1. Mirto Foletto, MD Bariatric Unit - Padova University Hospital (Italy) mirto.foletto@unipd.it Lessons from a Week Surgery Unit

2. standard of care resources 3rd millennium biggest challenge matchin'

3. Mainstays of bariatric practice Multidisciplinary discipline Private or Public settings Community or Academic Institutions Dedicated or intermingled wards Outcomes and costs Covering (insurance, self payer, NHS)

4. Bariatric procedures, on average, cost from $20,000 to $25,000

5. CoE policy Accreditation should impact on outcomes and costs

6. THE SETTING IS THE KEY ISSUE ! healthcare = complexity

7. Organizational pathologies (1) High variation of clinical processes underuse of effective care, overuse of supply-sensitive care and misuse, i.e. failures to execute procedures properly Low reliability (failure-free operation over time) of clinical processes Trust paper tools, memory, and hard work Ample tolerance toward clinical autonomy Reliability goals not explicitly stated Performance judged against (mediocre) averages of outcomes rather than benchmarks of processes

8. Organizational pathologies (2) Lack of system thinking little understanding of interactions between structures, processes, patterns and results; little involvement of key stakeholders, esp. front-line professionals Lack of statistical thinking overreactions in front of common causes, i.e. thinking that change has occurred and decisions are necessary when infact there is no change Lack of quality improvement methods messy use of fragments of improvement models

9. System thinking All work occurs in a system of inter-related processes, i.e. sets of sequential activities that turn inputs into outputs and outcomes, which affect customers A system is heavily influenced by connections among its parts, more than by the isolated performance of its elements; hence optimizing each one independently can result in an even poorer performance Processes should be studied systematically visualizing them through flowcharts and measuring their important steps Every system is perfectly designed to get the results it gets. If we want different results, we must change the system Statistical analysis is essential in order to turn data into useful knowledge

10. AIM TO ASSESS WHETHER A MODIFICATION TO THE APPROACH OF A PATIENT CANDIDATE FOR BARIATRIC SURGERY CAN IMPACT ON OUTCOMES AND COSTS setting: academic hospital intermediate intentensity of care "week surgery" ward

11. Methods 6-MONTH ACTIVITY PROSPECTIVE ANALYSIS OF LSG SINGLE SURGEON - SINGLE INSTITUTION BASED BEFORE (GROUP A) AND AFTER (GROUP B) Wk SURGERY UNIT ACTIVATION

12. VARIABLES Operating Room Time (OR) Hospital stay (HS) Early complications rate (EC) STATISTICS t-TEST FOR PARAMETRIC Fisher for non parametric set point p < 0.005 COSTS ASSESSED ACCORDING ACTIVITY BASED COST MODEL

13. The "Week Surgery" model Improving care through affordability what we had standardized clinical pathway patients' selectionhealth professionals 24-bed ward 2 ORs 8-14 10 scrub nurses 10 ward nurses 0-24 Mo-Th Gates closed Fr 20 patientssurgeons anesthesiologists

14. The "Week Surgery" model Improving care through affordability OR SLOTS wk surgery stakeholders bariatric unit hernia surg breast unit gall bladder endocrine surg skin and SQ E-G junction miscellaneous mo-wed thu-fri

18. standard of care who does what risk management

20. Group A ord ward (55 pts) Group B WS ward (67 pts) F 32 (58,2%) 47 (70,1%) M 23 (41,8%) 20 (29,9%) Age (anni) 47,2 ± 10,4 45,5 ± 9,8 BMI (kg/m 2 ) 48,4 ± 7,8 46,9 ± 7,7 comorbiditiescomorbidities 7 (12,7%) 10 (14,9%) morbid obesitymorbid obesity 25 (45,5%) 35 (52,2%) Super obeseSuper obese 23 (41,8%) 22 (32,8%) Previous bariatric surgery 16 (29,1%) 8 (11,9%)* 6-mos LSG outcomes by ward

21. Results Group A 55 pts Group B 67 pts Operative time (min) 89,3 ± 29 57,9 ± 12* early complications 10 (18,2%) 4 (6%) § Hospital Stay (days) 5,3 ± 2,6 3,4 ± 0,5* * p<0,0001 * p<0,0001 § p<0,04

22. COSTS OR + EC + HS = 2000 Euros Group A vs Group B

23. CONCLUSIONS Bariatric Surg A MODEL for elective Surgery Patterns of care IMPACT ON: OUTCOMES PERFORMANCE COSTS COE accreditation alone is not enough