Article

Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement

Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Veterans Administration Medical Center, Birmingham, AL, USA.
American journal of surgery (Impact Factor: 2.41). 11/2009; 198(5):600-6. DOI: 10.1016/j.amjsurg.2009.07.005
Source: PubMed

ABSTRACT This study evaluated elective surgical case cancellation (CC) rates, reasons for these cancellations, and identified areas for improvement within the Veterans Health Administration (VA) system.
CC data for 2006 were collected from the scheduling software for 123 VA facilities. Surveys were distributed to 40 facilities (10 highest and 10 lowest CC rates for high- and low-volume facilities). CC reasons were standardized and piloted at 5 facilities.
Of 329,784 cases scheduled by 9 surgical specialties, 40,988 (12.4%) were cancelled. CC reasons (9,528) were placed into 6 broad categories: patient (35%), work-up/medical condition change (28%), facility (20%), surgeon (8%), anesthesia (1%), and miscellaneous (8%). Survey results show areas for improvement at the facility level and a standardized list of 28 CC reasons was comprehensive.
Interventions that decrease cancellations caused by patient factors, inadequate work-up, and facility factors are needed to reduce overall elective surgical case cancellations.

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    • "Cancellations are caused by a sub-optimally functioning clinical system [29-31]. Consequently, reducing cancellations requires changing and improving the entire clinical system. "
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    ABSTRACT: Background Contextual factors influence quality improvement outcomes. Understanding this influence is important when adapting and implementing interventions and translating improvements into new settings. To date, there is limited knowledge about how contextual factors influence quality improvement processes. In this study, we explore how contextual factors affected measures to reduce surgery cancellations, which are a persistent problem in healthcare. We discuss the usefulness of the theoretical framework provided by the model for understanding success in quality (MUSIQ) for this kind of research. Method We performed a qualitative case study at Førde Hospital, Norway, where we had previously demonstrated a reduction in surgery cancellations. We interviewed 20 clinicians and performed content analysis to explore how contextual factors affected measures to reduce cancellations of planned surgeries. Results We identified three common themes concerning how contextual factors influenced the change process: 1) identifying a need to change, 2) facilitating system-wide improvement, and 3) leader involvement and support. Input from patients helped identify a need to change and contributed to the consensus that change was necessary. Reducing cancellations required improving the clinical system. This improvement process was based on a strategy that emphasized the involvement of frontline clinicians in detecting and improving system problems. Clinicians shared information about their work by participating in improvement teams to develop a more complete understanding of the clinical system and its interdependencies. This new understanding allowed clinicians to detect system problems and design adequate interventions. Middle managers’ participation in the improvement teams and in regular work processes was important for successfully implementing and adapting interventions. Conclusion Contextual factors interacted with one another and with the interventions to facilitate changes in the clinical system, reducing surgery cancellations. The MUSIQ framework is useful for exploring how contextual factors influence the improvement process and how they influence one another. Discussing data in relation to a theoretical framework can promote greater uniformity in reporting findings, facilitating knowledge-building across studies.
    BMC Health Services Research 05/2014; 14(1):215. DOI:10.1186/1472-6963-14-215 · 1.66 Impact Factor
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    • "This clinical dilemma often leads to same day surgical case cancellations resulting in delay and/or denial of the surgical care needed for these veterans. Same day case cancellation also results in wasting of the operating room (OR) resources and of valuable health care dollars [20]. Currently, there are no published guidelines to support the clinical decision making regarding perioperative management of patients with history of cocaine abuse [21]. Clinical practices vary widely based on individual anecdotes and personal experience. "
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    ABSTRACT: . Perioperative management of cocaine-abusing patients scheduled for elective surgery varies widely based on individual anecdotes and personal experience. Methods . Chiefs of the anesthesia departments in the Veterans Affairs (VA) health system were surveyed to estimate how often they encounter surgical patients with cocaine use. Respondents were asked about their screening criteria, timing of screening, action resulting from positive screening, and if they have a formal policy for management of these patients. Interest in the development of VA guidelines for the perioperative management of patients with a history of cocaine use was also queried. Results . 172 VA anesthesia departments’ chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Results. 172 VA anesthesia departments’ chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Conclusions . There is a general consensus that formal guidelines would be helpful. Further studies are needed to help formulate evidence-based guidelines for managing patients screening positive for cocaine prior to elective surgery.
    Anesthesiology Research and Practice 08/2013; 2013(2):149892. DOI:10.1155/2013/149892
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    • "The cancellation of planned surgeries is a well-recognized quality problem. High cancellation rates may indicate that scarce health resources are being used ineffectively, thereby increasing costs [1,2]. Patients are directly affected by cancellations; they increase waiting times and may lead to harmful delays of operations [2,3]. "
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    ABSTRACT: The cancellation of planned surgery harms patients, increases waiting times and wastes scarce health resources. Previous studies have evaluated interventions to reduce cancellations from medical and management perspectives; these have focused on cost, length of stay, improved efficiency, and reduced post-operative complications. In our case a hospital had experienced high cancellation rates and therefore redesigned their pathway for elective surgery to reduce cancelations. We studied how patients experienced interventions to reduce cancellations. We conducted a comparative, qualitative case study by interviewing 8 patients who had experienced the redesigned pathway, and 8 patients who had experienced the original pathway. We performed a content analysis of the interviews using a theory-based coding scheme. Through a process of coding and condensing, we identified themes of patient experience. We identified three common themes summarizing patients' positive experiences with the effects of the interventions: the importance of being involved in scheduling time for surgery, individualized preparation before the hospital admission, and relationships with few clinicians during their hospital stay. Patients appreciated the effects of interventions to reduce cancellations, because they increased their autonomy. Unanticipated consequences were that the telephone reminder created a personalized dialogue and centralization of surgical preparation and discharge processes improved continuity of care. Thus apart from improving surgical logistics, the pathway became more patient-centered.
    BMC Surgery 08/2013; 13(1):30. DOI:10.1186/1471-2482-13-30 · 1.24 Impact Factor
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