Standard Work in the Preoperative Assessment

Standard Work in the Preoperative Assessment

Michael Bohl, MD

Rajiv K. Sethi, MD


The concept of standard work was developed by Toyota engineer and founding father of lean methodologies, Taiichi Ohno, and is a central tenet of the Toyota Production System (TPS).1,2 The concept of standard work arose from Ohno’s observation that when a particular workflow is variable, unpredictable, and ambiguous, it is impossible to differentiate practices in that workflow that yield value from those that produce waste.3 This concept is very analogous to the basic principle in medical research that when comparing the effectiveness of two interventions, one must first identify a control group (the standard work) against which the intervention will be compared. Without defining the control group and the outcomes achieved in the control group, one has no way of knowing how valuable the studied intervention is. When applied to a work process, such as preoperative surgical assessments, this same concept holds true; before you can identify the aspects of a work process that add value, you must standardize that work process to control the variables present. Once you have established a standard process for a given type of work, then incremental changes can be made to the work process, and the outcomes of those changes can be compared to the outcomes achieved when using the standard process. This process can then be repeated indefinitely to achieve continuous process improvement (see Fig. 1).4,5,6

Why Apply Standard Work to Preoperative Assessments for Adult Reconstructive Spine Surgery?

Of all the procedures in the surgical armamentarium, adult reconstructive spine surgery is among the most dangerous with reported complication rates ranging from 25% to 80%.7,8 The types of complications suffered during these procedures can generally be categorized as (1) intraoperative, (2) short term (within 90 days postoperative), and (3) long term (>90 days postoperative). Intraoperative complications include high-volume blood loss, coagulopathy, neurologic injury, surgeon error or misjudgment, hypotension, myocardial infarction, and cerebrovascular accident.9,10 Short-term complications include local or systemic infection, venous thromboembolism, wound dehiscence, postoperative pain or implant-related problems requiring reoperation, and complications arising from comorbid conditions. Long-term complications include hardware failure, pseudoarthrosis, adjacent segment disease, and proximal or distal junctional failure.11,12,13,14,15

Given the high risk of morbidity for adult reconstructive spine surgery and the fact that these procedures are all electively performed, it is in the best interest
of both the patient and spine surgeon to begin one of these procedures optimally prepared. The literature contains numerous reports of standardized perioperative protocols successfully reducing the incidence of specific complications.9,11,16,17,18 The Seattle Spine Team Protocol (SSTP) is an example of a comprehensive approach to risk mitigation and outcome optimization that utilizes the principles of the TPS, specifically those relating to standard work and continuous process improvement.19 The SSTP is centered on three core components: (1) a live multidisciplinary preoperative conference comprised of all stakeholders in the care of these patients (surgeons, anesthesiologists, internists, physiatrists, mental health professionals, operating room [OR] staff, etc.) to assess the appropriateness of surgery on a case-by-case basis and to coordinate care from the preoperative state through discharge, (2) a collaborative intraoperative surgical team focused on increasing efficiency and mitigating risk through the use of two attending surgeons and a dedicated complex spine anesthesia team, and (3) the application of a rigorous intraoperative monitoring protocol to assess and treat blood loss and coagulopathy. As is done with any standard work process, the first step taken by the SSTP team was to deconstruct the existing process of their preoperative assessment into a value stream map that identifies those processes in place that aim to mitigate specific immediate, shortterm, and long-term complications. Figure 2A depicts this map in its current form and identifies all the subcategories of surgical morbidity that are addressed by the preoperative assessment. The next step is to further deconstruct the preoperative assessment process into specific components and further map the value added by these components onto the same value stream map. Figure 2B, for example, shows the specific value stream map for the multidisciplinary conference. After completing this for the entire preoperative assessment process, one is able to readily identify which parts of the work process are meant to target specific outcomes, and more importantly, one can establish a standard workflow for the entire preoperative assessment against which future incremental changes will be compared. In this fashion, the SSTP established a preoperative assessment in terms of standard work.

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Dec 19, 2019 | Posted by in ORTHOPEDIC | Comments Off on Standard Work in the Preoperative Assessment

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