Introduction: Attending surgeons have concurrent obligations to deliver high quality health care and train residents (1,2). In modern healthcare, lean principles are increasingly being applied to the processes preceding and following surgery (3,4). However, surgeons have limited data regarding variability and waste during a given operation (5). We measured this variability, using a key functional neurosurgery procedure: microvascular decompression (MVD) for treatment of trigeminal neuralgia. We also correlate variability with surgeons’ perceptions of risk and comfort, and aim to guide surgeons as they balance operative efficiency with training obligations.
Methods: We applied Plan, Do, Study, Act (PDSA) cycles to MVD. We created a standard workflow diagram, segmenting the basic components of the surgery (Figure 1). We timed these components for 15 operations, focusing on variation and wasted time. Concurrently, we administered a survey regarding surgeons’ perceived comfort and risk for each component. This was IRB approved. Statistical analysis was completed in R.
Results: The surgical components in Figure 1 were timed. Craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation (Figure 2). Waste inventory showed a median wasted time of 3 mins (range 0-20 mins). There was a statistically significant relationship between increasing level of training and increasing perception of safety (Figure 3). We also show the relationship between assessment of danger and variability in duration for each component of the surgery.
Conclusions: Using a PDSA cycle and risk-matrix analysis, we identified components of high variability and quantified waste within a key neurosurgical procedure. We have also shown significant differences in perception of comfort and risk across training levels. Danger zones and highly variable components are targets for interventions to improve trainee comfort and operative efficiency.
Patient Care: We have developed and demonstrated use of a tool to identify aspects of waste and high variability in neurosurgical procedures. Once waste and variability are identified, value can be increased. This tool can be applied with the goal of increasing the value of health care without compromising resident education.
Learning Objectives: By the conclusion of the session, participants should be able to
1) describe application of a PDSA cycle to evaluate efficiency in neurosurgical procedures
2) create a survey for obtaining resident self-assessment of surgical steps
3) describe how to correlate perceived comfort and risk with efficiency of a given component of a surgery.
References: 1. Bakaeen FG et al. Does the level of experience of residents affect outcomes of coronary artery bypass surgery? Annals of Thoracic Surgery 87(4):1127-33, 2009.
2. Bridges M and Diamond DL. The financial impact of teaching surgical residents in the operating room. The American Journal of Surgery 177: 28-32, 1999.
3. Skeldon SC et al. Lean methodology improves efficiency in outpatient academic uro-oncology clinics. Urology 83: 992-8, 2014.
4. McLaughlin N et al. Time-driven activity-based costing: a driver for provider engagement in costing activities and redesign initiatives. Neurosurg Focus 37: 1-9, 2014.
5. McLaughin N et al. Value-based neurosurgery: measuring and reducing the cost of microvascular decompression surgery. J Neurosurg 121: 700-8, 2014.