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Sampling Process Applied in Evaluation of Surgical System Efficiency and Operative Productivity in Sample Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
Tables
- TABLE 1.
Key Surgical System Efficiency Indicators Adapted From the Saving Lives Through Safe Surgery Program in Ethiopia, 2016–2020
Indicators Description Classification or Benchmark OR productivitya Definition: Total count of major, elective, and emergency surgeriesb performed in a health facility in target OR rooms/tables during the study period (i.e., 10 working days), excluding surgeries booked but canceled. Working schedule for elective surgeries is Monday–Friday, but the start times may vary. For this study, we used 6:00 am as the time when the night shift ends. Official work start time for civil servants is 8:30 am. Optimum: ≥2 surgeries per day in a major OR Functional operating table Definition: A surgical table actively used by the surgical team in an OR during the study period (i.e., 10 working days). Nonfunctioning OR/table is an operating room that has been closed or a room/table that has not been used for a major surgery in the previous 10 days each day during the study period. Functional: available for surgery 24 hours a day, 7 days a week SIST Definition: A time record for surgical incision of an elective surgical procedure scheduled for the first patient in a typical operation day (also known as a pacemaker case). In this study, the OR day starts at 6:00 am. A retrospective audit of SIST (HH:MM) was conducted by taking 10 randomly selected charts of the first-case surgery performed in the previous 90-day study period. Predefined SIST is a facility-defined specific time for first-case SIST, in writing, or communicated to surgical teams on the same. Early, earlier than 9:00 am.
Late, 9:00 am or later
Turnover Time The time lapse between 2 consecutive elective surgical procedures (i.e., the time difference between the first surgical case end time and the immediate next case). Incision start time was recorded on the surgical logbook or anesthesia sheet.
In this study, a retrospective chart review of 10 patient pairs (a total of up to 20 charts from each health facility) of consecutive post-surgical patients was conducted.
Acceptable: ≤30 minutes
Prolonged: >30 minutesc
Needs immediate improvement: >60 mins
Cancellation of elective surgery A nonemergent surgical procedure that is booked for operation but did not enter the theater or could not be operated on that day for various reasons. Cancellation rate was calculated as the number of elective surgeries booked for a given operation day and not operated on (numerator) divided by the total number of elective surgeries scheduled for the same day (denominator). Acceptable rate: <5%
Needs improvement: 5%–10%
Needs immediate improvement: >10%
In-hospital surgery waiting time The total duration of time lapsed from the time of admission to surgical wards until the recommended elective surgery, in the same facility. Not applicable for emergency surgery. A retrospective audit of time lapsed for individual surgical patients was conducted. Data aggregated for analysis and reporting purposes. Timely, <24 hours
Delayed, ≥24 hours
Abbreviations: OR, operating room; SIST, surgical incision start time.
↵a In this study, OR productivity is synonymous with OR output.
b Major surgery is any intervention occurring in a hospital OR involving the incision, excision, manipulation, or suturing of tissue, usually requiring regional or general anesthesia or sedation in a health care setting; this excludes all minor surgeries. Elective surgery is a nonemergent surgical procedure that is indicated for medical, surgical, or reconstructive purposes and could be delayed for at least 24 hours.
↵c Turnover time longer than 30 minutes may indicate loss of surgical system efficiency and may indicate wastage of resources.
- TABLE 2.
Surgical Operative Productivity in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
Level of Health Facilities Facilities, No. Average OR Tables per Facility, No. Total Surgeries in 10 Days, No. (%) OR Output (Productivity)a Average Surgeries per OR Table for 10 Days, No. Average Surgeries per OR Table per Day, No. Public specialized hospital 16 8.34 4,104 (45.06) 25 3 Public general hospital 38 2.97 2,031 (22.23) 18 2 Public primary hospital 77 1.7 1,309 (14.37) 10 1 Private hospital 32 3.25 1,664 (18.27) 16 2 Total 163 3 9,108 (100) 18.6 2 Abbreviation: OR, operating room.
↵a Note that the complexity of the surgical procedure and comorbidities patients had were not factored during analysis of operative performance.
- TABLE 3.
Characteristics of Select Surgical Inputs in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021a
Level of Care, Type of Facility Facilities, No. (%) OR Tables, No. (%) Functioning OR Table, No. (%) Average OR Table per Facility Surgical Beds, No. (%) Major Surgery,
No. (%)
Public specialized hospitals 16 (9.80) 158 (27.57) 134 (27.80) 8.34 1,375 (35.13) 22,420 (32.68) Public general hospitals 38 (23.31) 125 (21.81) 113 (23.44) 2.97 1,139 (29.01) 17,665 (25.75) Public primary hospitals 77 (47.23) 174 (30.36) 131 (27.17) 1.7 726 (18.55) 16,425 (23.94) Private hospitals 32 (19.63) 116 (20.24) 104 (21.57) 3.25 674 (17.22) 12,086 (17.62) Total 163 (100) 573 (100) 482 (100) 3 3,914 (100) 68,596 (100) Abbreviations OR, operating room.
↵a Of the primary health care units that were evaluated, 9 health center OR blocks were excluded from efficiency analysis due to lack of elective surgery service and the data.
- TABLE 4.
Surgical Incision Start Time for the First Patients of an Operation Day in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
Level of Care, Type of Facility Facilities, No. Predefined SIST, No. (%) Total Charts Audited, No. (%) SIST 6:00 am–8:30 am, No. (%) 8:31– 9:00, No. (%) 9:01– 9:30, No. (%) 9:31– 10:00, No. (%) After 10:01 am, No. (%) Public specialized hospitals 16 9 (56.25) 135 (15.32) 63 (46.67) 27 (20.00) 26 (19.26) 12 (8.90) 7 (5.20) Public general hospitals 38 16 (42.11) 300 (34.05) 122 (40.66) 60 (20.00) 51 (17.00) 33 (11.00) 34 (11.33) Public primary hospitals 77 18 (23.37) 276 (31.33) 58 (21.01) 19 (6.89) 62 (22.46) 59 (21.37) 78 (28.26) Private hospitals 32 8 (25.00) 170 (19.30) 55 (32.35) 21 (12.35) 23 (13.52) 15 (8.82) 56 (32.94) Total 163 51 (31.29) 881 (100) 298 (33.82) 127 (14.41) 162 (18.39) 119 (13.5) 175 (19.86) Abbreviation: SIST, surgical incision start time.
- TABLE 5.
Turnover Time Between Consecutive Elective Surgeries in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
Level of Care, Type of Facility Facilities, No. Total Charts Audited, No. Turnover Time, Minutes <30, No. (%) 31–60, No. (%) 61–90, No. (%) >90, No. (%) Average Turnover Time Public specialized hospitals 16 104 54 (51.90) 32 (30.76) 14 (13.46) 4 (3.84) 40.24 Public general hospitals 38 214 106 (49.53) 76 (35.51) 20 (9.34) 12 (5.60) 40.76 Public primary hospitals 77 158 68 (43.03) 44 (27.84) 26 (16.45) 20 (12.65) 40.5 Private hospitals 32 134 68 (50.76) 30 (22.38) 2 (1.49) 34 (25.37) 79.52 Total 163 610 296 (48.52) 182 (29.83) 62 (10.16) 70 (11.47) 50.25 - TABLE 6.
In-Hospital Waiting Time for Elective Surgeries in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
Level of Health Facility Facilities, No. Facility Reports on Wait Time, No. (%) In-Hospital Surgery Wait Time, Hours <24, No. (%) 24–72, No. (%) >72, No. (%) Average±SD Public specialized hospitals 16 10 (62.50) 4 (40.00) 4 (40.00) 2 (20.00) 59.90±27.85 Public general hospitals 38 23 (60.52) 10 (43.48) 10 (43.48) 3 (13.04) 68.36±26.80 Public primary hospitals 77 31 (40.26) 12 (38.71) 16 (51.61) 3 (9.68) 36.80±46.60 Private hospitals 32 15 (46.87) 7 (46.67) 8 (53.33) 0 (0) 18.33±3.06 Total 163 79 (45.93) 21 (43.75) 22 (45.83) 5 (10.42) 45.40±9.25 Abbreviation: SD, standard deviation.
- TABLE 7.
Association Between Operating Room Productivity and Presence/Absence of Predefined Surgical Incision Start Time for the First Patient in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
Operative Productivity Association, Significance Optimum,a No. (%) Suboptimum, No. (%) Total, No. Utilized predefined surgical incision start time Yes 20 (54.05) 5 (18.52) 25 P=.004 No, absent 17 (45.94) 22 (81.48) 39 Total 37 (100) 27 (100) 64 ↵a Optimum operative productivity is an average of 2 or more surgeries performed per day in a major operating room.
- TABLE 8.
Association Between In-Hospital Surgery Wait Time and Surgical Incision Start Time in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
In-Hospital Surgery Wait Time, Hours Association, Significance Timely <24, No. (%) Delayed ≥24, No. (%) Total, No. Surgical incision start time Early: Before 9:00 am 16 (94.12) 14 (60.87) 30 P=.016 Late: 9:00 am or after 1 (5.88) 9 (39.13) 10 Total 17 (100) 23 (100) 40 - TABLE 9.
Association Between Operative Productivity and In-Hospital Surgery Wait Time in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
In-Hospital Surgery Wait Time, Hours Association, Significance Timely <24, No. (%) Delayed ≥24, No. (%) Total, No. Operative productivity Optimuma 9 (64.29) 12 (57.14) 21 P=.673 Suboptimum 5 (35.71) 9 (42.86) 14 Total 14 (100) 21 (100) 35 ↵a Optimum operative productivity is an average of 2 or more surgeries performed per day in a major operating room.
- TABLE 10.
Association Between Operative Productivity and Turnover Time Between Successive Surgeries in Public and Private Health Facilities in Ethiopia, December 2020 to June 2021
Operative Productivity Association, Significance Optimum,a No. (%) Suboptimum, No. (%) Total Turnover time Acceptable: ≤30 minutes 7 (38.89) 5 (38.46) 12 P=.981 Prolonged: >30 minutes 11 (61.11) 8 (61.54) 19 Total 18 (100) 13 (100) 31 ↵a Optimum operative productivity is an average of 2 or more surgeries performed per day in a major operating room.
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