Enhancing surgical care

• “Dr Bugis, there are no inpatient or overnight beds. We can do the day-care hernia case while we sort it out. Just in case, which one of your patients has to be done and which ones can be cancelled?”

• “Dr Bugis, we probably will be a little late starting today. Dr Neverstarts­ontime is putting in a central line, an epidural, an arterial line, and doing a nerve block on your first patient. I hope we get all your cases in.”

• “Dr Bugis, your elective cholecystec­tomy took much longer than the scheduled time. We don’t have enough staff to stay beyond 1530 hours. If you can guarantee that you will be finished on time, we can start your last case.”

After 20 years in surgical practice as a general surgeon, it was easy to provide these examples of the challenges to patient care that are faced too often in too many operating rooms around BC. Despite the complexity of running an operating room (OR), most patients are provided with the highest quality of surgical care most of the time. 

As the population ages and as surgical skills and technology advance, there is more and more pressure on the system to perform. Add to this the challenge of cost containment and, indeed, it is time to make certain that quality, safety, efficiency, and access are not only maintained, but improv­ed, so that patients receive the care they need.

The Council on Health and Economic Policy (CHEP) of the BCMA addresses these issues in its new policy paper titled “Enhancing Surgical Care in BC: Improving Perioperative Quality, Efficiency and Access.” It discusses preoperative preparation of the patient, OR scheduling, start time and changeover times, post anesthesia recovery, beds, and discharge planning.

The CHEP paper recognizes the important link between quality and efficiency. Improved quality can mean improved efficiency. Therefore, the document supports the use of the surgical safety checklist and the National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons. 

It is also understood that improved efficiency means improved quality. Appropriate assessment of the patient before surgery, accurate scheduling, attention to equipment and technology requirements, on-time starts, and streamlined changeover times all impact how well the slate goes on a particular day and how many cases may get postponed or cancelled. These factors impact outcomes and quality. They also impact patient and provider satisfaction.

The recommendations also discuss establishing a provincial framework with standardized measures and goals, tailored to each institution. Then, the most crucial step in this process is identifying local surgeons and others on the team and providing them with time, training, resources, and authority to make changes. These changes might range from changing an entire culture of inefficiency to altering small details of a specific process. Measuring the outcome of the change must be part of the initiative.

As chair of the CHEP project group for this policy paper, I have struggled with the approach that we need yet another committee to im­prove OR efficiency. Why can’t we just fix it? Starting on time should not be so difficult. Yet, in over 20 years, I have not found a reliable way to make that happen, to provide care to everyone who was supposed to get it, or to get that short emergency case done during the day. 

There are examples in BC and elsewhere of successfully improving efficiency. We should learn from them. Still, there are many inefficiencies, bottlenecks, and challenges that exist. I think it is time to try a structured, objective approach to OR quality and efficiency that identifies, evaluates, and measures the problems and the solutions and that is funded properly to allow implementation. 

I would em­phasize that the key to these recommendations is the identification and participation of local physicians, nurses, and others who know the institutions where they work and the patients that they serve.

The CHEP paper is available on the BCMA’s website: www.bcma.org/publications-media/policy-statements-papers. 
—S. Bugis, MD
Chair, BCMA Surgical Care Project Group