Wicked complexity in surgical services: analysing perioperative high-risk, work practice organisation and context for future policy implementation

Background: Knowledge of perioperative risk and context are important as year-on-year the global volume of surgery is increasing. Despite decades of policy responses to surgical demand, national registries and local evidence report that a distinct cohort of surgical patients have a higher-than-average risk of complications with added costs to quality of life and service sustainability. The research aim was to examine the impact of context on how in practice the perioperative workforce (comprising clinicians and managers) understand risk, and how this knowledge influences their work practices and use of resources. Three questions were investigated: what has been the impact of health policy on the organisation and practice of perioperative care; how is perioperative work practice organised around low, intermediate and high-risk patients; and what do individuals, teams and organisations require to implement appropriate models of perioperative care for the high-risk patient?Methods: Mixed methods study. The research setting was four university adult general hospitals (113, 360, 440, 547 bed capacity) in a health district in NSW, Australia. Institutional ethics approved a mixed methods study – site observation (187 hours), secondary documents (223 documents: paper and electronic), survey (113 completed) and interviews (143 conducted). Purposive sampling targeted 129 participants in 167 roles, including multidisciplinary clinicians (nurses, doctors and allied health) in senior and junior roles, and managers. Data collection (September 2017 – June 2019) and analysis was conducted using a parallel convergent design through triangulation with descriptive statistics and thematic analysis.Results: National and state health policies that focused on access and efficiency successfully addressed high volume surgical demand for low and intermediate risk patients in predictable, reliable and linear perioperative business process models (BPMs). However, the policies are now three dec