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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.

Purpose – This paper focuses on efficiency as a central theme of the Italian health care reforms, combining macrolevel policies with microlevel (i.e., operating room) perceptions of the concept.

Design/Methodology/Approach – According to the phenomenographic approach, this analysis investigates how the components of a surgical team (22 semistructured interviews) experience efficiency in their daily workflows.

Findings – The main findings show that the concept of efficiency is multidimensional. According to participants’ perspective, several categories of efficiency collected in an outcome space emphasize an holistic view of efficiency driving health policies and strategies.

Social implications – The suggestion of further relationships between perspectives and other constructs (i.e., quality, safety, patient focus, process) at micro and macro level could enhance the impact of health reforms.

Originality/Value – A qualitative approach conducted at microlevel help to recognize the phenomenon (of efficiency), engaging the individual conception that practitioners have of the health efficiency.

Fostering the development of professional character in student physicians remains the most essential, yet challenging and sometimes elusive goal of those in medical education. Current understandings and contemporary approaches to learning and teaching can provide perspectives that may inform our thinking. In this chapter, learning with and from others is explored along with approaches that form the foundation for the development of professional character that integrates moral conduct into professional practice. The implications for both teaching and learning and the importance of the learning environment are discussed. Education as a moral endeavor and values-based practice is emphasized.

Designing and developing safe systems has been a persistent challenge in health care, and in surgical settings in particular. In efforts to promote safety, safety culture, i.e., shared values regarding safety management, is considered a key driver of high-quality, safe healthcare delivery. However, changing organizational culture so that it emphasizes and promotes safety is often an elusive goal. The Safe Surgery Checklist is an innovative tool for improving safety culture and surgical care safety, but evidence about Safe Surgery Checklist effectiveness is mixed. We examined the relationship between changes in management practices and changes in perceived safety culture during implementation of safe surgery checklists. Using a pre-posttest design and survey methods, we evaluated Safe Surgery Checklist implementation in a national sample of 42 general acute care hospitals in a leading hospital network. We measured perceived management practices among managers (n = 99) using the World Management Survey. We measured perceived preoperative safety and safety culture among clinical operating room personnel (N = 2,380 (2016); N = 1,433 (2017)) using the Safe Surgical Practice Survey. We collected data in two consecutive years. Multivariable linear regression analysis demonstrated a significant relationship between changes in management practices and overall safety culture and perceived teamwork following Safe Surgery Checklist implementation.

Purpose – Patient safety and adverse events continue to present significant challenges to the US health care delivery system. Mandated reporting of adverse events can be a mechanism to “coerce” hospitals to identify, evaluate, and ultimately improve the quality and safety of patient care. The objective of this study is to determine if the coercion of mandated reporting impacts hospital patient safety scores.

Methods – We utilize the US News and World Report 2012–2013 Best Hospital Rankings which includes patient safety data from US teaching hospitals. The dependent variable is a composite measure of six indicators of patient safety during and after surgery. The independent variable is state mandated reporting of hospital adverse events. Three control variables are included: Magnet accreditation status, surgical volume, and the percentage of surgical admissions.

Findings – Using ordered logistic regression (n = 670 hospitals) we find a positive, but not significant, relationship between state mandated reporting and better patient safety scores.

Implications – This finding suggests that regulatory policy may not actually prompt performance improvement, and our data point to the need for further study of both formal and informal processes to manage patient safety within the hospital.

Originality – While increased reporting of adverse events has been linked to hospitals providing safer care, no research to date has examined whether or not state-level mandates actually lead to improvements in patient safety.

Health care institutions in many Western countries have developed preoperative testing and assessment guidelines to improve surgical outcomes and reduce cost of surgical care. The aims of this chapter are to (1) summarize the literature on the effect of preoperative testing on clinical outcomes, efficiency, and cost; and (2) to compare preoperative testing guidelines developed in the United States, the United Kingdom, and Canada.

We reviewed the literature from 1975 to 2014 for studies and preoperative testing guidelines.

We identified 29 empirical studies and 8 country-specific guidelines for review. Most studies indicate that preoperative testing is overused and comes at a high cost. Guidelines are tied to payment only in one country studied. This is the most recent review of the literature on preoperative testing and assessment with a focus on quality of care, efficiency, and cost outcomes. In addition, this chapter provides an international comparison of preoperative guidelines.

The purpose of this study was to explore the cultural and structural conditions that influence male and female physicians’ career choices and career expectations. Although women constitute 59 percent of the physicians and 55 percent of the specialists in Finland in 2014, the rate of women in oto-rhino-laryngology (38 percent) was one of the lowest among the specialties. The data consist of semi-structured interviews with young physicians (N = 19), who have entered a career in oto-rhino-laryngology (ORL) in Finland.

The results point to three features which characterize the career pattern in the specialty. First, the specialty is not one that draws students to medicine per se but rather one that is chosen during medical training. The decision to specialize in ORL was by many respondents framed as a “coincidence,” while others were attracted by the diverse character of the specialty. Second, the skills needed for being a “good” practitioner were defined as handiness, courage, and social skills, but these were not defined in a gendered way. Third, the career prospects for women within the specialty were defined by a neutralizing or a gendering framework. The neutralizing framework was represented by the pipeline argument which suggests that there is a temporary time lag in women’s representation in higher positions and that women are advancing steadily in the academic and administrative pipeline. The gendering framework pointed to the male ethos of the surgical tasks in the specialty as a barrier for women’s advancement in those areas. This chapter concludes that the pipeline view belittles existing gender inequalities in men’s and women’s medical careers and views gender differences as temporary maladjustments rather than inherent features of gendered organizations.

The dynamics of the physician knowledge system in the Southern California Region of Kaiser Permanente are explored. The framing and analysis use concepts from the knowledge management literature and network theory. The criticality of this issue to the establishment of sustainable healthcare relates to the lynchpin nature of embedding evidence-based knowledge in healthcare practice and the simultaneous challenge of combining this with clinical knowledge that derives from practice.

The case study is compiled from longitudinal interviews with over 40 physicians and other stakeholders and an examination of archival information including published articles generated by the learning system.

The socio-technical approach to building this learning system was critical given the expectations of physicians for autonomy in making clinical decisions with respect to their patients. This robust learning system builds on rich professional and organizational networks, is led by physicians, and builds on and extends the foundation of evidence relating to quality and value. The goals of the physician practice and a robust measurement and feedback system provide focus for the learning system.

Accelerating the incorporation of evidence-based practice and increasing the scope and reach of the learning system entails building physician networks, having a robust system for critically examining and extending evidence, and a clear linkage to valued outcomes.

This detailed examination of the dynamics of knowledge absorption extends understanding of the capacity of medical care systems to absorb evidence-based knowledge.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.