Paul Bs Lai

Quality of surgery

How would you define ‘quality of surgery’? How do you measure it? Do you know if you are doing a decent job for your patients? To measure quality we need some reliable tools and measurement strategies. A number of clinical indicators are widely used as surrogates in an attempt to quantify certain elements of quality that were thought to be immeasurable in the past. However, some frontline clinicians may feel that these clinical indicators are simply figures that healthcare administrators played around in their armchairs. Worst still is that when they displayed resistance to these measurements, the implementation of clinical indicators in a constructive manner would end up as complete failure. Some colleagues may think the use of clinical indicators or measurement of quality is repackaging of the term ‘surgical audit of surgical outcomes’. Obviously, it would be too narrow or restricted if we just put our focus on post-operative complications and mortality. The whole surgical experience of our patients should be taken into account and quality should be referred to such wider concept. If good clinical indicators are being used effectively in organizations such as the Hospital Authority, apart from providing evidence for quality improvement, they would generate information useful for decision makers on resource allocation and re-deployment at the organizational level. If similar set of clinical indicators are being measured in different hospitals or departments, they can facilitate international or local bench marking and performance comparison. One of the many problems with measurement of clinical indicators is that while clinicians may improve their results on specific measures of performance, other issue may get neglected. This problem was demonstrated by a study on ‘pay-for-performance’ [colleagues working in the Hospital Authority may have goosebumps once they heard about P4P] in the United Kingdom. Primary care physicians only performed in areas tied to incentives and quality of care declined in areas not being tied to monetary incentives. Although one may argue that particular study on primary care cannot be extrapolated to surgical practice, it does not discount the challenges of making data collected meaningful and results measurable to achieve better surgical outcomes. Talking about surgical outcomes, the findings of inter-hospital variation by the Hospital Authority’s Surgical Outcome Monitoring and Improvement Program (SOMIP) was reported recently in the local news. Though the report said the variation was worrying, I think it is even more worrying in not knowing the variation of performance. Firstly, it is not scientific to assume every surgeon or every surgical unit would have the same level of performance. Secondly, without identifying areas of inadequacy, we cannot improve. The beauty of SOMIP is that data are collected by nurse reviewers and automatic catchment of computerized information of the IT system and the chance of underestimating the complication rate is much reduced. Knowing that not all harms are preventable, we can identify those correctable factors in our system and in longer term lead to improvement in surgical care. Furthermore, since the analysis of data is risk-adjusted, we can interpret the data scientifically and fair comparison of performance is allowed. Having said that, we must be mindful about the problem of “named and shamed” to individual hospital if we adopt a total transparency approach for the release of data to the public. Although a recent study showed there was not much progress in patient safety over a period of 6 years in the 10 hospitals in North Carolina, it should not be seen as a discouragement to our endeavor to improve the quality of surgical care. While we can have healthcare professionals educated about how to identify and fix safety hazards, or how to communicate better with team work through some CME activities, the most important task for us is to get ourselves engaged in the safety efforts. Although penetration of evidencedbased safety practices and cultivation of a culture of surgical safety take a little while, now would be the best time to buy-in. At the time when we can say ‘sit back, relax, and enjoy the surgery’ to our patients before they are put asleep by our anaesthetist friends – that’s high quality surgery reflecting our simple (sometimes naïve) intention to serve the best interests of our patients.

Eliminating waste in the spirit of lean thinking

The philosophy of eliminating waste, or ‘muda’ in Japanese, is the heart of lean management. In manufacturing or healthcare processes, work calls into two categories: the ‘value added’ and ‘nonvalue added’. Thus, in our care processes in hospitals, the steps that directly lead to patients’ desired healthcare outcomes are value-added work. Nonvalue added work is everything else; that is, all unnecessary nonvalue added work that does not add value to the customer or patient is regarded as ‘waste’. A patient going to hospital for a day-case hernia repair would be a straightforward example to illustrate the concept. On the day of surgery, the patient will go to hospital, check in and then get changed. The patient will then wait at a holding area for his turn to be wheeled into the operating room. After being transferred to the operating table, the anaesthetist will give the patient sedation or a general anaesthesia. The surgeon will then work on the patient’s hernia. After suturing the wound and applying a dressing, the patient will be woken up and transferred to the recovery room. The patient will then be later assessed to see if he or she is fit to go home. In this whole process, the main value-added work is the surgical operation. This is what the patient needs. All the rest is nonvalue added. Although work, such as anaesthesia, would be necessary, much of the waiting time would be unnecessary. The traditional approach to process improvement focuses on identifying local efficiencies in the valueadded processes. For example, by making the mesh for hernia repair available in the operating room would save time compared to having the runner nurse run to the store during the operation. While the result might be a significant percentage improvement for that particular process, there might be little impact on the overall value stream. This is particularly true, as in most healthcare processes, there are relatively few value-added steps, so improving those value-added steps will not amount to a lot of impact. The lean thinking, however, focuses on eliminating waste that is are both unnecessary and nonvalue added. Continuous improvement can thus be achieved through rounds of waste-reduction interventions to the workflow. Theoretically, not only will patients have a better experience, but the healthcare cost can also be driven down. There are seven main types of waste: overproduction, waiting, unnecessary transport, overprocessing or incorrect processing, excess inventory, unnecessary movement and defects. In surgical care inside the operating room, the most obvious example is waiting. In the hernia repair example mentioned earlier, a lot waiting is involved: waiting to be wheeled into the operating room after checking in at the OT control, waiting for surgeons to start the surgery, waiting for assessment before discharge and sometimes waiting for the painkillers to arrive before going home. Fixing some of these areas by reducing waiting times would certainly improve the patient’s experience. While waste-elimination work sounds simple, we need to implement work standards so that healthcare professionals can repeat the improved workflow and raise overall efficiency. Setting new standards can be powerful continuous improvement mechanisms. It also enhances the implementation of PDSA (Plan, Do, Study, Act) cycles to charge the momentum of change for the better.

Innovative surgical procedures

I came across this article in Medscape Surgery recently, reporting an manuscript published in Annals of Surgery on the complications of transvaginal natural orifice transluminal endoscopic surgery (NOTES). It was an interview with some surgeons on their view on this innovative procedure. Two male surgeons were asked if they would recommend transvaginal NOTES approach should their wives require surgery. One said yes and one said no. The one who said yes replied, “if my wife needed a cholecystectomy, (transvaginal) NOTES is the approach I would recommend.” Perhaps this is the most pragmatic approach to evaluate whether certain innovative procedures are indicated for our patients – to ask the surgeon if they are willing to offer the innovative surgery to themselves or someone they love. It is however a bit tricky in this particular novel surgery as it is impossible to conduct transvaginal NOTES on a male surgeon. But if you look at some recently published series of NOTES, it seems reasonable to conclude that NOTES is safe, feasible, and reproducible with previous training in the laboratory and a consistent team at a highvolume center. I was involved in a study of single-port versus standard 4-port laparoscopic cholecystectomy and on finishing the trial, we concluded the single-incision laparoscopic cholecystectomy resulted in much less post-operative pain. Since then, I routinely offer single-port laparoscopic cholecystectomy to my patients who were doctors themselves (some of them surgeons), telling them it is an alternative to the standard 4-port technique. Interestingly, all of them had chosen standard 4-port laparoscopic approach. But when I asked them after the successful operation why they did not choose the single-port approach, they all told me that they think I would be more proficient and safe in doing the standard 4-port laparoscopic cholecystectomy. They all based on their intuitive feeling that I would have done a lot more cholecystectomy using the standard 4-port approach. Deep down in their hearts, they all thought safety is their biggest concern. Prompted by the infamous Tuskegee Syphilis Study, the Belmont Report was produced in 1978 by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Ethical principles and guidelines for the protection of research subjects were recommended. The three fundamental ethical principles for human research were laid down – respect for persons, beneficence and justice. The concept of informed consent, risks-benefits assessment and selection of human subjects were then applied to uphold the principles. In the surgical world, because of the nature of surgical diseases, patients or potential subjects for clinical research may not have a lot of time to consider whether they should participate in a trial or not. I can imagine the difficulties if I suffered from a traumatic injury to the abdomen. I might have hypotension, tender abdomen and bleeding into the peritoneal cavity. If then I was asked if I am willing to participate in a clinical trial looking into the effectiveness of normal saline versus colloids in major abdominal injuries, I might doubt if the surgeons in the resuscitation room are sincere in saving my life. Why should I bother to think whether I should consent to a trial or not? In the spirit of ‘making sure that the patient wasn’t coerced into doing the experiment by means of threatening or bullying’, clinical researchers perhaps should not be over-enthusiastic in pushing patients for clinical trials of some wonderful innovative procedures. I personally would advocate the empathetic way of doing such a test – if I am (or my wife is) the patient (but with all my surgical knowledge), I am willing to try it out. But if you don’t agree, I can understand because when we talk about principles of something, it is very difficult to find something as ‘one size fits all’!