Search results

Health care institutions in many Western countries have developed preoperative testing and assessment guidelines to improve surgical outcomes and reduce cost of surgical care. The aims of this chapter are to (1) summarize the literature on the effect of preoperative testing on clinical outcomes, efficiency, and cost; and (2) to compare preoperative testing guidelines developed in the United States, the United Kingdom, and Canada.

We reviewed the literature from 1975 to 2014 for studies and preoperative testing guidelines.

We identified 29 empirical studies and 8 country-specific guidelines for review. Most studies indicate that preoperative testing is overused and comes at a high cost. Guidelines are tied to payment only in one country studied. This is the most recent review of the literature on preoperative testing and assessment with a focus on quality of care, efficiency, and cost outcomes. In addition, this chapter provides an international comparison of preoperative guidelines.

This paper aims to determine the one‐year incidence of, and risk factors for, perioperative adverse events during in‐patient and out‐patient anesthesia‐assisted procedures.

A quality assurance database was the primary data source. Outcome variables were death and the occurrence of any adverse event. Risk factors were ASA physical status (PS), age, duration and type of anesthesia care, number of operating rooms running, concurrency level and medical staff. Data were stratified by in‐patient or out‐patient, surgical (e.g. thoracotomy) or non‐surgical (e.g. electroconvulsive therapy), and were analyzed using Chi square, Fisher's exact test and generalized estimating equations.

Of 27,970 procedures, 49.8 percent were out‐patient and greater than 80 percent were surgical. For surgical procedures, adverse event rates were higher for in‐patient than out‐patient procedures (2.11 percent vs. 1.45 percent; p<0.001). For non‐surgical procedures, adverse event rates were similar for in‐patients and out‐patients (0.54 percent vs. 0.36 percent). The types of adverse events differed for in‐patient and out‐patient surgical procedures (p<0.001), but not for non‐surgical procedures. ASA PS, age, duration of anesthesia care, anesthesia type and medical staff assigned to the case were each associated with adverse event rates, but the association depended on the type of procedure.

In‐patient and out‐patient surgical procedures differ in the incidence of perioperative adverse events, and in risk factors, suggesting a need to develop separate monitoring strategies.

The paper is the first to assess perioperative adverse events amongst in‐patient and out‐patient procedures.

The purpose of this paper is to determine the impact of having a patient-designated caregiver remain overnight with ambulatory extended recovery patients on early postoperative clinical outcomes.

This was a retrospective cohort study of patients undergoing surgery requiring overnight stay in a highly resourced free-standing oncology ambulatory surgery center. Postoperative outcomes in patients who had caregivers stay with them overnight were compared with outcomes in those who did not. All other care was standardized. Primary outcomes were postoperative length of stay, hospital readmission rates, urgent care center (UCC) visits within 30 days and perioperative complication rates.

Among patients staying overnight, 2,462 (57 percent) were accompanied by overnight caregivers. In this group, time to discharge was significantly lower. Readmissions (though rare) were slightly higher, though the difference was not statistically significant (p=0.059). No difference in early (<30 day) complications or UCC visits was noted. Presence of a caregiver overnight was not associated with important differences in outcomes, though further research in a less well-structured environment is likely to show a more robust benefit. Caregivers are still recommended to stay overnight if that is their preference as no harm was identified.

This study is unique in its evaluation of the clinical impact of having a caregiver stay overnight with ambulatory surgery patients. Little research has focused on the direct impact of the caregiver on patient outcomes, especially in the ambulatory setting. With increased adoption of minimally invasive surgical techniques and enhanced recovery pathways, a larger number of patients are eligible for short-stay ambulatory surgery. Factors that impact discharge and early postoperative complications are important.

In Japan, health-care systems have long been supported by physicians' long working hours. To solve this problem, there is an urgent need to improve the working environment for physicians while practicing patient-centered medicine and controlling health-care costs. This paper aims to examine the effect of task shifting to nurses and discuss its usefulness from the perspective of health-care value co-creation.

This paper analyzes task shifting to nurses in acute care hospitals in Japan as a solution for the shortage of anesthesiologists. The authors discuss how the value was created from the perspective of the health-care ecosystem, with conceptual consideration of the value co-creation mechanism through patient-centered practices.

The study showed that task shifting initiatives in Japan can improve the motivation of nurses through human resource development while maintaining high quality. The study also suggested that task shifting from physicians to nurses may contribute to improving net income and maintaining the health-care system.

The findings are highly reproducible and can be immediately applied to initiatives at other medical institutions in Japan. Furthermore, it is suggested that these findings might provide some perspective on the realignment of fragmented healthcare in the USA.

It was confirmed in practical terms that micro-level initiatives have an impact on the macro level as well. In addition, the academic presentation of the concept has contributed to the deepening of value research.

Purpose – This paper focuses on efficiency as a central theme of the Italian health care reforms, combining macrolevel policies with microlevel (i.e., operating room) perceptions of the concept.

Design/Methodology/Approach – According to the phenomenographic approach, this analysis investigates how the components of a surgical team (22 semistructured interviews) experience efficiency in their daily workflows.

Findings – The main findings show that the concept of efficiency is multidimensional. According to participants’ perspective, several categories of efficiency collected in an outcome space emphasize an holistic view of efficiency driving health policies and strategies.

Social implications – The suggestion of further relationships between perspectives and other constructs (i.e., quality, safety, patient focus, process) at micro and macro level could enhance the impact of health reforms.

Originality/Value – A qualitative approach conducted at microlevel help to recognize the phenomenon (of efficiency), engaging the individual conception that practitioners have of the health efficiency.

The best treatment for femur fractures is the surgical one within 48 h from the admission to the hospital. These fractures have serious consequences, both in terms of morbidity and socio-economic impact. In the hospital A.O.R.N. Cardarelli of Naples in Italy, the mean pre-operative length of hospital stay (LOS) was nine days and just 4 per cent of patients was operated within the suggested time. Therefore, a diagnostic-therapeutic-assistance path (DTAP) was implemented to improve the process.

This paper analyzes two groups of patients (534 and 562, respectively) before and after the introduction of DTAP, through six sigma (SS) based on define, measure, analyze, improve and control cycle. Age, gender, American Society of Anaesthesiologists (ASA) score, cardiovascular diseases, diabetes and allergies were used as independent subgrouping variables. The t-tests and chi-square were performed to compare the groups, tools of SS were used.

The analyses were conducted considering overall patients and some subgroups. The overall reduction in LOS was about 54 per cent, patients without cardiovascular diseases and with a low ASA score had the highest reduction, more than 60 per cent. All the p-values proved a high statistically significant difference between the two groups.

The influence of the Italian health-care system is a minor limitation while, unfortunately, the lack of a follow-up did not allow quantifying the real gain in health of patients. A lean thinking analysis would suit this context.

There are practical advantages for both hospital and patients: the hospital will have an increase in admissions and more beds available, while patients will benefit of a faster intervention and a shorter wait.

This is the first analysis through SS of DTAP showing its positive influences in terms of both socio-economic impact and patients’ outcome. Policy leaders could use this study as an example to evaluate the introduction of the same clinical pathway in other health facilities.

The purpose of this paper is to demonstrate that nurse led discharge (NLD) could improve the efficiency of simple discharges from a short stay surgical ward without compromising patient safety.

A protocol for NLD was designed and implemented. Introduction of the protocol was audited and re-audited prospectively.

Introduction of the nurse led discharge protocol significantly reduced the rate of delayed discharge (p>0.001). The protocol successfully identified all patients for whom a NLD would be inappropriate and no patients discharged by the nursing team were re-admitted.

No formal measure of staff and patient satisfaction with the new protocol was performed.

The nursing team are now able to more effectively manage patient flow through the short stay surgical ward. Mismatch between demand for beds and capacity has reduced.

Patient experience has been improved by the release of time to care for our nurses and the elimination of unnecessary delay in discharge.

Formal protocol driven NLD can be a safe way of improving efficiency in patient flow. This pattern of discharge could be applied in many hospital systems.

Different surgical services demand operating rooms (OR) to treat elective patients, each competing for a limited supply of OR time. The purpose of this paper is to obtain empirical measures of performance in the management of OR. The current research compares technical efficiency of 11 specialties in elective operating theatre of Alzahra Hospital in Isfahan, Iran in autumn of 2009.

Data envelopment analysis (DEA) can be used as tools in management control and planning. First, the input oriented and variable returns to scale model of DEA technique has been applied and separate benchmarks for possible reductions in resources used has been derive, and significant savings are possible on this account.

The efficiency scores of inefficient specialties are between 0.62 and 0.96. Neurosurgery and general surgery are the best and the worst units. DEA results determine by how much hospitals can increase elective inpatient surgeries for each specialty.

The originality of this study is to obtain empirical measures of performance in the management of OR. DEA has not been applied to measure the efficiency of different department in an organization. The measures are common in different units and have been collected in a similar way.

Workplace voice is well-established and encompasses behaviors such as prosocial voice, informal complaints, grievance filing, and whistleblowing, and it focuses on interactions between the employee and supervisor or the employee and the organizational collective. In contrast, our chapter focuses on employee prosocial advocacy voice (PAV), which the authors define as prosocial voice behaviors aimed at preventing harm or promoting constructive changes by advocating on behalf of others. In the context of a healthcare organization, low quality and unsafe patient care are salient and objectionable states in which voice can motivate actions on behalf of the patient to improve information exchanges, governance, and outreach activities for safer outcomes. The authors draw from the theory and research on responsibility to intersect with theories on information processing, accountability, and stakeholders that operate through voice between the employee-patient, employee-coworker, and employee-profession, respectively, to propose a model of PAV in patient-centered healthcare. The authors complete the model by suggesting intervening influences and barriers to PAV that may affect patient-centered outcomes.