Skip to main content
SpringerLink
Log in

Initiating statistical process control to improve quality outcomes in colorectal surgery

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery.

Methods

Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group.

Results

A total of 1294 cases were analyzed—83 % elective (n = 1074) and 17 % emergent (n = 220). Emergent cases were 70.5 % open and 29.5 % laparoscopic; elective cases were 36.8 % open and 63.2 % laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6 % (elective laparoscopic) to 10.8 % (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0 %) and elective lap groups (77.6 vs. 26.1 %). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4 %), emergent lap (14.3 vs. 9.2 %), and elective lap (32.8 vs. 6.9 %). Elective open outliers did not follow trends of longer LOS or higher reoperation rates.

Conclusions

SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477

    Article  CAS  PubMed  Google Scholar 

  2. Wind J, Polle SW, Fung Kon Jin PH et al (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809

    Article  CAS  PubMed  Google Scholar 

  3. Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183:630–641

    Article  PubMed  Google Scholar 

  4. Wilmore DW, Kehlet H (2001) Management of patients in fast track surgery. BMJ 322:473–476

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  5. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149:830–840

    Article  PubMed  Google Scholar 

  6. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW (2003) Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 46:851–859

    Article  PubMed  Google Scholar 

  7. Kehlet H, Mogensen T (1999) Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 86:227–230

    Article  CAS  PubMed  Google Scholar 

  8. Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248:189–198

    Article  PubMed  Google Scholar 

  9. Kehlet H (2008) Fast-track colorectal surgery. Lancet 371:791–793

    Article  PubMed  Google Scholar 

  10. Collins TC, Daley J, Henderson WH, Khuri SF (1999) Risk factors for prolonged length of stay after major elective surgery. Ann Surg 230:251–259

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  11. Nicolay CR, Purkayastha S, Greenhalgh A et al (2012) Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg 99:324–335

    Article  CAS  PubMed  Google Scholar 

  12. Deming WE (1990) Some notes on management in a hospital. J Soc Health Syst 2:74–77

    CAS  PubMed  Google Scholar 

  13. Mohammed MA (2004) Using statistical process control to improve the quality of health care. Qual Saf Health Care 13:243–245

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  14. Deming WE (1980) The statistical procedure in the SENIC Project. Am J Epidemiol 111:470–471

    CAS  PubMed  Google Scholar 

  15. Shewhart WA (1922) On the measurement of a physical quantity whose magnitude is influenced by primary causes beyond the control of the observer and on the method of determining the relation between two such quantities. Proc Natl Acad Sci USA 8:248–251

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  16. Sedlack JD (2010) The utilization of six sigma and statistical process control techniques in surgical quality improvement. J Healthc Qual 32:18–26

    Article  PubMed  Google Scholar 

  17. NIST/SEMATECH e-Handbook of statistical method. 2012; 6.1.2. What are process control techniques? <http://www.itl.nist.gov/div898/handbook/pmc/section1/pmc12.htm>

  18. Delaney CP (2008) Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery. Dis Colon Rectum 51:181–185

    Article  PubMed  Google Scholar 

  19. Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ (2012) Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways. Am J Surg 203:353–355 discussion 355–6

    Article  PubMed  Google Scholar 

  20. Kim CS, Spahlinger DA, Kin JM, Billi JE (2006) Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med 1:191–199

    Article  PubMed  Google Scholar 

  21. Fry DE, Pine M, Jones BL, Meimban RJ (2011) The impact of ineffective and inefficient care on the excess costs of elective surgical procedures. J Am Coll Surg 212:779–786

    Article  PubMed  Google Scholar 

  22. Curran ET, Benneyan JC, Hood J (2002) Controlling methicillin-resistant Staphylococcus aureus: a feedback approach using annotated statistical process control charts. Infect Control Hosp Epidemiol 23:13–18

    Article  PubMed  Google Scholar 

  23. Ryckman FC, Schoettker PJ, Hays KR et al (2009) Reducing surgical site infections at a pediatric academic medical center. Jt Comm J Qual Patient Saf 35:192–198

    PubMed  Google Scholar 

  24. Duclos A, Touzet S, Soardo P, Colin C, Peix JL, Lifante JC (2009) Quality monitoring in thyroid surgery using the Shewhart control chart. Br J Surg 96:171–174

    Article  CAS  PubMed  Google Scholar 

  25. Chen TT, Chang YJ, Ku SL, Chung KP (2010) Statistical process control as a tool for controlling operating room performance: retrospective analysis and benchmarking. J Eval Clin Pract 16:905–910

    Article  PubMed  Google Scholar 

  26. Keller DS, Stulberg JJ, Lawrence JK, Delaney CP (2014) Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway. Dis Colon Rectum 57:194–200

    Article  PubMed  Google Scholar 

Download references

Disclosures

Drs. Deborah S. Keller, Jonah J. Stulberg, Justin K. Lawrence, Hoda Samia, and Conor P. Delaney have no conflicts of interest and nothing to disclose.

Author information

Authors and Affiliations

  1. Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106-5047, USA

    Deborah S. Keller, Justin K. Lawrence, Hoda Samia & Conor P. Delaney

  2. Department of Surgery, University Hospitals-Case Medical Center, Cleveland, OH, USA

    Jonah J. Stulberg

Authors
  1. Deborah S. Keller
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jonah J. Stulberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Justin K. Lawrence
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hoda Samia
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Conor P. Delaney
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Deborah S. Keller.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Keller, D.S., Stulberg, J.J., Lawrence, J.K. et al. Initiating statistical process control to improve quality outcomes in colorectal surgery. Surg Endosc 29, 3559–3564 (2015). https://doi.org/10.1007/s00464-015-4108-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-015-4108-y

Keywords

Search

Navigation