A System Approach To Surgical Improvement Assignment Paper
Texas Health Harris Methodist–Cleburne is one of the top performers in the country on the surgical care process-of-care measures, often referred to as the “core” or Surgical Care Improvement Project (SCIP) measures. The measures, developed by the Hospital Quality Alliance and reported to the Centers for Medicare and Medicaid Services (CMS), relate to achievement of recommended treatment in four clinical areas: heart attack, heart failure, pneumonia, and surgical care. In addition to its high performance on surgical measures, Texas Health is performing in at least the top 15th percentile in these other areas.A System Approach To Surgical Improvement Assignment Paper
This case study focuses on Texas Health’s achievement in providing recommended treatment related to surgical care. The hospital has relied on concurrent review, changes to care processes, and preprinted order sets to improve. It also has benefited from being a part of a larger health system. After the SCIP measures here introduced in 2004, an interdisciplinary workgroup aimed to identify opportunities for improving the hospital’s performance on these measures.
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Human factors is a discipline that spans engineering, cognitive psychology, and ergonomics and emerged specifically in response to the safety concerns of other high-risk industries. Although theoretically based, it has a resolutely practical emphasis, always aiming to bridge the gap between theory and application.16 Human factors thinking is now applied to healthcare in a variety of ways. Anesthetists have made important advances in safety through systematic incident monitoring and analysis, attention to design and ergonomic aspects of equipment, implementation of safety devices (such as the pulse oximeter), and attention to fatigue and cognitive overload.17–19 Joice, Hanna and Cuschieri20 have used human reliability analysis within endoscopic procedures. Mistakes and their precursors have been investigated in high hazard cardiac surgery21 and pharmacy.22 Human factors and ergonomics are also applied to the design of medical equipment to ensure it is efficient, effective and fail-safe A System Approach To Surgical Improvement Assignment Paper
Reason’s organizational accident model, which integrated much of the available human error theory and human factors knowledge,24,25 has been an influential general framework in healthcare. The Reason model has been adapted specifically for use in healthcare and a protocol produced to guide the investigation and analysis of clinical incidents.26,27 An important lesson of these analyses is that serious adverse events and complications are often preceded by a chain of individually unimportant errors and problems, in turn influenced by a wide variety of contributory factors. This finding points to the importance of direct monitoring of these minor events in attempting to understand and prevent serious adverse events.
Experience collected from 5200 cases of laparoscopic cholecystectomy (LC) and 29 patients (6 ours, 23 referred) with major common bile duct (CBD) injury during LC in our institute between December 1990 and July 2004 was reported to demonstrate that the system approach we applied in performing LC prevents CBD injury and enhances surgical performance. Each case of CBD injury was meticulously analyzed to identify causative factors. We developed preventive strategies focusing on 4 dimensions: patient, environment, procedure, and operator. Surgical performance was then evaluated to demonstrate improvements. Incidence of CBD injury was calculated for early and latter halves of the series to compare 5 parameters of surgical performance: patient selection, operation time, indwelling drainage tube, surgeon, and conversion rate. Results of accident analysis demonstrated that CBD injury followed definite mechanisms; several warning signs appearing before and during injury were identified and classified. According to these results, we designed strategies to prevent injury, including: setting up patient-selection program, controlling surgical environment, developing error-proof procedures, and constructing training programs. Incidence of CBD injury in the whole series was 0.12% (6/5200), 0.27% in early half (6/2224), and zero (0/2967) in latter half. Attending doctors had significantly shorter operation times in latter period for both elective and emergent LC. Rate of using drainage tubes for elective surgery by attending doctors was significantly decreased in latter period. Operation time for elective surgery by residents was similar in both early and latter periods. However, residents in latter period had longer operation times (around 23 min long, P<0.001) for emergent LC. Steps of our system approach include: (1) detailed accident analysis focusing on patient, environment, procedure, and surgeon; (2) developing 4 strategies directly responding to accident analysis results, including proper patient selection, control of environment, error-proof procedures, and a well-designed training program; and (3) demonstrating improved patient safety and surgical performance. Consistent use of systems approach promises continuing quality improvement. We believe our working model will help perform safer LC and also benefit other medical disciplines.A System Approach To Surgical Improvement Assignment Paper Improvements in quality, delivery and availability of healthcare are vital and rightly command attention at regional, national and global levels. As clinicians and scientists have advanced their understanding of the causes and mechanisms of disease and aging, we in the healthcare industry have developed and implemented new solutions, conscious of the need to address issues including access to care, increasing specialization, shortages of professionals and constrained budgets. Healthcare population investments can be categorized roughly into wellness and prevention, diagnostics, therapeutics, rehabilitation, and palliative care. At Intuitive, we focus on therapeutic care, specifically surgery – a critical healthcare pathway. We understand that most surgical patients do not look forward to surgery; yet in the United States, treatment by a surgeon is nearly a fact of life. One analysis estimates that Americans will undergo an average of nearly 8 surgical procedures, some simple and some complex, over the course of their lifetime [i]. Worldwide, estimates place the number of surgical procedures needed to meet global need annually in the hundreds of millions [ii]. With populations aging in many countries, this number is poised to climb even higher in the next decade and beyond. Providing today's healthcare requires professional collaboration among disciplines to address complex problems and implement new practices, processes, and workflows (AACN, 2011; Bridges, Davidson, Odegard, Maki, &Tomkowski, 2011; IOM, 2011).Often this collaboration magnifies competing or alternative discipline specific theories, language, and strategies to lead and sustain change management and to implement and support Continuous Quality Improvement (CQI) projects. Initially, professionals may perceive these differing views as mutually exclusive.A System Approach To Surgical Improvement Assignment Paper Lewin's Three-Step Model Change Management is highlighted throughout the nursing literature as a framework to transform care at the bedside (Shirey, 2013). One criticism of Lewin's theory is that it is not fluid and does not account for the dynamic healthcare environment in which nurses function today (Shirey, 2013). With the need to streamline resources and provide quality and safe healthcare, nurse leaders have focused on a rapid cycle approach to lead and sustain quality improvement changes at the bedside. One specific approach that is gaining rapid attention in healthcare is the "Lean System" for transformation. Experts assert that Lewin's theory provides the fundamental principles for change, while the Lean system also provides the particular elements to develop and implement change, including accountability, communication, employee engagement, and transparency. The purpose of this case review is to describe how one large, Midwestern, rehabilitation facility used a crosswalk methodology to promote interprofessional collaboration and to design an intervention model comes to implement and sustain bedside shift reporting. Project Background: Setting, Theoretical Bases, and Topic of Interest Founded in the mid-1950s, this 182-bed, acute, inpatient rehabilitation facility (IRF) is located in a large Midwestern city and known for its commitment to promoting interprofessional and collaborative patient care. Rehabilitation is an interprofessional practice by nature that requires physiatrists, nurses, occupational therapists, speech therapists, physical therapists, and ancillary departments to collaborate to identify and achieve patient goals and outcomes. In early spring of 2017, the IRF will open a new research hospital to replace the current building. The new research hospital, a private, not-for-profit acute in-patient and outpatient rehabilitation facility, will expand patient care and combine research activities that translate directly to patient care in real time to improve patient outcomes.A System Approach To Surgical Improvement Assignment Paper This evolving research hospital environment requires that nurse executives demonstrate collaborative problem solving across the spectrum of care. Nurse leaders and executives' formal training supports frequent use of Lewin's Three-Step Model for Change Management. Meanwhile, healthcare institutions' performance improvement departments often institute the Lean Systems Approach to quality improvement (Toussaint & Berry, 2013; Toussaint & Gerad, 2010). Integrating language from the Lean model within the theoretical basis of change theories used by the IRF healthcare culture would likely be a key factor for success continuous quality improvement activities. The IRF executive leadership team identified that the organization was reliable in initiating improvements, but was challenged to sustain and spread improvements throughout the organization. The Lean model had been adapted as the improvement system for the IRF. Integrating language from the Lean model within the theoretical basis of change theories used by the IRF healthcare culture would likely be a key factor for success continuous quality improvement activities. The Director of Performance Improvement gained leadership team approval to lead an effort to connect the Lean System tools with concepts that were common to several change management theories or frameworks, such as Diffusion of Innovations Theory; Donabedian's Structure, Process, and Outcomes Framework; and the Institute for Healthcare Improvement (IHI) Rapid Cycle Improvement Model, including Lewin (Donabedian, 2003; IHI, 2001; Lewin, 1951; Rogers, 2003). Concurrently, the manager of nursing outcomes met with her clinical nursing team to plan a pilot project for bedside shift reporting (BSR). Ultimately, this project serves to coalesce the aforementioned simultaneous events of the new research environment of the facility and the combination of change theory and Lean model concepts into a workable framework for interprofessional collaboration. While the BSR is not the focus of this case review, this project served as a catalyst for the interprofessional collaboration among executives; mid-level and staff nurses; performance improvement professionals; the patient-family education resource center; and director of ethics. The purpose of this article is to discuss an interprofessional collaboration that sought consensus among members of different disciplines who typically utilized different theoretical approaches to problem solving. We selected the crosswalk method to further collaboration and to create an intervention model for BSR. As BSR happened to be a substantive topic of interest to the organization, a natural opportunity emerged to display the utility of a crosswalk method as a tool to developing an intervention model.A System Approach To Surgical Improvement Assignment Paper Inherent in interprofessional collaboration is a requisite that each discipline shares an understanding of the similarities and a common language of the change process... With the current emphasis on interprofessional problem-solving approaches for CQI in mind, collaboration becomes an essential part in delivering quality care and leading CQI projects (AACN, 2011; Bridges et al., 2011; IOM, 2011). Inherent in interprofessional collaboration is a requisite that each discipline shares an understanding of the similarities and a common language of the change process it proposes to use to develop an intervention model. Because the language and perspectives differ, professionals often struggle to find common ground for understanding so that each discipline maintains an influence. Historically, many nurses have subscribed to Lewin's Three-Step Model for Change (Shirley 2013). For the past 10 years, the Lean System Approach has been at the forefront of efforts to implement and sustain change in healthcare delivery organizations (D'Andreamatteo, Lappi, Lega, & Sargiacomo, 2015). This section provides a brief overview of Lewin's Three-Step Model for Change and the Lean System Approach to change. Lewin's Three-Step Model for Change Healthcare organizations are complex adaptive systems where change is a complex process with varying degrees of complexity and agreement among disciplines. The Change Model. Complex adaptive systems require that, in order for organizations to maintain equilibrium and survive, the organizations must respond to an ever-changing environment. Healthcare organizations are complex adaptive systems where change is a complex process with varying degrees of complexity and agreement among disciplines (Plsek & Greenhalgh, 2001; Porter-O'Grady & Malloch, 2011). Lewin's Change Management Theory (Lewin, 1951) is a common change theory used by nurses across specialty areas for various quality improvement projects to transform care at the bedside (Chaboyer, McMurray, & Wallis, 2010; McGarry, Cashin & Fowler, 2012; Shirey, 2013; Suc, Prokosch & Ganslandt, 2009; Vines, Dupler, Van Son, & Guido, 2014). Lewin's theory proposes that individuals and groups of individuals are influenced by restraining forces, or obstacles that counter driving forces aimed at keeping the status quo, and driving forces, or positive forces for change that push in the direction that causes change to happen. The tension between the driving and restraining maintains equilibrium. Changing the status quo requires organizations to execute planned change activities using his three-step model. This model consists of the following steps (Lewin 1951; Manchester, et al., 2014; Vines, et al., 2104).A System Approach To Surgical Improvement Assignment Paper Unfreezing, or creating problem awareness, making it possible for people to let go of old ways/patterns and undoing the current equilibrium (e.g., educating, challenging status quo, demonstrating issues or problems) Changing/moving, which is seeking alternatives, demonstrating benefits of change, and decreasing forces that affect change negatively (e.g., brainstorming, role modeling new ways, coaching, training) Refreezing, which is integrating and stabilizing a new equilibrium into the system so it becomes habit and resists further change (e.g., celebrating success, re-training, and monitoring Key Performance Indicators [KPIs]) Other Considerations. Criticisms of Lewin's change theory are lack of accountability for the interaction of the individual, groups, organization, and society; and failure to address the complex and iterative process of change (Burnes, 2004). Figure 1 depicts this change model as a linear process. However, in addition to change theory, healthcare has also shifted to a robust system for change called the Lean Systems Approach. The Lean Model. The Lean Systems Approach (Lean) is a people-based system, focusing on improving the process and supporting the people through standardized work to create process predictability, improved process flow, and ways to make defects and inefficiencies visible to empower staff to take action at all levels (Liker, 2004; Toussaint & Gerard, 2010). To that end, Lean creates value for internal and external customers through eliminating waste (e.g., time, defects, motion, inventory, overproduction, transportation, processing). To create value and meet customer needs, Lean resources are provided in a robust toolkit. Value stream mapping is a tool to identify process relating to material and information and people flow. It is useful to identify value added and non-value added actions. Value stream mapping is then used to create a plan to eliminate waste, create transparency (visual management), implement standard work, improve flow, and sustain change. ...Lean is a way of thinking about improvement as a never-ending journey. Overall, Lean is a way of thinking about improvement as a never-ending journey. Lean starts as a top-down, bottom-up approach, requiring leadership support. Over time, the goal is for all staff to contribute to problem solving and designing improvements to add value as defined by the customer. Value is defined as the services that the customer is willing to purchase (Toussaint &Gerard, 2010). In healthcare, adding value or meeting the customer or patient needs often occurs at the bedside, and nurses who provide care are closest to the bedside. Lean offers a common system, philosophy, language, and tool kit for improvement. Many quality improvement approaches have parallels and one well known is Deming's Improvement Model of Plan, Do, Check, Act (Deming Institute, 2015). Deming's model is also utilized in the Lean approach as a structure to make and sustain improvements. The IHI refers to this as Plan, Do, Study, Act-Rapid Cycle Improvement Model (Scoville & Little, 2014). Both models, like Lean, strive for structure, methods, and improvement that never ends – continuous improvement, or Kaizen, in Lean terms. For an organization to reap the full benefit of the Lean approach, it is necessary to integrate a system-wide approach (D'Andreamatteo et al., 2015; Liker, 2004; Toussaint, 2015). Lean tools are designed to work together to maximize improvements within an organization and create a culture that embraces the journey of continuous quality improvement.A System Approach To Surgical Improvement Assignment Paper ...the Lean System exemplifies a culture where each staff member is empowered to make change. To this end, the Lean System exemplifies a culture where each staff member is empowered to make change. This culture focuses on creating value, supporting staff, and improving process flow to increase quality, reduce costs, and increase efficiency. Interprofessional collaboration is a necessary component to make improvements that involve going to the gemba (i.e., where the work is done or patient floor), to observe with our own eyes, ask questions, and learn. Other aspects of Lean are the importance of utilizing data and identifying root cause (5 Why's, or asking why five times). Becoming a learning organization by creating a safe environment to make mistakes (taking into account patient safety) is key in Lean; it is better to try, fail, learn, adjust, than to not try at all (Simon & Canacari, 2012). The Lean tools provide a medium for staff to break down problems, eliminate non-value added activities, and not only implement a new standard process, but sustain it as well (Kimsey, 2010; Liker, 2004; Mann, 2010). Kaizen, or continuous improvement, means adjusting how healthcare organizations operate to create value. Other Considerations. Incorporating Lean into the healthcare industry has been met with barriers. A common reaction to Lean within healthcare is that it only applies to manufacturing cars (e.g., the Toyota Production System) (Liker, 2004; Toussaint & Gerad, 2010; Toussaint & Berry, 2013). This reaction, in itself, becomes a barrier to apply and incorporate Lean into the healthcare industry. The interpretation of standard work being inflexible is also a barrier within healthcare. Standard work can be made flexible to adjust to unique patient scenarios and change according to changes in the healthcare environment, technology, and patient needs. Kaizen, or continuous improvement, means adjusting how healthcare organizations operate to create value. Many hospitals have been applying Lean, such as Virginia Mason Medical Center, ThedaCare, Mayo Clinic, and Seattle Children's Hospital (Toussaint & Berry, 2013). Furthermore, regulatory changes, such as those from the Centers for Medicare & Medicaid Services (CMS), and pressure on healthcare organizations to deliver high quality, safe and cost-effective care (Toussaint & Berry, 2013). [A no-blame culture] creates an environment whereby any member(s) of the organization can take action to improve performance and outcomes. Healthcare can often be a shame and blame culture, which is very different than Lean (Simon & Canacari, 2012; Toussaint & Gerad, 2010). A fundamental principle of Lean is that it attacks the process rather than the person or people to create a no-blame culture. The Lean Systems Approach is designed to build trust, engage staff to trystorm (try ideas rapidly to see if they work), measure improvement, and implement and sustain. The Lean System is designed for problems to rise to the surface and become transparent so that they can be addressed. This transparency (visual management), along with clear measures and coaching, keeps important concerns in view of staff. This creates an environment whereby any member(s) of the organization can take action to improve performance and outcomes (Mann, 2010).A System Approach To Surgical Improvement Assignment Paper Considering concepts from both Lewin's Three-Step Model for change and the Lean Systems Approach opens the possibility of using the best of each of these models to facilitate interprofessional collaboration and a problem-solving approach. Through interprofessional collaboration, nursing and other disciplines can continue to improve processes and outcomes for the greater good of patient outcomes and the healthcare industry (Brooks, Rhodes & Tefft, 2014). The next section offers a short explanation of the concept of interprofessional collaboration, which served as the problem-solving basis of our project to develop an intervention model for bedside shift reporting. Interprofessional Collaboration: A Problem Solving Approach ...collaboration can enhance collegial relationships and collapse professional silos, as well as improve patient outcomes. In one of the more widely-cited definitions of collaboration, Gray (1989) describes "a process through which parties who see different aspects of a problem can constructively explore their differences and search for solutions that go beyond their own limited vision of what is possible" (p. 5). Collaboration involves multiple disciplines that span across individual professional silos, hence the term interprofessional is used for this case review. Collaboration is based on a naturalistic inquiry process, whereby each party takes on the teacher role, educating others, and the learner role, an openness and willingness to receive information from others, relinquishing power and control to move beyond their own perspectives for benefit of change (Denzin & Lincoln, 2011; Gray, 1989). Communication serves as a mechanism for sharing knowledge and is the hallmark for improving working relationships (Gray, 1989). Collaborative efforts create spaces where connections are made, ideas are shared, opportunities for innovation flourish, and strategies for change to transpire (London, 2012). Today, healthcare associations and committees work diligently to ensure that interprofessional collaboration is part of their educational curriculum and practice standards. The American Nurses Association (ANA, 2009) lists "collaboration" as a standard of practice for nursing administration. Similarly, the Institute of Medicine (IOM, 2011) recommends that "nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States" (p. 32). ORDER HERE NOW Nursing driven improvement projects and change initiatives that require interprofessional collaboration are common in redesigning healthcare delivery. However, simply grouping healthcare professionals from differing disciplines together to work on a project does not always cultivate collaboration (Kotecha et al., 2015). Effective interprofessional collaboration is a blending of professional cultures that arises from sharing knowledge and skills to improve patient care, and exhibits accountability, coordination, communication, cooperation, and mutual respect among its members (Bridges et al., 2011; Reber, et al., 2011). Such collaboration can enhance collegial relationships and collapse professional silos, as well as improve patient outcomes (Kotecha et al., 2015.).A System Approach To Surgical Improvement Assignment Paper There are facilitating and hindering factors for interprofessional collaboration associated with nursing driven projects (Tviet, Belew, & Noble, 2015). Facilitating factors cited include: identifying key roles and individuals; soliciting early involvement and commitment from individuals and the group; and continuing to monitor progress and compliance well after implementation, including follow up with staff whose compliance is low. Hindering factors cited include: difficulty coordinating meeting times among multiple professions; bias of each profession as to what would work for them; discipline specific professional jargon; and the ability of one person or group to resist change and stop the project from moving forward (Ellison, 2014). Interprofessional collaboration lessens discipline-specific perspectives, thus improving quality of care and patient outcomes, and increasing efficiency and reducing healthcare resources. Interprofessional collaboration lessens discipline-specific perspectives, thus improving quality of care and patient outcomes, and increasing efficiency and reducing healthcare resources (Patton, Lim, Ramlow, & White, 2015). An initial effort by all parties to visually display alignments and confront differences may minimize frustration and miscommunication among professionals. As we considered the synergy of concepts from both the Lewin Three-Step Model for Change and Lean Systems Approach, our idea was to use crosswalk methodology to begin collaboration with an interprofessional perspective. The crosswalk is a robust qualitative method, often associated with theory building and inductive reasoning, which provides a compressed display or visual of meaningful information (Miles & Huberman, 1994). Table 1demonstrates the utility of the crosswalk method across domains, with examples from various domains to make comparative evaluations among programs, assessment tools, and theories to determine alignments and misalignments. Advantages of conducting a crosswalk are that it elucidates key connections and critical opportunities for growth and knowledge expansion, equitable resource allocation, and inquiry; and it depicts a large amount of information in a clear and concise manner. Disadvantages of the crosswalk method are that it often lacks the rigor and depth necessary to make causal links or provide generalizable information (Miles & Huberman, 1994). However, since the goals of qualitative methods are not causal links or generalizability, crosswalks can offer an intentional, systematic method to consider complex information in a meaningful way.A System Approach To Surgical Improvement Assignment Paper Surgeons and caregivers have made substantial progress in making surgery more effective and less disruptive for their patients. However, significant opportunity remains to improve outcomes, decrease variability and improve access to high-quality surgical care. For example, complication rates after difficult surgeries can run above 20% [iii]. Some studies that examine the difference between high-performing surgical teams and low-performing teams have shown that low-performing teams account for more than twice the number of complications per surgery than the high-performing groups [iv]. It is no wonder that surgery provokes anxiety. Significant opportunity remains to improve outcomes, decrease variability and improve access to high-quality surgical care. For the industry, progress in surgery requires a commitment to working with clinicians, hospitals and healthcare systems to develop and implement tools and processes that improve outcomes, decrease team-to-team variability and improve access to high-quality surgery. While these goals are said simply, surgery takes place within a sophisticated network of professions and locations, encompassing surgeons, nurses, anesthesiologists, critical care teams and others working in hospitals, surgery centers and offices. At its best, surgery is a choreographed and intricate interaction of highly trained healthcare professionals operating within and across different environments. Medical management using surgery is a continuum of care that includes more than what happens in the operating room; it begins at diagnosis, continues through care planning, patient and surgeon consultation, operating room preparation, the surgery itself and finally concludes with post-surgical care and recovery. Improving surgical care, expanding access to safe and effective surgery and reducing variability are therefore holistic "systems" issues that require systems solutions. For the past two decades, innovations in robotics, computing, networking, imaging, molecular design and analytics have enabled progress toward these goals. Those in flight simulation and aviation training have witnessed the substantial potential and progress afforded by the application of technology to complex human-machine systems. Applying these ideas to surgery, robotics, data analytics, machine learning and context-sensitive user interface design holds the obvious potential to help surgeons, patients and healthcare professionals make better decisions and facilitate better, more consistent interventions. While the vision is attractive, delivering meaningful systems improvements capable of realizing this potential is painstaking work. The lesson from technology adoption in different industries is likely to apply here – progress will be slower than proponents predict in the near term and the scale of adoption may be greater than they predict in the long term. The spread of new approaches across an industry only looks revolutionary to those on the outside. Those on the inside know it to be the result of decades of hard work.A System Approach To Surgical Improvement Assignment Paper Intuitive has spent more than twenty years developing and delivering minimally invasive robotic-assisted surgical tools, systems and solutions. Our earliest staff pioneered the field of robotic-assisted surgery with team members joining us from several of the first development groups in the field. We have meticulously improved our surgical systems over time with input and feedback from our global network of thousands of surgeon users who have performed more than 5 million robotic-assisted procedures. We have developed an ecosystem of services, support and data solutions that surround our tools and technologies – designed to enable implementation of efficient, effective robotic-assisted surgical programs by surgeons and hospitals. Going forward, our team is methodically advancing technologies in robotics, data analytics, machine vision, cloud computing, molecular design, advanced imaging and more. While we are fully immersed in these efforts, we understand that the problem to be solved is not at its heart a technology problem – it is enabling a systems approach to surgery that allows for more predictable, more available, higher quality outcomes across a population of patients and surgical teams. Our surgeon, hospital and healthcare system customers are committed to bringing effective, efficient and patient-centered therapies to those who depend upon them. We measure our progress through their eyes. A particularly influential and important model of error in the medical environment has been developed by Helmreich and colleagues at the University of Texas Human Factors Project.28 While influenced by the broad organizational approach of Reason and others, Helmreich's model has brought a new depth of approach through combining conceptual sophistication with hard-edged observational measures that have been applied in both aviation and medicine. Helmreich's model aids the identification of errors committed, incorporates error management strategies, and considers the impact of both immediate and systemic threats to patient safety. Immediate threats include such factors as fatigue, communication or patient related factors, such as a difficult intubation, while systemic threats concern organizational matters such as shift patterns and staffing. This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes.Summary Background Data:Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patient's stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work.Methods:Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an "operation profile" to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed.A System Approach To Surgical Improvement Assignment Paper A SYSTEMS APPROACH TO SURGICAL SAFETY An operating theater is an extraordinarily complex system. The complexity is manifested not only in the patient and their condition but also in the sophistication of instrumentation, the high volume of information that must be processed, the nature of communication and team co-ordination, and the urgency and occasional uncertainty with which decisions and interventions must be made. This complexity, combined with heavy workloads, fatigue, and production pressures, makes surgical care particularly vulnerable to adverse events. Despite this vulnerability, most cases are performed proficiently and safely, highlighting the resilience of individuals and surgical teams to the potential adversity of the setting. This suggests that in addition to studying errors, it is crucial to also study the achievements of teams and how threats to safety are successfully managed. In a recent paper Calland et al29 have argued for a "systems approach to surgical safety," pointing out that many other high-risk environments (such as aviation) have made effective use of systems approaches and studies of error in complex environments. Such approaches suggest that it is necessary to study all aspects of the system that comprises a surgical operation, including such issues as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. A number of important studies on error and adverse outcomes have been conducted from a surgical perspective20,30–32 but few have systematically addressed the full range of potentially important factors. Surgical adverse events may be due to poor communication, bad operative technique, malfunctioning or improperly used equipment, cognitive errors due to stress or inattention, all compounded by resource and organizational problems. However, these factors have been poorly studied in the field of surgery. Communication in the operating suite is often poor and may be implicated as a contributor to adverse outcomes.13,33,34 The effects of fatigue and stress on performance have been well documented but not taken seriously in healthcare35,36. Taffinder et al37 found that sleep deprivation similar to that of being on a night on call for surgical trainees increased the error rate by 20% and increased the time taken by 14% in a simulated surgical task. Noise in theater, which can reach 85 Db,38 can lead to deterioration in the ability to communicate, increase stress levels and affect complex motor skills.A System Approach To Surgical Improvement Assignment Paper Inexperience or lack of training also contributes to poor surgical outcome. A Canadian study39 looked at variations in outcome between patients with rectal cancer treated by specialist versus nonspecialist colorectal surgeons, and independent of that, between results of surgeons with high versus low volume work. The analysis showed that the risk of local recurrence was increased and disease specific survival was lower in patients treated both by surgeons not trained in colorectal surgery and by surgeons performing less than 21 procedures during the study. Thus the best result was obtained from the trained surgeon performing a higher volume of work (10.4% recurrence, 67.3% survival) and the worst by the untrained surgeon with low numbers (44.6% recurrence, 39.3% survival). Birkmeyer et al40 analyzed 14 types of procedures and demonstrated mortality decreased as volume increased with Begg et al41demonstrating similar findings for morbidity rates in radical prostatectomy. Prospective observational studies have been used to successfully understand the incidence and scope of adverse events. Observers attended a variety of case conferences, where adverse events were discussed and checklists were used to categorize error causation.42 Detailed observational and retrospective analyses of surgical failures associated with the neonatal arterial switch operation, has been performed by de Leval.32,43 These studies show that analytical observational techniques can be successfully used to identify and analyze surgical performance successes, deviations and failures. There is certainly a need for a better understanding of the factors that influence surgical outcome and outcomes in healthcare generally. A number of studies around the world suggest that approximately 10% of patients admitted to the hospital suffer some kind of harm, about half of which is preventable with current standards of treatment.1,2 Although the majority of these adverse events are minor, some lead to serious injury or death. A significant percentage of these adverse events are associated with a surgical procedure. For instance, in the Utah Colorado Medical Practice Study,1the annual incidence rate of adverse events among hospitalized patients who received an operation was 3.0%, of which half were preventable. Technique-related complications, wound infections, and postoperative bleeding produced nearly half of all surgical adverse events.A System Approach To Surgical Improvement Assignment Paper In the United Kingdom, complication rates for some of the major operations are 20–25% with an acceptable mortality of 5–10%.3 However at least 30–50% of major complications occurring in patients undergoing general surgical procedures are thought to be avoidable.4 The wide variation in surgical complication rates between different centers and different surgeons would support this view. Many adverse events classified as operative are, on closer examination, found to be due to problems in ward management rather than intraoperative care. For instance, Neale et al5 identified preventable pressure sores, chest infections, falls, poor care of urethral catheters in their study of adverse events, together with a variety of problems with the administration of drugs and intravenous fluids. The failure to remove swabs, needles, and instruments from a surgical site has for many years been a major problem in all fields of surgery. A swab or any other foreign body left in the body will result in considerable morbidity and even mortality.6 The costs of retreatment, additional surgical time, recovery, hospital stay, and subsequent litigation are considerable. Although there are strict protocols in the use of swabs and instruments in surgery, the process is exclusively human-led and involves a manual count of swabs, needles, and instruments at various stages of the procedure and a final count at the end. Despite this, diligence there is considerable opportunity for error. THE EXPLANATION OF SURGICAL OUTCOMES The primary determinants of surgical outcomes are generally held to be the patient's condition and the skills and performance of the individual surgeon. Some patient risk factors for anesthesia and surgery are generic, applying to any operation. Factors such as increased body mass index, advanced age, and the presence of comorbidity are associated with poorer outcomes and a higher risk for a range of complications.7 Risk factors for specific operations are also extensively studied, although it can be surprisingly difficult to identify a set of factors that consistently appears in different case series from different centers.8 The skills of the surgeon, and indeed of all members of the operative team, are an obvious prerequisite for a good outcome.9 Although it is clear that a certain level of skill is essential, it is more difficult to relate degrees of technical skill to outcomes. The introduction of laparoscopic cholecystectomy in the early nineties was a good example of the impact of technical skills on patient outcome. Although the overall complication rates were reduced, the incidence of major complication, such as bile duct injuries, significantly increased. Technical skills are very rarely assessed during actual operations whether for training or research purposes.10The primacy of technical skills is nevertheless the underlying assumption and is implicit in the creation of league tables or rankings of surgical performance.11 Once outcomes (usually mortality) have been correctly adjusted for patient risk factors, the remaining variance is presumed to be explained by individual surgical skill Case Study: A System Approach Review the case study in the article, Texas Health Harris Methodist-Cleburne: A System Approach to Surgical Improvement (Links to an external site.)Links to an external site.. After reviewing the case study, construct a written paper that addresses the following: •Explain organizational theories evidenced in this case study. •Analyze how Texas Health Harris Methodist-Cleburne is a learning organization. •Explain the organizational structure displayed in this case study. •Describe the leaders involved in this case study. •Discusses the role of the leaders in this case study. Including an introduction and conclusion paragraph, your paper must be three to five double-spaced pages (excluding title and reference pages) and formatted according to APA style as outlined in the Ashford Writing Center (Links to an external site.)Links to an external site.. Including the textbook, utilize a minimum of three (one of which is the case study article used for review) scholarly and/or peer-reviewed sources from the Ashford University Library that were published within the last five years. Document all references in APA style as outlined in the Ashford Writing Center APA Checklist (Links to an external site.)Links to an external site.. it is do tomorrow at midnight. Can you please let me know. I will appreciate your help.A System Approach To Surgical Improvement Assignment Paper This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions' experience that will be helpful in their own efforts to become high performers. Even the best-performing organizations may fall short in some areas or make mistakes—emphasizing the need for systematic approaches to improve quality and prevent harm to patients and staff. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution. A System Approach To Surgical Improvement Assignment Paper