An analysis of the process of colorectal surgery from an organizational perspective in Dutch hospitals

Background: The total costs of health care are rising worldwide and become a greater part of the GDP. This can be ascribed to an aging population, higher life expectancy, technological development and a greater need for high care quality by society. Care processes therefore have to be investigated and their relation with efficiency and effectiveness have to be assessed. In the Netherlands colorectal cancer (CRC) is the third most common cancer among males (14%) and the second most common among females (13 %). Objective/research question: To design and investigate methods to quantify efficiency and process characteristics of the surgical colorectal cancer pathway in Dutch hospitals. Methods: The research was conducted from February until August 2011. An explorative study was used to construct a measuring method to assess efficiency of the CRC surgical care. Different calculation methods and inputs and outputs were investigated. Based on the specific CRC surgical process an efficiency measure was constructed. Interviews, process observations and site visits were part of the study. Furthermore a mixed method design was used to assess Lean initiatives. First a framework was constructed using a literature review and on-site hospital visits. Relevant data was also available from earlier research. Five hospitals were visited during four days and data was collected using a retrospective (electronic) health record review, semi-structured interviews, and observations. After construction of the framework, the framework was applied to the collected hospital data to evaluate the usefulness. Besides correlations using a bivariate non-parametric Kendall’s tau test with efficiency measures as lead-times and number of hospital visits were analyzed. The demand for colorectal surgery is rising and efficient use of capacity and resources, improving quality and reducing costs is desirable. Different methods to assess efficiency exist in health care. Lean Thinking is a process-based management philosophy to decrease waste and construct a more efficient process design. Leanness is referred to as a quantitative term but what exactly should be quantified is not standardized. Results: Various efficiency measurement methods were investigated and a non-parametric calculation method was proposed. Also a first step is done using data available for a data envelopment analysis. Furthermore a framework was constructed for six lean categories, which are; operational focus, autonomous work cell, physical layout, multi-skilled team, pull planning and elimination of waste. In each category different items could be scores in order to get a quantifiable aggregated score per category. When applied to hospital data, differences and similarities between organizational and (design of) process characteristics were found. Furthermore some relations were found after the analysis of which a few are relevant. In further analysis on item-level more relevant relations were found. Conclusion/discussion: Different methods to measure efficiency in health care were found and a selection of methods and measures is proposed. Data Envelopment Analysis is a promising technique that can be used to assess efficiency using multiple inputs and outputs. Related to the process characteristics, differences between hospitals were found in both lead-times and number of hospital visits, as well the organization and design of the care process were found. The framework can be used as a scorecard to compare hospitals on six domains of process design characteristics. Most important relations that were found were that a multidisciplinary team slows down the care process, but quality can be high and the scoring high on the scorecard categories “pull planning” and “operational focus” proved a reduction of lead-times. A more detailed correlation analysis revealed that the availability of flow charts in an organization increased the speed of care delivery and the presence of a dedicated colon care nurse does not improve the lead-time and number of hospital visits.