{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T06:54:29Z","timestamp":1790837669775,"version":"4.1.0"},"reference-count":20,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T00:00:00Z","timestamp":1786492800000},"content-version":"unspecified","delay-in-days":42,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Qual"],"accepted":{"date-parts":[[2026,8,2]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:p>A structured, system-level quality improvement (QI) initiative at Singapore General Hospital was undertaken to reduce postoperative length of stay (LOS) after uncomplicated lower segment caesarean section (LSCS) and improve performance on the national Value-Driven Care clinical quality index. This project specifically targeted an increase in postoperative day 3 (POD3) discharge rates towards the 88% internal benchmark without compromising safety or increasing readmissions.<\/jats:p>\n                  <jats:p>Uncomplicated LSCS cases between October 2023 and September 2025 were included, with complicated caesarean sections and severe neonatal morbidity excluded. A single-centre pre\u2013post design was used, with October 2023\u2013September 2024 as the baseline period and October 2024\u2013September 2025 as the intervention period. Root causes of delayed discharge were identified using a fishbone (Ishikawa) analysis, informing a three-phase, system-level intervention: department-wide performance sharing, a bundled intervention (standardised patient education, multidisciplinary discharge coordination via Microsoft Teams and coding support) and clinician-specific feedback.<\/jats:p>\n                  <jats:p>Baseline POD3 discharge performance was 80.0% (n=352) after correction of coding inaccuracies. Following phased implementation, the postoperative LOS \u22643\u2009days rate increased to 84.5% (n=241) overall, with a more marked improvement from 83.3% to 92.5%\u2009after introduction of the bundled system-level intervention. Run charts showed an upward shift and reduced monthly variation in POD3 discharge rates, indicating more consistent practice. There was no clinically significant increase in 30-day readmissions, emergency attendances or postoperative complications, and a simple cost analysis estimated savings of SGD 70 884 from reduced LOS.<\/jats:p>\n                  <jats:p>This multidisciplinary, enhanced recovery after surgery-aligned QI project successfully shortened postoperative LOS for uncomplicated LSCS without evidence of harm. Core components\u2014clear discharge expectations, coordinated mother\u2013baby discharge planning, accurate coding and non-punitive clinician feedback\u2014are conceptually transferable to similar obstetric units seeking to optimise postcaesarean LOS within value-based care frameworks.<\/jats:p>","DOI":"10.1136\/bmjoq-2026-004151","type":"journal-article","created":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T12:40:43Z","timestamp":1786538443000},"page":"e004151","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Reducing postoperative length of stay in low-risk caesarean section: a system-level quality improvement initiative"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7720-2258","authenticated-orcid":false,"given":"Wenqian Grace","family":"Su","sequence":"first","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9232-7948","authenticated-orcid":false,"given":"Rachel Phoy Cheng","family":"Chun","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-4216-0192","authenticated-orcid":false,"given":"Hong","family":"Chan","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-5897-1451","authenticated-orcid":false,"given":"Xin Ni","family":"Chua","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bi Wei","family":"Cai","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katherine Concepcion","family":"Tesalona","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui","family":"He","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yih Yann","family":"Tay","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tze Tein","family":"Yong","sequence":"additional","affiliation":[{"name":"Obstetrics and Gynaecology, Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Devendra","family":"Kanagalingam","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9211-0685","authenticated-orcid":false,"given":"Liying","family":"Yang","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaohong Joella","family":"Ang","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wan Yu Yvonne","family":"Wong","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yingke","family":"He","sequence":"additional","affiliation":[{"name":"Anaesthesiology and Perioperative Sciences, Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-0528-4022","authenticated-orcid":false,"given":"Jia Xuan","family":"Yeo","sequence":"additional","affiliation":[{"name":"Office of Value Driven Care, Singapore Health Services Pte, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jia Hao Alvin","family":"Ngeow","sequence":"additional","affiliation":[{"name":"Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hairil Rizal","family":"Abdullah","sequence":"additional","affiliation":[{"name":"Anaesthesiology and Perioperative Sciences, Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason Shau Khng","family":"Lim","sequence":"additional","affiliation":[{"name":"Obstetrics and Gynaecology, Singapore General Hospital, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,12]]},"reference":[{"key":"2026093022550833000_15.3.e004151.1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0148343","article-title":"The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014","volume":"11","author":"Betr\u00e1n","year":"2016","journal-title":"PLoS One"},{"key":"2026093022550833000_15.3.e004151.2","unstructured":"WHO . WHO Statement on Caesarean Section Rates. Geneva: World Health Organization, 2015."},{"key":"2026093022550833000_15.3.e004151.3","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-020-74161-2","article-title":"Determinants of length of stay after cesarean sections in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015","volume":"10","author":"Cegolon","year":"2020","journal-title":"Sci Rep"},{"key":"2026093022550833000_15.3.e004151.4","first-page":"689","article-title":"Quality improvement in maternity care","volume":"129","author":"Main","year":"2017","journal-title":"Obstet Gynecol"},{"key":"2026093022550833000_15.3.e004151.5","first-page":"e153","article-title":"Enhanced recovery after caesarean delivery","volume":"130","author":"Sultan","year":"2020","journal-title":"Anesth Analg"},{"key":"2026093022550833000_15.3.e004151.6","doi-asserted-by":"publisher","DOI":"10.1097\/aog.0000000000002818"},{"key":"2026093022550833000_15.3.e004151.7","unstructured":"Times S . The 3 beyonds: Singapore\u2019s strategy to sustain quality healthcare as demand rises. 2023. Available: https:\/\/www.straitstimes.com\/singapore\/health\/the-3-beyonds-singapores-strategy-to-sustain-quality-healthcare-as-demand-rises"},{"key":"2026093022550833000_15.3.e004151.8","article-title":"Long-term risks and benefits associated with caesarean delivery","volume":"360","author":"Keag","year":"2018","journal-title":"BMJ"},{"key":"2026093022550833000_15.3.e004151.9","first-page":"1817","article-title":"Caesarean section without medical indication and risk of adverse outcomes","volume":"375","author":"Souza","year":"2010","journal-title":"Lancet"},{"key":"2026093022550833000_15.3.e004151.10","unstructured":"Knight M , et al . Length of hospital stay after caesarean section. BJOG 2019;126."},{"key":"2026093022550833000_15.3.e004151.11","article-title":"Barriers to early discharge after caesarean section","volume":"32","author":"Chua","year":"2017","journal-title":"Int J Obstet Anesth"},{"key":"2026093022550833000_15.3.e004151.12","unstructured":"Bernstein SN , et al . Hospital variation in post-cesarean length of stay. Obstet Gynecol 2018;131."},{"key":"2026093022550833000_15.3.e004151.13","unstructured":"Enhanced Recovery After Surgery (ERAS) society. 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