Systems thinking in the operating room

Background

The gap between the current and desired states of healthcare has been increasingly well established. There are a number of sobering statistics offered to illustrate that healthcare delivery falls short of proposed standards. Providing adequate (much less exceptional) healthcare poses an incredible challenge, not only due to the ever-increasing complexity of the patients and pathophysiology involved but also due to the mounting intricacy of the financial, infrastructural, and bureaucratic conditions that have been established along the way. In the early 2000s, the National Academy of Engineering and the Institute of Medicine (now known as the National Academy of Medicine) issued a joint report that called for broader application of engineering principles, shown to revolutionize other areas of industry, to the healthcare landscape. This was followed more than a decade later by statements from both the President's Council of Advisors on Science and Technology and the Royal Academy of Engineering that recommended stronger collaboration between engineering and medicine to leverage expertise and experience in both disciplines to address deficiencies in healthcare delivery. ^, Unfortunately, meaningful applications that align engineers and medical professionals are still relatively uncommon in medicine.

Systems engineering and the operating room

Systems Engineering (SE) represents an opportunity to enhance interdisciplinary collaboration and improve upon the delivery of medical care. SE involves the prospective design, implementation, integration, validation, management, and iteration of a system. In order to best illustrate how SE can be readily applied to medicine, we must first define a “system.” The International Council of Systems Engineering provides the following definition :

A system is a construct or collection of different elements that together produce results not obtainable by the elements alone. The elements, or parts, can include people, hardware, software, facilities, policies, and documents; that is, all things required to produce systems-level results. The results include system-level qualities, properties, characteristics, functions, behavior, and performance. The value added by the system as a whole, beyond that contributed independently by the parts, is primarily created by the relationship among the parts; that is, how they are interconnected.

Based upon this definition, a system is defined not only by its constituent parts (i.e., components) but also by the relationship that exists between those parts. Kossiakoff and colleagues, in their text entitled Systems Engineering Principles and Practice , offer a more distilled version and state that a system is “a set of interrelated components working together toward some common objective.”

Traditionally, the term system has been applied to machines and/or technologies that require complex engineering to create an operational unit. This is evident in the case of a motor vehicle that requires hardware (i.e., vehicle frame, dashboard, bumper, wheels) to interact with one another through the supply of fuel, electricity, software, and human interface in order to achieve the outcome of transportation, among other functions. Importantly, the term is not limited to highly technological systems but can also reference organizational, procedural, or computational scenarios. Based upon this latter consideration, numerous complex medical examples may apply, including patient-care pathways, perioperative programs, or even operating rooms. An operating room is, in fact, a highly complex system in that it involves people (i.e., surgeons, nurses, anesthesiologists, patients), hardware (i.e., mechanical ventilator, monitors, surveillance equipment, computers), software, interfaces (i.e., screens, cameras, keyboards, microphones), and intricate processes (i.e., checklists, policies) that are interrelated and share a set of common objectives. In this fashion, much like SE can be leveraged to improve upon the design and implementation of a motor vehicle, the approach can provide a useful strategy to optimize the efficiency, functionality, and ultimately the outcome of an operating room as well. Simply stated, SE guides the creation of complex systems and can therefore be applied to the operating room to address a host of problems.

Systems engineering drivers

There are two primary drivers for redesigning an existing system: a deficiency in the performance of the current design, and/or the availability of new technology or methodology that can significantly improve outcomes when incorporated into the design. In the operating room context these drivers manifest themselves as follows:

• 1.

  Deficiency in performance —Perceived or realized the gap between current and desired system outcomes. This may refer to a system that fails to consistently meet certain standards or operates inefficiently (i.e., excessive cost or time). In the operating room, this is represented by regular delays in procedure starts or room turnover times, failure to comply with performance standards such as sterilization or barrier technique, or even increased incidence of healthcare-associated conditions (i.e., surgical site infection, central line–associated bloodstream infection). Regardless, the existing system is unable to consistently achieve the established practice standards.

• 2.

  Technological opportunity —The development of new or updated technology is anticipated to improve existing performance. Examples in the operating room are plentiful in this regard and include new version anesthesia machines, echocardiography equipment, laparoscopic/robotic devices, alternate monitoring solutions, or an upgraded electronic medical record. The new technology provides the heightened capability to augment existing processes, improve diagnostic accuracy, or target a therapeutic window compared to that which is currently available.

Whether identifying a current deficiency or anticipating a future opportunity, the implication of utilizing SE to design the system is that the problem is highly complex and the solution will require some sensitivity and consideration for the impact on the entire system. Certainly, no well-intentioned provider sets out to underperform and it is not uncommon for outcomes to be predetermined by the poor design of existing systems. Conversely, providers often expect that a new technology (i.e., electronic medical record) will immediately narrow performance gaps only to experience issues with poor integration into practice or negative impacts on the workflow that only exacerbate existing inefficiencies. It is in these scenarios that the use of SE can serve to optimize medical care by identifying these issues ahead of time and mitigating them through the prospective system design.