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In 1989, Trent Regional Health Authority set up a Commission to enquire into the organization of day case surgery and encourage its use. Improved methods for measuring and comparing day surgical activity were developed using routine data sources. These revealed even greater variation between hospitals and specialties in the amount of day surgery performed than did the usual analyses. Arrangements for day surgery differed considerably between specialties. Few theatres, beds, or surgeons′ sessions were dedicated to day surgery, but general surgery and gynaecology used dedicated facilities more than other specialties such as ENT and ophthalmology. The Commission visited each hospital and found that day case facilities, organization and resources were poor in many of them. It was able to make specific recommendations for improvements. Day case surgery increased substantially over the period that the Commission operated, most hospitals reported that it had influenced changes in day surgery and that it had been useful, especially for local managers. Schemes to increase day surgery were funded. Highlights two elements for managing change: the need for good information about a problem, and the need to extend ownership of the issue throughout the organization.

Cataract surgery is a highly successful, high‐volume surgery, hence reducing surgical complications are imperative for organizations to deliver cost‐effective, high‐quality services that meet the needs of patients. This paper aims to describe 18‐month results of a sustainable program to maximize the safety of cataract surgery training.

Modifications to the comprehensive cataract‐training program and tested were developed in a controlled, interventional case series to evaluate their effect on trainee complication rates. Data collection and interpretation were performed in a prospective and blind manner.

Prior to intervention, PCR rates for trainee‐surgeons averaged 3.34 per cent cf international published figures of 4.6‐10 per cent. This compared with 1.89 per cent PCR rate for trained cataract surgeons (p<0.002, Mann Whitney test). Multiple interventions were introduced and enforced to maximize cataract surgery training safety. After 18 months follow‐up data were consistent with a statistically significant reduction in trainee PCR rates (1.53 per cent, p<0.007, Wilcoxon Signed Ranks test) compared with trained cataract surgeons (1.23 per cent, p<0.074, Wilcoxon Signed Ranks test). Parameters of training efficacy were improved or maintained during this period.

Limitations included using trained cataract surgeons as controls as apposed to a similar group of trainee surgeons. In addition, multiple interventions were simultaneously instituted, making identification of a single influential factor impossible to identify.

Maximally safe and effective cataract surgery training is achieved in Singapore without compromising service and quality markers. Similar training goals can be extrapolated to other surgical disciplines.

This is the first study to demonstrate maximally safe and effective cataract surgery training in a large patient group, over sustained periods.

This chapter examines why managed clinical networks are an appropriate approach to sustainable healthcare, and discusses the conditions for the effectiveness of these multi-stakeholder, clinician-led modes of organizing. It describes the development of a national clinical network to achieve system-wide improvement in the provision of publicly funded cardiac surgery services in New Zealand, and the subsequent evolution of a broader network encompassing the whole cardiac care patient pathway.

The case study of the two cardiac clinical networks focuses on the emergence and evolution of the networks over a four-year period from 2009. Data were collected from interviews with key stakeholders of both networks and from internal and published documentary evidence. Analysis of the case study is informed by network theory and prior studies of managed clinical networks.

Progress made towards the achievement of the goals of the initial cardiac surgery network encouraged a broadening of focus to the entire cardiac care pathway and the establishment of the national cardiac network. An important benefit has been the learning and increase in understanding among the different stakeholders involved. Both clinical networks have demonstrated the value of clinician engagement and leadership in improving the delivery of health services, and serve as a best practice model for the development of further clinical networks for health services that require a national population base.

The case study analysis of the two cardiac clinical networks identifies five mutually reinforcing themes that underpin network effectiveness: network structure, management and governance, and internal and external legitimation. These themes encompass a number of factors suggestive of successful managed clinical networks, and offer insights into the use of such networks in organizing for sustainable healthcare.

This study examines weight loss surgery patients’ experiences with vanity stigma. First, the research explores if and how vanity stigma occurrences differ for female and male surgery patients. Second, the research interrogates the role of this stigma in shaping patients’ feelings about their bodies.

The data stems from qualitative interviews (n = 44) and surveys (n = 55) with pre-operative and post-operative weight loss surgery patients. The author used narrative interview analysis to inductively identify and analyze prevalent themes.

Participants’ stigma experiences are differentiated by gender. Approximately half of female participants reported perceiving vanity stigma. Women who faced negative accusations were likely to distance themselves from such claims by citing personal disinterest in their bodies, whereas women who did not perceive vanity accusations were likely to express approval and pleasure in their post-weight loss bodies. Men, in contrast, were not accused of vanity. Men frequently characterized their post-surgical, post-weight loss bodies as having utilitarian value.

The study concludes that gender norms play a role in shaping bariatric surgery patients’ experiences with vanity stigma and body-related feelings. Limitations include the small number (n = 9) of male participants and the lack of a representative sampling frame for bariatric surgery patients.

Previous studies have not explored how gender shapes bariatric surgery patients’ experiences with appearance-related social scrutiny. This chapter adds to existing research on gendered body norms and reveals gendered dimensions of vanity stigma.

In this chapter I explore how conflicting discursive claims made by the medical community are consequential for bariatric weight loss surgery patients. Bariatric surgery has become increasingly common in the United States since the 1990s, with over 177,000 Americans undergoing surgery in 2006. Despite the surgery's growing popularity, the US medical community does not wholeheartedly endorse the surgery. Rather, different members of the medical community espouse contradictory evaluations of weight loss surgery. I broadly characterize this intra-medical community controversy and, then, discuss how conflicting claims have helped shape the bariatric surgery industry's discursive conception of an “ideal patient.” Next, I analyze actual patients’ negotiations of the ideal patient archetype, and find that patients’ responses follow three paths: embracing the ideal, having a mixed response to the ideal, and strategically complying with the ideal. As patients are compelled to grapple with the ideal archetype in order to access surgery, I conclude that the ideal archetype acts as a discursive frame connecting individual patients to broad bariatric surgery discourses.

This chapter examines the surgical body modification experiences of transgender and cisgender people in the United States. It analyzes how surgery consumers with different gendered histories pursue “enhanced” embodiment. Both cisgender and transgender people obtain similar surgeries, but their procedures are differently regulated. Based on 40 in-depth interviews, this chapter compares the presurgical and postsurgical experiences of transgender and cisgender people. The findings show that cisgender and transgender people felt similarly about their bodies before surgery and reported corresponding cosmetic and psychological motivations for surgery. Both groups also had comparable postsurgical outcomes and used surgery to actualize a more desirable gendered embodiment. Ultimately, surgery resulted in changed gendered embodiment that enhanced the self for both groups. It could be psychologically transformative for cisgender people and provide more of a cosmetic effect for transgender people. These findings complicate disparate regulations of transgender and cisgender surgeries. They highlight surgeries as body technologies that enhance gendered embodiment allowing both cisgender and transgender consumers to articulate gendered concepts of the self.

Context. The most advanced and fastest growing form of bariatric surgery is laparoscopic gastric bypass. Very little is known about population-based 180-day laparoscopic bypass costs, complication rates, readmission rates, and post-operative care.

Objective. To examine the 6-month costs and outcomes of laparoscopic vs. open bariatric bypass surgery using a national population-based sample.

Design. We use the 1998–2003 Nationwide Inpatient Sample to examine national trends in the rate of laparoscopic bypass. To examine post-operative outcomes, we examine insurance claims for 2,384 bariatric bypass surgeries, at 308 hospitals, among a population of 5.6 million non-elderly people covered by large employers across 49 states in 2001 and 2002. Multivariate logit regression analysis is performed to risk-adjust outcomes.

Main Outcome Measures. 180-day outcomes: 12 complications specific to bariatric surgery and 44 general post-operative conditions, readmission rates, ER rates, and expenditures following bariatric surgery.

Results. Between 1998 and 2003, the national percentage of bariatric bypass surgeries that were laparoscopic grew from 1.5 to 17.1%. There was no significant difference in in-hospital mortality between laparoscopy and open surgery. With the 2001–2002 claims data, we find that of the patients having bypass surgery, men had 48% lower odds of having laparoscopy and that high bariatric volume hospitals were close to four times more likely to use laparoscopy. Laparoscopic bypass, compared with open bypass, had 34% lower odds of a complication during the initial surgical stay, 27% lower odds of a 30-day complication, but no statistically significant difference in 180-day complications. Laparoscopy had 49% higher odds of having the general 44 post-operative conditions, with 45% higher odds of a readmission and 54% higher odds of an ER visit. However, overall, laparoscopy resulted in a 23% lower number of hospital days and 9% lower 180-day expenditures.

Conclusion. The laparoscopic cost-savings during the less invasive initial surgery stay outweigh the increase in post-discharge utilization. Further cost-savings will only emerge from laparoscopy only if its late post-operative complications are reduced. More cost-savings will also emerge as more physicians switch to the use of laparoscopy for bypass surgery.

Procedures can be categorized as certain surgeries based on their necessity and outcomes while others are classified as uncertain surgeries based on these areas. To account for this variance, policies such as the Affordable Care Act (ACA) call for health care providers to engage in shared decision making (SDM) with patients to ensure they are informed of treatment options and asked their preferences. Yet, gender may influence the decision-making process. Thus, this project examines the decision process and how gender impacts patients’ participation in decisions to undergo certain surgeries compared to uncertain surgeries.

This research project analyzed data from the National Survey of Medical Decisions 2006–2007 which surveyed the medical decisions of US residents 40 and older.

First, the data reveals that women felt more informed having uncertain surgeries compared to men. Second, patients were less likely asked their preference for surgery when undergoing certain surgeries compared to uncertain surgeries. Third, compared to men, women having uncertain surgeries were less likely to make the final decision to have surgery, compared to sharing the final decision with health care providers.

Due to the sample size, this project could not perform three-way interactions between gender, race, and surgery type.

Gender influences the level patients feel informed having uncertain surgeries. Though policy calls for SDM, health care providers are less likely to ask patients their preference for surgery regarding certain surgeries, relative to uncertain surgeries. Gender impacts the final decision-making process regarding whether patients should have uncertain surgeries.

Members of an organization facing change often struggle to adapt and may create new routines. Drawing on insights from a case study of bariatric robotic surgery, the authors illustrate how a new ecology of space transforms the ostensive and performative aspect of a routine during the introduction of a new technological artifact. The authors discuss two types of space: experimental and reflective. The authors show that the reflective space through debriefings enables practitioners to discuss the new patterns of interdependent actions. Practitioners explore the different aspects of the performative struggle with new artifacts and try to integrate new actions and delineate the boundaries of this change during experimental performances. The findings of this study throw light on the role of the reflective space in addition to the experimental space in routine change, and suggest that socio-material ensembles can produce opportunities for reshaping routines.

The authors determine how the scheduling and sequencing of surgeries by surgeons impacts the rate of post-surgical complications and patient length-of-stay in the hospital.

Leveraging a dataset of 29,169 surgeries performed by 111 surgeons from a large hospital network in Ontario, Canada, the authors perform a matched case-control regression analysis. The empirical findings are contextualized by interviews with surgeons from the authors’ dataset.

Surgical complications and longer hospital stays are more likely to occur in technically complex surgeries that follow a similarly complex surgery. The increased complication risk and length-of-hospital-stay is not mitigated by scheduling greater slack time between surgeries nor is it isolated to a few problematic surgery types, surgeons, surgical team configurations or temporal factors such as the timing of surgery within an operating day.

There are four major limitations: (1) the inability to access data that reveals the cognition behind the behavior of the task performer and then directly links this behavior to quality outcomes; (2) the authors’ definition of task complexity may be too simplistic; (3) the authors’ analysis is predicated on the fact that surgeons in the study are independent contractors with hospital privileges and are responsible for scheduling the patients they operate on rather than outsourcing this responsibility to a scheduler (i.e. either a software system or an administrative professional); (4) although the empirical strategy attempts to control for confounding factors and selection bias in the estimate of the treatment effects, the authors cannot rule out that an unobserved confounder may be driving the results.

The study demonstrates that the scheduling and sequencing of patients can affect service quality outcomes (i.e. post-surgical complications) and investigates the effect that two operational levers have on performance. In particular, the authors find that introducing additional slack time between surgeries does not reduce the odds of back-to-back complications. This result runs counter to the traditional operations management perspective, which suggests scheduling more slack time between tasks may prevent or mitigate issues as they arise. However, the authors do find evidence suggesting that the risk of back-to-back complications may be reduced when surgical pairings are less complex and when the method involved in performing consecutive surgeries varies. Thus, interspersing procedures of different complexity levels may help to prevent poor quality outcomes.

The authors empirically connect choices made in scheduling work that varies in task complexity and to patient-centric health outcomes. The results have implications for achieving high-quality outcomes in settings where professionals deliver a variety of technically complex services.