Detailed methods and results

of

an observational study on how micropolitics and power influence scheduling and staffing of surgical

operations.

Carsten Engelmann, Gudela Groteβ, Siegfried Geyer§ and Dzifa Ametowobla⌘

Head of Dpmt., Pediatric Surgery, Klinikum Brandenburg, Brandenburg Medical School Theodor Fontane

(MHB), Hochstr. 29, 14770 Brandenburg, Germany; mail for correspondance and reprints: ceng@mailbox.org,

telephone: 0049 3381 41 1271, fax: 0049 3381 41 1809, mobile: 0049 172 262 09 12

βHead of Dpmt., Work and Organizational Psychology. Department of Management, Technology and

Economics, University of Zürich (ETH), 8092 Zürich, Switzerland.

§ Head of Dpmt., Sociology Unit, Hannover Medical School (MHH), Carl-Neuberg St. 1, 30625 Hannover,

Germany.

⌘Technical University Berlin, Institute for Sociology, Frauenhoferstr. 33-35, 10587 Berlin, Germany.

Authors’ Contributions

Engelmann C Geyer G Grote G

Ametowobla D

Study conception/design x x x xAcquisition of data x xAnalysis and Interpretation of data

x x

Drafting of the manuscript x xCritical Revision of manuscript x x x x

CE and DA contributed equally to this work.

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1. Introduction:

Subject of this study are micropolitics and power in the process of surgical theatre planning.The operating List is the central medium for process steering in theatre suites throughout the world. It has important implications for patient safety and economic efficacy [1]. Much valuable research exists on List optimization, e.g. regarding late starts [2] or overruns. Solutions range from mathematical formulas [3] to psychometric determination [4] of the coordinator’s risk awareness [5]. Almost all of these studies rely on the assumption that the List is the result of a rational process that produces an optimal choice [6].

However, experienced clinicians will confirm that much of the final List’s form is determined by micropolitics: protagonists aim to influence decisions about convenient block time-slots, staffing of prestigious operations, etc. (figure 1) to benefit either themselves or (in case of seniors) the trainees they seek to promote.

Major teaching hospitals are often crowded with highly committed and ambitious surgeons who compete for resources. The resulting power struggles can be conceptualized as “Games” [7] in which surgeons strategically utilize specific situations, constellations, positions and organizational rules to their advantage. The processes involved appear obvious to the protagonists but there is a lack of empiric data regarding the role of power in surgical decision-making. Throughout the main surgical cultures (e.g. US, Continental European, UK, Japanese etc.) the crucial Games, are those concerning the question “Who carries out which operation and when?” Although the Game terminology might suggest that these issues are trivial or frivolous, they are of the utmost importance for the career, convenience and identity of the surgeon and, arguably, for the health outcome of the patient.

Systematic research in this domain is challenging: a surgeon may be able to recall instances of strong dissatisfaction concerning theatre allocation, but will regard them as isolated, local incidents, which may contribute to “unwritten rules” [8; 39] for career advancement, but cannot be studied systematically. Though all politics are said to be local [9] they are everywhere. The misconception of irresearchability partly arises from the fact that organizations’ micropolitics by definition involve “tacit procedures” [10] and implicit knowledge. Their exploration, especially in professional elites, is complicated by psychological resistance. Only under favorable conditions it is reduced enough to allow exploration. For this study we benefitted from the introduction of a major health IT system (HIT) which even hierarchically high-ranking surgeons could not circumvent [11]. As part of an innocuous review regarding the system’s booking functions we investigated the micropolitical aspects of operation planning. The planners’ frustration about the system’s productivity and safety facilitated further exploration. Overall we conducted a field study consisting of: 1. a comprehensive written survey of all executive surgical and clerical planners in two hospitals, 2. semi-structured interviews, and 3. document analyses. To our knowledge, such an “ethnographic power analysis” [12] has never previously been undertaken in a surgical context.

This work deals with a question relevant to surgeons worldwide, however the particular data presented here are from what can be called the “Continental European System”. Here, with exceptions, cases generically come into the institution. A booking agent decides (with varying involvement of the department’s head or faculty) when the case is scheduled and who will staff it. There is jockeying amongst surgeons and scheduler to game the system so that surgeons receive the best cases and times depending on privilege, specialization and other factors.

Our aim was an initial academic description of the process of executive operation allocation and planning. The goals were 1. identification of “powerholders” [13] and prevalent tacit procedures, 2. examination of the assignment mode of routine and exceptional operations by evaluating actual rank orders for surgical case booking data elements, and (3) examination how an operation planning extension in an HIT enterprise process control system changes micropolitical behavior.

A brief recall of two basic humanities concepts may be helpful. Politics is defined as “social interaction targeted towards obtaining a goal” [14], always involving the use of power. Power has scientifically well-categorized sources [15]: the functioning of the Theatre List is highly important for both the organization [16] and individuals. Consequently its control constitutes a very strong resource.

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Certainly cultural differences do exist. For example in the US, the allocation step happens earlier in the process depending on personalized referral or “take days”. Independent attending surgeons bring their patients to the operation room (OR) based on a pre-existing relationship. There is no senior surgical scheduler who is able to reassign cases to surgeons. This study is however the first to demonstrate the utility of examining the array of highly manipulated processes around operation theatre allocation of time slots or staff, which play out in various ways in all of the main surgical cultures.

2. Material and Methods:

This field study [17] covers sociological and ethnologic aspects of theatre planning.

Setting and HIT-System: Data were collected in a university hospital (7600 staff, 1500 beds, among Europe’s largest organ transplantation centers supplemented with a highly productive research campus) and in an acute care teaching hospital (1200 staff, 575 beds) both running the SAP R3 Business Process Control System (SAP AG, Walldorf, Germany). R3 is real-time resource planning and accounting software, which incorporates all key business functions of hospital organizations. It replaced a legacy network system that included diagnostic data but no accountancy and real-time features.The SAP Theatre Planning module function workflow is shown in figure 2. Physicians and other staff fill in a request form which is then assigned a timeslot, theatre and staff by the surgical departments’ executive theatre planner. Final coordination, especially between different departments, is assured by a Central Theatre Coordinator (CTC [18]).

Qualitative data: Between January 2013 and January 2015, 22 interviews (duration: 0.5 to 3 hours) with planning stakeholders (e.g. surgical department planners, head scrub nurses, CTC, IT specialists, line surgeons subdued to planning i.e. surgeons who are simply the subjects of staff allocations in the planning process and do not undertake planning themselves) were conducted and transcribed. Various theatre suite and software charters were reviewed.

Quantitative data: Based on field study results and STROBE criteria [19] a comprehensive questionnaire covering theatre planning was developed and pre-tested with non-eligible planners [20]: 73 items covering technical usability, organizational disasters and micropolitics were explored with 80 categorical, ordinal (employing uni- and bi-polar 5 point Likert scales (ULS 0 to 5, BLS –2 to +2) including neutral options), metric (M) and free text questions (FT, for questionnaire see Online Resource 2; estimated completion time 70 minutes). This article reports on decision making concerning scheduling and staffing. Respondents were asked to rank 1. the relative importance of information from the electronic request file, 2. the criteria used to make both types of decisions, and 3. the influence of stakeholders. Decision criteria were graded into “major” and “minor” criteria [21] from which overall ratings were computed by assigning two points to the former and one to the latter. Surgical procedures were differentiated in the questionnaire into “Interesting” (i.e. career-promoting) and “Uninteresting” (i.e. routine) operations. The exact definition of what constituted those classes of operations in their respective field was left to respondents’ personal discretion.Inclusion criterion: Persons (senior surgeons and senior nursing and clerical staff) with current executive HIT-planning rights, i.e. right to definitely allocate time-slots and staff. Exclusion criterion: simple user without executive planning rights. The anonymous questionnaires plus separate registration postcard for the management of two reminders were mailed physically. Source data was closed 22-04-15. After matrix-transfer it was computed with cross-table, mean-value and correlation statistics (McNemar, Mann Whitney and Fisher tests, SPSS Version 21.0). Relevant missing data are reported in brackets.

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3. Results

Quantitative information from the questionnaire.

Response rates: 43 of 56 questionnaires were received from executive surgical planning officials (70%; subgroups: 12/15 heads of department, 23/26 senior consultants, 2/5 specialists with completed residency, henceforth called “surgical planners”). The second group of respondents were senior clerical and nursing planners (return rate: 16 of 21, 76%, henceforth called “clerical planners”). Thus all surgical departments included in the survey (n=16) were covered two-sidedly. Respondents estimated their “own influence on the assignment of Interesting operations” 7.7 +/-2.4 points (surgical planners) and 1.5 +/- 2.8 points (clerical planners) on a Likert Scale from 1 to 10 (none to unrestricted, p<0.05).On average planners were responsible for 3.5 +/-1.2 theatres. 64 % had > 1 year experience with both the current HIT system. Interviewees described the social course of List-making according to figure 2.Classification of operations: 84% of all respondents stated that performing Interesting operations is important for surgical careers. 47% of surgical planners reported that surgeons tend to avoid Uninteresting operations while 18% of clerical planners held this view (missing: 15%).Information in the electronic request form: Respondents marked the three most important items (missing 17%): the “designated operating surgeon” achieved rank one (selected by 90%/36 of respondents), followed by the “requested operation” (85%/34), “expected duration” (72%/29), “diagnosis” (63%/25), “equipment” (58%/23) and “complexity of procedure” (50%/20). All other factors remained below 20%. The specification of the “operating surgeon” was significantly more important than “diagnosis” (p<0.05). Scheduling decisions: Planners attached the highest importance to the following items from the electronic request form: 1. “requested operation type” (4.7 +/-0.6 on Likert scale 1-5), 2. “designated operating surgeon” (4.1 +/-1,1), 3. “expected duration” (3.8 +/-1, 1) and 4. “requested time-slot” (3.5 +/- 1,2). The staffing proposal (“operating surgeon”) was deemed significantly (p<0.05) more important for scheduling than the “requested time-slot”.Scheduling decisions were negotiated almost exclusively among department surgeons, the influence of the CTC was negligible. Staffing decision (i.e. choosing the operating surgeon): The most important items from the electronic request form were likewise “requested operation type” (4.8 +/-0.5 on ULS 1-5)) and “operating surgeon” (4.6 +/- 0.64). Notably, clerical planners (having an “outside view”) ranked the staffing proposal at the top (5 +/-0). Assignment criteria for Interesting operations: For surgical planners the overall top criterion for the staffing decision was “surgical expertise” with 92% of maximum ranking points (57pt of 62 max; for rank calculation please see MM section and fig. 3; missing: 13%). This was followed by “operator’s need for skill development” (77%/48pt), “operator’s speed fits time-slot” (74%/46pt), “equity” (69%/43pt), “patient-doctor relationship” (58%/36pt) and “status” (58%/33pt). For clerical planners the overall top criterion was “operator’s need for skill development” (77%/17pt of 22 max), followed by “surgical expertise” (63%/14pt), “patient-doctor relationship” (59%/13pt), “status of operator” (55%/12pt) and “equity” (32%/7pt). As the most important minor criterion surgical planners chose “research achievements” and clerical planners, “connections to the planner”. Assignment criteria for Uninteresting operations: Here “equity” constituted the overall top criterion for staff assignment for both surgical planners (80%/49pt of 60 max) and clerical planners (81%/16pt of 20 max). The second most important criterion for surgical planners was “operator’s speed fits timeslot” (68%/41pt) whilst in the clerical planners’ perception the “patient-doctor relationship” advanced to rank two (78%/14pt). For surgical planners this relationship was the third most important criterion (58%/40pt) while clerical planners ranked operators’ “status” (75%/15pt) third (missing: 13%). Specific to this class of operations, the assignment-motive “disciplining” (convicting surgeons to do Uninteresting operations) ranked medium (55%/11pt) among clerical planners and medium to low (33%/20pt) among surgical planners. “Connections to planner” and “connections to leading surgeons” were acknowledged minor criteria for both types of planners (achieving between 44% and 50% of maximally obtainable rank points).Figure 3 summarizes the decision criteria groups for both types of planners. Concerning stakeholders’ influence on staffing decisions, surgical planners saw themselves as most influential (66%, 55 of 84 maximal rank points), followed by the department’s director (61%/51), the operating surgeon

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(47%/40) with the remaining all below 20% (patient 12%/14, requesting party 0%, central theatre coordinator 0%). Clerical planners ranked their own influence third (28%/11 of possible 39 rank points) after director and operating surgeon and set the patient’s influence to 15%/10.

Free text information from the questionnaire

“Creative” HIT planning. 35% of planners stated that they used creative strategies involving the HIT planning system to “defuse possible conflicts”. Respondents described subterfuges involving time and included the following four types: deliberate choice of the moment of online information release in crucial cases, outmaneuvering competing operators by binding them in simultaneous procedures, false declaration of emergencies, and deliberate underestimation of expected operation durations. The latter two strategies were used to prevent end-of-regular-duty cancellations.Good List, good planner. Survey participants finally characterized a good Theatre List and a good planner using free text replies. A good List should be, in order of importance, realizable, reliable (i.e. robust enough to cope with adverse events), and clearly presented without information overload. A good planner should be, in order of importance, an experienced surgeon with system knowledge, a flexible organizer, and a good politician. Safety, transparency and a sense of equity were not cited in the top three characteristics of either the List or the planner. Qualitative interviews. Surgical planners prevaricated when asked about their own use of power in connection with List-making. All planners we talked to emphasized that they personally based their decisions on a strict policy of equitable treatment for all parties involved. They recounted however that other planners were prone to favoritism. Surgeons subdued to planning and clerical planners reported that low status surgeons were unable get convenient slots while high status surgeons occupied such slots without using them. List-makers were said to enjoy privileges in return for their exclusive IT system mastery (e.g. avoidance of unattractive rotations, unnecessarily prestigious computer hardware). Four interviewees reported comprehensive hierarchical manipulations and courting of the planner. There were two reports of surgical staff being willing to pay for operations granted with sexual favours. In discussion of the micropolitical strategies associated with staffing decisions interviewees gave accounts of partial convergences of interest and coalitions, the creation of “packages/side-payments” and barter, pressure, secretion, denial of service (e.g. “non-support” by nurses) and exclusion in order to influence stakeholders. Moreover, respondents reported that Interesting operations were in some instances performed by surgeons who pre-operatively were not named on the Theatre List. Most of these strategies were said to be covert, i.e. involving mainly tacit procedures.

4. Discussion

Intangible phenomena may (arguably) influence surgical choices in the same way as well-researched medical factors. For example "Beauty" is a case in point: a surgeon may prefer to carry out a procedure he or she regards as technically elegant, rather than a (roughly) medically equivalent one without this perceived attribute. However, the investigation of these phenomena faces methodological difficulties [22], psychological resistance and lack of reward for researchers.One such topic involves the social and micropolitical aspects of theatre planning. They can be summed up by the question “Who carries out which operation and when?” While in the Anglo-saxon attending/consultant-team system it is mainly about block time (patient distribution processes occurred earlier), in the continental European tradition it is about both: patients are referred to departments and cases are then distributed to attending surgeons. In both cases the micropolitics of theatre planning merit scientific charting.This survey was focused on the main planning executives of surgical departments. These are normally experienced senior surgical and clerical executives who make decisions under temporal and political pressure. The two types of planners surveyed in this study behaved markedly differently: according to the questionnaire clerical planners were less likely to change request file data and adhered more closely to requested dates and procedures than surgical planners. Nevertheless the replies of experienced clerical planners provide an important “external perception” which contrasted interestingly the surgical planners’ “self-perception”. The survey results were complemented by interviews with planning staff. These gave planners opportunity to admit to their use of subjective assessments. For example for a given operation there are usually several

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candidates who are qualified to perform a procedure and there are no objective means to determine which team would be optimal. Planners admitted to basing their decisions on their subjective assessments of cases, surgeons’ skill levels, speed, merit or potential, as well as stakeholders’ political power. This amount of personal discretion qualifies planners as powerholders [13]. As one deputy planner interviewed put it: “The theatre planner knows about his power […]. He is the most powerful person for the residents.“ Among the classical sources of power [23] the control of the element “time” is particularly relevant for planners: They get to know first about upcoming operations.As survey replies showed, many planners released information about contested procedures at the latest possible moment. This prevented others from interfering in decisions and defused conflict between competing groups of surgeons. Another aspect of time-control is that surgeons have to ask the planner for a slot. Even for higher-ranking surgeons (such as the director) such slots can become a favor granted whenever the planner highlights the element of uncertainty [16], e.g. by feigning doubt about the feasibility of requests - “I am not sure whether this is possible. Let me see…”. In the institutions examined, planners were formally regarded as a kind of “secretary” who has to do the paperwork after the decision has been taken collectively by the consultants. This can be a consensusfiction [24] which is sometimes used as a defusing mechanism by groups (like surgical departments) in which internal conflict is a constant threat. While executive planners themselves were loath to talk about their own use of power and downplayed the influence of their position [25], almost all interviewees subdued to planning issued strongly worded criticism [6] which, anthropologically indicates cultural loading [26].

Summary of results and comparison with existing work.

Concerning the act of planning itself, tangible messages emerged from the data:

1. Scheduling concerns the time dimension of activity. Thus, it would be expected that temporal items would have been the most important information from the request file for prioritization. Instead “requested operation type” and „requested operating surgeon“ led the ranking.

2. Moreover decisionmaking for prioritization was said to occur mainly not with the CTC but by negotiation, sometimes conspiratorial in nature, among department surgeons including the department planner, who is manoevred into acting as an unwitting intermediary. This demonstrates that the concept of “bricolage“ [27, 10] is involved in obtaining convergence in decisionmaking.

3. The importance of staffing decisions is underlined by research showing that “requested operating surgeon” is the single most influential variable for outcome in many types of operations [ 28, 29], leading to a “star system” [30] which others contested [31].

By whatever means the answer is arrived at, the question “Who will operate?” is a crucial one. For a differentiated view on planners’ motives it is important to know whether a decision involves an Uninteresting (and best avoided) or Interesting (and sought-after) procedure. In this respect inventories of complex operations (“index procedures” [32]) have been devised to describe a department’s level of aptitude. A surgeon-centered classification into Interesting and Uninteresting operations has hitherto not been reported. Such a classification is in apparent contradiction of medical ethics, but the fact that only one respondent (of 59) contested it, indicates such categorization reflects implicit attitudes [ 33] of surgeons. This differentiation is further reinforced by the fact that in our study both types of operations were clearly assigned according to different criteria.We have seen it as pointless to devise absolute definitions for these categories because respondents’ operative scope varies according to subdiscipline, interest and experience level. However, a subjective discrimination makes sense: teaching hospitals are concerned with gaining expertise, in other words future options for action and careers. To advance to positions that confer high professional freedom, surgeons need the chance to perform prestigious, exceptional procedures. Career path options are strongly connected with the sociological topic of “Routine” and “Innovation” Games [34] (the former have a low tolerance for error while the latter permit more substantial liberty of action).

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4. Uninteresting operations were primarily allocated according to Social motives (e.g. equity). Interesting operations however were predominantly assigned according to Rational (objective) motives in surgical planners’ self-perception. Contrastingly, clerical planners rated rationality considerably lower and reported that Political, Rational and Social aspects were in their outside view each equally influential for the assignment of Interesting operations. Some prominent surgeons and theoreticists have emphasized the motive of equity in assigning operations as a cornerstone of a well-led surgical department [35]. However our survey showed its importance to vary significantly according to whether Interesting or Uninteresting procedures were under consideration. Interviews showed that sought-after, rarely performed operations incited surgeons to coalitions aimed at influencing the planner for career-advancing assignments. Finally a widespread barter of options for action was reported.

5. The survey yielded evidence of four types of manipulations involving time factors which respondents used to “defuse” conflicts (i.e. justified as being for the common good). These involved the “creative use” of the electronic booking system but were not entirely dependent on it: real-time properties facilitate micropolitical actions such as temporarily withholding information or reacting slowly to requests. However, certain manipulations could be traceable to individual planners via the HIT systems’ audit trails. We found, though, that the HIT system (beyond its immediate function as source of information) had a surprisingly low impact on micropolitics.

Limitations and how these were adressed. Quantitative approaches are, in isolation, insufficient to describe the complex power relations and implicit negotiations in theatre planning [36]. Qualitative interviews with professional elites such as senior executive planners require finesse, persistence and personal authority which may all lead to various validities [37].

Other limitations are: Assignment of decision criteria into groups of motives (“rational” etc.) is preliminary only and may

vary in other contexts (e.g. patient safety). Categories await consolidation in future studies. The focus of this study is on surgical planning officials and a complete inventory count of this group

plus interviews are delivered. Line surgeons subdued to planning greatly outnumber the planners. The discriminatory power of surveying them with a random sample would differ from the planners’ survey. Therefore line surgeons were covered by interviews only.

Self- and external cognition [38] can vary considerably.

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5. Conclusions and Implications for practice and future research:

Micropolitical factors are relevant for List-making and may have an impact on careers, workflow and patient safety. The modern mantra of transparency often remains fictional: micropolitical behavior concerning the most important List-making decisions clearly involve tacit procedures. The current work shows that List-making is, in principle, amenable to analysis. Academic surgical research should not leave this ground unclaimed but refine tools to study it. Moreover, brief, but formal, tuition in systematic knowledge of the basic mechanisms of “surgical micropolitics” could, and we argue, should, become part of the trainee surgeon’s professional curriculum.This would help equalize career opportunities [39] in that excellence in clinical surgery and research is not strictly correlated with political aptness. Moreover, hospitals could implement simple anti-manipulation strategies such as comparisons of actual to planned staffing in Theatre Lists.

Distribution processes within surgical communities are a worldwide phenomen. Future empirical examinations modelled on this work in the other main surgical cultures [40] could yield highly interesting commonalities as well as differences and thereby foster scientific insight into own practice. The interest of such research potentially extends beyond the prominent example [41] of surgery.

Acknowledgements: Staff mathematician Karin Rohwer-Menschig; Hannover Medical School (MHH),

Germany for expert advice regarding hospital SAP, Wendy Lynas, MA, Copenhagen and James Moran, PhD,

University of Konstanz for inspired editing, Prof. Windeler, Sociology TU Berlin for valuable advice during the

initial and final stages of this study.

Compliance with ethical standards

Funding No funding other than that from the generic hospital budgets was received for research or publication.

Conflict of interest All authors declare that they have no conflict of interest in the research.

Ethical approval/Protection of Human Subjects: Patients or animals were not involved such as the ethical

committee said it was not concerned. The institutions’ workers’ committee and the institutions legal affairs

department granted permission valid for all sites (Nr. 9510, 18.7.2013). All respondents did so by their own, free

decision, thereby declaring consent.

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Figures

Fig. 1 Operating Lists are created by rational resource exploitation algorithms and interpersonal competition for options for action and resources, e.g. convenient time slots or career-promoting operations

Legend to Fig. 1 Works [42] on theatre use [43-45] and scheduling [46] include (left circle) optimization of work flow [47], communication [48] and consideration of surgeons’ capacities (e.g. trainees’ vs. consultants’ speeds [49]). However, even if all rules are considered (e.g. priority for children or emergencies), for any given scheduling task several solutions may exist that are equally satisfactory from a medical point of view. Decisionmaking in the case of objectively equal options (“social convergence” [50]) depends on hitherto marginally researched political issues [51], right circle. Politics may even lead to objectively suboptimal choices

Fig. 2 Diagram of List-making process at department level

Legend to Fig. 2 Teams, with differing internal hierarchical structures (e.g. depending on tradition. Open circles: team doctors. Black squares: consultants), submit details of pending operations to the departments’ planning executive using a request form in the HIT system. The teams are part of a surgical department (n=16 in this study, e.g. cardiothoracic, ENT). The director has an overruling right of veto that is exerted to various degrees. The departments’ planning executive assembles and staffs the List from the requests. Then he/she negotiates it with the CTC who balances it against other departments’ Lists and available resources. This study is focused on the planning process prior to the CTC's involvement

Fig. 3 Grouped assignment criteria for “Interesting” and “Uninteresting” operations

Legend to Fig. 3 Planners chose up to three major and three minor criteria for staffing decisions from a panel of suggestions. Rankings were established by assigning 2 points for each major criterion and 1 point for each minor one. Percentages refer to maximal number of obtainable points (details in Method section). Criteria for staffing “Interesting” and “Uninteresting” operations were then categorized to form three sociologically defined motive groups: Rational motives includes items “operator’s speed fits available time slot” and “surgical expertise”. Social motives includes “equity” and “surgeon-patient-relationship”. Political motives consists of “operator’s status”, “connections to planner”, “connections to leading surgeons”, “operator’s need for skill development” and “research achievements” (applying to Interesting operations) or “disciplining” (applying to Uninteresting operations, respectively). Results were detailed per occupational background of responding planner