It feels like it doesn’t matter where you go, health systems are struggling. In the US, just about any procedure is super expensive. In the UK and Australia, waiting lists extend far into the future and patients are left sitting in ambulances as hospitals lack capacity. In France, staff shortages rage furiously, frustrating operations.
It might seem like hope is fruitless and there is little that can be done. But amidst this horrid backdrop, one London hospital is finding some serious gains with some neat optimizations to the way it handles surgery, as The Times reports.
Keep ‘Em Moving
The new innovative model is the brainchild of Imram Ahmad and Kariem El-Boghdadly, a pair of consultant anesthetists working at Guy’s and St Thomas’ NHS Foundation Trust. The latter compares the surgery setup to the way motorsport pit crews slash the time of a pit stop, by effectively splitting up tasks and designating their completion to certain individuals. For example, a Formula 1 team doesn’t change one tire at a time. Instead, 12 crew members change four tires at once—usually in less than 3 seconds.
The duo’s trick to speeding up surgery is similarly down to parallelizing operations. It involves setting up two operating theatres side by side. While surgeons are operating on one patient, another is being prepped in the second theatre.
When they complete one procedure, they can move straight to the next procedure with the patient already under anaesthetic and ready to go into surgery. “The anaesthetic happens while another patient is being operated on, and as soon as patient number one is done and leaves the operating room, the second patient has come in the operating room already anaesthetised,” El-Boghdadly told The Times.
Cleaning is optimized too, with nurses able to clean a theatre post-procedure in under two minute, ready for the next patient to roll in. The operating method is called “High Intensity Theatre”, or HIT for short, and typically runs on weekends at Guy’s and St Thomas’.
The results have been astonishing, helping clear long waiting lists in record time. One Saturday at St Thomas’ hospital saw a third of gynaecological oncology list cleared in a single morning. Where the team would usually do 6 operations in a full workday, they were able to clear 21 cancer diagnostic operations by lunchtime. HIT methods were also used to complete three months worth of breast cancer operations in just five days during one stretch in August, while a prostatectomy team were able to achieve a week’s worth of operations in just one day using the method.
El-Boghdadly is keen to note that it’s not about rushing surgery or cutting corners, but finding efficiencies. He notes that the hospital routinely knocks off two to three times as many surgeries in a day than when using more routine operational procedures.
Working more efficiently has knock-on health benefits too. Many diseases, like cancers, benefit from early detection. Getting patients in for surgery sooner could thus improve outcomes versus those who get stuck on waiting lists for weeks or months for a simple diagnostic.
Indeed, it’s not unlike the optimization that a manufacturing engineer might do to a production line. In a factory, there’s little value having workers around waiting for parts to assemble, for example. In much the same way, it’s silly to have high-dollar, highly trained surgeons twiddling their thumbs while they wait for patients to be prepped for their next surgery. Anything that keeps them working more and reduces their downtime can be a good efficiency gain.
Obviously, it’s still important for staff to take breaks to rest and the like, but the elimination of dead times and the dreaded “hurry up and wait” can be a huge boon. Why spend millions upon millions building more theatres and training more surgeons? If the HIT method really does work, then simply reallocating some staff resources can get many more surgeries out of existing staff in the same amount of time. Spread that across a whole hospital system, and the benefits would be huge.
With waiting lists in many countries stretching out to the moon, this methodology could be a long-overdue way to help get them back down, to the benefit of patients and administrators alike. Here’s hoping the HIT method can bring these benefits to more hospitals around the world.
Sounds like a good solution, though I wonder how long the folks working the line can really keep it up. Don’t want to burn out the staff long term or wear them down in a shift so they are making mistakes. That idle time isn’t exactly waste.
I’m no expert but from what I’ve read that sort of intensity is going to be pushing folks perhaps a bit too close to their limits where mistakes might be made rather more often (judging by accounts mostly of field hospital staff I read a long time ago). Which when its combat medicine or something makes a great deal of sense as the cost of not trying to cycle folks through as fast as possible is definitely higher than the cost of any extra mistakes made by folks working near or even beyond their sustainable limits.
Sounds like a terrible solution and malpractice waiting to happen
Agreed with the sentiment, I want to see the surgery complications percentages.
In general, the incentives here suck, and they’re set by the UK government interested to keep healthcare expenses criminally low while somehow having high fn taxes, like, really gotta wonder where they’re going huh. This “formula 1” effort reminds me of the Soviet “пятилетка за три года”, with all the memes that followed.
Uk has pretty normal tax percentage comparable to any other industrial nation with public healthcare, if google is to be trusted.
Yeah. When I was in the UK expenses were through the roof and pay was awful. Speaking of the five year plan, I always thought this poster was funny: https://upload.wikimedia.org/wikipedia/commons/d/d9/Yakov_Guminer_-_Arithmetic_of_a_counter-plan_poster_%281931%29.jpg
Yeah, this kind of “optimisation” is definitely going to kill people. Maybe even the surgeons too. Management stop thinks the man-month is real.
My kids had to have their eyes examined under anesthesia in one of the best hospitals in Poland, Children’s Memorial Health Institute. Children were prepped in one room, and then moved to another for the checkup. Then they were returned to the first room for wake-up injection, and then moved back to ophthalmology department, as all eye examinations took place at the ophthalmology clinic, so our line was parallel to them. Also when they had a small personnel shortage, doctors rotated between normal examination rooms and the one for kids under anesthesia…
I think the polish method might work suite well, bit I fear for this British one.
The problem is as written above, risk for burn out. A surgeon, doing highly complex work very heavy strain on the brain etc, doesn’t really need to improve his throughput. Getting plenty of rest is what is important, even if it doesn’t feel on between surgeries.
Its like managers trying to improve engineering. Often, it doesn’t work. Developers goofing off during ‘compilation’ (xkcd pun) serves also to rest the brain, help think of new creative methods.
I’m not a surgeon, but I would hope their work is not so simple that a factory worker could do it? Then again, surgeAI anyone?
I had a small toenail surgery last month and my surgeon was basically 20 minutes of anxiously waiting and test-cutting my toe to see if anesthesia had kicked in (it hadn’t) and then about 5 minutes of operation.
I think it would’ve beem way better for everyone if I’d gotten an anestetic, be left for 30 minutes for it to reallg work, and have the surgeon do three patients and a coffee break in those same 25 minutez.
Depends if you’re actually working the surgeons harder or just offloading a ton of prep/post work onto other staff whose time is less valuable, leaving the surgeons to just do the part they’re specialised in. No point having a surgeon stood round waiting for a prep team
I’m fairly sure the consultants running this scheme would not be designing a system that burns them out or makes their workload intolerable. Believe it or not folks like that are pretty concerned about patient safety.
I don’t know what consultants are like in the UK, but in the US, employee wellness is laughably absent from efficiency considerations, and many things that seem to be wellness are subtle ways to coerce workers to stay longer and take shorter breaks. I don’t want to assume this consideration is absent here without knowing more, but I also am not inclined to think it is automatically present, especially when the only nod to it is calling “hurry up and wait” something to be “dreaded”. That said, having short, high intensity but also high productivity periods (like the weekends in the example above) might actually be good for everyone, as it breaks up the grind a bit. The danger is that it’s often proved difficult to convince managers that a system that works really well for some people some of the time isn’t necessarily a system that works well for all people, all of the time. This system also notably reduces a redundancy to increase speed, but that also reduces safety because the surgeon and anesthetists aren’t free to jump in and help solve problems if something unexpected happens while they would normally be “waiting”. Again, there could be enough doctors and healthcare professionals available for an “all hands” emergency even so, but it’s a trade off worth considering.
Aside from needing 2x anesthesiologists and surg room techs, this is viable only of the duration of the surgery is very confidently known. Other wise you’ve got patient #2 needlessly under anesthetic.
Besides, every time Ive been “put under”, it seemed amazingly fast.
Quite right. And as my surgeon put it: all surgery is exploratory. Imaging only provides a limited picture. I went under for a pretty standard 45 minute obstruction op at 4:30 pm. The imaging was horribly misleading. The opp ended up taking 6 and a half hours. The poor surgeon and anesthetist finished at 11 pm.
Keeping a person under general anesthesia for an extra 30min to and hour does not up the risk for most people. It probably entails local anesthesia as well. If the surgeon doesnt have to wait for prep, wait for anesthesia, spend time talking to family afterwards, those are all timesavers. If you are paying for a surgeon, do you want to pay them to do surgery, wait an hour doing nothing or to give news to families that could he done by a nurse. It ends up saving the taxpayer money as the surgeons are being paid for surgery, and not keeping a seat warm.
I think the missing detail here is that surgeons are not robots whose only use is to cut and suture. Part of the value of a surgeon is deep knowledge, and that might mean a surgeon would catch something or ask an important question while talking to the family, evaluating a patient before the administration of anesthesia, or watching the patient as the theater is prepped. It might also mean that the surgeon finds something during surgery that was unexpected and requires an immediate change of plans, that can’t be accommodated with reasonable risk if the next patient is already prepped and there is no one to take over that next surgery for however long it takes the previous surgery to finish. An extra half hour may be fine, but as mentioned by others here, complications can range from “oh, that’s interesting” to basically a full additional workday or more of additional work, and worse, it’s not always immediately obvious how long it will actually take to work out a problem. For the more routine surgeries, and especially those that don’t require general anesthesia, having another surgeon available for emergencies (either one who is working but not actively operating or one on call) may be enough to handle that kind of situation, but it’s something that absolutely needs to be considered and planned for, and the benefits of having the expert available for more than just the active OR parts of the job should not be ignored.
Before the Olympic games in Sochi, Russia bought a bunch of Da Vinci robotic surgery machines and installed them at many nearby hospitals. Since then, surgeries have been batched much like the process described in this article. A friend of mine’s Mother needed a heart valve replacement, and was one of over 20 heart valve replacements done in a single day. Finding efficiencies like this makes good sense to me.
I believe they do eyes the same way.
Eyes are usually just twilight or valium and not general anesthetic. Vasectomies are the same way, and I had a friend whose doctor would schedule dozens of surgeries on the morning when the March Madness tournament started. (College basketball for non-USians). They send the guys home with a $50 voucher for a pizza location and doctor’s note to be off work for a few days, and the guys could recover and watch the games (while the doctor made a ton of money and then have the time off to do the same.) Free market FTW!
I want to bring this to my country.
What software is available to do this? It’s fine if it’s for manufacturing or surgery.
If there’s a book about it i would also like to know it please.
It’s basic continuous improvement methodologies but looking at processes rather than physical products and working with people who are willing to input at the start, try during and provide feedback at the end.
I am surprised that this decades-old methodology has only just gained some traction or is this just a case of the most high-profile or publicised result?
In my experience there are some industries that think they are special and require special innovations to do the same thing as other ‘normal’ industries. I’ve never seen anywhere that has actually been the case, outside of needing to convince the entrenched.
Long as it doesn’t result in a race to the bottom, or “lowest bidder, operates”.
There is inherent danger in approaching surgical procedures on very unique Human Beings with “assembly line” production methods. People are neither machines nor products, and the callous, reckless ” industry” mindset is stunning to me. MILLIONS of Covid-19 victims are yet fresh in their graves & MILLIONS more still suffer & fight to survive every day. Meticulous aseptic principles & techniques are absolutely essential!! Russia is our example? Really? I have 33 yrs as an RN in US operating rooms & we ARE the ideal standard to which all others are compared. I am also a bit cynically amused by the casual commentary: ALL surgery IS routine after all…until it is YOU.
I would agree if they are changing surgical procedures, but it does not look like they are. What they are changing is the staging and prep schedule/task assignments pre & post op. Changing who does those procedures, or how many people are doing the OR/patient prep, is far different from changing the standards for how that is done.
Are there risks? Sure, there will always be an unintended consequence somewhere. But there are consequences with current systems too, including overall lower quality of healthcare due to wait times and system capacity limits.
The book is called “The mythical man month”.
It’s called thinking about the problem.
Here in Germany, getting a physician appointment means sometimes waits for up to 6 months. The amount of lost personal seems to be around 50 % since corona started. I wonder what these people do today. Work laws are also not enforceable. They could have been training nurses left and right but no, some “foreigners” will do it. Sit and wait. You have to train the people, not let rot somewhere waiting year for some resolution… This ship sinks. /rant
I don’t want to brag, but it’s not uncommon to have a 6+ month waiting list in the US either…. (I know my wife’s clinic books 80-90% of capacity for only up to 6 months, and then takes urgent requests for the remaining head space.)
Seems many EU members are wrestling with the healthcare these days. Many also seem to think that hiring personel from outside the EU is the way to go, exploiting foreigners willing to work lower wages in hopes of getting visas etc. Agree on the sinking ship situation. Time someone started manning the pumps and plugging the holes.
Plenty of good doctors all over the world that would have to go back to square one, as in the complete beginning with school to practice in a new country. Also, doctors don’t get paid like they used to. This much I promise, at least in the US.
As for paralleling operations – sure, go for it, as long as it’s easy, low risk, predictable work and you can keep up with charts and not burn people out with long shifts. But that’s definitely not all surgery.
Here in the UK we’ve gone better – post Brexit a load of the foreign labour went home and the right wing are still banging the anti-immigration drum despite the care sector and farming sector crying out for workers.
That’s not a situation you can solve by bringing the migrant workers back, because the fundamental problem is that the foreigners were being used to stomp on the wages in that sector. It takes time to train new people, and you also have to pull your head out of your rear and start paying them properly.
The people who wish to import workforce are just trying to be modern day aristocrats, enjoying the high paying white collar jobs while pretending to be humanist by importing people of the third world into wage slavery.
Most “intelligent” people do things most absurdly….
Will this increase in productivity per surgeon end being used to cut surgeon numbers?
This reminds me about Top Gear laying asphalt on a street in one night instead of a week as usually.
this isn’t new. ever watch m*a*s*h? a lot of the plot lines in the show are lifted directly from historical records. battlefield surgeons work like a well oiled minigun.
What doctors (not surgeons) do could easily be done by AI. Cross-referencing symptoms and test results is all my GP really does. A knowledge-based profession that allows him to own a Porsche. Time for technology to stomp out that monopoly I think, given the doctor shortages and their high wages.
gps seem to have taken on the role of the bureaucrat. cant remember the last time i went to a physical and the doctor even checked for anything. vitals, blood draws, vaccines, and that’s about it. its like they are being told not to look for problems, which i kind of think is their job and the whole point of a physical. cant remember the last time they checked for a hernia and ive never had a prostate exam (and im over 40).
(if it’s your time to get a prostate exam, please, please go get one!)
Nowadays theres a home test you can buy at the chemist, prick of blood on a test strip and then some waiting, I thought I´d mention it, in case someone doesnt want to risk getting the finger.
My doctor told me a couple of years ago that digital rectal exams for prostate are no longer recommended. They just depend on the blood test now.
Please insist on at least a PSA blood test! Two of my co-workers had their doctors try to talk them out of the blood test as there are too many false positives; both of them had prostate cancer. I have a family history and insist on a PSA test every year.
You go with that, dear. Heck why not? Maybe Xbox “gaming” surgery streamed live on FB would be cool! Doctors I’ve worked with for 30+ years are NOT zooming to the club in flashy sports cars. Their “jobs” are their lives and they are never actually off “work”. Most are also hundreds of thousands in debt from financing medical school & residency before they start practicing. AI can do it better? Maybe Walmart will develop an AI Surgery Self-Check system and you can get your groceries & surgery together LMAO!!!
I’m a doctor, an anesthesiologist, in the US.
This “idea” is so… not new. It is standard practice in the 3 major centers I have worked in for almost the last 20 years. Specifically, it is common for a surgeon to bounce between cases in one of two rooms. At an academic center this is possible because the resident, fellow or other trainee typically can do the exposure and closure, while the critical “actual surgery” needs the supervising surgeon to be present. At private centers, a surgeon assistant, PA or NP can fulfill that role.
The problem is not surgeon availability. It is OR rooms and ancillary staff. You may be surprised to learn that physician salary is but a minor cost associated with healthcare. A majority is administrative overhead and ancillary staff including RNs, OR techs, etc. At our center, each of 7 operating rooms are booked workday start to finish, with additional allowance for the inevitable emergencies etc. We simply do not have twice the real estate, twice the nursing, twice the everything else needed to fully run a 2-room system. Surgeons would loooove to have 2 rooms every day. There just isn’t staff. There are already shortages of about every single role in a hospital from janitorial to surgeons and physicians. You simply cannot have twice the staff when we are all struggling to even have a single full staff. At our center we are about 30% short of nurses as-is. Good luck.
And the commenter above was right. Maybe for really routine surgeries (joint replacement comes to mind) that aren’t all that different, the system would work OK. We have had enough times where we put a patient under for anesthesia on the promise the surgeon is “almost done” in the other room only to sit there for 1, 2 or more hours needlessly exposing a patient to anesthetic agents while we wait. Especially for kids, where there is legitimate concern for exposure to the developing brain, we simply cannot do this.
Oh and for the record, my personal benchmark for “in the room” to “100% ready for surgery to start” is 5 minutes for adults and kids undergoing “routine” surgeries. I’m exceptional at this. So time to undergo anesthesia and “wake up” (another 5 minutes) is something surgeons and everyone else loves to blame for delays when it is simply a non-issue.
Yep I always find it hilarious when people say Dr.’s are paid too much. For 1, there is a shortage and it’s growing. For 2, my best friend is an M.D. (Interventional radiologist). He did 4 years of undergrad, master’s and a PhD (yes he did all those in 4 years) then 4 years of Medical school, then was working absurd hours for 3-4 years as a resident in Shreveport LA making about $40,000 a year.
So 12 years before he was fully qualified.
People that think Dr’s are paid too much are free to follow that path and get that pay themselves 😂
“He did 4 years of undergrad, master’s and a PhD (yes he did all those in 4 years)”
With all due respect, calling BS on that.
Maybe he means 4 years each? Undergrad (4) plus med school plus phd (for me, started and ended concurrently with med school so 7 total) plus residency (4) plus fellowship (1) so…16 years. I tell people if you want to do my job imagine graduating high school then starting over at kindergarten.
So you attended school until the 28th Grade!
B^)
I readily believe the ancillary staffing problem. Both major healthcare networks in my area laid off more than half the nurses (and various types of techs and assistants) because of lockdowns and then waited until 2023 to start re-hiring. Now many of those lost staff have found better paying jobs in other industries (often fast-food) and the hospitals are having trouble filling positions.
Maybe unions will help?
https://youtu.be/EgGvErotkIk
Always! But the trick with a Union is to get in well before you even think you might need it.
Also a US anesthesiologist here, and fully agree. “Flip rooms” are given whenever we have the personnel (each patient needs their own nurse, surgical tech, and anesthetist in addition to the surgeon who’s bouncing between rooms) and a surgeon who will stay ahead of the schedule.
When the lead surgeon breaks out, they need to head immediately to the preop area and speak to any pre-op patients that have arrived since the last time they were between cases, mark the site of the surgery, and speak to the family of the patient they just finished. Then walk right back into their second OR and get to work.
Not all surgeons – in fact a surprisingly small minority – are capable of using this opportunity efficiently. Some have structured their days so that they use the down time between cases to go see patients that are in the hospital (either new consults who haven’t had surgery yet, or post-op patients waiting to go home) rather than doing all of that before surgery begins or after it finishes. These are not people who can effectively use a flip.
In most cases, when it works at scale, it’s because the facility guarantees staff a minimum number of paid hours per working day regardless of when they go home. So if you are scheduled to work until three, but you finish at noon, you go home and get three hours’ pay anyway.
Thanks for sharing your actually informed opinion 😅. This all checks out with my experience as a… Large consumer of health care: shortages of support staff and lots of overhead but the physicians are kept quite busy. (I recall reading somewhere that 25% of the cost of care in the USA was attributable to billing and insurance overhead… I wouldn’t be surprised if that has gone up since I read it.)
For all you non pet owners, this is how spay / neuter clinic days are done & they get 100’s of of surgeries done in a day pet Veterinarian.
tnr programs are really exceptional at this as well. (dis)assembly line style.
Hopefully, they have enough of a break in between to purge everything about the previous patient from short term memory rather than misremember something…
Yeah, I get confused enough with various work orders in my job, I’d hate to have that happen with a surgeon.
Tom Shillue’s “Wrong Side Surgery”
https://m.youtube.com/watch?v=GoBE3KKkDSU
As a gynecologist, former software developer, former electrical engineer, I find some of the ideas expressed here quite interesting but not practical in the small hospital where I work where we have only three main ORs and one OR reserved for cesarean sections. Having surgeons move from one case to another and back sounds high-risk from my 20+ years of surgical experience. First you have to scrub, re-scrub and change gowns between cases and then bring your mindset back to what each specific patient needs and where you left off. The majority of time, patients are covered and therefore visual identity is lost as only the area actively undergoing a procedure is visible. We already have too many cases of wrong sided lungs, kidneys, ovaries, extremities being removed without adding the additional complication of shifting between rooms.
When I’m doing surgery all day long, I look forward to the breaks between cases to rest my mind, rest my body, eat, go to the bathroom, return calls, etc. The multitasking described in the article simply appears to be an opportunity for grossly increasing the number of errors and burnt out staff (while increasing the number of administrators slapping each other on the back for beating those miserable surgeons into more cases and therefore contributing more to the bottom line). If there are too many people in the backlog, we need more resources in the form of providers and facilities.
This kind of optimization may work in selected facilities and in certain industries, but I don’t believe it’s a new boon to healthcare. Perhaps in clinics this might work, as many clinics currently have multiple nurses “rooming” patients and have scribes available to record notes while the provider simply pops quickly from one room to the other. Naturally this may be more administratively efficient, but reduces the amount of talk time patients want to have with their provider and sadly minimizes time for education and preventative health discussions.
Also. LOL “surgeon downtime” is a laughable oxymoron. Trainees in US have a maximum 80hr work week, a restriction that is often manipulated or occasionally ignored and intentionally mis-reported. And that restriction does NOT exist for practicing physicians. Unless the system is massively different in the UK with lazy-ass surgeons sitting around all the time the implication that they are is pretty silly.
Us isnt really a good example, considering its pretty heavily profit oriented.
The Russians did something with even more division of labor for eye surgeries starting in ’88:
https://en.wikipedia.org/wiki/Fyodorov_Eye_Microsurgery_Complex
“with nurses able to clean a theatre post-procedure in under two minute”
And that’s how you get problems. And I’m not just saying that, it’s documented.
And incidentally I don’t know about the UK but normally it’s not the nurses that clean the place but specific cleaning staff.
We do this in US catheterization laboratories. We call it “flipping”. Two rooms, one doctor. Never knew that was innovative :)
“Cleaning is optimized too, with nurses able to clean a theatre post-procedure in under two minute,”
Yea thats the metric I want my operating room to be cleaned with. Not.
This kinda crap sounds great when coming from corporatist US american doctors trying to make a buck by ‘solveing problems’ in the systems like the NHS. Unfortunately all its done is lead to the instabilities and greed being transferred over to a system that has been superior to ours for a few decades and at least affordable and competent for most of a century. ..where our system in the US has long been one of the more competent in the world we lost our affordability, which makes competence worthless when no one can access it.
Lewin this is an interesting article. Quote:” In the UK and Australia, waiting lists extend far into the future and patients are left sitting in ambulances as hospitals lack capacity”. I don’t know the UK system but in Australia if you are prepared to pay for the procedure, you can get it done next week. (The fees are not insane like in the US).
If you want it for free then you have to wait. The thing is, it isn’t free, the government has to pay for it. Which means the taxpayers have to pay for it. They are also the voters who don’t like paying more taxes. As the government can’t charge the patients, demand is essentially unlimited. The unspoken truth is that the waiting times are used to control that demand.
Demand is portrayed as unlimited. The population however is finite, and thus, so is demand. Politics determines budgets. Health needs of the population is often a secondary consideration.