P. K. Rao1, A. J. Cunningham1, M. C. Boulos1, D. Kenron1, P. Mshelbwala2, E. Ameh3, S. Krishnaswami1 1Oregon Health And Science University,Department Of Surgery,Portland, OR, USA 2University of Abuja-Teaching Hospital,Department Of Surgery,Gwagalada, FCT, Nigeria 3National Hospital,Department Of Surgery,Abuja, FCT, Nigeria
Introduction: Lean healthcare methodology is frequently utilized in high income settings to maximize capacity and operational efficiency during process improvement (PI) initiatives. However, the utility of PI for healthcare in low and middle income countries (LMIC) has not been well studied. Operating theaters in LMIC are often characterized by high cancellation rates and delays resulting from suboptimal theater space, prolonged turnover times, and limited surgical workforce. In order to study the applicability of lean methodology in LMIC, a comprehensive pilot program was developed in 2017 to promote sustainable operating theater efficiency at two hospitals in Abuja, Nigeria.
Methods: Perioperative committees were established at both institutions, a primary-tertiary center and a quaternary referral center, to evaluate current processes, identify problems therein, and compile a list of priorities. A physician champion and a PI specialist in conjunction with local physician-partners held a workshop to address these priorities in December 2017 as part of an ongoing collaboration. The workshop was designed to teach practical applications of PI methodology, including process mapping, value stream thinking, and root cause analysis to nurses, surgeons, anesthesiologists, and administrators. Pre- and post-workshop surveys were administered to assess perceived benefit, and compared with a chi-square test of independence.
Results: In total, 42 individuals attended the PI workshop. 26/42 (62%) completed a pre-workshop survey, and 31/42 (74%) completed the post-workshop survey. Pre-workshop, 10 respondents (38.5%) believed a process improvement workshop would be valuable for them as individual providers, and 11 (42.3%) saw its value for the perioperative committee. After the workshop, all 31 respondents reported the workshop as valuable both personally and for the perioperative committee (p < 0.001), and all reported that PI methodology could benefit the institution overall. Workshop components identified as most valuable were development of quality improvement tools (52%), and fostering of team culture (36%). The most frequently listed barrier to PI implementation was the institutions’ ability to sustainably apply the concepts learned (40%). Outcomes from the workshop led to development of block time utilization measurements, optimal staffing and avoidable-delay dashboards, and workflow diagrams to track trends and improve perioperative care.
Conclusion:
Lean methodology may be more applicable in lean settings than previously recognized. All respondents noted that PI techniques have potential to improve operational efficiency. This could be of even greater relative benefit in such severely resource-constrained environments. Interval measurement of outcome data is planned at 1 year. Sustainability will be facilitated by telementoring, and future efforts include expansion beyond the perioperative setting to inpatient wards and outpatient clinics.