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Relationships between Volume, Efficiency, and Quality in Surgery — A Delicate Balance from Managerial Perspectives

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Abstract

Volume, efficiency, and quality in hospital care are often mixed in debate. We analyze how these dimensions are interrelated in surgical hospital management, with particular focus on volume effects: under financial constraints, efficiency is the best form of cost control. External perception of quality is important to attract patients and gain volumes. There are numerous explicit and implicit notions of surgical quality. The relevance of implicit criteria (functionality, reliability, consistency, customaziability, convenience) can change in the time course of hospital competition. Outcome data theoretically are optimal measures of quality, but surgical quality is multifactorially influenced by case mix, surgical technique, indication, process designs, organizational structures, and volume. As quality of surgery is hard to grade, implicit criteria such as customizability currently often overrule functionality (outcome) as the dominant market driver. Activities and volumes are inputs to produce quality. Capability does not translate to ability in a linear function. Adequate process design is important to realize efficiency and quality. Volumes of activities, degree of standardization, specialization, and customer involvement are relevant estimates for process design in services. Flow-orientated management focuses primarily on resource utilization and efficiency, not on surgical quality. The relationship between volume and outcome in surgery is imperfectly understood. Factors involve learning effects both on process efficiency and quality, increased standardization and task specialization, process flow homogeneity, and potential for process integration. Volume is a structural component to develop efficiency and quality. The specific capabilities and process characteristics that contribute to surgical outcome improvement should be defined and exported. Adequate focus should allow even small institutions to benefit from volume-associated effects. All volumes-based learning within standardized processes will finally lead to a plateauing of quality. Only innovations will then further improve quality. Possessing volume can set the optimal ground for continuous process research, subsequent change, innovation, and optimization, while volume itself appears not to be a quality prerequisite.

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References

  1. Dimick JB, Pronovost PJ, Cowan JA. Surgical volume and quality of care or esophageal resection Do high volume hospitals have fewer complications? Ann. Thorac. Surg. 2003;75:337–341

    Article  PubMed  Google Scholar 

  2. National Committee for Quality Assurance. A Road Map for Information Systems: Evolving Systems to Support Performance Measurement. Washington, DC National Committee for Quality Assurance, 1997

    Google Scholar 

  3. Pauly MV. Medical staff characteristics and hospital costs. J. Hum. Resources 1978;13(Suppl):77–111

    Google Scholar 

  4. Davenport RJ, Dennis MS, Warlow CP. Effect of correcting outcome data for case-mix: an example from stroke medicine. B.M.J. 1996;312:1503–1505

    CAS  Google Scholar 

  5. Kottler P. Designing and managing services. In Kottler P (ed.) Marketing Management, Upper Saddle River, NJ, Prentice-Hall 2003;443–469

    Google Scholar 

  6. Roth AV, Van der Velde M. Operations as marketing: a competitive service strategy. J. Operations Manage. 1993;10/3:303–328

    Google Scholar 

  7. Weitz J, Koch M, Friess H, et al. Impact of volume and specialization for cancer surgery. Dig. Surg. 2004;21:253–261

    Article  PubMed  Google Scholar 

  8. McArdle CS, Hole DJ. Influence of volume and specialization on survival following surgery for colorectal cancer. Br. J. Surg. 2004;91:610–617

    CAS  PubMed  Google Scholar 

  9. Process Management In Krajewski LJ, Ritzman LP (eds.), Operations Management—Strategy and Analysis. Upper Saddle River, NJ, Prentice-Hall, 2002;92–158

  10. Haraden C, Resar R. Patient flow in hospitals: understanding and controlling it better. Front. Health Serv. Manage. 2004;20:3–15

    PubMed  Google Scholar 

  11. Meredith J, Samuel JM, Project management—A Managerial Approach, 4th edition. New York, John Wiley & Sons, 2000;88–124

    Google Scholar 

  12. Hannan EL. Provider Volume–Patient Outcome Relationships in the Provision of Medical Care: An Update Rockville, MD, Agency for Health Research and Quality, 2001

  13. Hannan EL. The relation between volume and outcome in health care. N. Engl. J. Med. 1999;340:1677–1679

    Article  CAS  PubMed  Google Scholar 

  14. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N. Engl. J. Med. 1979;301:1364–1369

    Article  CAS  PubMed  Google Scholar 

  15. Birkmeyer JD. Understanding surgeon performance and improving patient outcomes. J. Clin. Oncol. 2004;22:2765–2766

    Article  PubMed  Google Scholar 

  16. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N. Engl. J. Med. 2003;349:2117–2127

    Article  CAS  PubMed  Google Scholar 

  17. Lee CN, Daly JM. Provider volume and clinical outcomes in surgery: issues and implications. Bull. Am. Coll. Surg. 2002;87:21–26

    PubMed  Google Scholar 

  18. Sowden AJ, Watt I, Sheldon TA. Volume of activity and healthcare quality: is there a link? In Ferguson B, Sheldon TA, Posnett J, eds, Concentration and Choice in Healthcare. London, Royal Society of Medicine, 1997;60–167

    Google Scholar 

  19. Yelle LE. The learning curve: historical review and comprehensive survey. Decision Sci. 1979;10:302–328

    Google Scholar 

  20. Bailey CD. Learning curve estimation of production cost and labor hours. Manage. Accounting Q. 2000 Sumer:25–31

  21. Nguyen NT, Paya M, Stevens M, et al. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann. Surg. 2004;4:586–594

    Google Scholar 

  22. Eakin KB, Kniesner TJ. Estimating a non-minimum cost function for hospitals. South. Econ. J. 1988;54:583–597

    Google Scholar 

  23. Evans RG, Walker HD. Information theory and the analysis of hospital cost structure. Can. J. Econ. 1972;5:398–418

    Google Scholar 

  24. Frech HE, Mobley LR. Resolving the impasse on hospital scale economies: a new approach. Appl. Econ. 1995;27:286–296

    Google Scholar 

  25. Lavers RJ, Whynes DK. A production function of English maternity hospitals. Socio-econ. Planning Sci. 1978;12:85–93

    CAS  Google Scholar 

  26. Dimick JB, Pronovost PJ, Cowan JA. Complications and costs after high-risk surgery: where should we focus quality improvement initiatives? J. Am. Coll. Surg. 2003;196:671–678

    Article  PubMed  Google Scholar 

  27. Friedman DM, Berger DL. Improving team structure and communication: a key to hospital efficiency. Arch. Surg. 2004;139:1194–1198

    PubMed  Google Scholar 

  28. Reinhardt UE. Can efficiency in health care be left to the market? J. Health Pol. Policy Law 2001;26:967–999

    CAS  Google Scholar 

  29. Health Care German Regulation. § 137 Abs. 1 Satz 3 Nr. 3 SGB V (Sozialgesetzbuch V) “Mindestmengenvereinbarung”

  30. Chassin MR, Hannan EL, DeBuono BA. Benefits and hazards of reporting medical outcomes publicly. N. Engl. J. Med. 1996;34:394–398

    Google Scholar 

  31. Marshall MN, Shekelle PG, Leatherman S. The public release of performance data: what do we expect to gain? A review of the evidence. J.A.M.A. 2000;283:1866–1874

    Article  CAS  PubMed  Google Scholar 

  32. NHS Centre for Reviews and Dissemination and Nuffield Institute for Health. Hospital volume and health care outcomes, costs and patient access. Effective Health Care 1996;2:1–16

    Google Scholar 

  33. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann. Intern. Med. 2002;137:511–520

    PubMed  Google Scholar 

  34. Christian CK, Gustafson ML, Betensky RA, et al. The Leapfrog volume criteria may fall short in identifying high-quality surgical centers. Ann. Surg. 2003;238:447–457

    PubMed  Google Scholar 

  35. Morrissey J. All benchmarked out. Even the top 100 hospitals can’t find many more ways to be more productive. Mod. Healthcare 1998;28:38–40, 42–44, 46

    Google Scholar 

  36. Long MJ, Ament RP, Dreachslin JL. A reconsideration of economies of scale in the health care field. Health Pol. 1985;5:25–44

    CAS  Google Scholar 

  37. Pena AD, Ndiaye M. Cost control, a myth or reality: do hospital costs really go down when quality goes up? World Hosp. Health Serv. 2004;40:28–32

    Google Scholar 

  38. Aletras V, Jones A, Sheldon T. Economies of scale and scope. In Ferguson B, Sheldon T, Posnett J, eds, Concentration and Choice in Healthcare, London Royal Society of Medicine, 1997

    Google Scholar 

  39. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harvard Bus. Rev. 2000;9/10:102–112

    Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, University of Heidelberg, INF 110, 69120, Heidelberg, Germany

    Thomas W. Kraus M.D., Markus W. Büchler M.D. & Christian Herfarth M.D.

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  1. Thomas W. Kraus M.D.
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  2. Markus W. Büchler M.D.
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  3. Christian Herfarth M.D.
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Correspondence to Thomas W. Kraus M.D..

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Kraus, T.W., Büchler, M.W. & Herfarth, C. Relationships between Volume, Efficiency, and Quality in Surgery — A Delicate Balance from Managerial Perspectives. World J. Surg. 29, 1234–1240 (2005). https://doi.org/10.1007/s00268-005-7988-5

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