Decoding the perioperative process breakdowns: a theoretical model and implications for system design.

BACKGROUND: Breakdowns in communication and coordination are situations of mismatch between actual and expected conditions in joint activities. Breakdowns have been identified as the leading cause of adverse events in healthcare, especially in the Operating Room environment. As a result, researchers have started to examine breakdowns in healthcare as emergent dynamics of teamwork. However, the occurrence and consequences of breakdowns related to inter-team processes are yet to be addressed at a fine level of detail. In this paper we seek understanding of breakdowns at the systemic level, and its relevance to design.

OBJECTIVES: The objective of this study is to bring forward an in-depth understanding of the impact of breakdowns on the surgical process by expanding the focus of analysis beyond teamwork dynamics, to the level of hospital system processes. This study also aims to examine the implications of such understanding of breakdowns for the design of clinical systems.

METHODS: Properties of breakdowns and repairs were inductively derived, and developed into a formal coding scheme, which was applied over a set of observed breakdowns from an elective surgery unit in a North American hospital. Systematic content analysis was employed to quantify qualitative data spanning 79 h of observations, followed by statistical hypotheses testing for relationships between variables of breakdowns and repairs.

MEASURES: Breakdown type, theme, tangibility, coordination scale, breakdown lifetime, repair strategy, and repair cost.

RESULTS: The results reveal that properties of breakdowns determine properties of repairs. The majority of breakdowns were outside the scope of teamwork--at the inter-team coordination level. The results also demonstrate that breakdowns usually propagate downstream in the surgical process, affecting the work of multiple teams, and the longer they propagate the higher the communication cost associated with the respective repair. The implications are two-fold: in terms of theory we develop a conceptual framework of breakdowns in perioperative work, and in terms of system design we propose a design framework informed by the acquired understanding of breakdowns.

CONCLUSIONS: This study achieved an initial understanding of the deep features of breakdowns from a process-oriented perspective, which allowed us to build the groundwork for a theoretical model of breakdowns in perioperative activities and to propose a design approach that tackles breakdowns during early stages of system development. The direct association between breakdowns and repairs can be exploited in both IT-system design and organizational design. The patterns of repair work can inform design so as to provide clinicians with the types of information that will prevent breakdowns from occurring or to mitigate the impact of breakdowns. The results reveal that preventing breakdown propagation should be a prime target in surgical applications design.