Coordination challenges in operating-room management: an in-depth field study.

Coordination Challenges in Operating-Room Management: An In-Depth Field Study Cheryl L. Plasters 1 MSN, RN, F. Jacob Seagull2 PhD, Yan Xiao2 PhD 1 University of Maryland School of Nursing, 2 University of Maryland School of Medicine Abstract: Dynamic settings possess complex information needs all requiring attention in order to be managed effectively. The following study describes the multi-faceted information exchanges essential for an operating room suite to be managed within the context of efficient, cost effective, safe practice. Through the combined use of observation, the Critical Incident Technique, and interviews, this study analyzed information issues that impact coordination. Results demonstrate how distributed team planning is inherent to the efficacy of the system, and discuss implications for information tools to support coordination within in a complex setting. INTRODUCTION Management of operating rooms (OR) requires the coordination of human and material resources in such a way that surgery can be performed efficiently, cost effectively, and safely. Annual cost estimates for surgical errors in 1999 were between $8.5 and $17 billion,1 with medical errors attributed to systemrelated errors, such as coordination breakdowns.2 Coordinating an efficient OR schedule balances cost containment, safe practice and staff satisfaction within a context of continual change, minimizing the consumption of “over-utilized OR time”.3 Voigt4 notes that the increased number of surgical patients receiving care in outpatient or same-day surgery settings has required greater coordination efforts by OR personnel in managing daily operations. Decisions involving OR coordination require input from multi-disciplinary stakeholders. Interdisciplinary collaboration and consensus from key players is facilitated by avoiding hierarchical or formal power structures, committing to promoting equality and collective responsibility5 and working for the attainment of group goals. Previous studies6-7 noted that participants, within environments in which planning is disbursed among many people, engage in distributed team planning. Within these domains, one decision can have multiple effects, making wellcoordinated decisions paramount. In the specific domain of an OR suite there are multiple stakeholders each possessing access to privileged information vital to the coordination of the OR. An OR suite was chosen for the current study to demonstrate the issues impacting decision making within a dynamic environment affected by distributed team planning because a concerted effort by a dedicated coordinator is required in order to ensure a safe and efficient schedule of cases on any given day. The dynamic setting requires decisions to be made based on oftentimes incomplete or sporadic information resulting in repercussions that propagate throughout the system. Computation and communication technology have the potential to improve group decision-making, increase efficiency, attain staff satisfaction, and promote the provision of safe patient care. However, to realize that potential requires a deep understanding of group decision-making processes, and the probable impact of computer decision-support tools on the system. Studies in a wide variety of dynamic environments,8-12 have shown a complicated picture of the coordination processes and coordinative artifacts, such as public display boards, used by distributed team members as decision support tools. Prior studies of OR management have evaluated the role of the charge nurse13 and whiteboard.14 These observational studies examined the communication patterns of the charge nurse and the role of a public display board for OR management. The current study expanded the scope of investigation, and assessed all key players involved in the peri-operative process. In conjunction with observation, the Critical Incident Technique (CIT)15 was used to enhance the understanding of the issues surrounding the exchanges of information and the effects the interchanges had on the management of the OR. CIT evaluates extremes of behavior within an environment from the stakeholders’ perspectives. Through the use of CIT, observations, and in-depth interviews, the study focused on the flow of communication and the coordination challenges. This approach was employed because observation alone may not provide the insight required to understand the complex cognitive elements impacting the changes to the daily plan as displayed on the whiteboard. The combination of methods revealed issues effecting the coordination of information and provided important data regarding design implications for information technology tools. AMIA 2003 Symposium Proceedings − Page 524 METHODS Observations of the management of information flow within a suite of six operating rooms were performed in a Level I trauma center. Only patients experiencing traumatic injury are admitted to this hospital but the admission may be scheduled via several routes or emergent thus increasing the chaotic nature of the environment. The OR staff is comprised of registered nurses, nursing assistants, scrub technicians and unit secretaries, all supervised by an OR charge nurse. The charge nurse collaborates with the OR staff, surgeons, anesthesia care providers, ancillary staff, facilities personnel and outside equipment suppliers in order to facilitate patient movement within the OR suite. Observations of communication among and between the OR personnel and other hospital departments were performed by two observers (one a registered nurse) at the apparent hub of the information exchanges for the OR schedule i.e.: the dry-erase display board or “whiteboard.” Twenty-four hours of observational data was collected between the hours of 6 a.m. and 4 p.m. because these hours are generally the busiest. However, observation alone did not provide clarity regarding the multifaceted negotiation required to achieve a surgical schedule for the day. To enhance this initial collection of data, an abridged form of CIT was employed. Through a series of probing and clarifying questions personnel whose position impacted the OR’s daily operations, were asked to provide examples of instances when daily plans were successfully executed and examples of instances when plans failed. Respondents were asked to specifically note factors that influenced the success or failure. This data was then synthesized with the data obtained via observation. Synthesis of the data from both observation and CIT resulted in a preliminary information flow map that highlighted six dimensions for each observed activity: goals, process initiators, input and output media, data content, and the issues that disrupted the daily OR schedule. The disruptions were particularly relevant to the resultant activity because the confusion provoked the initiator of the process to deviate from his or her agenda and seek out additional information based on the disruption in order to (...truncated)