A dedicated pediatric operating theatre : a good idea?

A dedicated pediatric operating theatre:

a good idea?

Company project MBA health care, ABS

Student: Lideke van der Steeg, 10733558

Supervisors: Prof dr J de Mast, ABS & drs D Cornelisse, AMC

Contact details:

a.vandersteeg@vumc.nl

Executive summary

The two academic medical centers of Amsterdam have the intention to merge.

Introduction

This intended alliance includes the creation of Woman-Child-Healthcare Center(WCHC). A research question concerning the WCHC is whether it is worthwhile to establish a dedicated pediatric operation room complex.

This question has two elements. First is the quality of care element: does a

Methods

dedicated pediatric operation room complex (OR) contribute to better quality of care? This question was assessed using structured interviews with the heads of the ORs of all academic medical centers in the Netherlands (n=8). The second element is the efficiency of the

operating rooms (OR): does the efficiency of the OR change if pediatric programs for all children are organized? This question was assessed using measurements at the OR using the presence of children on the operating program as a defining item.

The structured interviews showed a variety in actual organization of the ORs.

Results

However, several managers who did not have dedicated pediatric ORs expressed the wish to organize this. The basis for this wish invariably was the perceived need to concentrate these potentially difficult cases in their hospital, and the wish to increase the opportunity for pediatric anaesthetists to concentrate on their core business. The learning curve theory mentioned in both medical and management literature showed evidence in favour of concentration of certain patients or certain patient problems for dedicated teams. The measured programs showed significant differences on the individual level between children and adults with regard to turn-over-time and estimated anaesthesia time. In

addition, there were trends towards different results concerning pediatric, adult or mixed (at least one planned child in the schedule) programs. Programs with at least one child planned had a lower utilization percentage and the length of pediatric surgeries appeared more difficult to predict.

Both the interviews and the data showed that concentration of pediatric

Conclusion

surgeries in a dedicated pediatric operation room complex is worthwhile. Based on medical literature it will most likely result in an increase in quality of care and a decrease of

complications. And based on the measured data it will increase the efficiency of the OR at least for the adult surgeries.

Table of contents

Executive summary

2

Table of contents

3

I Introduction

5

I.A Background 6

I.B Current developments 8

I.C Research question 9

II Framing

12

II.A Introduction 12

II.B Quality of care 12

II.C Learning curve theory 16

II.D Efficiency 17

III Case description

21

III.A Define 21

III.A.1 Study design and CTQs 21

III.A.2 Measurements 22

III.A.3 Definitions 23

III.A.4 Statistics 24

III.B Measure 25

III.B.1 Interviews 25

III.B.2 Measurements in the OR 28

III.C Analyze 32

III.C.1 Hypothesis 1 33

III.C.2 Hypothesis 2 36

III.D Improvements 38

IV Critical Reflection

39

IV.A Process Management 39

IV.B LSS/DMAIC 39

IV.C Quality of Care 40

V Conclusions and suggestions for possible improvements

42

References

44

Appendices

46

Appendix 1: analysis of the current performance 46 Appendix 2: dedicated pediatric OR flowdown 47 Appendix 3: questions structured interviews 53 Appendix 4: CTQ flowdown for efficiency 55

I Introduction

The VU University Medical Center (VUmc) and the Academic Medical Center (AMC) are two academic medical centers located within the city of Amsterdam. About 3 years ago these two centers have expressed the intention to fuse. Most preferably a completely new Academic Hospital including research and education for 2 universities is created. However, this is a very costly proposal and so far finances are not sufficient. Therefore, this one new academic center is now stated to be the ultimate wish for the future and for now the two hospital boards have decided to keep the two locations but with a distinct profile per location.

One of the proposed changes in profile is that one of the two locations will have a Woman-and-Child-Healthcare-Center. This means an influx of women and children and their care, including an influx of pediatric surgical cases. With this in mind one of the questions posed by the steering group of the fusion with regard to the planning of the new profiles is

Is it worthwhile to establish a dedicated pediatric operation room complex?

This question forms the basis of this thesis.

The outline of the thesis will be as follows:

first the organisation of the two hospitals with regard to their operating theatre will be explained. In the medical literature the term operating room and operating theatre are used next to each other and both stand for the whole complex of individual operating rooms and the surrounding facilities. In addition the term operating room is also used to address a single room for surgery within the whole complex. From now on we will use the abbreviation OR when the entire operating theatre is meant, either dedicated pediatric or for both

children and adults. When an individual operating room is meant the term will be written in full.

After this background sketching the importance of the research question and the possible motivation behind the question will be examined. Furthermore the importance of an OR for any hospital will be highlighted. Next the methods used to assess the motivations behind the

research question will be addressed. Measurements, analysis and interpretation of results will be next, followed by a discussion and suggestions for implementation.

I.A Background VU medical center

The VUmc is a full-facility tertiary referral academic medical hospital in Amsterdam. It houses all medical specialties, has 5 research institutes and harbours students and interns from the VU university and residents in all medical specialties. It is the home-base of the life liner 1, a medical rescue helicopter and has a newly built emergency department. In addition it has 2 ORs. The first one contains 6 operating rooms and is primarily used for day care surgery and ‘smaller’ surgical specialties such as Ear Nose Throat surgery (ENT) and pediatric surgery. There is a separate pediatric recovery and the day care ward that is connected to this OR has a separate pediatric room. The second OR is located on the sixth floor. It consists of 10 operating rooms, including specialized rooms for endoscopic surgery, neurosurgery, robotic surgery and cardiothoracic surgery. It is recently renovated and has a hypermodern recovery with the possibility to ventilate patients for the first 24 hours post-operatively (high-care facilities). The recovery has no dedicated pediatric area, but has separate recovery rooms for patients and can designate one or more rooms for children.

All surgical specialties use both these ORs although some have dedicated rooms that are used preferably also in on-call hours.

In the VUmc pediatric surgery, pediatric urology and pediatric orthopaedics have programs with only children planned on it. However, occasionally in the pediatric orthopaedics schedule an adult may be planned as well if there are not enough children to complete the planning for the day or if an adult patient is more urgent. ENT, neurosurgery, reconstructive-and-cosmetic surgery (RCS), ophthalmology, facial surgery and occasionally gynaecology tend to plan their pediatric patients mixed with adults in one program. All children under the age of 6 years of age or with a complex medical history or undergoing complex surgery will be treated by pediatric anaesthetists. Children over the age of 6 without additional

In addition to the children on the OR there are also several locations outside the OR where children may require anaesthesia, for instance the MRI or CT-scans under sedation. On these locations anaesthesia for children is usually administered by pediatric anaesthetists.

When a program has children and adults scheduled the pediatric anaesthetist will complete the whole program. After hours the anaesthetist on call will have a pediatric colleague readily available for emergency pediatric surgeries.

Academic Medical Center

The AMC is also a full-facility tertiary referral academic medical center in Amsterdam. It is connected to the medical faculty of the University of Amsterdam. It has a large research institute called the AMC Medical Research (AMR) and harbours all medical specialties. The AMC has an official partner hospital, the Flevo hospital in Almere. Part of the secondary care (low-complex/high-volume care) is outplaced to this hospital and the medical professionals work together in both hospitals.

The AMC has a recently renovated OR which consists of 20 operating rooms located on the first floor for clinical care and 5 operating rooms on the main floor for day care and minor clinical procedures. Some rooms are specifically dedicated for certain specialties, such as the microscope for ophthalmology is in one operating room and two rooms are assigned for cardiothoracic surgery.

There are 2 recovery departments. The large recovery on the first floor has a separate pediatric unit. The smaller recovery located on the main floor does not have a separate pediatric area.

Pediatric surgery and pediatric urology are the two surgical specialties who have pediatric programs, all other specialties who treat children and adults have mixed programs with children and adults in one schedule. All children under the age of 1 year or with a complex medical history or who need to undergo complex surgery are treated by pediatric

anaesthetists. Patients over the age of 1 may be treated by ‘general’ anaesthetists. Also in the AMC anaesthesia is given on locations outside the OR, for instance on the intervention rooms of the radiology department. When it concerns paediatric anaesthesia on these outer locations anaesthesia is usually administered by pediatric anaesthetists. Recovery of these patients takes place on the recovery department of the OR or in a small area nearby the intervention room.

The recovery nurses can always consult a responsible anaesthetist in case of problems. In the case of children this will be either the pediatric anaesthetist who has given the anaesthesia during surgery or the responsible anaesthetist for the recovery.

Both the planning systems in AMC and VUmc work with a block planning approach, meaning that the different surgical specialties have dedicated OR-time they can fill with their own patients. These block hours are divided among the specialties at the beginning of the year and only in extreme circumstances block hours will be reassigned. If a specialty treats both adults and children they usually plan them according to the urgency of treatment and according to their position in the waiting list. This means that there are mixed programs (a day program with both children and adults), pediatic programs and adult programs.

I.B Current developments

Due to political development, but also because of the prospect of decreasing funding for health care VUmc and AMC have started negotiations concerning a merger of the 2

hospitals. The most important motivation for this merger is to reach more excellence in the three academic tasks being health care, research and education. However, it cannot be denied that limited funding and the necessity the reorganize health care as a whole and especially the more expensive health care in tertiary centers was also an important reason to examine the possibilities of fusion.

When asking the employees of both hospitals about the intended fusion most of them respond a bit anxious: ‘what will happen to my job?’ ‘I specifically choose for one of the two and what happens now?’ etc etc. The intended end goal of the fusion is a new hospital in which both AMC and VUmc can completely merge. This would lead to the largest academic hospital in the Netherlands and would create immense potential for innovation in health care and research. However, building such a new hospital will be a very costly operation and currently there is not enough funding to be found with neither the ministry of Health Care nor with the health care insurances. Thus, the two executive boards of AMC and VUmc have decided to continue with the fusion but for now create one hospital (University Medical Center of Amsterdam; UMCA) on two locations. Both locations will get a distinct profile. In the profile of the AMC it is intended to create a Women and Child Health Care Center

pediatric subspecialties with a sufficient number of medical specialists to not only be a center of excellence for health care but also become a center of excellence in several areas of pediatric research. Concerning surgical care of children it is intended that all children of both AMC and VUmc will have their surgeries in the WCHC.

I.C Research question

Currently both VUmc and AMC have several pediatric wards in the hospital. Within the AMC these wards are united within its pediatric hospital, the Emma Children’s Hospital. This will also become the name of the WCHC. It is the intention of the alliance steering group that the Emma Children’s Hospital will have all facilities necessary for excellent care for women and children. This implies that although it is not a stand-alone clinic such as the academic pediatric hospitals in Utrecht and Rotterdam, the Emma Children’s Hospital will function as a hospital within a hospital and will only use those facilities of the AMC that are either too expensive or too rarely used for single use by only the Emma Children’s Hopsital. Because of these developments it is not strange that the steering group would also be interested in the possibilities of a dedicated pediatric OR for the Emma Children’s Hospital. This pediatric OR would then be located within the current OR and would thus function as ‘an OR within an OR’. Thus the research question for this company project:

Is it worthwhile to establish a dedicated pediatric operation room complex?

To be able to answer the question whether a dedicated pediatric OR is wise it is first important to realize the value of an OR for a hospital.

An OR is usually one of the largest contributors to hospital finances and in general also one of the most costly units of the hospital (Cima, Brown, Hebl et al., (2011)), some authors even state that over 40% of the revenues of a hospital come from the OR (Peltokorpi (2011)) and about 60% of all patients admitted to a hospital are (partially) treated in the OR (Eijkemans, van Houdenhoven, Nguyen et al. (2010)). Very often the financial success of hospitals, and especially of a tertiary referral center with complex cases, depends on effective utilization of the OR (Young (2004)). This makes it worthwhile to focus on how the OR is functioning. In addition to these financial arguments it is known that both patients and staff are bothered

by inefficiency in the organization of the OR. Delays are inconvenient, they lead to last minute cancellations of surgeries and decrease quality of care for patients, and decrease of work-satisfaction for the staff (Sohrakoff, Westlake, Key et al. (2014)). Thus both patients and staff may profit from more efficiency.

However, Cima et al. (2011) state that the “greatest challenge for high-efficiency OR environment is accounting for variability in patient problems, operation types, and unexpected events that occur in any surgical practice”.

An important contributor to the variability may be the differences between adults and children. When meeting with OR personnel, anaesthesiologists, managers and surgeons the common denominator concerning pediatric surgeries is that it takes longer to perform such surgeries compared with adult care. The general feeling is that children (and their parents for that matter) require more time to put them at ease, all personnel tends to take things slower (or so it is perceived) and that the whole process goes at a slower pace. In addition the feeling is that programs with children on the schedule are more instable in the sense that due to coughs or other children-related illnesses more children are cancelled at the last minute leading to open spaces in the program. And some people express the idea that pediatric surgeries are more difficult to predict time-wise both due to unforeseen surgical events, but also due to the anaesthesia which may take more time compared to the same packages in adults.

The first hypothesis for this study is that the efficiency of the OR is influenced by a higher variability in operating- and non-operating time in children compared to adults.

However, there may also be another rationale behind the project question.

The academic medical centers in Utrecht and Rotterdam have a stand-alone pediatric hospital. This implies that they also have dedicated pediatric ORs. The academic hospitals in Groningen and Nijmegen also have a dedicated pediatric hospital, though not stand-alone. Nijmegen has a dedicated pediatric OR within the all-round OR and Groningen has a very distinct strategy concerning pediatric surgeries. The AMC has a pediatric hospital within its walls (the Emma Children’s Hospital) but no clear strategy for its pediatric surgeries. However, it seems that parents expect more and more dedication and having a children’s hospital and in the near future an official WCHC may warrant a distinct strategy for the

surgical departments of this WCHC. It creates a positive image and can possible help in the marketing of the WCHC as ‘the best pediatric hospital of the Netherlands’ as is currently the slogan of the Emma Children’s Hospital.

An argument for dedication may be that dedication leads to increasing quality of care, since the pediatric surgeries will be concentrated among a more limited number of medical professionals within the general OR. Thus these employees will be(come) more experienced which may lead to increased quality of care and less per- and postoperative complications.

So the second hypothesis of this project is: a dedicated pediatric OR influences quality of care.

II Framing

II.A Introduction

The purpose of this chapter is to clarify the theories and methods that are used to assess the research question.

In order to get helpful results and to complete a company project correctly it is essential to consider the project management. The first step in project management is deciding which research methods are needed to assess the question. It is thus essential to look closely at the proposed question and to deduce the arguments pro and con in order to come to

measurable quantities that will determine which method to use. In the description of the research question in chapter 1 it becomes clear that there are essentially two sides to this question, being the efficiency part and the quality of care part. The theories mentioned in this chapter will also be divided along this line and quality care will be assessed first.

II.B Quality of care

To come to measurable quantities for the quality of care element of the research question turned out to be rather difficult. Quality of care is defined by the definition of the word quality. According to Slack, Brandon-Jones, Johnston and Betts (2012, Ch 12, p 388) “quality is consistent conformance to customers’ expectations”. It thus needs to be understood from the point of view of the customer since it is defined by the customers’ expectations and perceptions. This definition both includes the idea of quality as a specification (what the product or service can do) and the idea of quality as conformance, meaning there are no errors.

Because of the fact that ultimately the customer judges the quality it is important to consider his/her expectations. That means that the organisation needs to be aware of the perception-expectation gap (Slack et al. Sec Ed (2009, Ch 17). In figure 1 these gaps are shown in a model. The gap between the customers’ expectations and his perception can be explained by different gaps.

Figure 1: a perception-expectation gap model of quality

Source: Slack N, Brandon-Jones A, Johnston R, Betts A. Operations and Process Management. 2nd Ed. Ch 17, Figure 17.4; p. 539.

Even though much of the quality of the operating room process is specified in its design, these design details are not all useful in defining quality. This finds its cause in the fact that only the consequences of the design are perceived by the customers/patients. These consequences are quality characteristics and they can be measured (Slack et al. (2012)). These measurements fall apart in two groups: variables and attributes.

Variables have a continuously variable scale whereas attributes are assessed by judgement and are binary.

Table 1 shows the variables and attributed for the process in the OR. These variables and attributes can be measured for a dedicated pediatric OR, but just as well for a mixed OR (ie

surgical programs with children and adults in the same schedule) and results can be compared and may lead to improvement.

Table 1: variable and attribute measures for quality characteristics

Operating room program

Characteristic Variable Attribute

Functionality Number of programs that ended in overtime

Is overtime acceptable?

Appearance Number of operating rooms completely adjusted for the proposed customers (children or adults)

Are patients satisfied with how the operating room looks?

Reliability Proportion of ORs that had a good utilisation

Are all patients operated as planned?

Durability Number of times services at the OR are innovated or evaluated.

Is the operation schedule going as planned?

Recovery Proportion of last minute cancellations resolved satisfactory

Do patients / parents feel that the OR deals satisfactory with problems?

Contact The extent to which patients feel well treated by the OR-staff

Do patients feel well treated?

Another schedule to come to measurable quantities for quality is shown in figure 2. Figure 2:

This figure shows other measurable quantities compared to the quality characteristics such as proposed by Slack. However, if one would look at quality of care in the sense of freedom from deficiencies there are features that can be assessed, but they have to be assessed over a period of time and cannot be measured at the time the primary process (the surgical procedure) occurs.

The source of figure 3 is from Juran’s Quality Handbook 5th edition (Juran and Godfrey (1999)). It elaborates about the two definitions of Quality as they are proposed by Juran. The first definition concerns the features of the product and the satisfaction of the customer with the product. This has obviously a close relationship with the earlier definition as used by Slack that also emphasizes the importance of the perceptions of the customer. According to Juran quality increases when a product or a service gives more customer satisfaction. The second definition is about Freedom of Deficiencies and this concerns rework, less

complications etcetera. Aspects of both definitions are shown in figure 3. Figure 3:

Obviously freedom of deficiencies is a state to strive for. Although nobody denies that

deficiencies should not occur especially not when working with people it is not that simple to measure them, since in medicine and especially in surgery deficiencies do not always show

themselves during or immediately after the process. Therefore it is wise to look at constructs in the management of processes that may prevent deficiencies. One of these constructs is the learning curve theory.

II.C Learning Curve Theory

The basis for the learning curve theory can be found in the observations that repetitive tasks become easier with experience. When the same process is repeated without pause speed will increase and mistakes will lessen.

TP Wright (1936) developed the learning curve theory during his research in airplane

manufacturing in the 1920s and 1930s. He observed that building airplanes took less and less time once the workers had more experience.

After its use in manufacturing the learning curve theory also found its way in services and now in medicine. The volume-quality discussion is a good example. In most surgical specialties the medical professionals are convinced that if you would perform the same surgery several times during one day you would gain speed and the number of complications would decrease. Thus the definition of the learning curve.

Waldman, Yourstone and Smith (2003) have looked into learning curves in health care in general and they have concluded that although health care is not the same as manufacturing health care also exists for a large part out of processes that can be standardized and these processes may profit from repetition. They state that management processes and

organizational structures in health care improve through the application of research findings which is the basis of evidence based medicine.

The authors have proposed a flow diagram for learning in health care and this flow diagram shows that learning curves may result in the decrease of complications. This flow diagram is shown in figure 4.

Figure 4:

Source: Waldman JD, Yourstone SA, Smith HL. Learning curves in health care. Health Care Manage Rev, 2003 p43..

II.D Efficiency

Although learning curves and the theory behind it are a helpful structure to prevent or at least diminish complications and increase speed another item is efficiency in itself. Even when increasing speed through repetition it may be that the process contains waste and is not very efficient. Thus when analysing a process in health care efficiency deserves

The research question harbours an efficiency element: is efficiency of the surgical process influenced by the presence of children?

This implies that there are possible differences in the process efficiency between adults and children.

One of the possible methods to study these possible differences is LEAN Six Sigma (LSS). Both LEAN and Six Sigma methodologies are tools for quality improvement. They are both designed to improve efficiency and quality of a give process but from a different perspective.

Lean focuses on reducing waste and on only including steps in a process that are value-adding. It aims at synchronisation of supply and demand and uses methods such as ‘just-in-time’. The ultimate goal is achieving a flow of services and products that always delivers exactly what the customer wants or needs at the right time, at the right place for the lowest possible cost (Slack et al. Ch 11 (2012)). This implies that waste reduction is an important strategy and value adding is essential. Important in achieving the goals of lean is that every person in the process is involved and that everybody adopts or accepts the philosophy of continuous improvement.

Six Sigma is aimed at reducing variation in a process through the application of statistical methods. It is designed to achieve both continuous and breakthrough improvements in a process. The definition of Pande , Neuman and Cavanagh (2000) describes Six sigma as follows: “Six Sigma is a comprehensive and flexible system for achieving, sustaining and maximising business success. Six sigma is uniquely driven by close understanding of

customer needs, disciplined use of facts, data, and statistical analysis, and diligent attention to managing, improving, and reinventing business processes.”

Lean and Six Sigma have proven to be complementary and are now merged in a single strategy being LeanSixSigma (LSS) (DelliFraine, Langabeer and Nembhard (2010); de Mast, Does, de Koning and Lokkerbol (2012)). The participants in LSS projects have clear functions which have their own ‘titles’. As de Mast, Does and Erdmann (2015) have explained in their vision document the projects usually work ‘bottom-up’. The line-managers lead projects that aim to improve processes they manage. They are called green belts. The employees who participate in these projects are the yellow belts. Their function is constantly searching for

waste reduction and process improvement in their work-processes. In addition the management of the improvement project is organised top-down and is performed by the

black belt, who in his turn is supervised by the master black belt. He or she is the one with

the most experience in LSS and is able to manage and steer the different improvement projects that are done within a certain organisation.

The methodology LSS uses for projects is DMAIC. This approach consists of 5 phases being ‘Define Measure Analyse Improve Control’. Each phase has its own specific milestones that need to be completed. In DMAIC roadmap guides the project members (the

aforementioned Green Belts and Black Belts) through the project. It forces the members to ask the right questions, use the appropriate instruments and techniques and organize the results in an structured way. Each phase is broken down in two steps which are shown in figure 5.

Figure 5:

source: de Mast J, Does RJMM, de Koning H, Lokkerbol J. (2012) Lean Six Sigma for Services and Healthcare p37

The first step in LSS is to break the research question down into measurable quantities the so-called critical-to-quality characteristics (CTQ) (de Koning and de Mast (2007)). An often

used tool to do this is the CTQ flowdown. This flowdown is used to decompose the project question and to structure it into clearly defined and measurable CTQs. In addition it clarifies how the CTQs relate to the strategy of an organization and the project objectives, thus explicating the rationale of the project.

Using these CTQs as the basis for the measurement plan it is important to realise that the measurements and the consequent data need to give a just presentation of the current performance of the process.

Essential objectives of performance that need to be addressed in the measurement plan are quality, speed, dependability, flexibility and cost (Slack et al. (2012) Ch 13).

The process to be analysed in this company project is the current efficiency of the OR of the AMC. The question is whether a dedicated pediatric OR is wise. This would only be the case if the efficiency of the current process is influenced by the way children are planned on the OR. It is thus sensible to review the current process for the 5 objectives of performance and to adjust the measurement plan accordingly.

III Case description

Since the process was managed using the DMAIC method the phases of the DMAIC form the basis of the case description.

III.A Define

III.A.1 Study design and CTQs

As mentioned in the introduction there are two ways to look at this project question. The CTQ-flowdown for this project question shows this as well. The CTQ-flowdons can be found in appendix 2.

The two elements are quality of care and efficiency.

First the quality of care element: does a dedicated pediatric (OR) contribute to better quality of care?

When looking at the flowdown the assumption is that concentration or clustering of

pediatric patients may lead to more experience of the medical professional, higher speed of the process, less complications (deficiencies) and thereby increasing quality of care. These are less well defined concepts compared to length of anaesthesia induction time etc. Since it turned out to be difficult to assess these parts of the CTQ flowdown with a

stopwatch in the operating room it was decided to interview the managerial heads of the 8 academic ORs in the Netherlands. Based on the CTQ flowdown questions for this structured interview were formulated and the order of the questions was partly based on the answers given.

In Appendix 3 the questions and the way the interview was held when certain answers were given can be found. The interviews were done by phone.

The main items for these interviews were: -quality of care

- experience and complication possibilities -logistics

The second element is the efficiency of the operating rooms (OR): does the efficiency of the OR change if a dedicated pediatric OR is organized? This question was assessed using historic and measured data of the OR using the presence of children on the operating program as a defining item. Since the WCHC will be situated in the AMC it was decided to only measure in

outpatient

clinic planning admission holding entry OR AIT surgery AET leaving OR Recovery ward/home

the AMC and to include the medical professionals of the VUmc only in the preparation phase.

The CTQ flowdown for efficiency can be seen appendix 4.

For all CTQs results were compared based on type of program (pediatric vs adult vs mixed) and based on type of patient (pediatric vs adult)

III.A.2 Measurements

First a process map of the surgical process was drawn up (figure 6) in order to understand the possible differences that may exist between children and adults. Not all steps have been included in this project, but they may be addressed in follow-up projects.

Figure 6: process map of the surgical process

AIT = anesthesia induction time; AET = anesthesia emergence time

At the outpatient clinic the treating surgeon has to make an educated guess concerning the time the intended procedure will take. This time includes time for anaesthesia. Based on this time the planning is made. Currently the planning is done per surgical specialism which has block hours that run from 8:00 hours until 16:30 hours. In some cases the block hours run from 8:00 until 12:15 hours (half-day block hours).

In the educated guess the surgeon has the option to check historical times for comparable procedures but this is not obligated. In addition the anaesthesiology department has formulated time-estimates for certain anaesthesiology packages (for instance when a patient needs peripheral venous access, an arterial line and regional anaesthesia the

anaesthetist expects to need 80 minutes induction time). The surgeon is expected to include this in his estimation but again this is not mandatory. There is a moment of control after the definite schedule planning, but it is not completely clear whether or not planned times are adjusted 100% to the time estimates of the anaesthetists.

The part under investigation for this project is the time from entering the OR until the time leaving the OR including the turn-over at the recovery. In addition, the accuracy of the time estimations by both the surgeon and the anaesthetist were assessed as this may be an

TAT

1st patient

in OR

AIT surgery AET TOT

2nd patient

in OR

AIT surgery AET

etc

For the surgical program as a whole another process map was formulated (figure 7):

Figure 7:

AIT=anesthesia induction time; AET = anesthesia emergence time; TOT= turn-over-time; TAT= turn-around-time

Programs were eligible for measurement if they consisted of 4 or more patients. Programs were considered mixed if the planning contained at least one child and one adult. Pediatric programs had only children in the age of 0 until 15 years on the schedule and adult programs had no patients under the age of 16 in the schedule.

Measurements were done using a stopwatch and started at 7:45 at the OR. Time of entry of the first patient was noted and from that moment on all separate steps in the process were recorded. This was as detailed as the time needed to do the Time-Out Procedure. For this current project those steps were analysed of which the project group up front thought there might be differences between children and adults. The steps of the process maps were leading.

III.A.3 Definitions

Some of the definitions are focused on the situation in our own hospital. Others are based on the guidelines of the Association of Anesthesia Clinical Directors (AACD) (Overdyk, Harvey, Fishman and Shippey (1998)), an American society for anaesthetists whose primary responsibility is operating room management.

TOP = Time-out procedure: this procedure is a standardized questionnaire that is mandatory to go through at the beginning of the procedure. As the patient enters the OR the whole team is assembled including scrub nurse and nurse anaesthetists. Together with the patient (or his accompanying person ie parent in case of children) his identity is established, the procedure is run through, side of surgery is established where necessary and additional aspects such as antibiotics, special anaesthesiology technics and the presence of all needed instruments are established.

ACT = anaesthesia controlled time: this is the time needed for induction of anaesthesia at the beginning of the procedure before the surgeon can start with skin preparation and the time needed to either wake up the patient or prepare him for transport to the Intensive Care Unit.

AIT = anaesthesia induction time: this is the time needed by the anaesthetist for induction of the anaesthesia. There are two ways to perform measurement. One is to start measuring after the Time-out procedure, the other one is starting the clock the moment the patient enters the OR. In our analyses we have done both. We have clocked the time needed for the time-out and for AIT we use the time since entering the OR until the patient is released for skin prep.

AET = anaesthesia emergence time: this is the time the anaesthetist needs to wake up the patient or prepare him for transport to the Intensive Care Unit, to transfer him into his bed and to leave the OR. Time measurement starts as soon as the surgeon finishes surgery and the surgical drapes are removed. It ends when the patient leaves the OR.

TOT = turn-over-time: the interval between the departure of patient A from the OR until the arrival of patient B. This time interval is used to clean the OR and to change instruments such as ventilators if necessary. In a program with adults and children the ventilators need to be changed for instance based on the weight of the next patient.

TAT = turn-around-time: this is the interval between removal of the surgical drapes of patient A and the surgical incision for the subsequent patient. This is thus the time during which no surgery is taking place, being AET + TOT + AIT. In our analyses this factor is not used. We have used the separate steps of AIT, AET and TOT.

Utilisation: the ratio of in-room-time + TOT to all available staffed block time. In other words time the OR is used including TOT divided by the actual available time (ie from 8 till 16:30). In case a surgery starts before 16:30 but ends in overtime, only the period until 16:30 is taken into consideration. The time in OR after 16:30 hours is considered overtime.

First-case-on-time start: The moment the first case of the day starts. There are several definitions for on-time. We have defined on-time as the moment the TOP starts, since at this moment in time the complete surgical and anaesthesia team is present and the process can start.

Unused operating time: the time between the departure from the operating room of the last patient of the planned program and the end of the available OR time.

Overtime: the time between the end of the available planned time and the departure of the last patient from the operating room.

All defined time measurements are expressed in minutes, except utilisation which is a ratio. For unused operating time and overtime both minutes have been measured and ratios have been calculated.

Utilisation ratio = used time / available time

Unused time ratio = unused time at end of program / available time Overtime ratio = time after end of block hours / available time

III.A.4 Statistics

All statistical procedures were performed using the statistical program Minitab 17 (http://minitab.com). A histogram was made to see the distribution of the measured patients among the different medical specialties. The data were checked for a normal distribution. If the distribution was normal means were compared using the ANOVA,

otherwise the median was used and compared between groups using the Kruskal Wallis test. Data on program level were compared using the distinction between mixed, pediatric and adult programs. Significant differences were established using Kruskal Wallis test.

Data on patient level were compared between adults and children. Again first normal distribution was tested. In case of non-normal distribution a test for non-parametrical data was used being the Kruskal Wallis test.

In case of normal distribution the ANOVA was used.

III.B Measure III.B.1 Interviews

Six heads of the ORs of the Academic Medical Centers in the Netherlands were interviewed. One manager previously held a presentation during the MBA track about her organisation and those data were used. Data concerning the 8th center were collected from one of the line managers. The results of these interviews are discussed following the line of the CTQ flowdown. In appendix 2 the different arguments whether or not a dedicated pediatric OR is a good idea are numbered and the answers of the interviewees on the different questions are clustered according to these numbers.

The first question of the structured interview was:

“ Do you have OR programs that mix children and adults?” Based on the answer on this question the interview evolved.

One center answered ‘No’ to this question, in addition to the two hospitals with a stand-alone-pediatric hospital who thus have no choice whether or not to plan by specialty or plan mixed pediatric programs. The choice in this hospital to have a dedicated pediatric OR was made several years ago. The most important advocates at that time were the anaesthetists who felt that a dedicated pediatric center would lead to a higher exposure of the pediatric anaesthetists to children, thus leading to a faster learning curve and better quality of care with more tempo and less anesthesiology related complications. This answer refers to CTQ1

which concerns the learning curve for anaesthetists and nurse anaesthetists.

Although 5 academic centers answered that they did mix adults and children in 1 OR

program, at least one expressed the strong wish to have a dedicated pediatric OR. Attempts to organize this had failed mainly due to the inability of the surgical specialties to fit a new OR system into their agenda.

All other managers gave the same answers to the question if they could envision advantages of clustering of children. Advantages found or expected from a dedicated pediatric OR were more exposure to children for pediatric anaesthetists, faster learning curve for fellows, more dedicated personnel, less complications and higher tempo. All heads saw these advantages mainly for the anaesthetists and nurse anaesthetists. The care of pediatric patients under anesthesia is more secure, involves smaller margins and requires more capacities concerning mathematics and this requires special experience in nurse anaesthetists. They all felt that the tasks of scrub nurses did not differ that significantly between children and adults and thus they did not see the truly added value of completely dedicated scrub nurses for children specifically. In addition, there are dedicated scrub nurses for different surgical specialties and this, was felt, should be enough.

Although not mentioned in the CTQ flowdown as a possible advantage of dedicated pediatric OR it was stated by the managers that another important advantage of clustering of children was the improvement of logistics especially concerning the recovery. One of the prerequisites in order to be able to perform pediatric surgery is a pediatric recovery with specialized recovery personnel. This is more efficient if more children at a specific time need

to be admitted to this recovery. Whether a surgical specialty would plan 1 child or a whole program with children the pediatric recovery needs to be up and running.

CTQ4 concerns the variation in the OR process. It states that scheduling of comparable

patients (ie only adults or only children) variability might be more easy to compensate. One of the instruments to decrease variability is accurate estimation of procedure time.

Questions concerning these estimations were included in the interview.

When asked about the accuracy of the estimated length of surgery the universal answer was that this was a problem. The way to handle this differed per center. Some centers accepeted overtime and had a staggered shift staffing model which allowed for more overtime without upping the costs. Another center had weekly meetings with every specialty to talk the planning through. Once everybody agreed the program would be finished even if certain procedures took (much) longer than estimated. However if this happened often than those meetings would be firm and planning would be changed if deemed necessary. In other centers there were weekly meetings with only the OR management and sometimes additional anaesthetists who would judge the planning for feasibility. And one center had central planning which allowed them to adjust estimated times as they saw fit.

Another possibility was reallocation of OR time. If one specialty was not able to fill his block hours these would be redistributed in order to use the available time as efficient as possible. This method however was very seldomly used and is only possible if there are weekly

meetings with all specialties and the different specialties know that when block hours are taken away that they will be returned at another time, or will not add costs.

Concerning utilization of the OR in general the gut feeling of most department heads was that pediatric programs had a lower utilization compared to adult programs. The impression was that these procedures are more difficult to predict and children are more often

cancelled due to illness or fever. At this moment we did not look into the data of the different centers to verify this feeling.

Regarding CTQ5 planning problems were perceived as disadvantages of clustering of

children. In an attempt to organise a dedicated pediatric OR one of the manager was more

or less vetoed by the surgical specialists who claimed that this would interfere with the planning of their other clinical duties. Having a dedicated pediatric OR would mean for some specialties half-day programs instead of whole-day programs and this was not acceptable to them.

CTQ6 regarded the waiting time for pediatric patients when a dedicated pediatric OR was set up. This waiting time was mentioned by the managers but they were not sure if this would

be a major problem.

However, the planning of on-call services was perceived as a potential problem. The

planning of the anaesthesiology personnel both in regular and on call hours was mentioned by all managers during the interviews. In the stand alone pediatric hospitals all children were treated by pediatric anaesthetists. In the other centers premature babies and complex children were always treated by a pediatric anaesthetist. Anaesthesia of older children was sometimes done by ‘general’ anaesthetists who felt confident and capable. The age of children this happened with varied per center. This usually occurred only during on-call hours (evening, night and weekends).

Acute surgery in children was usually performed after the regular OR hours, unless it was extremely urgent. There was one center who would break into programs when necessary, but had the understanding with the surgeons that the elective cases would always be allowed to finish even after regular hours. All except one had pediatric anaesthetists available for acute cases. Sometimes a little changing of anaesthetists was necessary, but usually it was not a big problem. In all but one center the pediatric anaesthesiology staff was large enough to facilitate at least one acute OR per day.

III.B.2 Measurements in the OR

General data

To assess whether there is a difference in programs with or without children planned it was decided to measure complete programs and to focus on the potential differences between adults and children. Only programs of medical specialties who treated both children and adults were eligible. In order to measure also pediatric programs pediatric surgery and pediatric urology were included since in the AMC they are the only two medical specialties who planned complete pediatric programs.

A program needed to consist of at least 4 patients in order to have sufficient changes per day. A mixed program contained at least one child and one adult.

Eventually 28 programs were measured, ultimately resulting in 101 patients. The patients were divided into 47 children aged between newborn and 15 years of age, and 54 adults aged 16 years or older.

Figure 8 shows the different surgical specialties and the number of children and children per specialty.

Figure 8:

RCS = reconstructive and cosmetic surgery; PS= pediatric surgery; ENT= ear-nose-throat surgery; GYN=gynaecology; URO = urology; PURO = pediatric urology; OPH= ophthalmology; GS=general surgery; ORT=orthopedics

General data of the programs can be found in table 2. Table 2:

Mixed (n=11) Children (n=10) Adult (n=7)

First case on time 1 1

Overtime 6 4 2

Early finish program 5 5 4

Program as planned 8 5 7 Patients cancelled 2 4 2 O S C R PS ENT GYN URO O R U P OPH GS ORT 0 5 0 1 5 1 0 2 S C R PS ENT GYN URO_PURO OPH GS RT 1 s yc ne uq er F m s il a i c e p s l a c i g r u 2 y d li h c o n / s e y o nes P y tl a i c e p s l a c i g r u s r e p s tl u d a d n a n e r d li h c f o m a r g o t s i H o n / s e y d li h c : e l b a ir a v l e n a

Data verification

The OR has an electronic data system (chipsoft until October 2015). In this system the OR team needs to register times during the surgical process. Times that need to be entered are the entrance of the patient into the OR, the start and ending of the anaesthesia induction, the time of start and ending of the surgical procedure and the moment the patient leaves the OR. With these times all defined timeframes can be calculated.

The measurements done for this project were done with a stopwatch and the steps of the process map were divided into even smaller steps. For the analyses however it was decided to use the larger timeframes. All measurements were done in minutes.

To judge whether historical data were trustworthy and to assess whether further

measurements were necessary the analyses started with data verification. It was established that the measured times and the recorded times in the electronical system did not differ significantly, see also table 3.

Table 3: data verification

Variable Q1 Median Q3 Mean SD

Induction (m) 10.5 16.0 21.0 16.91 9.25 Induction (c) 10.0 13.0 19.0 16,16 9.72 Induction (d) -4.0 1.0 4.0 -1.13 4.03 Emergence (m) 8.0 12.0 17.0 13.29 7.08 Emergence (c) 8.0 13.0 19.0 14.13 8.22 Emergenc (d) -3.0 -1.0 0.5 -1.13 4.03 Total OR time (m) 72.0 103.0 154.5 116.26 60.27 Total OR time (c) 72.0 104.0 156.0 116.52 59.45 Total OR time (d) -1.0 0.0 1.0 2.3 10.72

m=measured; c=computer; d=difference; a negative connotation implies that the measured time was shorter than the computer time.

With regard to the starting times of the first cases per program there were no differences and overtime and the non-use of operating time were comparable between our

measurements and the registered times in the computer system.

Thus the conclusion of the data verification is that the data measured can be used and extrapolated to draw conclusions upon.

Program data

Now that the data have been verified as being a representative sample of what is going on in the OR it is possible to look at the data more into detail.

The program data were analysed first.

The results can be found in table 4. Since there were some significant outliers it was decided to compare the median only.

Table 4

Mixed (n=11) Children (n=10) Adult (n=7) p-value Time before start

(min)

10.0 (5.0-12.0) 11.5 (6.75-18.5) 8.0 (5.0-17.0) 0.470

Early finish (min) 55 (22.5-103.5) 41.0 (27.0-157.0) 46.0 (25.8-97.8) 0.946

Overtime (min) 15.0 (7.8-107.5) 27.0 (12.5-73.0) 7.0 (3.0-13.0) 0.166

Utilisation (ratio) 0.960 (0.86-0.98) 0.955 (0.85-0.983) 0.94 (0.87-0.98) 0.935

Early finish (ratio) 0.09 (0.025-0.173) 0.17 (0.075-0.425) 0.09 (0.0525-0.12) 0.22

Overtime (ratio) 0.04 (0.02-0.525) 0.11 (0.035-0.245) 0.01 (0.01-0.03) 0.123 Min=minutes; represented are the medians, between brackets Quartile 1-Quartile 3

When looking at the data the feeling arises that the children programs tend to show more variability in starting time, early finish and overtime. It may be that 28 programs are not enough to confirm these facts. To be able to confirm or overrule these trends comparison with historical data seems sensible and needs to be done in the near future.

Patient data

When looking more into detail the programs have been split into children and adults and times concerning the procedure, the anaesthesiology and the accuracy of planning were analysed. Results are shown in table 5.

The table shows that the turn-over-time for children takes significantly longer than for adults. When looking into the measurements more detailed it was found that the waiting time in the recovery room for a nurse to take over the patient was longer in children than in adults.

Table 5

Children (n=47) Adults (n=54) p-value AIT (min) 28.0 (21.0-37.0) 29.0 (23.0-31.0) 0.777

AET (min) 11.0 (8.0-16.0) 11.0 (7.75-17.25) 0.99

ACT (min) 42.0 (32.0-55.0) 41.5 (31.0-48.25) 0.905

TOT (min) 18.0 (14.0-21.25) 14 (11.0-17.0) 0.03

Diff anesth actual vs guess 0.0 (-8.0-10.0) -1 (-9.5 – 8.0) 0.639

Diff surg actual vs guess -8.0 (-22.0-9.0) -1 (-18.25 – 12.50) 0.363

Diff proc actual vs guess 3.0 (-20.0-35.0) 14.0 (-8.0-28.25) 0.328

Diff ACT vs package anesth -24.0 (-63.0–10.0) -11.0 (-32.0- -2.0) 0.019

Min=minutes; AIT/AET/ACT/TOT see definitions; diff = difference; anesth=anesthesia; surg=surgical procedure; proc= total procedure=anesthesia + surgical procedure. Results represented in median, between brackets quartile 1 – quartile 3; negative connotation, actual time was shorter compared guessed time

Another significant difference between adults and children was the estimated time for anaesthesia. Both the length of time the guesses differed from the actual measured time was longer for children as well as the variability was larger in children.

III.C Analyze

In order to value the data that was brought together ‘levels of evidence’ were defined. These are not the levels as they are used to grade (medical) literature, but levels used only and specifically for this thesis:

Level A: significant results in real-time measurements.

Level B: trends in real-time measurements, where possible confirmed by historical data. Level C: data found in medical / managerial literature.

Level D: opinions of the interviewees.

The data mentioned in paragraph III.B will be analysed using both hypotheses and the CTQ flowdowns. The strength of any conclusions will be based on the ‘levels of evidence’.

III.C.1 Hypothesis 1: efficiency in the OR is influenced by a higher variability in operating - and non-operating time in children compared to adults.

This hypothesis was assessed using both the measurements on the OR and the data of the interviews and refers to CTQ flowdown 3 and 4. In addition the CTQs in appendix 4 refer to this hypothesis.

The most important aspect of efficiency in the OR is the utilisation ratio (van Veen-Berkx, Elkhuizen, van Logten et al. (2015)) and both CTQ flowdown 3 and 4 state utilisation as a CTQ.

Utilisation in its turn is determined by the ratio between used operating time including TOT and non-used operating time, ie late start and early finish.

Analyses have been performed on program level and on patient level.

CTQ 3 and 4: influence on utilisation if scheduling only adult and pediatric programs.

On program level no significant differences between the three types of programs (adult, pediatric, mixed) were found. Trends however were observed.

First-case-on-time starts were seldom, only 7%. Although the number of minutes won if this percentage would increase is limited (median late start is 10 minutes) it could make the difference between finishing the intended program or having to cancel the last patient. Considering the fact that 8 out of 28 programs needed to cancel at least 1 patient this is an issue to look into. Level of evidence: A

Concerning the cancelled patients: the observed trend was that this happened more with children than with adults. This finding suggests that the deviation/variation in the pediatric programs compared to the planning is larger compared with mixed and adult programs. The number of programs per type however was too limited to come to significant

conclusions. This needs to be confirmed with further analyses of the historical data. Level of evidence: B

CTQ 3 also refers to the time spend in the operating room for the AIT.

To be eligible for measurement the programs had to consist of at least four patients. This implies that the procedures were not extremely complex (or time-consuming) and usually the complexity of surgery and anaesthesia is linked. Nevertheless in cases where patients needed additional anaesthesia next to the general anaesthesia (for instance an epidural) a

trend was observed that in adults not all additional techniques were performed in the operating room. Some things were done in the holding area thus reducing the AIT needed in operating room. In children all additional procedures are usually performed once the child is under general anaesthesia and thus need to be done in the operating room itself. Thus the supposed benefit of having either adult programs or pediatric programs is confirmed by the measurements on a level B.

Even though part of the anaesthesia can be performed outside the operating room in selected cases it is still important to make correct guesses concerning time needed for the surgery and the complete operating process.

Data showed that estimating these times was more difficult for pediatric surgical procedures than for adult procedures. An explanation might be that pediatric surgeries occur in limited numbers compared to adult surgeries. When one does a procedure less often speed is usually difficult and limited experience may cause difficulties both in estimating the needed time and difficulties in maintaining tempo during the actual surgery. This is not a reproach of the surgeons who treat children but a known fact that the numbers of pediatric patients per diagnosis in a tertiary center are limited. This hampers serial operations and thus

consequent experience. In addition the anaesthetists also turned out to be of base

concerning the estimated times for the anaesthesiology packages. This seemed to be more the case for pediatric procedures than for adult anaesthesia but may be due to the

aforementioned trend that part of the adult anaesthesia was done outside the actual operating room.

Level of evidence for these findings is level A and B for the estimated guesses and also level D since all interviewees answered ‘poorly’ on the question whether surgeons were able to estimate the needed time for a procedure.

The last CTQ related to efficiency that turned out to be significantly different between children and adults was the TOT. The turn-over-time for children was significantly longer implying that more time was needed for the transfer of the patient. When looking into more detail it was found that for instance the waiting time in the recovery before the patient could be turned over to the recovery nurse was longer in children. This might be due to the fact that in children a dedicated pediatric recovery nurse had to take over the patient

instead of any nurse that was available in the case of an adult. Also the actual transference took longer in case of a child (data not shown).

In the scheduling of patients the computer program automatically puts in a fixed amount of time for TOT but it does not take into account whether the patient is a child or an adult. This may need to be changed.

Level of evidence: A

So both on patient level as on program level it seems that children show more variability compared to adults. This warrants the conclusion that if children would be extracted from the mixed programs the resulting adult programs would have less variability and thus higher utilisation.

Hence hypothesis 1 is actually confirmed, although some of the observed differences are trends and not statistically significant. Before changing the current way of programming the operating schedules it is wise to check the trends using the available historical data. Since it was found that the measured data are comparable with the historical data these analyses can be executed.

III.C.2 Hypothesis 2: a dedicated pediatric OR influences Quality of Care.

This hypothesis was assessed in the interviews. This implies that the level of evidence for all conclusions is Level D. The essential CTQs follow from the flowdowns 1, 2, 5 and 6.

CTQ 1 and 2 concern the experience the treating medical specialists if a dedicated pediatric

OR would be realised. When asking medical professionals what is important for good quality of care the majority will answer specialization. The more often you do a procedure the better you will be(come), the faster you will be and the less complications you will cause. In the preparation of this project several meetings were held with the (pediatric)

anaesthetists of both hospitals, with the head of the OR in the AMC and with the data manager of the AMC. Their universal feeling was that a dedicated pediatric OR would eventually result in diminishing of variability concerning anaesthesiology times, in more experience in both pediatric anaesthetists and OR personnel (specifically nurse

even in less post-operative complications in general. Unknowingly, probably, they all referred to the learning curve theory.

In the interviews with the managers of the ORs in the other academic hospitals the same feeling emerged: clustering of pediatric patients would lead or had led to increased volume per pediatric anaesthetist, increased experience and might lead to less complications and higher quality of care.

Some of the heads that did not have a dedicated pediatric OR expressed the strong wish to have such an OR whereas those who did have an pediatric OR could not think of any reasons to go (back) to mixed programs.

Another argument that came forward in the interviews as a benefit of clustering children was the handling of acute pediatric cases. When programs are clustered most ORs tend to plan a pediatric anaesthetist for the entire program even when there is only one child on the schedule. This makes the planning more simple compared to switching the anaesthetist as soon as the surgery of the child is finished. However, this may lead to a pseudo-shortage of pediatric anaesthetists the moment an acute pediatric case is called in. In some ORs there is always a pediatric anaesthetist available for the acute operating rooms, but in other ORs trouble arises the moment acute pediatric anaesthesia is needed. With clustering of the children there are less programs that need a pediatric anaesthetist so chances are that more pediatric anaesthetists are available when acute pediatric cases are called in. One manager even goes so far( or has to go this far) that when there is no pediatric anaesthetist available within an acceptable timeframe the child is transferred to another hospital.

CTQ flowdowns 5 and 6 concern the possible negative side effects of a dedicated pediatric

OR. These side effects were mentioned by several managers who saw significant advantages of a dedicated pediatric OR and were inclined to implement this. The most important side effects concern schedule problems with the surgical specialties. If a surgical specialty does not treat enough children to fill a complete program on a regular basis than specialties are obligated to accept half-day block hours and this may interfere with the remaining work schedule.

This is a legitimate argument. However, it does not mean that the project is not viable. It means that changing the schedules on the OR should not only involve the OR but the whole

process of patient care of these surgical specialties. It is known that efforts that are focussed on a single component of the process, in this case the OR scheduling, are unlikely to have a substantial or sustainable impact (Cima et al. (2011)).

In the stand-alone pediatric hospitals the situation obviously is different because they have a separate dedicated pediatric OR. In both Utrecht and Rotterdam only the pregnant women are in the OR schedule. The data of these hospitals therefore may be very well used as a benchmark concerning peri- and postoperatively anaesthesiology related complications. This might be an extra argument in favour of clustering.

Concerning complications it is known that it is often very difficult to pinpoint the exact cause of a complication. However, things like length of procedure, length of anesthesia,

temperature of the patient at the end of the procedure are all factors that contribute to the occurrence of complications. When we are able to prove that clustering of pediatric patients leads to less waste during the process, increased speed and better management of the patient as a whole this may be an additional argument in favour of clustering pediatric patients.

Currently the 8 OR managers work together in a benchmark to verify how their own organization is performing concerning utilization, overtime, production, capacity etcetera. Yet they do not have a registry for post-operative complications that is shared among each other. If this combined database for OR-related complications (both anaesthesia and surgery related) for children could be set up it might make a clear statement concerning the need to cluster children.

So all in all concerning hypothesis 2 indications are that quality of care for both children and adults may improve from a dedicated pediatric OR. Serial production in both patient groups should (with experience eventually) lead to less complications and an increased quality of the process.

III.D Improvements

In recent years numerous studies have been published concerning efficiency in the OR. One of the most important conclusions and a recognizable feeling is worded by Krupka and Sandberg (2006). They state that it is difficult to improve perioperative efficiency enough to be able to add cases because most interventions only save a few minutes per case.

Therefore they propagate that only turning over the OR completely on the subjects of technology, separate induction rooms and the possibility of pro memori patients (patients who may be treated if there is enough time left in the schedule during the day).

Even though the first part of their conclusion represents a sentiment easily recognized it remains questionable if a radical turnaround is the only possible solution.

Since this research project was a DMA project the focus was on the analyses of the data. However, options for improvement have been found. They will be discussed in chapter V, together with the general conclusions of this thesis.

IV Critical reflection

IV.A Process management

The MBA track that is the basis for this company project was inspired initially by the

intended alliance of the VUmc and the AMC. All but one students were employees of either of the hospital. The study program was focused on health care in general in combination with classic MBA subjects, but the merger of both hospitals was often used as a case during the lectures. In addition, focus of the company projects was the intended merger and suitable subjects for the company projects were suggested by the steering group for the fusion.

Obviously, this is an excellent method to both integrate the students in the fusion trajectory and to make sure that the company projects were relevant to both hospitals who invested in the MBA.

Next to the suggestion of subjects the method to execute the company project was also predefined. It was the intention that the students would use the Lean Six Sigma methods for their project and would behave themselves as black belt in the process.

In hindsight this prerequisite somehow prevented a thorough evaluation of other methods possible. Focus was primarily on LSS and the DMAIC method and process management was not a priority for me since I followed the schedule and thought that was the process

management needed.

However when deducing the research question and allowing myself to look beyond the boundaries of efficiency it turned out that quality of care was another important element of the research question. Once this was established additional theories were explored and the measurement plan was adjusted accordingly.

IV.B LSS / DMAIC

During my internship and residency as a surgeon and my fellowship as a pediatric surgeon I was never very conscious of the organisation of care. I continued my education and worked in the schedule my supervisors proposed and somehow did not realise that improvement of the organisation of care was possible. As a consultant this notion dawned on me, but how