The main priority of the political system, not only in Italy but also internationally, is to reduce public debt and to streamline national health service (NHS) costs. Consequently, health managers need to acquire operating methods within their managerial structures so that all available resources are better planned in terms of effectiveness and efficiency, without compromising patient safety , .
In this way, the most complex process in terms of human resources, economic resources, Medical device, ICT systems and clinical risks for patients and health professionals is the surgical process. This side has motivated the requirement to closely monitor all tasks performed by health professionals involved in the whole health process. Nowadays the NHS is described, analyzed and built by productive process.
The Surgical process absorbs a large amount of the facility, around 25% and the increase in costs will continue in the coming years due to the evolution of the technologies used in operating rooms, i.e. a medium size Hospital (300 beds), medium surgical complexity (no Cardiac Surgery, no Neurological Surgery, no Transplant Center) has an expenditure for 1 operating room per year around 1 Million Euros . But how can we foster efficiency if we don’t know the processes that absorb resources in detail? How can we aspire to this widely spread management formula: ‘if you can measure it, you can understand it. If you can understand it, you can control it, you can improve it’ .
The management team must be able to know with absolute transparency all the stages of the process that make up the complex path of each surgical patient. With this information, all necessary changes will be able to be made to the workflow, rendering the system more effective, i.e. ensuring a better service to citizens under a user clinical point of view (perception of quality) and efficient, i.e. a reduction in business costs.
2 Control tower approach (CTA)
Accordingly, with the scenario described before confirming the need to implement monitoring and management workflow systems that are able to highlight critical issues and to better allocate resources in terms of efficiency and sustainability .
In order to identify the information categories needed to know the whole surgical process is necessary to divide these in two main categories, supply and demand.
Demand Information Group (DIG) contains the information that identify patients and its needs in terms of care.
Instead Supply Information Group (SIG) contains information about hospital resources in order to cover the supply.
The Demand Information Group (DIG) is simple to determine, because by it we have to answer the follow questions:
How many patients are in waiting list?
What kind of surgical procedure they need?
What kind of patients they are? In terms of demographic and comorbidities information.
However, in this group is interesting add all information about patient that can be increase the accuracy in what the patient needs in order to achieve his heath status.
Those information are available by clinical perspective in every health facility in quite simple way.
In order to understand the SIG is necessary to answer the follow questions:
Which health actors are directly involved in the process for each patient? (Surgeons, Nurses, Anaesthesiologists, Radiologists, others)
Which Department are involved in the process for each patient? (Surgery, Radiology, Laboratory, others)
Which kind of medical devices are necessary to perform the surgical procedure?
Who is in charge to guarantee the proper functioning of medical devices?
Who (or Which Hospital Department) is in charge to guarantee the availability of medical devices?
Who is in charge to plan the admission and discharge of the patient in terms of logistics and bed occupation?
The Information included in this group are about:
Human resources (every health actor involved in the process of care in terms of his work to make possible the surgical procedure, i.e. surgeon, nurse, anaesthesiologist, radiologist, clinical engineer, technician, others)
Medical Devices (every device needed to perform the surgical procedure from surgery kit to surgical robot)
Logistics availability (operating rooms, beds, others).
The core of the Control Tower Approach for the surgical process is to clear understand what the Hospital needs to cover the demand. To perform a single surgical procedure all process phases must be properly carried out and aligned.
As in any industrial production process, each action performed within a stage is crucial to prepare for performing the next step.
2.1 The surgical process
The surgical process analyzed in terms such as industrial production process has the goal of produce the “health product for the patient” and its central part is performed in the operating room by a surgical team. This does not mean that the precedent and subsequent phases of the operating room have minor importance, in fact to obtain a high quality “health product” and reduce to a minimum the clinical risks related to the patient it is necessary that each phase of the process is carried out in the right way.
The surgical process consists of three main phases Preparatory, Surgical and Dismissal (see Figure 1).
Preparatory phase, begins when the patient is placed in the waiting list and then enters the path (becomes part of the Demand side). It ends when the patient is ready to be transfer to the operating theater.
It is divided into two sub phases:
OUT Hospital, it includes all diagnostic tests and medical examinations to be performed in a day hospital regime. At the end of this phase the patient is ready to be hospitalized.
IN Hospital in it are included all actions immediately precedent surgery with the goal of making the patient ready for entering the operating room.
Surgical, begins with the patient entry in the Operating Block and ends with his return to the ward (subsequent to possible transfers in the ICU).
Discharge, including all subsequent actions to the previous step that are intended to discharge the patient to home.
It is divided into two sub phases:
IN Hospital, it covers all actions necessary to enable independent at home.
OUT Hospital, it concerns the follow-up actions.
By these approach the goal is to monitor the entire process like an industrial process and plan the work by semester/moth/week/day based on the trade off between supply and demand.
The Hospital needed to have instruments and skills in order to satisfy the Demand of Health of their citizens in order to minimize:
Waiting time for patient
Clinical risk for patient
Clinical risk for hospital employee
Cost for the NHS both in terms of medical device and human resources
The number of patient treated
The quality of care
The outcome for the patient
Different experiences are described in the scientific literature , ,  concerning the attempt to track the path of the surgical patient. In all the reference domain is restricted to the operating theatre without taking into account what happens before and after. This phases, described above, are fundamental to the correct planning of the production process because if its not included in the process to right plan the daily work, they may introduce bottleneck in the process.
What we argue in this paper is the evidence that nowadays the health process has to be treat as productive process.
3.1 Hospital evidence
The Forlì Hospital case in 2013  demonstrated that an operating room block (ORB) can be increase its efficiency in terms of cost reduction and clinical risk management by an introduction of a performance model called operating room management system (ORMS) in order to put under control the process. ORMS approach is based on the need of knowledge of the surgical patient pathway in order to know who, where and when make an action on the patient into the ORB.
In Figure 2 is show the view of process piece related to the OR from the Engineering point of view as a productive process.
The data collected from the “productive process” are the baseline to transform numbers in available information to healthcare managers in order to have managerial impact on the process.
By the end of 2013, the system was able to track 23.503 entire patient flows from beginning to end. It also was able to identify the individuals who were involved in each step, and the locations where the different activities took place. A clinical engineer in charge of the OR process management regularly shared, by the OR board with the OR block’s healthcare professional the relevant key performance indicators.
The results obtained by the implementation of a management workflow system and a key role as head of a surgical productive process are the following: there is firstly an increase in the number of surgical procedure from 2009 (4574) to 2010 (5015) than an assessment since 2011 up to 2013. In fact, the raw utilization increases from 52% in 2009 to 59% in 2013. The unscheduled procedure decrease from 23% in 2009 to 11% in 2013. The overtime occurrence decrease from 30% in 2009 to 20% in 2013. The underutilization increase from 22% in 2009 to 27% in 2013.
In the Table 2 below was describing the impact of the principal efficiency indicators on the raw utilization from 2009 to 2013.
The main actor in OR is “time” and the main management goal is to allocate the right amount of time to each service on every given day in order to reduce the cost of OR process. Wang et al. described how the majority of OR cases have a normally distributed duration.
This report suggests that it is possible to reduce or control inefficiency even in an efficient system. This may be also possible by translating the problem of efficiency/inefficiency to surgical lists. On a similar tone, Pandit et al. introduce the concept of “capacity” as expression of the surgical operating lists described by the minutes or hours of surgical time per week available to it. To optimize OR utilization, the surgical operating list should be based on historical surgical timing.
To achieve the above points, it is necessary a coordination group, which as a control tower for an airport, is able to plan the work in relation to the needs of the patient and the hospital possibilities. The Group should be multidisciplinary and directed by a clinical engineer, because he has the ability of global vision of the problem. There are many processes in healthcare that are still unclear and cannot be assessed by standard methods. However, by applying a CTA, these processes can also be accessible and clear, with the aim of improving the quality of service provided and of reducing expenditure.
The core issues with any productive process are the goal needs, the problem to be solved, the effort to get the data and the data’s value. There is a balance between providing too much information and not enough. On one hand, too much information can make figuring out the status a bit like looking for a needle in a hay stack, while too little runs the risk that you don’t include something important and relevant. Without a long term strategy – what decisions those numbers would enable – it’s impossible to build a correct analysis and look for questions that would support those decisions. That kind of thinking is called goal, question, and metric. The implementation of a Control Tower Approach allows for the management of productive process, able to guide hospital managers to identify the best strategies to optimize resource consumption and to improve the risk management of patient safety in response to the guidelines of the World Health Organization.
Research funding: The author state no funding involved. Conflict of interest: Authors state no conflict of interest. Material and methods: Informed consent: Informed consent is not applicable. Ethical approval: The conducted research is not related to either human or animal use.
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About the article
Published Online: 2016-09-30
Published in Print: 2016-09-01
Citation Information: Current Directions in Biomedical Engineering, Volume 2, Issue 1, Pages 345–349, ISSN (Online) 2364-5504, DOI: https://doi.org/10.1515/cdbme-2016-0077.
©2016 Matteo Buccioli et al., licensee De Gruyter.. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License. BY-NC-ND 4.0