Wicked complexity in surgical services: analysing perioperative high-risk, work practice organisation and context for future policy implementation

Abstract

Background: Knowledge of perioperative risk and context are important as year-on-year the global volume of surgery is increasing. Despite decades of policy responses to surgical demand, national registries and local evidence report that a distinct cohort of surgical patients have a higher-than-average risk of complications with added costs to quality of life and service sustainability. The research aim was to examine the impact of context on how in practice the perioperative workforce (comprising clinicians and managers) understand risk, and how this knowledge influences their work practices and use of resources. Three questions were investigated: what has been the impact of health policy on the organisation and practice of perioperative care; how is perioperative work practice organised around low, intermediate and high-risk patients; and what do individuals, teams and organisations require to implement appropriate models of perioperative care for the high-risk patient?

Methods: Mixed methods study. The research setting was four university adult general hospitals (113, 360, 440, 547 bed capacity) in a health district in NSW, Australia. Institutional ethics approved a mixed methods study – site observation (187 hours), secondary documents (223 documents: paper and electronic), survey (113 completed) and interviews (143 conducted). Purposive sampling targeted 129 participants in 167 roles, including multidisciplinary clinicians (nurses, doctors and allied health) in senior and junior roles, and managers. Data collection (September 2017 – June 2019) and analysis was conducted using a parallel convergent design through triangulation with descriptive statistics and thematic analysis.

Results: National and state health policies that focused on access and efficiency successfully addressed high volume surgical demand for low and intermediate risk patients in predictable, reliable and linear perioperative business process models (BPMs). However, the policies are now three decades old, have resulted in unintended consequences and not addressed the clinical and organisational complexity evident in the three larger hospitals today. The high-risk complex care surgical patient traversed parallel BPMs that were not linear but rather, unpredictable complex adaptive systems. High-risk patients had more invasive surgery and the challenges of chronic multisystem disease and ageing. Complications were more common and cumulative with increased utilisation of hospital resources across multiple fragments of perioperative care; increasing specialty specific expertise were co-opted from multiple clinical disciplines, multiple ‘one-off’ teams were deployed for rescue, resuscitation, and critical care. Complications were associated with months-long hospital stays, discharge to a care level higher than home and readmissions.

For high-risk patients the impact of context on the perioperative workforce caring for them could be synthesised as a wicked complexity in perioperative context (WCPC). Wicked complexity is a complexity that was unintended, unwarranted and promulgated by the behaviours of the practice environment. Three research arcs were identified. In the policy arc, at the intersections of the three themes of compression of time and space, fragmentation of care and clinical complexity, there was a wicked complexity in competing priorities and demands (WCCPD) arising from the pressure on clinicians and managers to deal with the ‘here and now’ and not delay care processes downstream. In the risk and practice arc, at the intersections of the three themes of multiple incomplete understandings of high-risk, work practice organisation and an unclear patient outcome measure, there was a wicked complexity in gaps in fully comprehending high-risk (WCGFCHR). In the interprofessional arc, at the intersections of the three themes of professional immersion, multiple formations of perioperative teams and using technology, there was a wicked complexity in gaps in perspective (WCGP). Service sustainability in the perioperative system evolved to encompass WCPC. WCPC was the outcome and rendered solutions clinicians, managers and the organisation derived by continually adjusting elements of care to address current challenges. Wicked complexity in perioperative context is represented by the equation: WCPC = WCCPD +WCGFCHR + WCGP

Discussion: Continually adjusting elements of perioperative care to address current challenges is supported by frontline clinicians and the initiatives of local and international medical colleges and societies However, the consequences of continuing this strategy alone without acknowledging and addressing WCPC, include: the potential practical inability of the majority of clinicians and clinician managers to be involved with new initiatives as they continue to struggle with competing priorities and demands in day-to day practice, the organisational gaps in fully comprehending high-risk and the cultural gaps in perspective.

The research shows that what is critically needed is a commonly agreed and complete definition of perioperative high-risk that considers the impact of context and culture. The impact of context on the perioperative workforce and their patients can be clearly analysed and articulated. Addressing WCPC systematically enables the charting of an evolving course to equip clinicians and managers to: deal with the impact of context, face economic challenges to service sustainability and address the needs of the high-risk complex care perioperative patient.

It is necessary and time to revisit a policy strategy that was successful short-term, a workforce generation ago when surgical services were first re-engineered. Namely, an investment in leadership for the future, capable of generating the solutions to optimising care for the high-risk surgical patient, both clinically and contextually. This may only be achieved through interprofessional education and collaboration at all levels of policy enactment, across all professions. The health services research perspective that enabled defining WCPC could work to simultaneously address clinical complexity, context and culture.