Relationships between Volume, Efficiency, and Quality in Surgery — A Delicate Balance from Managerial Perspectives

Department of Surgery, University of Heidelberg, INF 110, 69120 Heidelberg, Germany.
World Journal of Surgery (Impact Factor: 2.64). 11/2005; 29(10):1234-40. DOI: 10.1007/s00268-005-7988-5
Source: PubMed


Volume, efficiency, and quality in hospital care are often mixed in debate. We analyze how these dimensions are interrelated in surgical hospital management, with particular focus on volume effects: under financial constraints, efficiency is the best form of cost control. External perception of quality is important to attract patients and gain volumes. There are numerous explicit and implicit notions of surgical quality. The relevance of implicit criteria (functionality, reliability, consistency, customaziability, convenience) can change in the time course of hospital competition. Outcome data theoretically are optimal measures of quality, but surgical quality is multifactorially influenced by case mix, surgical technique, indication, process designs, organizational structures, and volume. As quality of surgery is hard to grade, implicit criteria such as customizability currently often overrule functionality (outcome) as the dominant market driver. Activities and volumes are inputs to produce quality. Capability does not translate to ability in a linear function. Adequate process design is important to realize efficiency and quality. Volumes of activities, degree of standardization, specialization, and customer involvement are relevant estimates for process design in services. Flow-orientated management focuses primarily on resource utilization and efficiency, not on surgical quality. The relationship between volume and outcome in surgery is imperfectly understood. Factors involve learning effects both on process efficiency and quality, increased standardization and task specialization, process flow homogeneity, and potential for process integration. Volume is a structural component to develop efficiency and quality. The specific capabilities and process characteristics that contribute to surgical outcome improvement should be defined and exported. Adequate focus should allow even small institutions to benefit from volume-associated effects. All volumes-based learning within standardized processes will finally lead to a plateauing of quality. Only innovations will then further improve quality. Possessing volume can set the optimal ground for continuous process research, subsequent change, innovation, and optimization, while volume itself appears not to be a quality prerequisite.

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    • "Thus, it seems logical that any interpretation of the results published should take into account not only the comparability of the design of the studies, but also the specific characteristics of each healthcare system and the time frame of the observations [46]. Furthermore, it might be a mistake to consider greater volume as a standard to predict better quality, when it is more likely the structures, the experience and specialization of the professionals, and the many different processes linked to this type of intervention that are responsible for better results, as many authors have pointed out [47-49]. "
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