Abstract
ObjectivesTo examine the effectiveness of a “systems” approach using Lean methodology to improve surgical care, as part of a programme of studies investigating possible synergy between improvement approaches.SettingA controlled before-after study using the orthopaedic trauma theatre of a UK Trust hospital as the active site and an elective orthopaedic theatre in the same Trust as control.ParticipantsAll staff involved in surgical procedures in both theatres.InterventionsA one-day “lean” training course delivered by an experienced specialist team was followed by support and assistance in developing a 6 month improvement project. Clinical staff selected the subjects for improvement and designed the improvements.Outcome MeasuresWe compared technical and non-technical team performance in theatre using WHO checklist compliance evaluation, “glitch count” and Oxford NOTECHS II in a sample of directly observed operations, and patient outcome (length of stay, complications and readmissions) for all patients. We collected observational data for 3 months and clinical data for 6 months before and after the intervention period. We compared changes in measures using 2-way analysis of variance.ResultsWe studied 576 cases before and 465 after intervention, observing the operation in 38 and 41 cases respectively. We found no significant changes in team performance or patient outcome measures. The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention.ConclusionsThis version of “lean” system improvement did not improve measured safety processes or outcomes. The study highlighted an important tension between promoting staff ownership and providing direction, which needs to be managed in “lean” projects. Space and time for staff to conduct improvement activities are important for success.
Highlights
Despite the extensive interest in lean approaches in healthcare [1,2,3] there is a shortage of evidence about the impact and execution of such initiatives [4,5,6]
We found no significant changes in team performance or patient outcome measures
The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention
Summary
Despite the extensive interest in lean approaches in healthcare [1,2,3] there is a shortage of evidence about the impact and execution of such initiatives [4,5,6]. The strong current focus on patient safety in healthcare has resulted in interest in using systems improvement approaches such as lean to enhance the safety of clinical work processes. The objective of this study was to evaluate the use of a light-touch intervention based around limited lean training to improve in-theatre performance and clinical outcome in orthopaedic trauma surgery. This intervention was performed as part of a multi-site research programme (Safer Surgical Services—S3), whose aims were to compare the effectiveness of safety and quality interventions in surgery based on improving safety culture with those based on improving systems of work, and to determine whether using both types together had an additive or synergistic effect. Each study tested the effect of a different intervention or combination of interventions
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