Standardizing Best Practices Research: Identifying and Reducing Variability in Surgical Procedures

  • July 25, 2018

In this post, we’ll look closely at how detailed process-mapping of procedures can be employed to re-engineer procedures and gain a better understanding of variability across surgeons in time and approach.

Study 1: Reduced operative time by 20%

The Royal Orthopedic Hospital NHS Trust [iii] shows the value of surgical process mapping. Here, the intraoperative processes of the carpal tunnel release, were carefully mapped then re-engineered.

First, they ran the procedure five times and recorded the average time for each step, mapping the major sub-processes (and their steps) within those steps.

Restructuring included:

  • Recognizing anesthetic shouldn’t be outside the OR
  • Ensuring the technical infiltration process is effective and safe
  • Identifying effective use of time for the scrub nurse to arrange instruments & perform the initial swab
  • Rearranging so the nurse can scrub in ten minutes prior to the tourniquet application and surgeon scrubbing-in.
  • Aiding, the nurse with a list of instruments slated and sequence of use for the procedure

Some sub-processes were now to be conducted simultaneously.

After restructuring, all members of the OR team discussed the results and additional small changes were made based upon their feedback. A visual map of the restructured process was displayed in the OR, with a period of two weeks allocated for learning, at which point eight more procedures were run, with mapping and timestamping conducted again. This resulted in a mean reduction of 20% in total operating time. The decrease by seven minutes from a mean of 34.4 minutes, at a notional cost of $100/OR minute, represents a $700 savings per procedure. To accomplish this, they reduced the number of steps in the procedure from 66 to 37, a reduction of 44%.


Study 2: Process Modeling Yields Opportunities for Educational Improvement and Standardization

At the University Medical Center Leipzig [v], the intraoperative processes of 105 cataract procedures, as performed by three surgeons (two outpatient, one inpatient), were mapped and analyzed. In conducting this mapping, they recorded who was performing a given action, what was being done during that activity, the material whereby it was done, where anatomically it was done, and when it was done (i.e. its duration)

They identified instances of highly significant differences (p<0.001) in technical step duration. For example, the duration of “opening of the lens bag by rhexis cannula” was statistically-significant between surgeons 1 & 3, and between 2 & 3. They found surgeon 3 to have a “distinct preference” for the instrument used to “hold bulbus oculi”. Surgeon 3 also “had the least repetitions and usually shortest performance times”

These researchers concluded “that detailed profiles could be gathered with the help of Surgical Process Modeling” to “provide… an exact, validated and objective decision base for the support of surgical teaching in the realm of evidence-based eye surgery”. In particular, “a profound exchange of experience [between surgeon and residents] would be very useful. Surgeon 3, had the least repetitions and usually shortest performance times. Also, a training of the step ‘paracentesis with right hand’ could lead to an amelioration of results.”


Study 3: Operative Data are Needed to Enable Selection of “the Best Operative Approach”

At the University of Chicago and NorthShore University Health System, co-authored by our CMO and co-founder Dr. Alex Langerman [iv], examined variations in performance of the pancreaticoduodenectomy. The technical steps taken by 5 surgeons during this procedure were compared, to a popular surgeon textbook’s outline (Mastery of Surgery) and to nursing and anesthesia textbooks.

Across the 5 surgeons, major variations were identified: the order of operations, the type of resection tool used and the technique for division of the pancreas. Furthermore, “…they found 21 surgical step data points that differed among the 5 surgeons”.

To explain why variations occurred, they interviewed past fellows to find the source(s) they referred to for operative techniques used in independent practice. Three factors were identified: “percentage of training time spent with a mentor, consistency of the surgical mentors’ technique, and mentor’s teaching style…” Highlighting the fact that Fellows choose techniques related to their mentors opposed to objective best practice criteria, or their own outcomes and skill level. This represents a strong need for further analysis of the impact of variability in teaching methods on Residents at different stages and a need for objective. Individualized data enables Residents to select the operative method most appropriate for their skill level. This need for analysis is supported by a “recent publication by Birkmeyer et al which indicates that amongst the most important reasons for variation in surgical technique are the different attitudes and beliefs about indications and that surgical technique and approach rather than comparative effectiveness [vii]”.


[i] Birkmeyer JD, Reames BN, Mcculloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet. 2013;382(9898):1121-9.

[ii] Boulay L. “Eliminating Unnecessary Practice Variation in Laparoscopic Appendectomy and Laparoscopic Cholecystectomy”.

[iii] Casaletto JA, Rajaratnam V. Surgical process re-engineering: carpal tunnel decompression–a model. Hand Surg. 2004;9(1):19-27.

[iv]Davidson SJ, Rojnica M, Matthews JB, Langerman AJ. Variation and Acquisition of Complex Techniques: Pancreaticoduodenectomy. Surg Innov. 2016;23(6):586-592.

[v] Neumeister, Michael W. “Welcome to the Department of Surgery”. SIU School of Medicine Surgery.

[vi] Neumuth T, Wiedemann R, Foja C, et al. Identification of surgeon-individual treatment profiles to support the provision of an optimum treatment service for cataract patients. J Ocul Biol Dis Infor. 2010;3(2):73-83.

[vii] Nguyen, Michelle C, Luzum, Matthew J, Renton David B, Phillips, Gary S, Moffatt-Bruce, Susan D. Significant Variation in Surgical Supply Cost Secondary to Surgeon Preference for Laparoscopic Cholecystectomy. JACS. 2015;221(4):S132-133.

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