Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon.
Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
Oper Neurosurg (Hagerstown). 2018 Sep 1;15(3):332-340. doi: 10.1093/ons/opx289.
Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed.
To apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases.
Process maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability.
Temporal variabilities in duration of decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and instrument defects accounted for 15% and 66% of all waste, respectively.
This pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.
提供更高价值的医疗服务是政府和公众的最终目标。通过标准化手术步骤来提高效率，可以改善患者的治疗效果，降低成本，并实现更高价值的医疗服务。精益原则和方法已经提高了围手术期医学的及时性；然而，手术本身的流程映射尚未完成。
应用计划-执行-研究-行动（PDSA）循环方法，使用精益原则对腰椎后路器械融合（PIF）进行改造，创建标准工作流程，确定浪费，消除术中变异性，并检验试点病例的可行性。
由一名机构内的神经外科教员通过 PDSA 循环创建了 5 例 PIF 手术的流程映射。计划，将 PIF 模块化到基本组件中；执行，映射和计时组件；研究，分析结果；行动，确定浪费。创建了浪费清单、 spaghetti 图和每个步骤花费的图表。为了比较不同的 PIF 步骤，对手术步骤进行了广泛定义，并使用箱线图和 whisker 图进行分析，以评估变异性。
减压与关闭和硬件与关闭的持续时间存在显著差异（P=0.003）。手术步骤持续时间的变异性以关闭时最小，暴露时最大。等待和器械缺陷等浪费分别占总浪费的 15%和 66%。
本试点系列表明，精益原则可以标准化手术工作流程并确定浪费。尽管时间和劳动力密集，但精益原则和 PDSA 方法可以应用于手术步骤，而不仅仅是围手术期。
