There is evidence that clinicians' workload can adversely affect clinical performance, resulting in adverse events and lower quality of care. However, current methods of measuring clinical workload are often crude (e.g., nurse-patient staffing ratios), retrospective (based on the volume of work units performed), and do not apply to the unique model of the one-patient-at-a-time care performed in the operating room (OR). Moreover, traditional organizational metrics of surgical workload or quality provides limited guidance for addressing problems. To address this problem, we developed an instrument, the Quality and Workload Assessment Tool (QWAT), to measure the perceived clinical workload of individual nurses, surgeons, and anesthesia providers, as well as that of the surgical team as a whole. The QWAT also elicits data about intraoperative "non-routine" events (or NREs). NREs are any deviation in optimal or expected care for a given clinical situation. NREs are thus a measure of care process quality. In our conceptual model, a variety of performance shaping factors (PSF) contribute to workload, which is a determinant of processes of care that, in turn, affect patient outcomes. In this project, we tested this model of surgical workload and its mediating effects on intra-operative quality of care and patient safety.
Objectives: The purpose of this study was to: Aim 1) refine a robust conceptual model linking clinical workload and intraoperative care quality; Aim 2) test the validity and reliability of the QWAT; and Aim 3) examine the relationships between key variables associated with clinical workload and surgical care quality.
The purpose of this study was to: Aim 1) refine a robust conceptual model linking clinical workload and intraoperative care quality; Aim 2) test the validity and reliability of the QWAT; and Aim 3) examine the relationships between key variables associated with clinical workload and surgical care quality.
For Aim 1, using nominal group interview techniques, 8 surgeons, 14 anesthesia providers, and 34 OR nurses provided their insights about the various factors they perceived to be important in understanding the relationships between (individual and team) clinical workload, PSF, and care quality (NREs, morbidity/mortality). In Aim 2, we used written synopses of 6 actual cases, chosen to exemplify different levels of clinical workload, to assess the criterion validity and inter-rater reliability of the QWAT. In Aim 3, we collected 1,000 surgical cases in 5 VAMC Ors that are a representative cross-section of VA surgical care (370 from VA Nashville, 212 at San Diego, 160 at Los Angeles, 156 at West Haven, and 118 at Durham). For each case, we collected data about targeted PSF, had participating surgeons, anesthesia providers (Aps), and nurses (RNs) complete the QWAT (pre- and post-case), and assessed immediate (NRE, quality score) measures of surgical quality. We are waiting for VASQIP to provide 30-day mortality and major morbidity data for our study patients. In our primary analysis to date, we created multivariate regression models to test the association between workload and NREs controlling for patient, site, and clinican type (AP, RN, surgeon) for individual and team workload.
For Aim 1, OR clinicians agreed that case difficulty rating was not as heavily dependent on patient characteristics or procedural complexity as most would expect. Second, NREs have a cascade of causation, often beginning before the day of surgery. Third, NRE prevention can be partially outside of the control of the OR providers. Inter-professional differences included: level of awareness (especially by surgeons) of other professions' case difficulty; emphasis on particular NRE causations and effective intervention/prevention; and recognition of the role of personal performance (surgeons were least likely to take a systems view). In Aim 2, the vignette study showed that the QWAT was sufficiently reliable. Surgeons' ratings had the highest inter-rater reliability while nurses' had the lowest. The latter finding suggests that perioperative VA nursing documentation may not provide sufficient detail to allow other nurses to assess case difficulty. For Aim 3, in the 1,000 cases with complete data, 406 (41%) contained at least one NRE. Workload ratings were significantly higher in NRE-containing cases than in non-NRE cases, both pre- and post-case. Increased pre- and post-case workload was associated with lower post-case quality of care ratings. Aps and RNs had very similar pre- and post-case workload ratings. Surgeons' ratings were significantly higher than other OR team members. Aps and RNs team workload ratings were higher than their individual ratings whereas surgeons' individual and team ratings were similar. Additional analyses (pending receipt of VASQIP data) will examine the relationship of workload, NREs, and 30-day patient outcomes
NREs were associated with higher pre- and post-case workload. Surgeons had a different view of their own, and of the team's, workload. There is a need for better communication between the three OR disciplines. The QWAT and NRE tools yield information about the unique attributes of processes and events that occur routinely during surgical care. The high incidence of intraoperative NREs at 5 diverse sites suggests ample opportunities for improvement in VA OR processes and outcomes. NREs could be used as a dependent variable in prospective perioperative safety/quality research and in quality improvement interventions.
This study generated new knowledge and methods that contribute significantly to our understanding of the factors affecting the conduct and quality of surgical care in the VA. This is the first step toward identifying early warning signs of suboptimal and unsafe processes. The results will provide a more rational basis for improving working conditions, clinician training and staffing, care processes, and technology design. The program will enhance the VA's ability to measure and affect surgical workload and quality, augment the value of NSQIP data, and establishing guidelines for institutional workload to improve surgical care.
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Treatment - Observational, Treatment - Comparative Effectiveness
Adverse events, Implementation, Safety