Elsevier

Applied Ergonomics

Volume 41, Issue 5, September 2010, Pages 701-712
Applied Ergonomics

Improving cardiac surgical care: A work systems approach

https://doi.org/10.1016/j.apergo.2009.12.008Get rights and content

Abstract

Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.

Section snippets

The OR environment

There are a variety of environmental factors in the OR that could potentially affect surgical performance. These include the general OR layout and clutter (Ofek et al., 2006), as well as ambient factors such as noise (Healey et al., 2007), lighting (Fanning, 2005), motion/vibration (Trivedi et al., 1997) and temperature (Gosbee and Gosbee, 2005). While all of these factors are important, the first two, OR layout and noise, have received most of the attention in the literature, and will

Teamwork and communication

Effective teamwork and communication have long been recognized as imperative drivers of quality and safety in almost every industry. Like most industries, healthcare is a team-based profession. However, as more data become available, there is increasing recognition that poor communication and teamwork are causal factors in a large percentage of sentinel events within healthcare systems. In fact, the Joint Commission (2006) reports “communication” as the number one root cause (65%) of reported

Tools and technology

The practice of cardiovascular surgery demands daily interface with highly sophisticated technologies. However, few of these medical technologies have been designed with the end-user in mind, increasing the likelihood of “user error” (Ward and Clarkson, 2007). However, poor design is not the only issue that can negatively impact performance and use of medical technology. The process by which new technology is introduced and implemented can also have a tremendous impact on user acceptance and

Task and workload factors

Job task factors such as physical and mental workload can dramatically impact performance and safety (Gawron, 2000). Physical workload is often affected by task duration, strength requirements to complete the task, and behavioral repetition, whereas mental workload factors generally refer to a task's cognitive complexity (mental demand), time pressure, and criticality or risk (Finegold et al., 1986). Neither task dimension is completely independent of the other. Both types of workload can

Organizational influences

Several organizational factors have the potential to impact the delivery of safe and reliable healthcare and many of these factors have been discussed in the literature (Keroack et al., 2007). However, the topic of establishing and promoting a culture of safety within healthcare organizations “has become one of the pillars of the patient safety movement” (Nieva and Sorra, 2003). The general concept of “safety culture” is not new and is generally traced back to the nuclear accident at Chernobyl

The role of the surgeon

Within the current conceptualization of the SEIPS model, the central component around which all other OR work systems factors revolve is the surgeon. However, as the above discussion clearly illustrates, the SEIPS model contrasts with traditional “person-centered” approaches that focus specifically on the negative consequences of surgical errors and disciplinary reactions to address them. Rather, the model focuses on factors that foster surgical excellence, as well as work system interventions

Measuring success

As indicated by the SEIPS model one of the key criteria for evaluating the impact of work system interventions on improving surgical care are patient outcome variables. Within cardiac surgery, however, the impact of any intervention on reducing surgical errors that significantly impact patient safety is difficult to establish because of their relatively low rate of occurrence. As stated previously, post-operative mortality and morbidity is less than 5% for most procedures; therefore, few

Conclusion

Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, considerable variability in surgical outcomes still exists across institutions and individual surgeons; moreover, surgical errors that significantly impact patient safety continue to occur. Historically, surgical errors have been viewed as being determined primarily by the technical skill of the surgeon. However, focusing only on individual skill assumes that surgeons and other members of

Acknowledgments

Supported by grant 1UL1RR025011 from the Clinical and Translational Science Award (CTSA) program of the National Center for Research Resources, National Institutes of Health.

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