title: A multilevel analysis of factors influencing the flow efficiency of the cataract surgery process in hospitals.
abstract: OBJECTIVE
  To detect factors contributing to variation in cataract surgery processes.
  
  
  METHODS
  A multilevel study was conducted to compare the process of cataract surgery between hospitals in Belgium. The main data were collected through non-participative observations and time measurements in four hospitals. Surgeons (n = 16) performing cataract surgery in the selected region and their patients (n = 274) undergoing cataract surgery were observed. Flow efficiency is measured in the operating room (OR) as time for preparation, surgery, exit and turnover.
  
  
  RESULTS
  Flow efficiency in the OR can be negatively influenced by the severity of the cataract [+2.778 (1.139) min in preparation time (p < 0.05); +4.616 (1.786) min in surgery time when severe cataract (p < 0.05)] and the presence of special-cause variation [+2.832 (1.893) min preparation time (p < 0.05); +2.503 (1.277) min surgery time (p < 0.05); +1.181 (0.350) min exit time (p ≤ 0.001)]. Administering topical analgesia instead of peribulbar [+13.548 (4.436) min preparation time (p ≤ 0.001)], retrobulbar [+3.856 (1.548) min surgery time (p ≤ 0.05)] or general analgesia [+5.617 (2.536) min surgery time (p < 0.05); +5.175 (0.817) min exit time (p ≤ 0.001)] enhances flow efficiency. The experience of surgeons (>15 years) impacts flow efficiency [+12.838 (5.922) min surgery time when low experience]. The volume of cataracts performed annually per surgeon did not have a significant impact on flow efficiency. The use of specialized scrub nurses [-7.146 (3.099) min preparation time (p ≤ 0.05); -2.116 (0.586) min turnover time (p ≤ 0.05)] and the eye clinic design [-1.742 (0.686) min exit time (p < 0.05); 2.296 (1.034) min turnover time (p ≤ 0.05)] benefit flow efficiency.
  
  
  CONCLUSIONS
  Controllable and uncontrollable factors with clinical and organizational causes influencing flow efficiency in the cataract process were found. These factors can be taken into account in the management of the healthcare process.
authors: Department of Innovation, Entrepreneurship and Service Management, Ghent University, Ghent, Belgium.
authors: Melissa
authors: M
authors: De Regge
authors: Department of Innovation, Entrepreneurship and Service Management, Ghent University, Ghent, Belgium.
authors: Paul
authors: P
authors: Gemmel
authors: General Hospital AZ Zeno, Knokke, Belgium.
authors: Philippe
authors: P
authors: Duyck
authors: Department of Ophthalmology, Ghent University, Ghent, Belgium.
authors: Ilse
authors: I
authors: Claerhout
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001530:Belgium; D002387:Cataract Extraction; D017598:Efficiency, Organizational; D005260:Female; D006767:Hospitals, District; D006801:Humans; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D009873:Operating Rooms / Q000458:organization & administration*; D061646:Operative Time; D010818:Practice Patterns, Physicians'; D017064:Process Assessment, Health Care / Q000458:organization & administration*
keywords: cataract surgery; flow efficiency; operations management; variation