Enhancing surgical systems

Abstract

The new millennium was a turning point for the scrutiny of quality and safety in healthcare. An increasing number of studies, investigations, reports and audits worldwide acknowledge that there is a significant risk of unintentional harm to surgical patients. The reasons for this are complex, but, in broad terms, surgical systems are to some degree failing to establish equilibrium in balancing service demands with systems development. In order to resolve this, healthcare must adopt a systems approach to performance. This means addressing the current tensions and discordance that exist between innovation, service efficiency, working hours, training periods, skill development, assessment and safety. There is a clear ethical and financial rationale for healthcare to invest more heavily in a systems approach to performance and safety research. Not only would it improve the service to patients, it may reduce the escalating cost of litigation and provide secondary benefits from the research it needs, more transparency of roles and responsibilities, better working conditions, training and service efficiency. The overall goal is to design surgical systems so they evolve to meet both the medical demands of society and the demands of reliable operational safety. From within and without, surgical systems continue to experience disturbance and change. There is relentless innovation in new technology affording new ways of working but producing new constraints and unorthodox demands on professional skill. The introduction of the European Working Time Directive now limits the hours of time for learning during a surgical career, and the UK Modernising Medical Careers programme has condensed training to allow faster routes to qualification. There are simply less clinical opportunities for surgeons to become expert; they along with other professionals in surgery must gain a range of skills that are increasingly complex yet under-specified. For instance, surgeons acknowledge the fact that higher order cognition contributes to skilful surgery, but there has been little attention paid to the cognitive processes that underpin surgical performance. Likewise, teamwork is highly relevant to a successful surgical career, but it does not feature highly in surgical training. Communication has risen to prominence more recently, but assessments tend to focus almost entirely on the surgeon’s interaction or interface with the patient, at the exclusion of the wider system of work. Only the Accreditation Council for Graduate Medical Education explicitly demands that resident trainee surgeons obtain specific knowledge, skills and attributes to demonstrate ‘systems-based practice’, which they define as, ‘‘Manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of healthcare and the ability to effectively call on system resources to provide care that is of optimal value’’. In short, professional skills training are not meeting the demands of modern surgery. A reliance on individual skills alone, however, will not achieve safety. There are many components to the system; we must design each optimally to integrate to the whole. A. N. Healey (&) Imperial College, University of London, London, UK e-mail: a.healey@imperial.ac.uk