Improving performance reliability in surgical systems

Health care has evolved rapidly to meet the medical demands of society, but not to meet the demands of consistent operational safety. In other high risk domains in which the consequences of systems failure are unacceptable, organisational and operational work systems have been developed to deliver consistent, high-quality, failure-free performance. In this paper we review contributions to a special issue of Cognition, Technology and Work on 'Enhancing Surgical Systems'. We consider their implications for improving the reliability of care processes in light of theoretical developments in the area of high-reliability organisations and resilience engineering. Health care must move from reactive safety cultures to be more proactively resilient to the continual threats posed by complexity in clinical care processes and the multi-professional hospital environment. Our analysis emphasises the importance of team working for reliable operational performance. A schematic framework to illustrate how safety interventions in surgery might cohere within an organisational strategy for achieving high-reliability is proposed. The implications for continuous quality improvement and effective regulation of system safety over differing time scales and organisational levels are discussed. © 2007 Springer-Verlag London Limited.