A Study of a Hospital Operating Unit as a Foundation for Future Improvements

Abstract: The main objective of the research presented was to gain an understanding of how the dynamics between professionals, tools and objectives work in an operating unit in order to obtain knowledge useful when designing the operating unit of the future with emphasis on the work environment, effectiveness and patient safety. By investigating how different professions in the operating theatre view their work and its dynamics, as well as observing how the work is actually carried out, it is possible to get a conception of the dynamics and motives that determine how the work is constituted. This research explores how different professions view their work by means of an interview study, and how the work is carried out in practice by means of a direct observation study. Together, the results of the studies provide two different perspectives on operating theatre work. In both studies, the perspectives of the professionals play an important role. How something is perceived influences how we decide to act. To increase the potential for improvement, widening those perspectives plays a central role. By doing so, the practice will in turn appear more complex to the practitioners; there will be more aspects to take into consideration. More contradictions and options will be visible. To improve the practitioners’ capability to handle this increased complexity, trust is identified as an important tool. Trust is a mechanism that can suspend doubt or complexity in such a way that it is possible to make effective decisions even when the number of options is too large to handle. Previous research indicates that surgical teams are not as cohesive as could be expected and that communication failures frequently occur in the operating theatre. The first study presented in this thesis elaborates on how this can come about. It investigates how different healthcare professions in the surgical team orientate themselves towards their task and how this can be affected by the organizational and social context. Virtual reality supported semi-structured interviews were conducted with 15 participants recruited from all personnel categories of the surgical team. Activity theory was used as a theoretical framework to analyze the interviews. The results indicated that poor team functionality to some degree can be explained by different activity orientations between professions, which leads to different views on work activities and tension between them. Social and organizational support structures in the daily practice are pointed out as a means to facilitate trust and experience sharing between professions. This can promote the establishment of a common view among different professionals in the operating team and increase interprofessional communication, hence overcoming communication thresholds in the operating theatre. To improve safety in the operating theatre, checklists have gained considerable support in recent years, often in the form of a pre-operative timeout. The World Health Organization (WHO) has developed its own timeout checklist, which has been adopted by several Swedish operating units. Previous research indicates that timeout checklists reduce complications from surgery and can even improve the safety attitude of the team members. Thus, the effects of the checklist have been studied, but little research has been carried out on how the checklist is actually used in practice. This is investigated in the second study included in this thesis to determine how the surgical team uses and relates to the checklist as well as to identify and explain deviations from it. Twenty-four timeout procedures of four different, but common, operations were video recorded and analyzed according to a predefined protocol based on the WHO checklist instructions. The results showed that compliance varied between questions. The questions with the best compliance appeared to be the ones that made the most sense and were perceived as the most important by the participants. In half of the observed procedures, personal presentations did not occur and in five of those cases, they were postponed. This indicates that these questions, intended to facilitate communication between team members, were not perceived as contributing to patient safety in any meaningful way. The results also showed that surgeons and anesthesiology personnel dominated much of the timeout. It is likely that the positive effects on patient safety attributed to the checklist can be improved by making the connection between the checklist, communication and teamwork more explicit and by altering the checklist so that the different professions more equally involved.