Best practices for managing surgical services: the role of coordination

Interprofessional education in cardiothoracic surgery: a narrative review

Interprofessional education, an approach where healthcare professionals from various disciplines learn with, from, and about each other, is widely recognized as an important strategy for improving collaborative practice and patient outcomes. This narrative review explores the current state and future directions of interprofessional education in cardiothoracic surgery. We conducted a literature search using the PubMed, Scopus, and Web of Science databases, focusing on English-language articles published after 2000. Our qualitative synthesis identified key themes related to interprofessional education interventions, outcomes, and challenges. The integration of interprofessional education in cardiothoracic surgery training programs varies across regions, with a common focus on teamwork and interpersonal communication. Simulation-based training has emerged as a leading modality for cultivating these skills in multidisciplinary settings, with studies showing improvements in team performance, crisis management, and patient safety. However, significant hurdles remain, including professional socialization, hierarchies, stereotypes, resistance to role expansion, and logistical constraints. Future efforts in this field should prioritize deeper curricular integration, continuous faculty development, strong leadership support, robust outcome evaluation, and sustained political and financial commitment. The integration of interprofessional education in cardiothoracic surgery offers considerable potential for enhancing patient care quality, but realizing this vision requires a multifaceted approach. This approach must address individual, organizational, and systemic factors to build an evidence-based framework for implementation.

The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

Commentary on Burns, Nembhard and Shortell, "Integrating network theory into the study of integrated healthcare": Revisiting and extending research on structural and processual factors affecting coordination

Burns et al.'s innovative recommendation to use social network theory to study integration will contribute to our understanding of how healthcare systems can optimally deliver high quality, coordinated, person-centered care. We discuss three enhancements to this approach. (1) In increasing our attention to social network analysis and processual perspectives, we must not "throw out the baby with the bathwater" and abandon research that includes formal organizational structure. Structure remains an important focus for researchers and healthcare managers, who spend considerable resources on reorganizing. Since there is evidence that formal structure affects social processes and coordination, future research should build on that evidence and investigate how coordination is affected by the segmentation of organizations into units and the structures and processes designed to integrate interdependent work across those units. Conducting network analysis in the context of formal structure can help us better understand how formal structure affects both social networks and coordination. (2) Using multi-level, mixed methods, and qualitative research will be critically important to fully understand how and why formal organizational structure, social networks, and processual dynamics contribute to coordination or fragmentation of care. Because the relationships among these constructs occur not only within, but also across multiple levels, multi-level research is necessary to understand their effects on coordination. In considering the individual level, patients can be studied as a role embedded in networks. In addition, however, we must not lose a focus on patients as people at the center of multi-level networks, whose attitudes, values, preferences and goals may directly affect processual dynamics and coordination of care. (3) Finally, our field lacks precision in nomenclature, specification of levels, and the constructs within them, including ambiguity around even what is meant by "structure" and its variations. Furthermore, different authors use "macro", "meso", and "micro", differently, contributing to confusion in the discourse on organizational phenomena. Greater clarity and consistency in terminology is needed to facilitate research and improve communication across the field.

Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions

OBJECTIVES

Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery.

METHODS

We developed a conceptual framework of patient, process, and structure factors associated with surgical AEs on the basis of a literature review. This framework informed our semistructured interview guide with (1) open-ended questions about a specific outpatient AE that the participant experienced and (2) outpatient surgical patient safety risk factors in general. We interviewed nationwide Veterans Health Administration surgical staff. Results were coded on the basis of categories in the conceptual framework, and additional themes were identified using content analysis.

RESULTS

Fourteen providers representing diverse surgical roles participated. Ten reported witnessing an AE, and everyone provided input on risk factors in our conceptual framework. We did not find evidence that patient race/age, surgical technique, or surgical volume affected patient safety. Emerging factors included patient compliance, postoperative patient assessments/instruction, operating room equipment needs, and safety culture.

CONCLUSIONS

Surgical staff are familiar with AEs and patient safety problems in outpatient surgery. Our results show that processes of care undertaken by surgical providers, as opposed to immutable patient characteristics, may affect the occurrence of AEs. The factors we identified may facilitate more targeted research on outpatient surgical AEs.

Frontline meetings as support for cross-boundary coordination in hospitals

Purpose

The purpose of this paper is to investigate frontline meetings in hospitals and how they are used for coordination of daily operations across organizational and occupational boundaries.

Design/methodology/approach

An in-depth multiple-case study of four purposefully selected departments from four different hospitals is conducted. The selected cases had actively developed and embedded scheduled meetings as structural means to achieve coordination of daily operations.

Findings

Health care professionals and managers, next to their traditional mono-professional meetings (e.g. doctors or nurses), develop additional operational, daily meetings such as work-shift meetings, huddles and hand-off meetings to solve concrete care tasks. These new types of meetings are typically short, task focussed, led by a chair and often inter-disciplinary. The meetings secure a personal proximity which the increased dependency on hospital-wide IT solutions cannot. During meetings, objects and representations (e.g. monitors, whiteboards or paper cards) create a needed gathering point to span across boundaries. As regards embedding meetings, local engagement helps contextualizing meetings and solving concrete care tasks, thereby making health care professionals more likely to value these daily meeting spaces.

Practical implications

Health care professionals and managers can use formal meeting spaces aided by objects and representations to support solving daily and interdependent health care tasks in ways that IT solutions in hospitals do not offer today. Implementation requires local engagement and contextualization.

Originality/value

This research paper shows the importance of daily, operational hospital meetings for frontline coordination. Organizational meetings are a prevalent collaborative activity, yet scarcely researched organizational phenomenon.

Hospital Staffs' Perceptions of Postoperative Nutrition Among Colorectal Patients: A Qualitative Study

BACKGROUND

After lower gastrointestinal surgery, few patients start eating within timeframes outlined by evidence-based guidelines or meet their nutrition requirements in hospital. The present study explored hospital staffs' perceptions of factors influencing timely and adequate feeding after colorectal surgery to inform future interventions for improving postoperative nutrition practices and intakes.

METHODS

This qualitative exploratory study was conducted at an Australian hospital where Enhanced Recovery After Surgery guidelines had not been formally implemented. One-on-one semistructured interviews were conducted with hospital staff who provided care to patients undergoing colorectal surgery. Interviews lasted from 21 to 47 minutes and were audio recorded and transcribed verbatim. Data were analyzed using inductive thematic analysis. Emergent themes and subthemes were discussed by all investigators to ensure consensus of interpretation.

RESULTS

Eighteen staff participated in interviews, including 9 doctors, 5 nurses, 2 dietitians, and 2 foodservice staff. Staffs' responses formed 3 themes: (1) variability in perceived acceptability of postoperative feeding; (2) improving dynamics and communication within the treating team; and (3) optimizing dietary intakes with available resources.

CONCLUSION

Staff and organizational factors need to be considered when attempting to improve postoperative nutrition among patients who undergo colorectal surgery. Introducing a feeding protocol, enhancing intraprofessional and interdisciplinary communication, and ensuring the availability of appropriate, nutrient-dense foods are pivotal to improve nutrition practices and intakes.

Health Care Coordination Theoretical Frameworks: a Systematic Scoping Review to Increase Their Understanding and Use in Practice

BACKGROUND

Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible.

METHODS

To identify relevant frameworks, we searched MEDLINE®, Cochrane, CINAHL, PsycINFO, and SocINDEX from 2010 to May 2018, and various other nonbibliographic sources. We summarized framework characteristics and organized them using categories from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. Based on expert input, we then categorized available frameworks on consideration of whether they addressed contextual factors, what locus they addressed, and their design elements. We used predefined criteria for study selection and data abstraction.

RESULTS

Among 4389 citations, we identified 37 widely diverse frameworks, including 16 recent frameworks unidentified by previous reviews. Few led to development of measures (39%) or initiatives (6%). We identified 5 that are most relevant to primary care. The 2018 framework by Weaver et al., describing relationships between a wide range of primary care-specific domains, may be the most useful to those investigating the effectiveness of primary care coordination approaches. We also identified 3 frameworks focused on locus and design features of implementation that could prove especially useful to those responsible for implementing care coordination.

DISCUSSION

This review identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications. Greater application of these frameworks in the design and evaluation of coordination approaches may increase their consistent implementation and measurement. Future research should emphasize implementation-focused frameworks that better identify factors and mechanisms through which an initiative achieves impact.

Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

Surgical perioperative pathways-Patient experiences of unmet needs show that a person-centred approach is needed

AIM

To explore patients' and healthcare professionals' experiences of patients' surgical pathways in a perioperative setting.

BACKGROUND

Elective surgical pathways have improved over the past decades due to fast-track programmes, but patients desire more personalised and coordinated care and treatment. There is little knowledge of how healthcare professionals' collaboration and communication affect patients' pathways.

DESIGN

The overall framework was complex intervention method. A phenomenological-hermeneutic approach was used for data analyses. COREQ checklist was used as a guideline to secure accurate and complete reporting of the study.

METHODS

Field observations (120 hr) and semi-structured interviews (24 patients) were undertaken during 2016-2017. Healthcare professionals involved in the pathways were interviewed: (a) 13 single interviews and (b) 13 focus group interviews (37 healthcare professionals) were conducted. The Consolidated Criteria for Reporting Qualitative Research checklist was used.

RESULTS

Patients asked for individualised information adapted to their life and illness experiences. Furthermore, healthcare professionals need access to a quick overview of individual patients and their perioperative pathway in the electronic patient journal (EPJ). Agreements made with patients did not always reach the right receiver, there was poor interpersonal communication and the complex teamwork between many healthcare professionals made pathways incoherent and uncoordinated. Healthcare professionals who had the time to talk about other subjects than the disease with smiles and good humour gave patients a feeling of security.

CONCLUSION

Patients wanted to be treated as individuals, but often they received standard treatment. Healthcare professionals had the intention of treating patients individually, but the EPJ and information provided to patients were not easy to access.

RELEVANCE TO CLINICAL PRACTICE

Visible information about the patient's whole pathway could improve healthcare professionals' care and treatment. In addition, systematic feedback from patients' could make it possible to adjust information, care and treatment to achieve a more coherent pathway. Particular attention needs to be paid to how electronic healthcare systems can underpin relational coordination in pathways.

Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System

Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies

BACKGROUND

Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.

METHODS

Systematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool.

RESULTS

Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

CONCLUSIONS

Struggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42017067367.

No one can whistle a symphony: how hospitals design for daily cross-boundary collaboration

Purpose The purpose of this paper is to investigate how and with which mechanisms health care professionals in practice design for collaboration to solve collective hospital tasks, which cross occupational and departmental boundaries. Design/methodology/approach An in-depth multiple-case study of five departments across four hospitals facing fast to slow response task requirements was carried out using interviews and observations. The selected cases were revealing as the departments had designed and formalized their daily hospital operations differently to solve collaboration and performance issues. Findings Local collaboration across occupational and departmental boundaries requires bundles of behavioral formalization elements (e.g. standardized plans, resource allocation decisions, assigned formal roles, and handoff routines), and liaison devices (e.g. huddles, boards, and physical proximity), which are used in parallel or sequence. The authors label this "designed collaboration bundles." These bundles supplement the central organizational structures, processes, and support systems less capable of ensuring fluent coordination at the front line. Practical implications Health care professionals and hospital managers can consider designing bundles of organizational design features to proactively develop and ensure collaboration capable of solving collective tasks and bridging departmental and occupational silos to improve health care delivery. Originality/value This research paper addresses the fundamental organizational challenge of how to achieve efficient collaboration by studying how formal structures and processes are used in combination on the hospital floor, thereby going beyond previous research that studies these mechanisms individually.

The Influence of Telepathology on Coordination Practices

BACKGROUND

Coordination between physicians and allied professionals is essential to the effective delivery of care services and is associated with positive patient outcomes. As information technology can radically transform how professionals collaborate, both researchers and healthcare accreditation bodies are devoting a growing interest to the means of achieving better coordination.

INTRODUCTION

The primary aim of this study is to explain the extent to which and how coordination practices between pathologists, technologists, and surgeons are transformed when telepathology is being implemented.

MATERIALS AND METHODS

An interpretive case study was conducted. A total of 60 semistructured interviews with key participants were conducted, in addition to several days of direct observation of telepathology-based intraoperative consultations (IOCs).

RESULTS

Three major kinds of transformation of coordination practices were observed. First, the telepathology system itself constrains and disrupts coordination routines, such as the presentation of slides. Second, anticipating IOC, proactively performed by the laboratory personnel in traditional settings, requires more formal requests in a telepathology context. Third, local technologists become more autonomous in performing complex macroscopy manipulations and managing the laboratory tasks traditionally performed by pathologists.

CONCLUSIONS

Successful coordination of work in a telepathology-based IOC context requires that significant transformations be anticipated and accounted for. Project managers need to formalize new work processes, support the transformations in professional roles, and mitigate the major hindrances that small material changes may have on work routines.

Applying the High Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study

BACKGROUND

The lack of a tool for categorizing and differentiating hospitals according to their high reliability organization (HRO)-related characteristics has hindered progress toward implementing and sustaining evidence-based HRO practices. Hospitals would benefit both from an understanding of the organizational characteristics that support HRO practices and from knowledge about the steps necessary to achieve HRO status to reduce the risk of harm and improve outcomes. The High Reliability Health Care Maturity (HRHCM) model, a model for health care organizations' achievement of high reliability with zero patient harm, incorporates three major domains critical for promoting HROs-Leadership, Safety Culture, and Robust Process Improvement ®. A study was conducted to examine the content validity of the HRHCM model and evaluate whether it can differentiate hospitals' maturity levels for each of the model's components.

METHODS

Staff perceptions of patient safety at six US Department of Veterans Affairs (VA) hospitals were examined to determine whether all 14 HRHCM components were present and to characterize each hospital's level of organizational maturity.

RESULTS

Twelve of the 14 components from the HRHCM model were detected; two additional characteristics emerged that are present in the HRO literature but not represented in the model-teamwork culture and system-focused tools for learning and improvement. Each hospital's level of organizational maturity could be characterized for 9 of the 14 components.

DISCUSSION

The findings suggest the HRHCM model has good content validity and that there is differentiation between hospitals on model components. Additional research is needed to understand how these components can be used to build the infrastructure necessary for reaching high reliability.

Association of a Surgical Task During Training With Team Skill Acquisition Among Surgical Residents: The Missing Piece in Multidisciplinary Team Training

Importance

The human patient simulators that are currently used in multidisciplinary operating room team training scenarios cannot simulate surgical tasks because they lack a realistic surgical anatomy. Thus, they eliminate the surgeon's primary task in the operating room. The surgical trainee is presented with a significant barrier when he or she attempts to suspend disbelief and engage in the scenario.

Objective

To develop and test a simulation-based operating room team training strategy that challenges the communication abilities and teamwork competencies of surgeons while they are engaged in realistic operative maneuvers.

Design, Setting, and Participants

This pre-post educational intervention pilot study compared the gains in teamwork skills for midlevel surgical residents at Wake Forest Baptist Medical Center after they participated in a standardized multidisciplinary team training scenario with 3 possible levels of surgical realism: (1) SimMan (Laerdal) (control group, no surgical anatomy); (2) "synthetic anatomy for surgical tasks" mannequin (medium-fidelity anatomy), and (3) a patient simulated by a deceased donor (high-fidelity anatomy).

Interventions

Participation in the simulation scenario and the subsequent debriefing.

Main Outcomes and Measures

Teamwork competency was assessed using several instruments with extensive validity evidence, including the Nontechnical Skills assessment, the Trauma Management Skills scoring system, the Crisis Resource Management checklist, and a self-efficacy survey instrument. Participant satisfaction was assessed with a Likert-scale questionnaire.

Results

Scenario participants included midlevel surgical residents, anesthesia providers, scrub nurses, and circulating nurses. Statistical models showed that surgical residents exposed to medium-fidelity simulation (synthetic anatomy for surgical tasks) team training scenarios demonstrated greater gains in teamwork skills compared with control groups (SimMan) (Nontechnical Skills video score: 95% CI, 1.06-16.41; Trauma Management Skills video score: 95% CI, 0.61-2.90) and equivalent gains in teamwork skills compared with high-fidelity simulations (deceased donor) (Nontechnical Skills video score: 95% CI, -8.51 to 6.71; Trauma Management Skills video score: 95% CI, -1.70 to 0.49).

Conclusions and Relevance

Including a surgical task in operating room team training significantly enhanced the acquisition of teamwork skills among midlevel surgical residents. Incorporating relatively inexpensive, medium-fidelity synthetic anatomy in human patient simulators was as effective as using high-fidelity anatomies from deceased donors for promoting teamwork skills in this learning group.

Malpractice in paediatric minimally invasive surgery - a current concept: Results of an international survey

This study aimed to assess malpractice in paediatric minimally invasive surgery (MIS), and attitudes, prevention strategies and mechanisms to support surgeons while they are under investigation. An observational, multicentric, questionnaire-based study was conducted. The survey questionnaire was sent via mail, and it comprised four sections. Twenty-four paediatric surgeons (average age 54.6 years), from 13 different countries, participated in this study. The majority had >15 years of experience in MIS. Three (12.5%) surgeons reported a total of five malpractice claims regarding their MIS activity. The reasons for the claims were a postoperative complication in 3/5 (60%) cases, a delayed/failed diagnosis in 1/5 (20%) cases and the death of the patient in 1/5 (20%) cases. The claims concluded with the absolution of the surgeon in all cases, and monetary compensation to the claimant in two (40%) cases. Eleven (45.8%) surgeons were invited as expert counsels in medico-legal actions. Medico-legal aspects have a minimal impact on the MIS activity of paediatric surgeons. In this series, claims concluded with the absolution of the surgeon in all cases, but they had a negative effect on the surgeon's reputation and finances. A key element in supporting surgeons while they are under investigation is always to choose a surgeon who is an expert in paediatric MIS as legal counsel. A constant update on innovations in paediatric MIS and appropriate professional liability insurance may also play a key role in reducing medico-legal consequences.

Improved outcomes following implementation of an acute gastrointestinal bleeding multidisciplinary protocol

BACKGROUND

Effective multidisciplinary management of gastrointestinal bleeding (GIB) requires effective communication. We instituted a protocol to standardize communication practices with the hypothesis that outcomes would improve following protocol initiation.

METHODS

We performed a retrospective cohort analysis of 442 patients who required procedural management of acute GIB at our institution during a 50-month period spanning 25 months before and 25 months after implementation of a multidisciplinary communication protocol. The protocol stipulates that when a patient with severe GIB is identified, a conference call is coordinated among the gastroenterology, interventional radiology, and acute care surgery teams. A consensus plan is generated and then reassessed following procedural interventions and changes in patients' status. Patients' characteristics, management strategies, and outcomes were compared before and after protocol initiation.

RESULTS

Patient populations before and after protocol initiation were similar in age, comorbidities, outpatient use of antiplatelet/anticoagulant medications, admission vital signs, and admission laboratory values. The median interval between admission and the first procedure was significantly shorter in the protocol group (40 vs 47 hours, p = 0.046). The proportion of patients who received packed red blood cell transfusions decreased following protocol initiation (41% vs 50%, p = 0.018). Median hospital length of stay was significantly shorter in the protocol group (5.0 vs 6.0 days, p = 0.014). Readmissions with GIB were decreased after protocol implementation (8% vs. 15%, p = 0.023).

CONCLUSION

Implementation of a multidisciplinary protocol for management of acute GIB was associated with earlier intervention, fewer packed red blood cell transfusions, shorter hospital length of stay, and fewer readmissions with GIB. Future research should seek to establish causal relationships between communication practices and outcomes.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Improving care coordination using organisational routines

PURPOSE

The purpose of this paper is to systematically apply theory of organisational routines to standardised care pathways. The explanatory power of routines is used to address open questions in the care pathway literature about their coordinating and organising role, the way they change and can be replicated, the way they are influenced by the organisation and the way they influence health care professionals.

DESIGN/METHODOLOGY/APPROACH

Theory of routines is systematically applied to care pathways in order to develop theoretically derived propositions.

FINDINGS

Care pathways mirror routines by being recurrent, collective and embedded and specific to an organisation. In particular, care pathways resemble standard operating procedures that can give rise to recurrent collective action patterns. In all, 11 propositions related to five categories are proposed by building on these insights: care pathways and coordination, change, replication, the organisation and health care professionals. Research limitations/implications - The paper is conceptual and uses care pathways as illustrative instances of hospital routines. The propositions provide a starting point for empirical research.

PRACTICAL IMPLICATIONS

The analysis highlights implications that health care professionals and managers have to consider in relation to coordination, change, replication, the way the organisation influences care pathways and the way care pathways influence health care professionals. Originality/value - Theory on organisational routines offers fundamental, yet unexplored, insights into hospital processes, including in particular care coordination.

How to achieve care coordination inside health care organizations: Insights from organization theory on coordination in theory and in action

Understanding how health care organizations can achieve care coordination internally is essential because it is difficult to achieve, but essential for high-quality and efficient health care delivery. This article offers an answer by providing a synthesis of knowledge about coordination from organization theory, where coordination is a central research topic. The article focuses on intra-organizational coordination, which is challenging especially across boundaries such as departments or professions. It provides an overview of the classic coordination mechanisms, e.g., standardization of work processes, but also of recent insights that have identified the conditions that are required to achieve coordination, and how these conditions can be provided by formal mechanisms, such as standardization, but also informally by drawing on features of the emerging situation. Such research highlights the contribution of, e.g., routines like those guided by care pathways or of artifacts like displays. The coordination insights are also discussed as regards inter-organizational care coordination.

The relationship between voice climate and patients' experience of timely care in primary care clinics

BACKGROUND

Aspects of the patient care experience, despite being central to quality care, are often problematic. In particular, patients frequently report problems with timeliness of care. As yet, research offers little insight on setting characteristics that contribute to patients' experience of timely care.

PURPOSE

The aims of this study were to assess the relationship between organizational climate and patients' reports of timely care in primary care clinics and to broadly examine the link between staff's work environment and patient care experiences. We test hypotheses about the relationship between voice climate--staff feeling safe to speak up about issues--and reported timeliness of care, consistency in reported voice climate across professions, and how climate differences for various professions relate to timely care.

METHODOLOGY

We conducted a cross-sectional study of employees (n = 1,121) and patients (n = 8,164) affiliated with 37 clinics participating in a statewide reporting initiative. Employees were surveyed about clinics' voice climate, and patients were surveyed about the timeliness of care. Hypotheses were tested using analysis of variance and generalized estimating equations.

FINDINGS

Clinical and administrative staff (e.g., nurses and office assistants) reported clinics' climates to be significantly less supportive of voice than did clinical leaders (e.g., physicians). The greater the difference in reported support for voice between professional groups, the less patients reported experiencing timely care in three respects: obtaining an appointment, seeing the doctor within 15 minutes of appointment time, and receiving test results. In clinics where staff reported climates supportive of voice, patients indicated receiving more timely care. Clinical leaders' reports of voice climate had no relationship to reported timeliness of care.

PRACTICAL IMPLICATIONS

Our findings suggest the importance of clinics developing a strong climate for voice, particularly for clinical and administrative staff, to support better service quality for patients.

Organizational predictors of coordination in inpatient medicine

BACKGROUND

As the care of hospitalized patients becomes more complex, intraprofessional coordination among nurses and among physicians, and interprofessional coordination between these groups are likely to play an increasingly important role in the provision of hospital care.

PURPOSE

The purpose of this study was to identify the independent effects of organizational factors on provider ratings of overall coordination in inpatient medicine (OCIM).

METHODOLOGY/APPROACH

This was an exploratory cross-sectional, descriptive study. Primary data were collected between June 2010 and September 2011 through surveys of inpatient medicine nurse managers, physicians, and chiefs of medicine at 36 Veterans Health Administration medical centers. Secondary data from the 2011 Veterans Health Administration national survey of nurses were also used. Individual-level data were aggregated and analyzed at the facility level. Multivariate linear regression models were used to assess the relationship between 55 organizational factors and provider ratings of OCIM.

FINDINGS

Organizational factors that were common across models and associated with better provider ratings of OCIM included provider perceptions that the goals of senior leadership are aligned with those of the inpatient service and that the facility is committed to the highest quality of patient care, having resources and staff that enable clinicians to do their jobs, and use of strategies that enhance interactions and communication among and between nurses and physicians.

PRACTICE IMPLICATIONS

To improve intraprofessional and interprofessional coordination and, consequently, patient care, facilities should consider making patient care quality a more important strategic organizational priority; ensuring that providers have the staffing, training, supplies, and other resources they need to do their jobs; and implementing strategies that improve interprofessional communication and working relationships, such as multidisciplinary rounding.

Virtual operating room for team training in surgery

BACKGROUND

We proposed to develop a novel virtual reality (VR) team training system. The objective of this study was to determine the feasibility of creating a VR operating room to simulate a surgical crisis scenario and evaluate the simulator for construct and face validity.

METHODS

We modified ICE STORM (Integrated Clinical Environment; Systems, Training, Operations, Research, Methods), a VR-based system capable of modeling a variety of health care personnel and environments. ICE STORM was used to simulate a standardized surgical crisis scenario, whereby participants needed to correct 4 elements responsible for loss of laparoscopic visualization. The construct and face validity of the environment were measured.

RESULTS

Thirty-three participants completed the VR simulation. Attendings completed the simulation in less time than trainees (271 vs 201 seconds, P = .032). Participants felt the training environment was realistic and had a favorable impression of the simulation. All participants felt the workload of the simulation was low.

CONCLUSIONS

Creation of a VR-based operating room for team training in surgery is feasible and can afford a realistic team training environment.

A qualitative study assessing the barriers to implementation of enhanced recovery after surgery

BACKGROUND

Previous studies have quantitatively assessed Enhanced Recovery After Surgery (ERAS) guideline implementation and compliance, and identified the existence of compliance issues with the programs. This is the first study to qualitatively assess the reasons behind compliance issues in ERAS programs. The aim of this study was to elicit barriers to implementation and functioning of the ERAS program at Royal Prince Alfred Hospital.

METHODS

A series of interviews were carried out with key stakeholders in order to explore barriers preventing effective functioning of the program 1 year after implementation. Interview transcripts were analysed. Data analysis involved a grounded theory methodology.

RESULTS

Analysis of the data identified four key themed areas of practice that presented barriers: patient-related factors, staff-related factors, practice-related issues, and resources. These overarching themes were generated from subcategories that were linked to generate theory.

CONCLUSIONS

For the ERAS program to be implemented successfully with high levels of element compliance, the four key areas need to be addressed. As barriers to ongoing effective care become apparent, these should be managed in order to optimize the synergistic effects of this multimodal program of patient care.

Examining the validity of AHRQ's patient safety indicators (PSIs): is variation in PSI composite score related to hospital organizational factors?

Increasing use of Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) for hospital performance measurement intensifies the need to critically assess their validity. Our study examined the extent to which variation in PSI composite score is related to differences in hospital organizational structures or processes (i.e., criterion validity). In site visits to three Veterans Health Administration hospitals with high and three with low PSI composite scores ("low performers" and "high performers," respectively), we interviewed a cross-section of hospital staff. We then coded interview transcripts for evidence in 13 safety-related domains and assessed variation across high and low performers. Evidence of leadership and coordination of work/communication (organizational process domains) was predominantly favorable for high performers only. Evidence in the other domains was either mixed, or there were insufficient data to rate the domains. While we found some evidence of criterion validity, the extent to which variation in PSI rates is related to differences in hospitals' organizational structures/processes needs further study.

Improving medical leadership and teamwork: an iterative process

Purpose

– This paper aims to present a two-decade effort to improve team functioning and patient outcomes in inpatient stroke rehabilitation settings.

Design/methodology/approach

– The principal improvement effort was conducted over a nine-year period in 50 Veterans Administration Hospitals in the USA. A comprehensive team-based model was developed and tested in a series of empirical studies. A leadership development intervention was used to improve team functioning, and a follow-up cluster-randomized trial documented patient outcome improvements associated with the leadership training.

Findings

– Iterative team and leadership improvements are presented in summary form, and a set of practice-proven development observations are derived from the results. Details are also provided on the leadership training intervention that improved teamwork processes and resulted in improvements in patient outcomes that could be linked to the intervention itself.

Research limitations/implications

– The practice-proven development observations are connected to leadership development theory and applied in the form of suggestions to improve leadership development and teamwork in a broad array of medical treatment settings.

Practical implications

– This paper includes suggestions for leadership improvement in medical treatment settings using interdisciplinary teams to meet the customized needs of the patient populations they serve.

Originality/value

– The success of the team effectiveness model and the team-functioning domains provides a framework and best practice for other health care organizations seeking to improve teamwork effectiveness.

Malpractice awareness among surgeons at a teaching hospital in Pakistan

Background

The duty of a doctor to take care presumes the person who offers medical advice and treatment to unequivocally possess the skills and knowledge to do so. However, a sense of responsibility cannot be guaranteed in the absence of accountability, which in turn requires a comprehensive medical law system to be in place. Such a system is almost non-existent in Pakistan. Keeping the above in mind, we designed this study to assess the knowledge, attitudes and practices of surgeons regarding malpractice at a tertiary care center in Pakistan.

Methods

This was an observational, cross-sectional, questionnaire-based study conducted during a three month period from 31st March, 2012 to 30th June, 2012 at Civil Hospital, Karachi. Surgeons who were available during the period of our study and had been working in the hospital for at least 6 months were included. Self-administered questionnaires were distributed after seeking informed, written consent. The specialties included were general surgery, cardiothoracic surgery, neurosurgery, ophthalmology, otolaryngology, plastic surgery, pediatric surgery, orthopedic surgery, oral and maxillofacial surgery and gynecology and obstetrics. The study questionnaire comprised of four sections. The first section was concerned with the demographics of the surgeons. The second section analyzed the knowledge of the respondents regarding professional negligence and malpractice. The third section assessed the attitudes surgeons with regard to malpractice. The last section dealt with the general and specific practices and experiences of surgeons regarding malpractice.

Results

Of the 319 surgeons interviewed, 68.7% were oblivious of the complete definition of malpractice. Leaving foreign objects inside the patient (79.6%) was the most commonly agreed upon form of malpractice, whereas failure to break news in entirety (43.9%) was most frequently disagreed. In the event of a medical error, majority (67.7%) were ready to disclose their error to the patient. The most common perceived reason for not disclosing the error was threat of a claim or assault (90.9%). Majority (68.3%) believed that malpractice had a negative effect on reputation. Only 13(4.1%) had received at least one legal claim for damages. Only about three-fourths (75.5%) had the habit of frequently obtaining informed consent from the patients. 83(26.0%) expressed reluctance in accepting a case that was deemed to be difficult. Financial gains and liabilities were responsible for biased approach in 8.5% and 12.2% of the respondents respectively.

Conclusion

There is a dire need of programs aimed at increasing awareness among practicing surgeons in our setup. Proactive measures are required for the formulation of an efficient system of litigation. Physician accountability will not only arouse a greater sense of responsibility in them, but will also augment the confidence placed by patients on the healthcare system.

[Undesirable events during the perioperative period and communication deficiencies]

In recent decades, anaesthesia and surgery have undergone major scientific and technical developments. However, these improvements have not solved a recurring problem, communication deficiencies within teams in charge of surgical patients. Current figures show that 21% to 65% of accidents and errors in patient management during the perioperative period are related to communication problems. These problems occur when gaps arise in the continuity and coordination of care within teams. Some of the contributing factors to these gaps are emergency status of patients, staff shifts and handovers following patient transfers. To minimize the impact of these phenomena, it is important to improve standardization of information flow within operating theatres and to improve teamwork between anaesthetists and surgeons. This can be done through crew resource management training programs or simulation. This should ultimately contribute to minimise medical error and improve the overall quality of care provided to patients in operating theatres and during all the perioperative period.

An evaluation of information transfer through the continuum of surgical care: a feasibility study

OBJECTIVE

To evaluate information transfer and communication (ITC) across the surgical care pathway with the use of Information Transfer and Communication Assessment Tool for Surgery (ITCAS).

BACKGROUND

Communication failures are the leading cause of surgical errors and adverse events. It is vital to assess the ITC across the entire surgical continuum of care to understand the process, to study teams, and to prioritize the phases for intervention.

METHODS

Twenty patients undergoing major gastrointestinal procedures were followed through their entire surgical care, and ITC process was assessed using ITCAS. ITCAS consisted of 4 checklists for 4 phases of the surgical care.

RESULTS

ITC failures are distributed across the entire surgical continuum of care. Preprocedural teamwork and postoperative handover phases have the maximum number of ITC failures (61.7% and 52.4%, respectively). Moreover, it was found that information degrades as it crosses from one phase to another. Of patients, 75% had clinical incidents or adverse events because of ITC failures.

CONCLUSIONS

The study demonstrated that ITC failures are ubiquitous across surgical care pathway and there is an imminent need to modify current ITC practices. Standardization of ITC through use of checklists, protocols, or information technology is essential to reduce these communication failures.

Extreme makeover: Transformation of the veterans health care system

The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.

Defining team performance for simulation-based training: methodology, metrics, and opportunities for emergency medicine

Across health care, teamwork is a critical element for effective patient care. Yet, numerous well-intentioned training programs may fail to achieve the desired outcomes in team performance. Hope for the improvement of teamwork in health care is provided by the success of the aviation and military communities in utilizing simulation-based training (SBT) for training and evaluating teams. This consensus paper 1) proposes a scientifically based methodology for SBT design and evaluation, 2) reviews existing team performance metrics in health care along with recommendations, and 3) focuses on leadership as a target for SBT because it has a high likelihood to improve many team processes and ultimately performance. It is hoped that this discussion will assist those in emergency medicine (EM) and the larger health care field in the design and delivery of SBT for training and evaluating teamwork.

Developing a NSQIP module to measure outcomes in children's surgical care: opportunity and challenge

Under the guidance of the American College of Surgeons (ACS) and in partnership with the US Department of Veterans Affairs (VA), the National Surgical Quality Improvement Program (NSQIP) has been developed to improve the quality of surgical care in adults on a national level. Its purpose is to provide reliable, risk-adjusted outcomes data so that surgical quality can be assessed and compared between institutions. Data analysis consists of reporting observed to expected ratios (O/E) for 30-day postoperative mortality and morbidity measurements. A surgical clinical nurse reviewer is assigned at each medical center to collect information on 97 variables, including preoperative, operative, and postoperative factors for patients undergoing major operations in the specialties of general and vascular surgery. Eligible operations are entered into the database on a structured 8-day cycle to ensure representative sampling of cases. Since the introduction of the program into the VA system, there has been a 47% reduction in 30-day postoperative mortality and a 42% reduction in 30-day postoperative morbidity. Over 160 institutions have enrolled with the ACS in its adult NSQIP. In 2005, a planning committee was formed by the ACS and the American Pediatric Surgical Association to explore the development of a children's surgery NSQIP module. In conjunction with the Colorado Health Outcomes Program at the University of Colorado, a program potentially applicable to all children's surgical specialties has been designed. This manuscript describes the development of that Children's ACS-NSQIP module.

Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions

BACKGROUND

Since the Institute of Medicine patient safety reports, a number of survey-based measures of organizational climate safety factors (OCSFs) have been developed. The goal of this study was to measure the impact of OCSFs on risk-adjusted surgical morbidity and mortality.

STUDY DESIGN

Surveys were administered to staff on general/vascular surgery services during a year. Surveys included multiitem scales measuring OCSFs. Additionally, perceived levels of communication and collaboration with coworkers were assessed. The National Surgical Quality Improvement Program was used to assess risk-adjusted morbidity and mortality. Correlations between outcomes and OCSFs were calculated and between outcomes and communication/collaboration with attending and resident doctors, nurses, and other providers.

RESULTS

Fifty-two sites participated in the survey: 44 Veterans Affairs and 8 academic medical centers. A total of 6,083 surveys were returned, for a response rate of 52%. The OCSF measures of teamwork climate, safety climate, working conditions, recognition of stress effects, job satisfaction, and burnout demonstrated internal validity but did not correlate with risk-adjusted outcomes. Reported levels of communication/collaboration with attending and resident doctors correlated with risk-adjusted morbidity.

CONCLUSIONS

Survey-based teamwork, safety climate, and working conditions scales are not confirmed to measure organizational factors that influence risk-adjusted surgical outcomes. Reported communication/collaboration with attending and resident doctors on surgical services influenced patient morbidity. This suggests the importance of doctors' coordination and decision-making roles on surgical teams in providing high-quality and safe care. We propose risk-adjusted morbidity as an effective measure of surgical patient safety.

Medical team training: applying crew resource management in the Veterans Health Administration

BACKGROUND

Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS).

METHODS

The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned.

RESULTS

Examples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings.

DISCUSSION

An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.

Relationship of Processes and Structures of Care in General Surgery to Postoperative Outcomes: A Hierarchical Analysis

BACKGROUND

The majority of studies relating processes and structures of surgical care to outcomes focus on mortality alone, even though morbidity outcomes are frequent, costly, and can have an adverse effect on a patient's short- and longterm survival and quality of life. The purpose of this study was to identify the important processes and structures of surgical care that relate to 30-day, risk-adjusted postoperative morbidity in general surgery.

STUDY DESIGN

Department of Veterans Affairs general surgery patients operated on in the period October 1, 2003 to September 30, 2004 at medical centers that participated in the Patient Safety in Surgery (PSS) Study and responded to a process and structure of care survey were included in this study. The patient's risk information was combined with key process and structure variables in a hierarchical maximum likelihood analysis to predict 30-day postoperative morbidity.

RESULTS

A number of hospital-level processes and structures of care were identified that predicted 30-day postoperative morbidity. The dominant factor was university affiliation. Affiliated hospitals showed an increase in risk of morbidity even after adjustment for patient risk.

CONCLUSIONS

Risk-adjusted morbidity is higher in Veterans Affairs hospitals that are affiliated with university medical centers. These findings mandate additional study to identify the exact factors responsible for this increased morbidity.

Relationship of Processes and Structures of Care in General Surgery to Postoperative Outcomes: A Descriptive Analysis

BACKGROUND

The systematic collection of quantitative data on structures and processes from surgical services participating in the National Surgical Quality Improvement Program (NSQIP) has not been a focus to date. Efficient collection of useful measures of structures and processes may improve understanding of surgical outcomes and strategies for improving the quality of surgical care, as NSQIP continues to expand. The purpose of this article was to describe results of a quantitative survey designed to measure surgical care structures and processes within NSQIP sites.

STUDY DESIGN

A cross-sectional survey was mailed to 123 Department of Veteran Affairs (VA) and 14 private sector sites participating in the Agency for Healthcare Research and Quality (AHRQ)-funded Patient Safety in Surgery (PSS) Study. The survey included questions about organizational structures and processes of preoperative, intraoperative, and postoperative general surgical care services. For this study, we included only data from 90 VA sites that returned a survey (73% response rate). We used descriptive statistics and examined the bivariate association of structures and processes items or scales with risk-adjusted observed-to-expected (O/E) ratios of surgical morbidity and mortality.

RESULTS

Examination of frequency or means and standard deviations of items and scales revealed substantial variation in the structures and processes of surgical care services in participating VA sites, with correlation analyses demonstrating that, of 35 process and structure variables, there was a statistically significant relationship with the hospital's observed-to-expected ratio for 14 variables for morbidity, but only 4 variables for mortality.

CONCLUSIONS

This descriptive analysis provides support for the potential importance of measuring organizational structures and processes of care in addition to risk-adjusted morbidity and mortality.

Relationship of Processes and Structures of Care in General Surgery to Postoperative Outcomes: A Qualitative Analysis

BACKGROUND

With increased focus on improving surgical care quality, understanding structures and processes that influence surgical care is timely and important, as is more precise specification of these through improved measurement.

STUDY DESIGN

We conducted a qualitative study to help design a quantitative survey of structures and processes of surgical care. We audiotaped 44 face-to-face interviews with surgical care leaders and other diverse members of the surgical care team from 6 hospitals (two Veterans Affairs, four private sector). Qualitative interviews were transcribed and analyzed to identify common structures and processes mentioned by interviewees to include on a quantitative survey and to develop a rich description of salient themes on indicators of effective surgical care services and surgical care teams.

RESULTS

Qualitative analyses of transcripts resulted in detailed descriptions of structures and processes of surgical care services that affected surgical care team performance--and how particular structures led to effective and ineffective processes that impacted quality and outcomes of surgical care. Communication and care coordination were most frequently mentioned as essential to effective surgical care services and teams. Informants also described other influences on surgical quality and outcomes, such as staffing, the role of residents, and team composition and continuity.

CONCLUSIONS

Surgical care team members reinforced the importance of understanding surgical care processes and structures to improve both quality and outcomes of surgical care. The analysis of interviews helped the study team identify potential measures of structures and processes to include in our quantitative survey.

A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability

BACKGROUND

Breakdown in communication among members of the healthcare team threatens the effective delivery of health services, and raises the risk of errors and adverse events.

AIM

To describe the process of developing an authentic, theory-based evaluation instrument that measures communication among members of the operating room team by documenting communication failures.

METHODS

25 procedures were viewed by 3 observers observing in pairs, and records of events on each communication failure observed were independently completed by each observer. Each record included the type and outcome of the failure (both selected from a checklist of options), as well as the time of occurrence and a description of the event. For each observer, records of events were compiled to create a profile for the procedure.

RESULTS

At the level of identifying events in the procedure, mean inter-rater agreement was low (mean agreement across pairs 47.3%). However, inter-rater reliability regarding the total number of communication failures per procedure was reasonable (mean ICC across pairs 0.72). When observers recorded the same event, a strong concordance about the type of communication failure represented by the event was found.

DISCUSSION

Reasonable inter-rater reliability was shown by the instrument in assessing the relative rate of communication failures displayed per procedure. The difficulties in identifying and interpreting individual communication events reflect the delicate balance between increased subtlety and increased error. Complex team communication does not readily reduce to mere observation of events; some level of interpretation is required to meaningfully account for communicative exchanges. Although such observer interpretation improves the subtlety and validity of the instrument, it necessarily introduces error, reducing reliability. Although we continue to work towards increasing the instrument's sensitivity at the level of individual categories, this study suggests that the instrument could be used to measure the effect of team communication intervention on overall failure rates at the level of procedure.

Analysis of surgical errors in closed malpractice claims at 4 liability insurers

BACKGROUND

The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention.

METHODS

We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded.

RESULTS

Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001).

CONCLUSIONS

Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors.

The role of the Veterans Affairs Medical Centers in patient care, surgical education, research and faculty development

Veterans Administration (VA) medical centers have had a long history of providing medical care to those who have served their country. Over time, the VA has evolved into a facility that has had a major role in graduate medical education. In surgery, this had provided experience in the medical and surgical management of complex surgical disease involving the head and neck, chest, and gastrointestinal tract, and in the fields of surgical oncology, peripheral vascular disease, and the subspecialties of urology, orthopedics, and neurosurgery. The VA provides a venue for the attending physician and resident to work in concert to allow the resident to shoulder increasing accountability in decision-making and delivery of care in the outpatient arena, the operating room, and the intensive care unit. Medical students assigned to a VA hospital are afforded a great opportunity to be exposed to preoperative planning, discussions leading to informed consent for surgery, the actual operation, and postoperative care. Numerous opportunities at the VA are available for novice and experienced medical faculty members to develop and/or enhance skills and abilities in patient care, medical education, and research. In addition, the VA offers unique opportunities for academic physicians and other healthcare professionals to administer its many programs, thereby developing leadership skills and experience in the process. The VA is uniquely situated to design and conduct multicenter clinical trials. The most important aspect of this is the infrastructure provided by the VA Cooperative Studies Program. Of the four missions of the Department of Veterans Affairs, research and education is essential to provide quality, state of the art clinical care to the veteran. The National Surgical Quality Improvement Program (NSQIP) is an example of how outcomes based research can favorably impact on patient outcome. Looking across the horizon of information solutions available to surgeons, the options are limited. This is not the case for the Department of Veterans Affairs. With the congressionally mandated charge for the VA to compare its quality to private clinicians, the advent of the "Surgery Package" became possible. The VA will continue its leadership position in the healthcare arena if it can successfully address the challenges facing it.

Team functioning and patient outcomes in stroke rehabilitation

OBJECTIVE

To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes.

DESIGN

Prospective observational study.

SETTING

Veterans Administration (VA) inpatient and subacute rehabilitation units.

PARTICIPANTS

Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS).

RESULTS

Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness.

CONCLUSIONS

Characteristics of team functioning predict selected rehabilitation outcomes.

Evidence-based outcome data after hernia surgery: A possible role for the National Surgical Quality Improvement Program

Since its inception in 1994, the National Surgical Quality Improvement Program (NSQIP) has been used to compare the performance of all Veterans Administration (VA) hospitals offering major surgical procedures. The program's outcome data are used to identify areas of both excellent and poor performance. The data can also be used to focus on specific procedures, especially high frequency operations such as inguinal herniorrhaphy. Following several successful feasibility studies, the NSQIP has been adopted by the American College of Surgeons (ACS) and is being offered nationwide in the non-VA sector. Given the profound decrease in operative mortality and morbidity seen within the VA, it seems realistic to expect similar improvements in global-and procedure specific-surgical outcomes within the non-VA sector.