Contribution of Coordination Theories to the Determination of Human Factors Associated With Operating Room Perceived Performance

BACKGROUND

The efficient and fluid organization of surgical interventions in an operating room (OR) and operating suite (OS) is important as these are among the most expensive units to run in medical-surgical facilities. The complexity of OS organization requires careful coordination, defined here as the directing of individuals' efforts toward achieving common and explicitly recognized goals. There is currently sparse literature on OS coordination, especially in the French context. This study aimed to respond to this gap by reporting on the coordination mechanisms associated with the perceived performance of OS across 4 facilities in an urban setting in France.

METHODS

We used a qualitative comparative case study based on ethnographic methodology to explore 4 facilities (2 teaching, 1 general, and 1 private). Several investigation techniques were used for data collection (semistructured interviews, participant and nonparticipant observations, and informal interviews) in the OR, the OS, the regulation council (dedicated to adapting the necessary resources to specific procedures and patients' health status), and the OS council (dedicated to strategic and operational OS transformations and adaptations, and responsible for finding solutions to organizational problems). Analysis was guided by Okhuysen and Bachky's theoretical framework on coordination and multi-team systems theory. Data were compared across the 4 facilities and triangulated using the different techniques to ensure coherence and accuracy.

RESULTS

Overall, 48 interviews with health care providers and hospital managers and 200 hours of direct observations were performed. The OR exhibited a high degree of coordination, whereas improved perception of performance in the OS depended on managerial competency, trust, and authority. Perceived performance in the regulation council and OS council, on the other hand, depended on the identification of formal objectives by all stakeholders and the development of common understanding (developing agreement, direct information sharing, creating common perspective, substitution, bringing groups together, and storing of knowledge).

CONCLUSIONS

Based on existing literature on multi-team systems (as represented in the OS organization), this study identifies success factors influencing OS coordination. These include the OS manager's leadership skills; the identification of formal system objectives; and professional differentiation between stakeholders (absence/decrease of a sense of belonging to a multi-team system). This differentiation was related to the high degree of specialization within OS teams, each bringing different norms, cultures, and contingencies that induce dissonance in organization and task performance. Interventions targeting these success factors might improve coordination, and thus performance, in the OS.

Reduction of Nonoperative Time Using the Induction Room, Parallel Processing, and Sugammadex: A Randomized Clinical Trial

BACKGROUND

An important variable in the operating room is the nonoperative time (NOT), the time between skin closure on a previous case and skin incision on the following case. Mismanagement of NOT can result in significant financial losses and delays in the operating room (OR) schedule, which can negatively impact efficiency and patient, surgeon, and staff satisfaction. NOT includes general anesthesia induction time (IT), emergence time (ET), and turnover time (TOT), and can be calculated by adding the 3 components. OR efficiency can be increased by applying parallel processing for general anesthesia induction and OR cleaning and reversal of neuromuscular blockade with sugammadex to reduce the 3 components of NOT without compromising patient safety.

METHODS

This is a prospective, randomized study of 111 patients 18 to 75 years of age, American Society of Anesthesiologists (ASA) I-III, undergoing surgery requiring general anesthesia and muscle relaxation. Patients were randomly assigned to the control group (traditional linear processing for induction of anesthesia and OR cleaning and neuromuscular blockade reversal with neostigmine/glycopyrrolate) and the active group (parallel processing for induction of anesthesia and OR cleaning and neuromuscular blockade reversal with sugammadex). The primary outcome measured is the difference in the NOT. The secondary outcomes are surgeon and patient satisfaction.

RESULTS

NOT was significantly shorter in patients who underwent the parallel processing strategy and received sugammadex compared to the patients in the control group (25.0 [18.0-44.0] vs 48.0 [40.0-64.5] minutes; Cliff' delta = 0.57; P < .001). After excluding the cases in the experimental group that were put into sleep in the OR (ie, the first case of the room), IT, ET, TOT, and NOT were further reduced and remained statistically significantly lower than the control group. Satisfaction scores from surgeons were significantly higher in the active group than in the control group (P < .001). There was no significant difference in the satisfaction scores of patients between the 2 groups.

CONCLUSIONS

Our study showed that interventions, such as parallel processing during induction of anesthesia and room cleaning instead of linear processing and the use of the faster-acting sugammadex instead of the combination of neostigmine and glycopyrrolate for the reversal of rocuronium-induced neuromuscular blockade, resulted in shorter IT, ET, TOT, and therefore NOT, in addition to higher surgeon's satisfaction.

Monitoring operating room performance with control charts: findings from a Greek public hospital

OBJECTIVE

To describe the development and demonstrate the use of a statistical framework based on statistical quality control (SQC) in order to monitor the performance of operating rooms (ORs).

DESIGN

Data related to scheduled surgical operations have been collected from the information system of an existing Greek hospital. The data that contain the anesthesia and operation start and completion times of the operations carried out in the 14 ORs of the hospital are analyzed using control p-charts and hypotheses testing. The results obtained provide crucial information to health-care managers.

SETTING

A large Greek public hospital.

PARTICIPANTS

Real-world data captured on daily basis from January 2015 to November 2017.

INTERVENTION

The proportion of the idle time of an OR over its total available time is proposed as an OR key performance index. We present two directions of data monitoring and analysis: one that uses control p-charts and a second based on hypotheses testing. The improved Laney's p΄-chart and the Laney's approach for cross-sectional data are employed in order to overcome overdispersion that affects OR idle time data.

RESULTS

The proposed methodology allows hospital management (i) to monitor the percentage of the idle time of an operating room through time and (ii) to identify the ORs that demonstrate exceptionally high or low percentage of idle time at a given period of time.

CONCLUSION

SQC charts are simple, yet powerful tools that may support the hospital management in monitoring OR performance and decision-making. The development of a dedicated management information system that automatically captures the required data and constructs the corresponding control charts would support effectively managerial decision-making.

Effective Surgical Teams: An Integrative Literature Review

It is imperative to understand the factors that contribute to effective surgical teams. The aim of this integrative review was to evaluate the aids and barriers for perioperative teams in functioning effectively, preventing adverse events, and fostering a culture of safety. The literature search was undertaken of 15 databases, which resulted in 70 articles being included. It was found perioperative teamwork was not widely understood. Findings indicated barriers to effective surgical teams comprised of confusion in tasks and responsibilities, existing hierarchies and prevailing misconceptions and understanding among team members. Although numerous quality initiatives exist, the introduction of protocols and checklists, team effectiveness in the perioperative setting is still insufficient and challenges in establishing effective surgical teams continue. Further research is recommended to obtain a comprehensive perception of environmental influences and barriers surgical teams encounter in the delivery of safe quality care.

“Ethnographic” thematic phenomenography

Purpose

The workplace is a context of increasing interest in information literacy research, if not necessarily the most visible (Cheuk, 2017). Several studies have described contextual, relationship-based experiences of this subjective, knowledge-development focussed phenomenon (Forster, 2017b). What research contexts and methods are likely to be most effective, especially in workplaces which contain professions of widely differing ontologies and epistemological realities? The paper aims to discuss these issues.

Design/methodology/approach

An analysis and description of the value and validity of a “qualitative mixed methods” approach in which the thematic form of phenomenography is contextualised ethnographically.

Findings

This paper describes a new research design for investigation into information literacy in the workplace, and discusses key issues around sampling, data collection and analysis, suggesting solutions to predictable problems. Such an approach would be centred on thematic phenomenographic data from semi-structured interviews, contextualised by additional ethnographic methods of data collection. The latter’s findings are analysed in light of the interview data to contextualise that data and facilitate a workplace-wide analysis of information literacy and the information culture it creates.

Originality/value

Insights from recent research studies into information literacy in the workplace have suggested the possibility of an epistemologically justifiable, qualitative mixed methods design involving an ethnographic contextualisation of a thematic phenomenographic analysis of the information culture of an ontologically varied and complex workplace – with the potential for descriptive contextualisation, categorisation and generalisability.

Perioperative accountable care teams: Improving surgical team efficiency and work satisfaction through interprofessional collaboration

The purpose of this performance improvement project was to design, implement and evaluate an interprofessional education initiative intended to improve surgical team efficiency, communication and work satisfaction. The development of interprofessional perioperative accountable care teams in three surgical specialties, cardiothoracic, neurosurgery and orthopedics, demonstrated a reduction in turnover time, increased staff, patient and surgeon satisfaction, and increased operating room (OR) revenue generated by the surgical specialties within one year of implementation.

Efficiency improvement in the operating room

BACKGROUND

In the changing health care environment, health systems, hospitals, and health care providers must focus on improving efficiency to meet an increasing demand for high-quality, low-cost health care. Much has been written about strategies and efforts to improve efficiency in the perioperative periods, yet the time when the patient is in the operating room-the intraoperative period-has received less attention. Yet, this is the period in which surgeons may have the most influence.

METHODS

Systematically review published efforts to improve intraoperative efficiency; assess the outcomes of these efforts, and propose standardized reporting of future studies.

RESULTS

A total of 39 studies were identified that met inclusion criteria. These divided naturally into small (single operative team), medium (multi-operative team), and large (institutional) interventions. Most studies used time or money as their metric for efficiency, though others were used as well.

CONCLUSIONS

There is substantial opportunity to enhance operating room efficiency during the intraoperative period. Surgeons may have a particular role in procedural efficiency, which has been relatively unstudied. Common themes were standardizing tasks, collecting and using actionable data, and maintaining effective team communication.

Postoperative health and patients' experiences of efficiency and quality of care after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, two to six months after surgery

PURPOSE

To study post-discharge health after Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC), and to analyse patients' experiences of in-hospital efficiency and quality of care.

METHODS

In-depth individual telephone interviews using an interview guide with open-ended questions were performed with 19 patients with peritoneal carcinomatosis between April and October, 2012. Data were analysed with systematic text condensation.

RESULTS

Four themes were identified: 1) Coming home was an essential step in the recovery process and the focus was on getting well physically despite mental stress, uncertainty about the medical rehabilitation plan and the future. 2) Health was affected negatively by postoperative chemotherapy and its side effects. 3) Stoma - a necessary evil affecting the patient's social life. 4) Quality of care and efficiency were defined in patient-centred terms and inter-personal care from the patient's perspectives on micro level. Despite all, 32% of the patients described being fully recovered and had started to study or work two months after surgery.

CONCLUSIONS

The study gives insights into some real-life experiences described by patients. The study results can be used to prepare written information, to design a postoperative rehabilitation plan for future patients with Peritoneal Carcinomatosis (PC) and to create a home-page through which patients can receive support from both health care professionals and other fellow patients.

Making the invisible visible--operating theatre nurses' perceptions of caring in perioperative practice

The aim of this study was to describe operating theatre nurses' (OTNs') perceptions of caring in perioperative practice. A qualitative descriptive design was performed. Data were collected with interviews were carried out with fifteen strategically selected operating theatre nurses from different operating theatres in the middle of Sweden. A phenomenographic analysis was used to analyse the interviews. The findings show that operating theatre nurses' perceptions of caring in perioperative practice can be summarised in one main category: To follow the patient all the way. Two descriptive categories emerged: To ensure continuity of patient care and keeping a watchful eye. The operating theatre nurses got to know the patient and as a result became responsible for the patient. They protected the patient's body and preserved patient dignity in perioperative practice. The findings show different aspects of caring in perioperative practice. OTNs wanted to be more involved in patient care and follow the patient throughout the perioperative nursing process. Although OTNs have the ambition to make the care in perioperative practice visible, there is today a medical technical approach which promotes OTNs continuing to offer care in secret.

Student nurses' experiences of preserved dignity in perioperative practice - Part I

BACKGROUND

In recent years, operating theatre nurse students' education focussed on ethical value issues and how the patient's dignity is respected in the perioperative practice. Health professionals are frequently confronted with ethical issues that can impact on patient's care during surgery.

OBJECTIVE

The objective of this study was to present what operating theatre nurse students experienced and interpreted as preserved dignity in perioperative practice.

RESEARCH DESIGN

The study has a descriptive design with a hermeneutic approach. Data were collected using Flanagan's critical incident technique.

PARTICIPANTS AND RESEARCH CONTEXT

Operating theatre nurse students from Sweden and Norway participated and collected data in 2011, after education in ethics and dignity. Data consisting of 47 written stories and the text were analysed with hermeneutical text interpretation.

ETHICAL CONSIDERATIONS

The study was conducted accordance with the Declaration of Helsinki and approved by a local University Ethics Research Committee.

FINDINGS

The findings revealed that students experienced that operating theatre nurses perserved patient's dignity in perioperative practice by being present for each other and making themselves known to the patient. Operating theatre nurses caring for the patient by being compassionate and preserved the patient privacy. The new understanding that emerged was that the operating theatre nurse students understood that the operating theatre nurse wanted to care for the patient like a human being.

DISCUSSION

In the discussion, we have illuminated how professional ethics may be threatened by more pragmatic and utilitarian arguments contained in regulations and transplant act.

CONCLUSION

Preserved dignity is an ethical and caring act. Ethical questions and how to preserve dignity in perioperative practice should be discussed more both in educations of healthcare professionals and in clinical practice.

Interprofessional teamwork in the trauma setting: a scoping review

Approximately 70 to 80% of healthcare errors are due to poor team communication and understanding. High-risk environments such as the trauma setting (which covers a broad spectrum of departments in acute services) are where the majority of these errors occur. Despite the emphasis on interprofessional collaborative practice and patient safety, interprofessional teamworking in the trauma setting has received little attention. This paper presents the findings of a scoping review designed to identify the extent and nature of this literature in this setting. The MEDLINE (via OVID, using keywords and MeSH in OVID), and PubMed (via NCBI using MeSH), and CINAHL databases were searched from January 2000 to April 2013 for results of interprofessional teamworking in the trauma setting. A hand search was conducted by reviewing the reference lists of relevant articles. In total, 24 published articles were identified for inclusion in the review. Studies could be categorized into three main areas, and within each area were a number of themes: 1) descriptions of the organization of trauma teams (themes included interaction between team members, and leadership); 2) descriptions of team composition and structure (themes included maintaining team stability and core team members); and 3) evaluation of team work interventions (themes included activities in practice and activities in the classroom setting).Descriptive studies highlighted the fluid nature of team processes, the shared mental models, and the need for teamwork and communication. Evaluative studies placed a greater emphasis on specialized roles and individual tasks and activities. This reflects a multiprofessional as opposed to an interprofessional model of teamwork. Some of the characteristics of high-performing interprofessional teams described in this review are also evident in effective teams in the community rehabilitation and intermediate care setting. These characteristics may well be pertinent to other settings, and so provide a useful foundation for future investigations.

Operating room data management: improving efficiency and safety in a surgical block

Background

European Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety.

Methods

The developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011.

Results

Raw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011).

Conclusions

The developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.

Clinical teachers' views on how teaching teams deliver and manage residency training

BACKGROUND

Residents learn by working in a multidisciplinary context, in different locations, with many clinical teachers. Although clinical teachers are collectively responsible for residency training, little is known about the way teaching teams function.

AIM

We conducted a qualitative study to explore clinical teachers' views on how teaching teams deliver residency training.

METHOD

Data were collected during six focus group interviews in 2010.

RESULTS

The analysis revealed seven teamwork themes: (1) clinical teachers were more passionate about clinical expertise than about knowledge of teaching and teamwork; (2) residents needed to be informed about clinical teachers' shared expectations; (3) the role of the programme director in the teaching team needed further clarification; (4) the main topics of discussion in teaching teams were resident performance and the division of teaching tasks; (5) the structural elements of the organisation of residency training were clear; (6) clinical teachers had difficulty giving and receiving feedback and (7) clinical teachers felt under pressure to be accountable for team performance to external parties.

CONCLUSION

The clinical teachers did not consider teamwork to be of any great significance to residency training. Teachers' views of professionalism and their own experiences as residents may explain their non-teamwork directed attitude. Efforts to strengthen teamwork within teaching teams may impact positively on the quality of residency training.

Efficiency as a domain of health care systems: a phenomenographic approach

PURPOSE

This paper focuses on efficiency as a central theme of the Italian health care reforms, combining macrolevel policies with microlevel (i.e., operating room) perceptions of the concept.

DESIGN/METHODOLOGY/APPROACH

According to the phenomenographic approach, this analysis investigates how the components of a surgical team (22 semistructured interviews) experience efficiency in their daily workflows.

FINDINGS

The main findings show that the concept of efficiency is multidimensional. According to participants' perspective, several categories of efficiency collected in an outcome space emphasize an holistic view of efficiency driving health policies and strategies.

SOCIAL IMPLICATIONS

The suggestion of further relationships between perspectives and other constructs (i.e., quality, safety, patient focus, process) at micro and macro level could enhance the impact of health reforms.

ORIGINALITY/VALUE

A qualitative approach conducted at microlevel help to recognize the phenomenon (of efficiency), engaging the individual conception that practitioners have of the health efficiency.