Table 2.

Example of professional work: replacing a heart valve on a sedated patient.

Professional work – Work in which a healthcare professional or team of professionals are the primary agents, with minimal active involvement of patients, family caregivers, and other non-professionals Example: Surgery team replacing the aortic valve on a sedated patient

Agent(s): Cardiac surgeon, fellow surgeon, physician assistant, anesthesia attending, perfusionist, scrub nurse, circulating nurse Co-agent(s): Anesthesia fellow, anesthesia resident, supply technician, patient

Work system factors. Person(s) factors include skill levels of all of the involved parties, experience with the procedure, and professionals’ personal preferences concerning the procedure (e.g., preferences for tools and supplies, use of time-outs, and patient transfer processes). Task factors include the difficulty of the surgical case and the familiarity of work tasks for various team members. Tool/technology factors include the availability or usability of patient monitoring technologies and patient checklists, various other medical devices (anesthesia machine, perfusion machine), supplies, whiteboard, and various checklists (e,g, surgical equipment count checklist). Organization factors include the number of hours or surgeries worked per day by the team members, whether work-arounds need to be used due to lack of personnel, whether all team members can work in unison and can speak up, and the availability of appropriate detailed procedures for emergency situations. Internal environment factors include operating room hygiene, lighting, air quality, noise, workspace design and layout, and operating room size. External environment factors may be the impact of budget and cost on the quality of the tools/technologies used, market-influenced pay levels for personnel, and societal expectations for patient and family preferences. These factors interact to shape surgical performance.

Process. The process of surgically replacing the aortic valve of a patient includes applying the anesthetics to the patient, surgical skin preparation to prevent infections, inserting central line(s), opening the patient, connecting the patient to the perfusion machine, aortic cross clamp, delivering cardioplegia to stop the heart and the cardiopulmonary bypass, replacing the aortic valve, restarting the heart, disconnecting the patient from the perfusion machine, placing pacing wires and drainage tubes, and closing the patient. Performance of each may be shaped by unique configurations of work system factors.

Outcomes. Proximal outcomes include successful completion of the surgery, minimal errors and adverse events (such as intraoperative aortic dissection), and surgical team member stress and fatigue. Distal outcomes include full recovery of the patient, patient satisfaction with their care and trust in the healthcare delivery system, no downstream complications (e.g., healthcare-associated infections), job satisfaction of surgical team members, and long-term profits for the institution.