Surgeons as Educators A Guide for Academic Development and Teaching Excellence

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Pareto Analysis
Vilfredo Pareto was an Italian economist born in 1848 who was known for the
Pareto principle, or 80-20 rule, in which he recognized that 80% of the property
was owned by only 20% of the inhabitants [ 63 ]. This principle was later popularized
in the 1950s by business management consultant Joseph M. Juran [ 37 ], who sought
to increase financial returns through increased efficiency by focusing company
resources on the sectors that generated the highest revenue [ 60 ]. While it has largely
been studied in business management, it can be applied to healthcare QI and resi-
dent education [ 28 , 42 , 53 ]. It can be applied to healthcare delivery as illustrated by
the following example:

A surgical department is allotted a set amount of block time to schedule their operative

cases, but the department’s surgical wait times are becoming increasingly longer as the

practice expands. Using the Pareto principle to reduce wait times while working within the

confines of the allotted block time, the department may review case times for their 10 most

commonly performed procedures to identify which cases take the longest to perform on

average. After identifying which cases dominate the utilization of the department’s block

time, members of the team can work together to increase efficiency in the operating room

by standardizing instruments sets or equipment needed, defining clearer roles for all per-

sonnel in the room, and improving surgical technique.

Fault Tree Analysis
Fault tree analysis is a tool used to understand how the interaction of several indi-
vidual faults leads to a negative outcome [ 48 , 82 ]. It is a technique particularly use-
ful in risk and safety analysis. At the top of the fault tree, the undesired event is
listed. A hierarchy tree is then constructed starting from the undesired event until all
potential causes are identified. Figure 11.4 depicts an illustration of a fault tree

“Five Whys” Approach

A post-operative patient who did not receive VTE chemoprophylaxis is diagnosed

with a pulmonary embolism.

1. Why did the patient not receive VTE chemoprophylaxis post-operatively?

• The patient was not ordered for VTE chemoprophylaxis.

2. Why was VTE chemoprophylaxis not ordered for the patient?

• The resident entering the patient’s orders forgot to order VTE chemoprophylaxis.

• VTE chemoprophylaxis was not a part of the order set that the resident used.

4. Why is VTE chemoprophylaxis not a part of the order set?

• Not all surgeons want their patients on VTE chemoprophylaxis post-operatively.

• The risk of post-operative bleeding varies depending on surgical procedure, technique,
  and individual patient characteristics.

Why did the resident who entered the patient’s orders forget to order VTE chemoprophylaxis?

Why do not all surgeons want their patients on VTE chemoprophylaxis post-operatively?

Fig. 11.3 Stepwise Five Whys approach as applied to an example of a postoperative patient who
did not receive VTE chemoprophylaxis and is diagnosed with a pulmonary embolism

11 The Role of Educators in Quality Improvement