Patient Experiences With Interventions to Reduce Surgery Cancellations

A Qualitative Study

Einar Hovlid; Christian von Plessen; Kjell Haug; Aslak Bjarne Aslaksen; Oddbjørn Bukve

Disclosures

BMC Surg. 2013;13(30) 

In This Article

Method

Theoretical Basis for Interventions to Reduce Cancellations

Reducing cancellations is a complex task because the causes are multifactorial, i.e. they are related to patients, organizational issues and clinical staff.[1,15] Common causes for cancellations are related to patients' medical conditions, inadequate medical pre-assessment, overbooking of lists, facility shortcomings, and patient non-attendance.[1,6,16] Because the reasons for cancellations are multi-factorial, interventions to reduce cancellations need to take into account the complexity of the problem. The literature suggests that most cancellations can be avoided by redesigning work processes, improving planning and coordination, and performing earlier clinical pre-assessment of patients.[16,17] It has also been suggested that patients themselves should select the date of surgery, receive early notice of their operating day, and a reminder of their appointment.[17] Involving patients in these ways may even increase their satisfaction with treatment decisions during initial consultations, which is a strong predictor of attendance for surgery.[18]

Design

We did not find relevant literature about patient experiences with interventions to reduce cancellations. Thus, we chose a qualitative design with semi-structured interviews to explore the field.[19] Moreover qualitative methods are useful in evaluative studies because they are open to unexpected inputs.[20]

We conducted a comparative case study and interviewed patients from two hospitals, A and B.[21] In hospital A the pathway for elective surgery was redesigned and in hospital B it remained unchanged. This design enabled us to get rich data about patient experiences. Furthermore, we could isolate the effects of the interventions and establish a probable relationship between the interventions and patient experiences.

Description of the Case

Hospital A is a district general hospital where the pathway for elective surgery was redesigned. It has seven operating suites and 34 surgical beds. Hospital B, is a local hospital with three operating suites and 14 surgical beds. The two hospitals belong to the same local health authority and have the same senior management team. Initially, both hospitals had a similar clinical pathway for elective surgery and faced the same quality problems with their services. As a consequence, the health authority planned a redesign of the pathways at both hospitals. For practical reasons, the revised plan was abandoned at hospital B.

Hospital A redesigned its pathway through the following interventions: earlier clinical pre-assessment, improved flow of information among surgeons and anesthesia personnel, patient participation in selecting the date for surgery, centralization of preparation and discharge of patients to a single unit, a telephone call to patients two days prior to surgery, and a common computer-based system for scheduling operations across all surgical departments.[13] The mean cancellation rates at hospital A and B after the interventions was respectively 4,9% and 6,1%. Table 1 displays the main differences between the original and the redesigned pathways.

Recruitment

Clinicians at hospitals A and B recruited patients for the study. They handed out an information letter describing the purpose of the study during the pre-surgical medical assessment. Patients who agreed to participate signed an informed consent form. The clinicians returned the form by mail and the first author called the patients after they had completed their surgery. We recruited 10 patients at hospital A and eight patients at hospital B.

Data Collection

Between January and March 2011, the first author conducted semi-structured telephone interviews with patients who had undergone operations at hospitals A and B. For patients under 18 years of age, the first author interviewed a parent. We purposively sampled patients with different characteristics with regard to gender, age and type of surgery (day surgery/in-patient-stay).[22] The interviews took place 1 to 7 months after the patients had completed their surgery.

The interviews followed a guide with open-ended questions to explore the experiences of the patients. The guide was based on a literature review about patient experiences of interventions to improve care,[23–26] the interventions implemented to reduce cancellations at hospital A and on the different phases of elective surgery, the consultation at the out-patient clinic, the time spent waiting for surgery, and the hospital admission for surgery. The guide is enclosed in the Additional file 1.

The first author made consecutive case notes of the interviews. Furthermore, we started analyzing the data during the data collection. Thus the data collection and data analysis were iterative steps. From the case notes and our analysis, we observed that the last two interviews did not add any new information, i.e. we had reached saturation of our data. We then concluded that the sample size was sufficient for the purpose of this study and stopped recruiting patients.[19,27,28]

Analysis

We audio-taped the interviews, transcribed them verbatim, and transferred them to HyperRESEARCH 2.8.3 computer software (ResearchWare, Inc., 2009) for coding. We performed a content analysis using a direct approach, as described by Hsieh and Shannon.[29] Based on the theory about interventions to reduce cancellations, we developed a coding scheme to reflect the interventions implemented at hospital A, i.e. earlier clinical pre-assessment, patient participation in scheduling the surgery, telephone calls to patients prior to surgery, and centralized preparation and discharge. The first author coded the interviews and identified passages where the patients described experiences related to these interventions.

The last author read all the interviews and validated the coding; the first and last authors then compared codes from the two hospitals. The aim was to identify how the patients' experiences were related to the interventions that reduced cancellations at hospital A. Using an iterative process of coding, then reflecting on the codes and condensing, the first and last authors identified common themes relating to how the patients had experienced these interventions.[30]

A professional bilingual translator translated the quotations in this article from Norwegian into English. Quotations were adapted from an oral style to a written format to enhance readability without changing the content or meaning.[31]

Ethical Considerations

Patients participated after informed, written consent and could withdraw from the study at any time. The Western Department of the Regional Committee for Medical and Health Research Ethics in Norway deemed a full ethical review unnecessary because sensitive patient data were not included in the study. The study protocol was accepted by the Norwegian Social Science Data Services, which reviewed ethical aspects relating to the collection and handling of data (e.g. voluntary participation based on informed consent, anonymity of informants, and appropriate storage of data).

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