Systems science is the study of how component parts of a system interact with each other. It may seem counterintuitive to consider that medical care and systems science are linked, but in fact the component parts of a care cycle are infinitely complex. An in-patient admission for a patient receiving back surgery involves a single hospital, many different practitioners from multiple different departments: radiology, pathology, pharmacy, rehabilitation, surgery ad infinitum, all with individual processes, inefficiencies, and errors. Scaling this example up (or down) just reveals increasing system complexity: this in-patient admission is a single hospital among many different institutions, even within a city, and many more across the state. The state’s medical care lies within a larger network of similar regional states and, ultimately, within the massive medical system of the United States.
According to the Centers for Medicare & Medicaid Services, the health share of United States GDP in 2016 was 17.9%. This equates to $3.3 trillion, or $10,348 per person. The health share of GDP is expected to grow to 19.7% by 2026. The Institute for Healthcare Improvement has promoted the so called Triple Aim, a mission to improve population health, improve patient experience of care, and reduce per capita cost of health care. These ambitious goals have inspired a national culture of continuous quality improvement. The goal is not simply cost reduction but is instead improved value of healthcare; this means improving patient outcomes while decreasing cost.
There is no simple answer to blunt the rising cost of US healthcare, but by focusing on small parts of this complex system, we can create meaningful change.
A main process improvement tool used by medical practitioners to improve the value of healthcare is Lean production and was adapted from the Toyota Motor Corporation. Lean production philosophy is simple; it empowers all individuals contributing to a process to identify potential intrinsic waste and eliminate it while optimizing the product. The mechanism of improvement follows a Plan/Do/Study/Act cycle:
Plan phase, a problem or process that needs improvement is identified.
Do phase, the process is observed and measured to identify wasteful and valuable components. The process map is used at this stage to define valuable and wasteful component steps.
Study phase, the process is analyzed and component steps are determined to be valuable or wasteful.
Act phase allows for process improvement by enacting strategies or solutions to minimize wasteful or non-value added steps
Lean principles have been very effective in decreasing inefficiencies in mass production. Factories and assembly lines are designed to minimize time and material waste. For example, installing a door onto the vehicle prior to finishing the interior would be a source of waste, as workers would be constantly opening and closing the door to install parts into the interior of the car. Similarly, Lean principles have been used in the surgical realm to enhance perioperative efficiency by improving the punctuality of on-time first start morning cases and decreasing turnover time between surgical cases. Surgical workflows themselves have classically been thought to be resistant to standardization. Surgeons have been traditionally viewed as independent entities that cannot or are unwilling to be modified.
We decided to apply Lean principles to a heterogeneous set of low back spinal fusion surgeries to see if process improvement was possible in this paradigm. We chose these procedures because these are very common neurosurgical procedures performed in the US. Between 2001 and 2011, the number of spinal fusion surgeries increased from 288,000 per year to 488,000 per year (a 70% increase). This trend continues to this day.
We began in the Plan phase by creating a process map where we defined similar modular steps within each surgical procedure. This included the surgical exposure, discectomy/decompression (removing the intervertebral disc or removing parts of the bone which are causing symptomatic compression of nerves), hardware placement, and surgical closure. The Do phase involved tracking the time and waste for each modular step. In the Study phase, we analyzed these results, and in the Act phase we implemented improvement strategies.
Operating room efficiency is a natural target for process improvement aimed at improving the value of care overall. The operating room is a system within itself; nurses, students, technicians, anesthetists, and surgeons all work together to provide the best care they can. Despite best intentions, every system has inefficiencies which can be improved upon to lower cost. It often takes a shift in the organizational culture for individuals to identify wastes and enact meaningful change. Increasingly, comparative data benchmarks medical care among competing systems. This consumer transparency has become a main driver of iterative process improvement. Adopting Lean principles is straight forward, even when applied to neurosurgical procedures, and will facilitate all healthcare providers and caregivers to deliver the highest value healthcare. There is no simple answer to blunt the rising cost of US healthcare, but by focusing on small parts of this complex system, we can create meaningful change.
Featured image credit: Operating by Piron Guillaume. CC0 via Unsplash.