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Play #5 – Standardizing Best Practices: Identifying and Reducing Variability in Surgical Procedures



In our last post, we discussed the implementation of parallel processing to increase OR efficiency. In this post, we’ll continue the process theme and 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.

The Opportunity

Many hospitals are taking on standardization initiatives, to streamline processes and make life easier on staff, as well as to reduce costs. The OR, in particular the intra-operative processes of the OR, is the last area for many hospitals to tackle – even though it is the largest revenue center!

Variability in surgical procedures, across surgeons and across patients, is a given. Certain variability is inherent to clinical practice – a surgeon is left or right handed and requires different setup, a patient is bariatric and requires different tools. Yet the codification of where this variability exists and the opportunity to identify and promulgate best practices is a science just beginning to emerge.

Mapping out intra-operative activity allows a new dataset that improves hospital financial, operational and clinical performance by:

  • Reducing OR setup and intra-operative time
  • Reducing anesthesia time for patients

Additionally, performance quality is inherently improved by improving team confidence in procedure steps with an approved “map” of activities.

What Can We Learn from Research?

Study 1: Reduced operative time by 20%

A study at The Royal Orthopedic Hospital NHS Trust [i] shows the value of surgical process mapping. Here, the intraoperative processes of a very common hand surgery procedure, the carpal tunnel release, were carefully mapped then re-engineered.

They first 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 that it did not make sense to keep anesthetic agents outside of the OR, nor was the technical infiltration process itself as effective or as safe as it could have been, as well as identifying that it was not an effective use of time for the scrub nurse to arrange instruments & perform the initial swab and instrument count after the tourniquet was already inflated. Instead, they arranged for the nurse to scrub in ten minutes prior to the tourniquet application and surgeon scrubbing-in. In addition, the nurse would be aided by a list of instruments slated for the procedure as well as their sequence of use. Some sub-processes were now to be conducted simultaneously.

Once the restructuring was complete, it was discussed with all members of the OR team 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

In a second study at the University Medical Center Leipzig [ii], the intraoperative processes of 105 cataract procedures, as performed by three different experienced surgeons (two outpatient, one inpatient), were mapped and comparatively 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 across surgeons. For example, the duration of “Opening of the lens bag by rhexis cannula” was found to be statistically-significant between surgeons 1 & 3, as well as 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 no. 3, for instance, had the least repetitions and usually shortest performance times. Also, a training of the work 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”

A third study at the University of Chicago and NorthShore University Health System, co-authored by our CMO and co-founder Dr. Alex Langerman [iii], examined variations in performance of the pancreaticoduodenectomy, otherwise known as the Whipple Procedure. The technical steps taken by 5 surgeons during this procedure were compared to one another, to a popular surgeon textbook’s outline (Mastery of Surgery), as well as to nursing and anesthesia textbooks.

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

In an effort to explain why these variations occurred, they also interviewed past fellows to find out the source(s) from which they extracted most of the operative techniques they use in independent practice. Three major factors were identified: “percentage of training time spent with a mentor, consistency of the surgical mentors’ technique, and mentor’s teaching style…” The fact that Fellows choose techniques related to their mentors as opposed to objective best practice criteria, or their own outcomes and skill level. This selection bias highlights a strong need for further analysis of the impact of variability in teaching methods on Residents at different stages of development, and a need for objective, individualized data to enable Residents to select the operative method most appropriate for their skill level. This need for further 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 [v]”.

What are the Critical Enablers of Procedural Mapping and Analysis Projects?

Our experience suggests that there are three critical enablers of surgical process and re-design efforts, including:

  1. The Ability to Perform Side-by-Side Comparisons. The ability to visualize differences between surgical procedures is an essential enabler of surgical process mapping and optimization projects. In particular, the ability to detail major steps and sub-steps of a given procedure is critical to identifying variability, as is the ability to capture sub-steps of a procedure by role (e.g. surgeon/resident, anesthesiologist, surgical tech, and circulator). With ExplORer Surgical, it’s possible to review procedures for different surgeons side-by-side with this level of detail and quickly identify variances in approach overall and by role. The need for this capability is apparent in the carpal tunnel release study above which included significant procedural mapping, comparative analysis, and redesign.

Figure 1. Variability in step time across surgeons at a given institution for a laparoscopic prostate removal

  1. The Ability to Collect Procedural Data. Collecting procedural data at scale is time consuming and negatively impacts the quality and cost of procedural evaluation and redesign efforts. With Explorer, surgical teams can efficiently collect not only time data by step and sub-step of a procedure, but also track task completion by specific roles, document errors, and collect evaluative assessments. And, this can be done from within, or outside, the sterile field. Armed with this data, teams are in an advantaged position to compare and contrast procedures. as well as enable post re-design training. Imagine if the cataract team in the study above had been equipped with an organic application like Explorer which could enable education, rapid preparation, and real-time reference during procedures.


Figure 2. ExplORer tablet in use intraoperatively by a scrub, during which rich data is recorded


  1. The Ability to Syndicate Best Practice Procedures. To ensure their sustainability and impact, procedural re-design efforts must be able to share best practice approaches with surgical teams and enable their ongoing evaluation. With ExplORer Surgical, surgery departments can share best practice procedures and iteratively A/B test competing procedures, ensuring that surgical team performance is more uniform across a health system. Imagine if Residents and Attending Surgeons could examine operative data and determine which procedural protocol was right for use by a Resident a given skill level?



Figure 3. View of the ExplORer “Big Board. Once you have the best practices identified, you can share them and enable other teams to practice it, so more than just a consultative service, the data lives on

If you are considering implementing process mapping and analysis, we’d love to hear from you and have a conversation about your and our insights and perspective. Please contact us at info@explorersurgical.com to set up a conversation.


Although the OR, particularly intra-operative processes, is one of the last areas for hospitals to tackle and drive down costs and increase efficiencies, substantial gains are possible.

As we saw in the above research, substantial gains can be made through the collection and study of intra-operative processes, and the analysis of variability. This is particularly true in the reduction of procedural durations, improvement in education, increased standardization of technique, and perhaps most interestingly, in the identification of the most appropriate surgical protocol to be used by surgeons at specific skill levels. With the added benefit of intra-operative technology like ExplORer Surgical, performance improvement initiatives can happen at greater scale and with greater ease and collaboration across surgical teams.

About ExplORer Surgical

ExplORer Surgical is an interactive surgical playbook that reduces disruptions and wasted disposables by improving surgical team communication. ExplORer Surgical also provides real-time performance and scheduling data to OR administrators to enhance the quality of care and efficiency. Surgical teams use the software to coordinate their activities while managing their tools and supplies in a way never before possible. The result is optimal teamwork, increased efficiency, and high performance.

If you are working to improve the performance of your surgical teams, contact us at info@explorersurgical.com, we’d like to speak with you and see if we can help accelerate your progress.

Posted By: Tom Knight, COO, and Andy Rapoport, Operations Manager

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

[ii] 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.

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

[iv] 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.

[v] 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.

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

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




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