Professeur SIELEZNEFF IGOR – CHU TIMONE – CHRU NORD – MARSEILLE
INTRODUCTION
The operation in the operating room is a subject of constant criticism, with surgeons considering that too much time is being wasted there. The debate is generally not very constructive between an administration obsessed with performance indicators that are poorly suited to the uncertain environment of the operating room (1) and surgeons who are exasperated by the time they waste waiting unnecessarily. However, despite using all technocratic means to find harmony within teams, investing in the construction of more modern buildings, and using increasingly complex technological means, the operation in the operating room remains the weak link in the care of patients undergoing surgery. Numerous and complicated processes are put in place to avoid possible legal attacks and to ensure maximum patient safety during treatment. Numerous meetings are organized, revolving around a governance built on the model of the Pole teams, where each team tries to find agreement with the others by repeating tedious, long, and often not very useful block advice, each desperately trying to « pull the blanket to themselves ». Demotivation is at the end of a path that is nevertheless rich in standards, best practice recommendations, regulatory texts, etc.
Patients are dissatisfied with this care, in which amateurism is often blatant. They pass through dirty and worn-out, unmaintained premises, sometimes even under the watchful eye of staff busy with non-hospital tasks. Feelings of insecurity and deep dissatisfaction are quickly transmitted, tarnishing the image of the hospital environment where medical personnel, caregivers or not, often do everything possible to erase these shortcomings of which they are aware but not responsible, and for which they are the only ones who permanently receive complaints from patients. In the end, the operating program is disrupted, and the post-intervention care rooms are either empty or clogged, causing disorganization in all downstream structures (resuscitation, radiology, biology, pathological anatomy, emergency reception, hospitalization units, etc.).
There is no doubt that economic production can be improved in this company where « everything is going wrong, » while reducing the suffering of staff. We will try to identify the main anomalies leading to these dysfunctions, to this costly loss of surgical time, and to human errors whose frequency is constantly increasing (2). »
MANIFESTATIONS OF MALFUNCTIONING OF THE OPERATING BLOCK ARE PERMANENT.
The administration, whose role is above all to guarantee compliance with the public contract, has gradually interfered in the management of the operating room, mistakenly considering it as a business (3). We have thus gradually all become specialized workers working in the service of a production tool. It is no less true that it is essential to control our practices for the benefit of all stakeholders, especially patients.
The manifestations of malfunctioning of the operating room are observable at all times. Each of us can see them. Their proportion varies from one block to another (lower in a disciplinary block, significantly higher in the case of multidisciplinarity) (2); we will focus on the main ones.
- HUMAN PROBLEMS ARE OBVIOUSLY AT THE FOREFRONT
Human management of the operating room is based on the curious need of certain surgeons to overexpress an ego that is sometimes too expansive, when the only driving force should be success in the care of patients. This mode of expression betrays the weakness of a multidisciplinary block, with the administration seizing the opportunity to divide and conquer. The sharing of mainly human resources quickly becomes disharmonious, an additional source of rivalry and suspicion.
The programming and management of resources quickly give way to organized anarchy, ultimately causing each health worker to waste their time in the operating room, and the quality of medico-surgical services to constantly decline (4).
The symptoms of anarchy can be seen all the time. There is turmoil in the operating room because the tasks are not previously and individually defined, causing slippage in function, particularly towards Operative Room Nurses students. We note that there are also exchanges of negotiated time slots from person to person, depending on the expected workload or the surgeon. The anticipation and preparation of operating rooms are imperfect, sometimes even impossible due to last-minute changes in the occupancy of the premises or the presence or absence of sufficient staff.
The symptoms of anarchy can be seen all the time. There is turmoil in the operating room because the tasks are not previously and individually defined, causing slippage in function, particularly towards Operative Room Nurses students. We note that there are also exchanges of negotiated time slots from person to person, depending on the expected workload or the surgeon. The anticipation and preparation of operating rooms are imperfect, sometimes even impossible due to last-minute changes in the occupancy of the premises or the presence or absence of sufficient staff.
The study by Young et al. reveals that the quality of postoperative results also depends on the coordination methods upstream of the operating room and the level of qualification of the assisting staff (2). The study compared observed mortality and morbidity rates for twenty different surgical departments. The findings are very telling: half of the services perform well, while the other half perform significantly worse. In this work, the quality of coordination was assessed on three levels: the quality of care, teaching and monitoring of staff, and administrative supervision. For the first two parts, the twenty services studied had both high and comparable competence. The quality of postoperative results was correlated with the effectiveness of coordination in patient care. Quality items are the result of common sense and professional conscience.
The author explains that the exchange of information between nursing and non-nursing staff is the basis of satisfactory coordination: upstream of the operating room, visits are made together and patients also receive a visit from the operative theatre nurses in the preoperative period. The unit’s nurses thus establish the link with the anesthesia teams, if this is not already the case with the surgeons. The exchange is therefore not limited to viewing a digital file in a dedicated virtual IT space. Multidisciplinary units perform poorly because Nurses have too many contacts and suffer from permanent interruptions of tasks making them unavailable at the bedside.
These interruptions translate into a decline in efficiency and mutual trust. Success also depends on the presence in the care unit of written medical and nursing protocols, and the working time of Nurses is managed in such a way as to facilitate periods of training or upgrading. Conversely, the results are poor in teams where these provisions are lacking. There are often associated aggravating factors, such as little coordination, no regular meetings, absence of a protocol, and independent and different modalities of action of the surgeons making up the team, remote hospital management, insufficient staff, or poor organization.
The third point relates to the administrative authority and the current paradigm of valuation to the detriment of health actors and equipment. This study is revealing in the matter. It clearly shows that the results are poor where the administration does not organize multidisciplinary meetings stating human and material needs or reporting on the evolution data of mortality and morbidity rates, as well as the means allocated to reduce them. Experience shows that such meetings are unfortunately often more an opportunity to express grievances in an aggressive fashion due to the high level of suffering among staff.
The exercise of authority is complex in a potentially hostile environment (4). In addition to difficulties sometimes of individual origin, the command can be affected by structural causes whose resolution is most of the time impossible: human incompetence of collaboration, absence of delegation of power for the management of human resources, existence of conflicting adverse powers or pressure groups. These difficulties render attempts at coordination or consensus-building ineffective. Today, the care paradigm must change to prioritize quality services in the face of increasingly restrictive budget constraints.
2. THE DISCUTABLE AND UNOPTIMIZED MANAGEMENT OF THE OPERATING EQUIPMENT
After an operation, surgical equipment is most of the time managed by specialized platforms. The lack of dialogue perhaps explains the vast majority of the anomalies encountered: damaged or incorrectly reassembled equipment, disappearance of instruments, incomplete trays, recent instruments replaced by worn equipment, too slow or insufficient supply, etc.
Most of these anomalies could, on their own, call into question the principle of decentralized management of specialized equipment. Controlling expenditure, which is impossible to specify with officials, remains at the heart of the questions. There is not a day when the Operative Room Nurses does not complain about these anomalies to the chagrin of the surgeons, often requiring the use of several platforms for the same intervention while working in sometimes dangerous conditions due to lack of material or use of inappropriate instruments.
3. DIFFICULTIES OF A STRUCTURAL NATURE
The architectural design of the new operating theaters is delivered to specialized practices whose experience in the medical environment varies. Structures, whose aesthetics are certainly exceptional, prove to be conducive to the operative activity: difficult access to operating theaters, congestion of traffic areas due to lack of premises dedicated to the storage of equipment, absence of dismantling areas, no dedicated circuit for the evacuation of soiled objects, oversized post-intervention surveillance rooms, no waiting area for patients in prospect of an intervention, intrusion of individuals in the absence of secure door closures, etc. Too often, medical participation in the architectural development of the blocks boils down to signing an attendance sheet and presenting a fait accompli, when most anomalies are reported and could be avoided.
The architecture of operating theaters actually responds to many strategic issues; the environment must be efficient enough to implement a strategy of progressive asepsis, the free expression of highly qualified personnel, and the use of high-tech materials. These simple objectives are thwarted by the elements mentioned above and by poorly anticipated flows within structures whose dimensioning is either unsuitable or too ambitious. Too great geographical distances also lead to a drift in the operative programming (8).
Current structures usually occupy a very large area and involve too many intermediaries: the delays accumulated during these multiple stages accentuate the disorganization of the unit, and ultimately of the hospital as a whole.
4. THE DISPUTABLE ORGANIZATION OF THE GOVERNANCE OF THE OPERATING BLOCKS
The rationalization of costs is often at the heart of the discussion, while the qualities of patient care and the well-being of staff at work remain in the background. Managers, concerned about the operation of the hospital, make every effort to seize its management, since this is one of the most expensive areas of the hospital (9). Acronyms are widely used in meetings and can be confusing for younger surgeons. The sizing of the operating room is the main concern of administrators: it consists of forecasting in the short term (one year at most) the number of operating rooms to be offered, as well as the « volume » of human resources to be expected. The forecast remains undersized, explaining the suffering and dissatisfaction of staff, and then of patients whose intervention is delayed or scheduled more and more late (10).
There is a problem with the positioning of the block council in the overall functional organization (11); it actually fits into a larger operating structure, which in principle also includes a steering team and a committee of users of the structure. The work of this group aims to define an operating room charter, which must be part of the virtuous circle of evaluation followed by continuous improvement. The hope of a return on investment is quickly undermined by the weariness of stakeholders to participate in sterile meetings, the permanent shortage of staff, the lack of follow-up measures, and ultimately the lack of an update procedure.
CONCLUSION
Without any other choice possible, the surgeon and the nursing staff, whose qualifications are nevertheless of a higher level, must for the moment be resigned to waiting while undergoing the dictates of an administration watered by ideas of transhumanism (12), largely amplified by GAFA. The surgeon cannot help but waste their time between operations because « block scheduling » (13) has become an organizational priority, resulting from an operational point of view in an anarchic organized distribution.
Today, the distribution of operating programs and human resources are managed by multiple algorithms for which cost reduction is the only priority, without taking into account the human factor (which is only judged to be present or absent based on volumetric data, without considering the quality of life at work), except for that of “shift staffing” (14), with the sole objective of a “nominal load”. Optimization and Monte-Carlo approximation (15), Lagrangian relaxation (and its variations: beam method, column generation, sub-gradient descent) (16), heuristics such as “dive and fix” (17), “bin packing” algorithm (18), and other computer calculations are not productive and should stay away from organizational processes.
The results obtained following good communication between the multiple human stakeholders in an operating theater are much better, and we have forgotten that the experience of the surgeon is the simplest and most effective means of management. The skilled person should remain at the center of decisions. However, it is to be feared that our hyper-controlled society (« millefeuilles ») will retain power.
In conclusion, the management of operating rooms is facing multiple challenges, including human management, equipment management, structural design, and governance organization. The focus on cost reduction and performance indicators has led to the neglect of the quality of patient care and the well-being of staff. An anarchic distribution of resources and an absence of communication and coordination among stakeholders result in poor outcomes and dissatisfied patients. It is important to prioritize the experience and expertise of healthcare professionals in decision-making and to involve them in the design and management of operating rooms. Computer calculations and algorithms should be used as tools to support decision-making rather than as the primary determinant of operational processes. Only through collaboration, communication, and a patient-centered approach can we improve the quality of care and ensure the well-being of staff in operating rooms.
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