title: Initiating statistical process control to improve quality outcomes in colorectal surgery.
abstract: BACKGROUND
  Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery.
  
  
  METHODS
  Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group.
  
  
  RESULTS
  A total of 1294 cases were analyzed--83% elective (n = 1074) and 17% emergent (n = 220). Emergent cases were 70.5% open and 29.5% laparoscopic; elective cases were 36.8% open and 63.2% laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6% (elective laparoscopic) to 10.8% (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0%) and elective lap groups (77.6 vs. 26.1%). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4%), emergent lap (14.3 vs. 9.2%), and elective lap (32.8 vs. 6.9%). Elective open outliers did not follow trends of longer LOS or higher reoperation rates.
  
  
  CONCLUSIONS
  SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106-5047, USA. debby_keller@hotmail.com.
authors.forename: Deborah S
authors.initials: DS
authors.lastname: Keller
authors.affiliation: Department of Surgery, University Hospitals-Case Medical Center, Cleveland, OH, USA.
authors.forename: Jonah J
authors.initials: JJ
authors.lastname: Stulberg
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106-5047, USA.
authors.forename: Justin K
authors.initials: JK
authors.lastname: Lawrence
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106-5047, USA.
authors.forename: Hoda
authors.initials: H
authors.lastname: Samia
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, University Hospitals-Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106-5047, USA. Conor.Delaney@UHhospitals.org.
authors.forename: Conor P
authors.initials: CP
authors.lastname: Delaney
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003107:Colorectal Surgery / Q000592:standards* / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D010535:Laparoscopy / Q000379:methods; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D010043:Outcome and Process Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D011183:Postoperative Complications; D011184:Postoperative Period; D011446:Prospective Studies; D058996:Quality Improvement / Q000706:statistics & numerical data*; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies
keywords: Healthcare outcomes; Healthcare utilization; Length of stay; Quality improvement