. Fellows choose techniques based on factors not directly related to their own outcomes but rather mentor factors. Whether fellows adopt techniques that will be optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.
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Fong AJ, Smith M, Langerman A. Efficiency improvement in the operating room. J Surg Res 2016; 204:371-383. [PMID: 27565073 DOI: 10.1016/j.jss.2016.04.054] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 03/15/2016] [Accepted: 04/20/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND In the changing health care environment, health systems, hospitals, and health care providers must focus on improving efficiency to meet an increasing demand for high-quality, low-cost health care. Much has been written about strategies and efforts to improve efficiency in the perioperative periods, yet the time when the patient is in the operating room-the intraoperative period-has received less attention. Yet, this is the period in which surgeons may have the most influence. METHODS Systematically review published efforts to improve intraoperative efficiency; assess the outcomes of these efforts, and propose standardized reporting of future studies. RESULTS A total of 39 studies were identified that met inclusion criteria. These divided naturally into small (single operative team), medium (multi-operative team), and large (institutional) interventions. Most studies used time or money as their metric for efficiency, though others were used as well. CONCLUSIONS There is substantial opportunity to enhance operating room efficiency during the intraoperative period. Surgeons may have a particular role in procedural efficiency, which has been relatively unstudied. Common themes were standardizing tasks, collecting and using actionable data, and maintaining effective team communication.
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Affiliation(s)
- Abigail J Fong
- University of Chicago Operative Performance Research Institute, Chicago, Illinois; Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Meghan Smith
- University of Chicago Operative Performance Research Institute, Chicago, Illinois; Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois
| | - Alexander Langerman
- University of Chicago Operative Performance Research Institute, Chicago, Illinois; Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois.
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Surgical process analysis identifies lack of connectivity between sequential fluoroscopic 2D alignment as a critical impediment in femoral intramedullary nailing. Int J Comput Assist Radiol Surg 2015; 11:297-305. [PMID: 26194487 DOI: 10.1007/s11548-015-1262-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Identifying key steps and barriers within complex and simple surgical procedures can be accomplished in a structured and rigorous manner using surgical process modeling. For lower extremity long bone fracture stabilization, the current standard of care is closed intramedullary (IM) nailing, which, despite its widespread use, is associated with challenges that greatly impact operative time and lead to the frustration of medical staff. The aim of this study was to identify challenging surgical steps in IM nailing and understand their underlying causation. METHODS Eight semi-structured interviews with staff orthopedic surgeons and eight detailed surgical observations were conducted to understand the surgical steps, challenges and adapted techniques used in IM nailing. Hierarchical decomposition was then utilized to structure the IM nailing surgical procedure into phases, steps and activities. RESULTS In the developed IM nailing surgical process model, the most challenging steps were identified as fracture reduction (75%) and entry point selection (25%), both of which were associated with high levels of frustration in the observed surgeries. Both of these steps utilize 2D fluoroscopic imaging to guide 3D alignment. Challenges arise when the alignment in one plane is lost while adjusting the alignment in the perpendicular plane. This leads to unpredictable repetition of activities which can be time-consuming and frustrating. CONCLUSION Identifying the causation of surgical challenges in IM nailing through surgical process modeling forms a knowledge base that can be used to guide future improvements to techniques and surgical instrumentation.
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Neumuth T, Wiedemann R, Foja C, Meier P, Schlomberg J, Neumuth D, Wiedemann P. Identification of surgeon-individual treatment profiles to support the provision of an optimum treatment service for cataract patients. J Ocul Biol Dis Infor 2011; 3:73-83. [PMID: 22500196 DOI: 10.1007/s12177-011-9058-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 03/21/2011] [Indexed: 11/30/2022] Open
Abstract
One objective of ophthalmological departments is the optimization of patient treatment services. A strategy for optimization is the identification of individual potential for advanced training of surgeons based on their daily working results. The objective of this feasibility study was the presentation and evaluation of a strategy for the computation of surgeon-individual treatment profiles (SiTPs). We observed experienced surgeons during their standard daily performance of cataract procedures in the Ophthalmological Department of the University Medical Center Leipzig, Germany. One hundred five cases of cataract procedures were measured as Surgical Process Models (SPMs) with a detailed-to-the-second resolution. The procedures were performed by three different surgeons during their daily work. Subsequently, SiTPs were computed and analyzed from the SPMs as statistical 'mean' treatment strategies for each of the surgeons. The feasibility study demonstrated that it is possible to identify differences in surgeon-individual treatment profiles beyond the resolution of cut-suture times. Surgeon-individual workflows, activity frequencies and average performance durations of surgical activities during cataract procedures were analyzed. Highly significant (p < 0.001) workflow differences were found between the treatment profiles of the three surgeons. Conclusively, the generation of SiTPs is a convenient strategy to identify surgeon-individual training potentials in cataract surgery. Concrete recommendations for further education can be derived from the profiles.
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Neumuth T, Krauss A, Meixensberger J, Muensterer OJ. Impact quantification of the daVinci telemanipulator system on surgical workflow using resource impact profiles. Int J Med Robot 2011; 7:156-64. [DOI: 10.1002/rcs.383] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2011] [Indexed: 12/22/2022]
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Neumuth D, Loebe F, Herre H, Neumuth T. Modeling surgical processes: a four-level translational approach. Artif Intell Med 2011; 51:147-61. [PMID: 21227665 DOI: 10.1016/j.artmed.2010.12.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 10/14/2010] [Accepted: 12/07/2010] [Indexed: 11/18/2022]
Abstract
MOTIVATION The precise and formal specification of surgical interventions is a necessary requirement for many applications in surgery, including teaching and learning, quality assessment and evaluation, and computer-assisted surgery. Currently, surgical processes are modeled by following various approaches. This diversity lacks a commonly agreed-upon conceptual foundation and thus impedes the comparability, the interoperability, and the uniform interpretation of process data. OBJECTIVE However, it would be beneficial if scientific models, in the same context, shared a coherent conceptual and formal mathematical basis. Such a uniform foundation would simplify the acquisition and exchange of data, the transition and interpretation of study results, and the transfer and adaptation of methods and tools. Therefore, we propose a generic, formal framework for specifying surgical processes, which is presented together with its design methodology. METHODS The methodology follows a four-level translational approach and comprises an ontological foundation for the formal level that orients itself by linguistic theories. RESULTS A unifying framework for modeling surgical processes that is ontologically founded and formally and mathematically precise was developed. The expressive power and the unifying capacity of the presented framework are demonstrated by applying it to four contemporary approaches for surgical process modeling by using the common underlying formalization. CONCLUSIONS The presented four-level approach allows for capturing the knowledge of the surgical intervention formally. Natural language terms are consistently translated to an implementation level to support research fields where users express their expert knowledge about processes in natural language, but, in contrast to this, statistical analysis or data mining need to be performed based on mathematically formalized data sets. The availability of such a translational approach is a valuable extension for research regarding the operating room of the future.
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Affiliation(s)
- Dayana Neumuth
- Innovation Center Computer Assisted Surgery (ICCAS), Medical Faculty, Universität Leipzig, Semmelweisstr. 14, 04275 Leipzig, Germany.
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Analysis of surgical intervention populations using generic surgical process models. Int J Comput Assist Radiol Surg 2010; 6:59-71. [PMID: 20526819 DOI: 10.1007/s11548-010-0475-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 04/20/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE According to differences in patient characteristics, surgical performance, or used surgical technological resources, surgical interventions have high variability. No methods for the generation and comparison of statistical 'mean' surgical procedures are available. The convenience of these models is to provide increased evidence for clinical, technical, and administrative decision-making. METHODS Based on several measurements of patient individual surgical treatments, we present a method of how to calculate a statistical 'mean' intervention model, called generic Surgical Process Model (gSPM), from a number of interventions. In a proof-of-concept study, we show how statistical 'mean' procedure courses can be computed and how differences between several of these models can be quantified. Patient individual surgical treatments of 102 cataract interventions from eye surgery were allocated to an ambulatory or inpatient sample, and the gSPMs for each of the samples were computed. Both treatment strategies are exemplary compared for the interventional phase Capsulorhexis. RESULTS Statistical differences between the gSPMs of ambulatory and inpatient procedures of performance times for surgical activities and activity sequences were identified. Furthermore, the work flow that corresponds to the general recommended clinical treatment was recovered out of the individual Surgical Process Models. CONCLUSION The computation of gSPMs is a new approach in medical engineering and medical informatics. It supports increased evidence, e.g. for the application of alternative surgical strategies, investments for surgical technology, optimization protocols, or surgical education. Furthermore, this may be applicable in more technical research fields, as well, such as the development of surgical workflow management systems for the operating room of the future.
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