One-stop cholecystectomy clinic: an application of lean thinking-can it improve the outcomes?
Lean thinking principles were utilised to set up 'One-stop
cholecystectomy clinics' at which patients underwent the surgical
and the preoperative assessment during the same visit. The main aims
were to reduce the number of patient hospital visits, preoperative
admissions and the waiting time to surgery. The results showed a
significant reduction in the number of patient visits as well as the
waiting time to surgery thus highlighting that patient care can be
improved by good team working and lean management.
KEYWORDS One-stop clinic / Lean management / Waiting time
Elsayed, Sameh Effat Abd
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Nov, 2012 Source Volume: 22 Source Issue: 11|
|Product:||Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance|
The concept of lean thinking and lean management originated in the 1900s by Henry Ford, and was subsequently developed and practiced in the 1930s by Kiichoro Toyoda for the Toyota production system (Bowen & Youngdahl 1998). Lean management is based on the theory of flow of processes i.e. as one process finishes, other one should start (Womack & Jones 1998). It is a methodology that tries to reduce cost, waste, time, defects, and faults and tries to increase productivity, quality and customer satisfaction (Womack & Jones 1998). Benefits of lean management implementation in the healthcare industry have been shown by various studies (Murray & Berwick 2003, Endsley et al 2006, King et al 2006). The key step is the establishment of lean culture, in which a multi-disciplinary team is responsible for the overall functioning with the manager acting as an enabler and a teacher (Womack et al 2005). The lean culture is customer focused and hence extremely good service can be established in health services, since the main principle that underpins the National Health Service (NHS) is excellence in patient care (Womack et al 2005).
Incidence of gallstone disease and cholecystectomy has increased over the past five decades in the UK (Somasekar et al 2002). The usual routine care requires that patients booked for cholecystectomy come back a second time for the surgical preoperative assessment. The patients are normally assessed by the surgeon on their first visit who either orders some investigations or, if deemed suitable, requests preoperative assessment which is normally carried out on the second visit. This practice is inconvenient, as it creates logistic burden and potentially increases the waiting time before surgery. The incidence of gall bladder disease is high and the number of patients awaiting elective cholecystectomy is a significant proportion of those awaiting elective surgery (Somasekar et al 2002). This delay in surgery has been reported to increase the number of preoperative admissions as well as postoperative complications (Lo et al 1998). The prolonged waiting time before cholecystectomy increases patient morbidity i.e. recurrent attacks of biliary colic/cholecystitis, and thereby not only increases the healthcare cost (Somasekar et al 2002) but also affects the patient's quality of life (Derrett et al 1999).
The concept of the 'one-stop' clinic for cholecystectomy has been implemented in a few hospitals in the UK. It utilises the principle of 'lean thinking' whereby the patient undergoes both the surgical and the preoperative assessments during the same 'single' visit (Figure 1). The main aim of this is to shorten the waiting time to surgery and hence reduce preoperative hospital admissions and improve patient satisfaction (Somasekar et al 2002). The routine care on the other hand requires multiple hospital visits (Figure 2).
[FIGURE 1 OMITTED]
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The evaluation of such applications of lean healthcare in terms of improved outcomes is scarce (Kollberg et al 2006). It requires planning of healthcare studies in a systematic way with defined outcome measures (Kollberg et al 2006). In this article, we will focus on the design and conduct of such a study in the settings of a district general hospital (DGH).
The effect of the 'one-stop cholecystectomy clinic' on the waiting time, preoperative hospital visits and preoperative admissions due to gall-bladder disease has not been assessed previously to the best of our knowledge. Therefore the aims of this study were to compare of difference in waiting list time, number of hospital visits and preop admissions amongst the patients attending the 'one-stop cholecystectomy clinic' versus the 'routine care'.
A comparative cohort study was conducted based on the type of clinic attended (one-stop clinic or the routine care). Primary outcome variables were: the waiting time until cholecystectomy, and the number of preoperative hospital visits. A secondary outcome was the number of preoperative hospital admissions due to gall stone problems (cholecystitis, pancreatitis, obstructive jaundice) while awaiting surgery. A flow diagram of the study is illustrated in Figure 3.
[FIGURE 3 OMITTED]
This study was conducted at the general surgery department of William Harvey Hospital (WHH), Kent. It is a DGH consisting of 550 beds and managed by the East Kent Hospitals University NHS Foundation Trust (EKHUFT 2010). This NHS foundation trust is one of the largest acute trusts in the UK serving a population of about 720,500 people. WHH serves around 300,000 people from a mix of small towns and a rural population. Being an acute trust, it is one of the busiest DGHs as it serves all the general surgical specialties including upper & lower gastrointestinal, breast, endocrine, with remote vascular and urological cover (EKHUFT 2010).
The study consisted of adult patients presenting with symptomatic gallstone disease to the surgical clinic. Patients who attended either a 'one-stop clinic' or the routine pathway during the year 2010 and booked for surgery were included.
Non probability convenient sampling was conducted based on following criteria:
* Adult male and females with symptomatic gallstone disease Exclusion criteria
* Immunocompromised patients
* Patients unfit for 'one stop cholecystectomy clinic' i.e. high risk patients who require extensive perioperative work-up
* Patients who refuse surgery
The sample size was calculated by using software 'Sample size determination in health studies - A practical manual' version 2.0 (Lwanga & Lemeshow 1991). With the following parameters:
* 5% level of significance and 80% power of the study
* standard deviation of waiting time for laparoscopic cholecystectomy of 12 weeks (Somasekar et al 2002)
* mean waiting time in patients undergoing routine care for laparoscopic cholecystectomy of 18 weeks (Gurusamy et al 2008)
* mean waiting time in patients attending one-stop clinic for laparoscopic cholecystectomy of 10 weeks (assumed to decrease by 8 weeks)
at least 36 patients were required in each group i.e. 72 patients altogether. Inflating the sample size by 10% to account for incomplete or missing medical records, at least 40 patients were required in each group.
Data were collected by a trained data collector uniformly for all the patients on a specified pretested questionnaire. The data included patient demographics, anthropometric measures, co-morbidities including any chronic medical condition, number of hospital visits, date of booking for surgery, actual date of surgery, total waiting time and hospital admissions during the waiting time period. Data were collected for both the groups from clinical notes provided by the medical records team.
The dependent variables were: waiting time, defined as 'the number of days from clinic date until cholecystectomy'; the number of patient hospital visits before cholecystectomy; and the number of preoperative admissions. Age, gender, smoking history and co-morbidities including hypertension, diabetes, asthma, cardiac disease, weight (kg) and height (cm) were taken as co-variates.
Patient identification was kept anonymous by assigning specific codes. The key to the codes was with the principal investigator only; this key was safely destroyed as soon as the data were entered and cleaned. Information filled in the questionnaire was validated by the principal investigator for consistency. Any errors were pointed out and clarified. Data were entered on the software Epi Data (Lauritsen & Bruus 2003) according to the code book.
Data were analysed using Statistical package for social scientists (SPSS) software version 14 (SPSS 2005). Descriptive statistics were computed: proportions for the categorical variables, mean (and standard deviation) for continuous variables having normal distribution, median (and interquartile range) for continuous variables having skewed distribution. Log rank test was applied to look for the mean difference of waiting time between the two groups. Student t-test was conducted to look for the difference in the number of preoperative visits, preoperative hospital admissions, age and body mass index (BMI). The Mann-Whitney U test, chi-square test or Fisher exact test, was applied wherever appropriate. A p-value of <0.05 was considered to be significant.
The data were anonymised by specific coding to maintain patient confidentiality. Identification information, which was accessible to the principal investigator only, was destroyed as soon as the data were entered. Since this study was an observational health services research which did not involve any direct patient contact or any intervention, the regional ethical committee designated it as a 'grey area project' and it did not need ethical approval. The study was registered with the EKHUFT Research & Development committee and an approval to proceed was granted.
The total number of medical records reviewed was 141, of which 12 were excluded. These patients were either unfit for one stop clinic (n=6), immunocompromised (n=1) or did not want laparoscopic cholecystectomy (n=5). Hence, the total number of patients included in the study was 129. The number of patients who attended the one stop laparoscopic cholecystectomy clinic was 59 while 70 patients attended the routine care clinic.
Out of the total of 129 patients 78.3% (n=101) were female and 21.7% (n=28) were male. The mean age was 49.3 years (SD 16.6 years), the youngest being 18 and the oldest 88 years. Patients attending the one stop clinic were younger (43.8[+ or -]14.6 years) than those attending routine care (53.9[+ or -]16.9) (p=0.001). The gender distribution was similar amongst the two groups. Currently, 25.6% were smokers, similar distribution amongst the two groups (p=0.46). The BMI of patients attending the one-stop clinic was 29.8[+ or -]5.7kg/[m.sup.2] and that of the routine care group was 30.1[+ or -]6.3 kg/[m.sup.2] (p=0.8). The past medical history showed that hypertension and diabetes were more prevalent in the routine care group (10% and 8.5% respectively) than the one-stop group (1.7% and 0% respectively).
The number of hospital visits and preoperative admissions was much lower amongst patients who attended one-stop clinics. The length of waiting time to surgery was significantly shorter in one-stop clinic patients as compared to the routine care (Table 1).
The basic idea of the one-stop clinic is to assess the patient's clinical problem, conduct the relevant investigations that would help to reach a decision about their diagnosis and make a definitive treatment plan during the same hospital visit (Jackson 2009). This is a patient-led service that delivers best practice by a multi-disciplinary teamwork (Jackson 2009). The service is unlike the traditional culture where a patient has to visit the hospital more than once for clinical evaluation followed subsequently by investigations and then a treatment plan is devised. Our study provides clear evidence that 'one-stop cholecystectomy clinics' reduced the mean waiting time to surgery as well as the number of preoperative hospital admissions.
Waiting time for laparoscopic cholecystectomy varies in different hospital settings. The study by Chevuru & Eyre-Brook (2002) has shown that the median waiting time for laparoscopic cholecystectomy at a district general hospital was 24.28 weeks (170 days), ranging from 0.85 to 69.14 weeks (6 to 484 days). The median waiting time for elective laparoscopic cholecystectomy was 27.27 weeks (190.9 days) while it was 10.1 weeks (70.5 days) amongst those who were admitted with acute cholecystitis (Cheruvu & Eyre-Brook 2002). Better results were shown in the study by Garner et al (2009), which reported that the median time for the routine elective cholecystectomy patients with symptomatic gall stone disease was 17 weeks; while it was 11 weeks (range 2 to 28 weeks) for the acute hospital admissions. A meta analysis has shown that the waiting time for delayed laparoscopic cholecystectomy ranges from 6 to 12 weeks and that for early laparoscopic cholecystectomy is less than 7 days (Gurusamy et al 2009). The waiting time to surgery with the establishment of one-stop clinics was shortened to about 7 weeks which is significantly less than the other studies (Chevuru & Eyre-Brook 2002).
Lean thinking principles helped to improve the patient care by reducing the waste i.e. patients' extra hospital visits and shortening the time period till definitive treatment (i.e. waiting time to surgery and the number of preoperative hospital admissions). It also helped to coordinate the flow by involving multi-disciplinary teams. The responsibility of initiation and coordination to implement a set of activities was taken by the lean leader. In lean culture, the team leader may be any healthcare professional i.e. a nurse, doctor, paramedic or healthcare manager (Jackson 2009). Regular meetings were conducted, problems and issues were highlighted and solutions were implemented. Since each member of the team was thoroughly involved right from the outset, everyone played their role with enthusiasm resulting in the success of the service.
Four steps are involved in designing a lean process (Endsley et al 2006). These are:
* Step 1: Map the current state of the process from patient's perspective
* Step 2: Identify the waste
* Step 3: Map the future state of the process removing the waste and maximising the process flow
* Step 4: Test and revise the new process
We set up a one-stop laparoscopic clinic at our DGH based on lean principles and the steps mentioned above. This study evaluated this service in comparison to the routine care. It reduced the waiting time to surgery as desired by the Department of Health in the UK. Since, our study highlights the benefits of one-stop clinic in patients with gall bladder disease we recommend that such a service should be replicated at other DGHs in the UK.
Bowen DE, Youngdahl WE 1998 "Lean" service: in defense of a production line approach International Journal of Service Industry Management 9 (3) 207-25
Cheruvu CVN, Eyre-Brook IA 2002 Consequences of prolonged wait before gallbladder surgery Annals of The Royal College of Surgeons of England 84 (1) 20-22
Derrett, S, Paul C, Morris JM 1999 Waiting for elective surgery: effects on health-related quality of life International Journal for Quality in Health Care 11 (1) 47-57
East Kent Hospitals University NHS Foundation Trust 2010 About East Kent Hospitals Available from: http://www.ekhuft.nhs.uk/patients-and-visitors/about-us/ [Accessed April 2012]
Endsley S, Magill MK, Godfrey MM 2006 Creating a lean practice Family Practice Management 13 (4) 34-38
Garner JP, Sood SK, Robinson J, Barber W, Ravi K 2009 The cost of ignoring acute cholecystectomy Annals of The Royal College of Surgeons of England 91 (1) 39-42
Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR 2009 Meta analysis of randomised controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis British Journal of Surgery 97 (2) 141-50
Gurusamy KS, Samraj K, Fusai G, Davidson BR 2008 Early versus delayed laparoscopic cholecystectomy for biliary colic Cochrane Database of Systematic Reviews (4) DOI: 10.1002/14651858.CD007196.pub2
Jackson J 2009 One-stop outpatient and pre-operative assessment Nursing Management 15 (9)
King DL, Ben-Tovim DI, Bassham J 2006 Redesigning emergency department patient flows: Application of lean thinking to healthcare Emergency Medicine Australasia 18 (4) 391-7
Kollberg B, Dahlgaard JJ, Brehmer P 2006 Measuring lean initiatives in healthcare services: issues and findings International Journal of Productivity & Performance Management 56 (1) 7-24
Lauritsen J, Bruus M 2003 EpiData. A comprehensive tool for validated entry and documentation of data The EpiData Association Odense, Denmark
Lo CM, Liu CL, Fan ST, Lai EC, Wong J 1998 Prospective randomised study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis Annals of Surgery 227 (4) 461-7
Lwanga S, Lemeshow S 1991 Sample size determination in health studies: a practical manual World Health Organization Available from: http://whqlibdoc.who.int/publications/9241544058_(p1-p22).pdf [Accessed April 2012]
Murray MM, Berwick DM 2003 Advanced access: reducing waiting and delays in primary care The Journal of American Medical Association 289 (8) 1035-40
Somasekar K, Shankar PJ, Foster ME, Lewis MH 2002 Costs of waiting for gall bladder surgery British Medical Journal 78 (925) 668-9
Statistical Package for Social Scientists 2005 SPSS for Windows SPSS Inc. Chicago, USA
Womack JP, Jones DT 1998 Lean thinking: banish waste and create wealth in your corporation Simon & Schuster Available from: www.simonandschuster.com/ [Accessed April 2012]Womack JP, Byrne AP, Fiume O, Kaplan GS, Toussaint J, Miller D 2005 Going lean in healthcare Cambridge, MA, Institute for Healthcare Improvement
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by Khurram Siddique, Sameh Effat Abd Elsayed, Raza Cheema, Shirin Mirza, and Sanjoy Basu
Correspondence address: Mr. Khurram Siddique, Specialist Registrar General Surgery, East Kent Hospitals University NHS Foundation Trust. Email: firstname.lastname@example.org
About the authors
FCPS, MRCS, MSc (Surg Pract)
Specialist Registrar General Surgery, East Kent Hospitals University NHS Foundation Trust
Sameh Effat Abd Elsayed
Core Surgical Trainee, East Kent Hospitals University
NHS Foundation Trust
MSc (Epi & Biostatistics, Pak)
Aga Khan University, Pakistan
MSc (Uni. East Anglia)
William Harvey Hospital, Ashford
Consultant Upper GI Surgeon, East Kent Hospitals University NHS Foundation Trust
No competing interests declared
Provenance and Peer review: Unsolicited contributed; Peer reviewed; Accepted for publication April 2012.
Outcome One-stop Routine P-value variable clinic care Mean waiting 7.3 (95% 16.6 (95% CI <0.001 time in CI 14.0-19.2) weeks 6.2-8.5) Number of 9 (15.2%) 19 (27.1%) 0.28 preop hospital admissions: n (%) Table 1 Outcome variables in one-stop cholecystectomy clinic vs. routine care
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