P. Serrato1, V. Msosa2, J. Kondwani2, M. Nkhumbwah2, M. Brault3,4, R. Heckman1, S. Weiner3, G. Mulima2, M. Sion1 1Yale University School Of Medicine, New Haven, CT, USA 2Kamuzu Central Hospital, Lilongwe, Malawi 3Yale University School Of Public Health, New Haven, CT, USA 4University Of Texas Health Science Center At Houston School of Public Health, Houston, TX, USA
Introduction: A 2017 study found that 44% of scheduled elective surgeries were cancelled at a public tertiary center in Lilongwe, Malawi. This high rate makes case cancellation a priority issue at this hospital, yet no one has captured the complexity of its contributing factors nor its impacts. This study evaluates staff and patient perspectives on case cancellation at this hospital, allowing us to identify areas of waste, define a process map for surgical case completion, and characterize the impact of cancellation among these stakeholders.
Methods: We conducted participatory process mapping and in-depth, individual interviews with hospital staff (n=23) and surgical patients (n=10) to detail peri-operative processes and perspectives on cancellations. We used purposive sampling to recruit staff based on their hospital role and years of experience. We selected patients whose surgery had been cancelled. Interviews were audio-recorded and transcribed for process mapping accuracy and thematic analysis using the constant comparative method and NVivo software. Process map legend: rounded rectangles and solid arrows indicate patient flow, sharp rectangles indicate actions or decisions by key stakeholders, dashed arrows indicate actions occurring in parallel to patient flow, diamonds indicate decisions to cancel or proceed with the case, and stars indicate potential intervention points.
Results: Interviewed staff detailed role-specific perspectives on perioperative processes leading to surgical case cancellation and completion. Specific steps of the perioperative process were delineated, generating a process map from a patient flow perspective (Figure 1). Unavoidable causes of case cancellation were evident, such as unreliable water supply and material resource shortages. Potentially modifiable areas of wasted time and resources were also found such as chronic tardiness, communication barriers, and inadequate preoperative assessment. Thematic analysis of perceived impacts of cancellation revealed compromised provider-patient relationships, emotional distress, communication breakdown, and wasted resources. Staff reported feelings such as frustration, embarrassment, fear, and pity. Patients expressed feelings such as sadness and demoralization following their cancelled surgery.
Conclusion: This pre-implementation study highlights a process map that identifies modifiable barriers to surgical case completion as well as negative impacts of cancellation. These findings provide targets for implementation projects that aim to decrease waste, reduce cancellation rates, and mitigate harm following cancellation. This framework may be adapted and applied in similar settings with high elective case cancellation rates.
