Surgical Services Process Improvement: A Holistic Approach

Added on May 3, 2018

surgerySurgery is one of the most challenging areas of medicine in which to provide safe and reliable care. The unique characteristics and logistics of surgical care—the resource intensity, wide variation in patient acuity and procedure types, scheduling and process flow complexities, and technology and communication demands—can lead to inefficient and inconsistent processes that create safety vulnerabilities. In fact, incident analyses have consistently shown that surgical services are associated with higher harm rates than medical specialties.[1], [2], [3] 

In addition to compromising patient and workforce safety, process disruptions—such as breakdowns in communication, ineffective teamwork and lack of compliance with process measures—can threaten a health system’s economic vitality. Surgery represents nearly half of hospitals’ revenue, according to an AHRQ report, and an increasing percentage of hospital revenue is at risk in the evolving value-based payment environment.

Given these dynamics, surgical services process improvement has become a key strategic priority for many organizations. Unfortunately, improvement efforts frequently fall short, either because they don’t account for the inherent complexities of the processes involved or because they don’t reflect the concept that every surgical procedure is the endpoint of multiple processes, each of which contributes to a safer outcome.

As with any system of processes, the key to a good surgical outcome—a safe, high-quality experience—is to control all the variables that could influence that outcome, including those that come into play long before the first incision and extend far beyond the last suture. This requires engaging and aligning all the contributing stakeholders (surgeons, anesthesiologists, pre-anesthesia staff, preoperative nurses, schedulers, surgical nurses, techs, sterile processing and supply staff, and patients) and optimizing all the relevant processes (capture of lab test results; on-time receipt of consents, history and physical, case order selection, block scheduling and associated policies; performance reporting and improvement; and patient registration, communication and preparation).

To achieve this, organizations should adopt a holistic approach that focuses on three areas: safety culture, education and process improvement.

Safety Culture: Commit to Zero Harm

Process improvement efforts targeting safety outcomes will “stick” only if they are supported by a positive safety culture that penetrates every part of the organization. In such a culture, safe practices and the goal of Zero Harm are instilled in every member of the workforce. Creating such a culture requires establishing a nonthreatening environment in which every individual is expected and encouraged to speak up for safety and question practices and processes they think could compromise patient safety. Empowering staff in this way requires buy-in and support from leadership, administration and the entire care team. The best way to achieve this is to connect the safety vision back to the patient. Making the patient’s welfare the main consideration encourages the team to focus on outcomes rather than hierarchy and supports individual and group accountability.

Education: Teach, Don’t Preach

While it’s generally assumed that all staff adhere to standards of practice, oversights in compliance with quality standards occur frequently. High rates of turnover and difficulty retaining nurses and surgical techs can contribute to this deficit. Surgical education programs vary widely in their breadth and ability to meet the demands of orienting new staff, checking competencies and monitoring temporary staff or “travelers.” For this reason, knowledge gaps can vary widely and can exist throughout the system, whether in sterile processing, facilities and maintenance, environmental services or intraoperative practice. Some common issues include lack of adherence to manufacturer instructions for use (IFUs) regarding skin prep, surface disinfection or instrument sterilization; knowledge gaps among service line needs; knowledge gaps between clean vs. sterile; high foot traffic in and out of ORs; and inappropriate clean and dirty workflow.

Every employee in the surgical services ecosystem must clearly understand their responsibilities as they relate to quality standards, the importance of full compliance with them and the potential consequences of noncompliance. To this end, clinical educators, infection control specialists, surgical leadership, experts from key supporting areas (i.e., sterile processing) and service line leads should be involved in evaluating and improving education programs. Medical staff should also be engaged to ensure they understand the need for the program and their participation. This, paired with a culture of safety and commitment to Zero Harm, works effectively to support adherence.

Past safety events should also be used as teaching tools. Dashboards indicating safety performance should be visible to all staff, and the results of cause analyses should be discussed in order to create understanding around safety vulnerabilities and ways to avoid them.

Human factors awareness training that focuses on improving interprofessional cooperation and team performance—such as aviation-derived crew resource management—can also improve the safety and reliability of surgical services.

Process Improvement: Start from the Beginning

A key factor in mitigating the risks associated with surgery, particularly among sicker patients, is a robust presurgical screening process. This should start with an understanding of the surgeons’ office structure to understand the criteria they have in place for screening patients and the postsurgical follow-up process they utilize. Wherever possible, ORs should provide support and recommendations on how educational partnerships can be formed and programs can be made consistent across practices operating at the facility.

The hospital presurgical screening process should also be considered. In the hospital setting, this process typically is led by anesthesia, with clear criteria for screening needs using ASA guidelines. Standardized processes should also be employed for presurgical testing and patient management protocols specific to disease, procedure, comorbidities and other risk factors. Well-designed testing and preparation protocols help ensure patients are optimized for their procedure and improve quality outcomes.

Tactics such as daily multidisciplinary huddles to review the next day’s schedule, verify patient preparation and flag potential problems can enhance reliability and increase patient safety by reducing opportunities for harm and ensuring process adherence.

Despite the complexity of surgical services management and the myriad processes that define it, meaningful and sustained improvements in quality, productivity and safety can be achieved by addressing process improvement holistically from a culture and systems perspective. Such an approach is not only important to ensuring strategic success; it is essential to delivering on the patient promise of safe, high-quality, patient-centered care. 


[1] Gawande, A.A., et al. 1999. “The incidence and nature of surgical adverse events in Colorado and Utah in 1992.” Surgery 126(1): 66–75.

[2] Vincent, C., G. Neale, and M. Woloshynowych. 2001. “Adverse events in British hospitals: Preliminary retrospective record review.” BMJ 322(7285): 517–519.

[3] de Vries, E.N., et al. 2008. “The incidence and nature of in-hospital adverse events: A systematic review.” Quality and Safety in Health Care 17(3): 216–223, doi: 10.1136/qshc.2007.023622.