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Research >> EHRLL >> Boston Children's Hospital

Perioperative Process Improvement, Boston Children's Hospital


Children with medical complexity (CMC) are a challenging patient population with intricate, multisystem health needs. The perioperative environment has significantly advanced over the last two decades, especially due to technological advancements, which also has introduced greater system complexity and associated safety and cost issues. In this project, we apply industrial engineering methods to understand, measure, analyze, and improve the perioperative processes associated with CMC undergoing spinal fusion surgery at Boston’s Children Hospital. The
objective is to improve health outcomes, patient safety, and family satisfaction while reducing hospitalization costs.


A multidisciplinary team of systems engineers, organization experts, primary care pediatricians, other healthcare professionals, and patient representatives meet on a weekly basis as part of an interdisciplinary patient safety learning lab. Conventional process mapping such as cross-functional maps and more contemporary systems analysis methods such as Functional Resonance Analysis Method (FRAM) are utilized to thoroughly understand process flow and stakeholder interactions in the preoperative phase. Failure Modes and Effects Analysis (FMEA) and Contrast Analysis point out to the systems critical junctures at risk for failure. All the methods help derive a more robust perioperative process that is capable of being spread in different clinical settings.


Process understanding through cross functional process maps and FRAM revealed that there is a lack of standardization and non-linearity in the preoperative phase. FMEA showed that most failures occurring in this phase are due to lack of communication between stakeholders, and CA underscored that patient and family involvement in this transition of care play a major role in making the system more resilient to process changes and able to sustain potential failure modes. This has prompted the multi-disciplinary team to focus on risk stratifying prospective spinal fusion patients at early stages, in order to address critical health issues and consequently reduce adverse events in subsequent perioperative phases (intraoperative and postoperative).   

Partners & Research Team

Joseph Salem, BE, HSyE

Margaret R. O’Neill, BS, Boston’s Children Hospital

Jay G. Berry, MD, MPH, Boston’s Children Hospital

Joanne Cox, MD, Boston’s Children Hospital

Nathan Holler, HSyE

Tiago B.C. Jabur, BS, HSyE

Charis Crofton, BA, Boston’s Children Hospital

Connor Johnson, BS, Boston’s Children Hospital

Erin Ward, MS, Patient and Family Representative

Sara J. Singer, PhD, Harvard School of Public Health

James C. Bnneyan, PhD, HsyE

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