Aspects of the surgical team’s and patients’ perception of efficiency, and the recovery process after major abdominal surgery

Background

Laws and regulations from Swedish National Board of Health and Welfare (SFS, 1982:763, § 2 a) emphasis that leadership should fulfill the demands on patient safety and quality, work based on knowledge towards efficient care process offering care within a reasonable amount of time with the patients in focus. “Lean production” is one example of how the work process can be made efficient and has been used in health care for improving quality of care with minimum cost and for delivering what patients need at the right time. The aim is to reduce all steps that have little or no value for the patients in the care chain. Team members are involved in creating a smooth patient flow, reducing waiting time for patients, and improving the quality of care. The main question is, how can health care professionals increase efficiency at work with enhanced co-operation with the patients?

Health care should be based on good contact between health care professionals and the patient, the patients’ decision-making and integrity. The care process and treatment should be performed through dialogue with the patient. This raises another question; what is the patient’s role in making the care process efficient while maintaining quality of care?

The concept of efficiency is defined in different ways. In health care there is no common understanding of the concept of efficiency, which may constitute an unidentified obstacle to leaders’ efforts to promote efficiency. Leaders urging staff to work efficiently may sometimes meet strong reactions from staff members, who believe that demands for increased efficiency means just more stress at work.

At Uppsala University Hospital, Uppsala, Sweden, an extensive surgical treatment (cytoreductive surgery, CRS and hyperthermic intraperitoenal chemotherapy, HIPEC) has been used for selected patients with peritoneal carcinomatosis (PC) since 2003. It is a complex procedure and is difficult to standardize. A surgical team comprising surgeons, anesthesiologists, operating room nurses, nurse anesthetists, and assistant nurses was created at the hospital to work only with patients diagnosed with PC. Resources were given to the team members to plan work and schedule patients.
In the literature, there is a knowledge gap about understanding the concept of efficiency and involving patients in the health care teams to affect the quality of care and efficiency in care.

Aims

  1. To explore variations in how staff and leadership working in a non-team organisation within an operating department understand and experience operating room efficiency.
  2. To explore how organised surgical team members (Peritoneal Carcinomatosis team) and their leaders understand operating room efficiency.

Method

In the first study, 21 staff members and their supervisors, in an operating department in a Swedish county hospital were interviewed. The second study was performed in a 1100- bed University hospital in Sweden where 11 participants, nine team members from the same team and their two leaders were interviewed. The analysis was done with a phenomenographic approach which aims to discover the variations in how a phenomenon is understood by a group of people.

Results

In the non-team organization six categories were found in the understanding of operation room efficiency: A) having the right qualifications; B) enjoying work; C) planning and having good control and overview; D) each professional performing the correct tasks; E) completing a work assignment; and F) producing as much as possible per time unit. The most significant finding was that most of the nurses and assistant nurses understood efficiency as individual knowledge and experience emphasizing the importance of the work process, whereas the supervisors and physicians understood efficiency in terms of production per time unit or completing an assignment.
In a team organisation seven ways of understanding operating room efficiency were identified: doing one’s best from one’s prerequisites, enjoying work and adjusting it to the situation, interacting group performing parallel tasks, working with minimal resources to produce desired results, fast work with preserved quality, long-term effects for the patient care, and a relative concept. When talking about the quality and benefits of delivered care, most of team members invoked the patient as the central focus. Despite seven ways of understanding efficiency between the team members, they described their team as efficient. The nurses and assistant nurses were involved in the production and discussed working in a timely manner more than the leaders.

Members of the group during 2010

Erebouni Arakelian RN, MSc, PhD student

Haile Mahtheme MD, Ass professor

Lena Gunningberg, RN, Ass professor

Jan Larsson MD, PhD

Karin Norlén MD, PhD

Publications

Arakelian E., Gunningberg L., Larsson J. (2008) Job satisfaction or production? Variation in how staff and leadership understand operating room efficiency: a qualitative study. Acta Anaesthesiol Scand, 52: 1423-28.

Arakelian E, Gunningberg L, Larsson J. How operating room efficiency is understood in a surgical team: a qualitative study. Int J Qual Health Care, 2010 Nov 23. [Epub ahead of print]

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