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A Systems Approach to Surgery

Martin McKneally
Martin McKneally
During the SARS outbreak, there was remarkable variation between surgery units in our university affiliated hospitals. Some surgeons-in-chief worked diligently and effectively at telephone triage to inform referring doctors where to send their patients, optimizing care throughout the area. "Open fracture in a transplant patient - send her to the ER, bypass the screen, I'll set it up." "Open fracture in a healthy patient - take him to Barrie - I'll make the contact."

Others, barricaded out of elective surgical practice, examined outpatients in the offices of colleagues in the city. One went off looking at potential positions elsewhere. None seemed aware of what their counterparts were doing. As I informally surveyed and summarized these responses for a health policy talk (www.ctsnet.org/doc/7771), I realized I was looking at a non-system of surgical care.

Surgery as a System of Care

Surgery can be viewed as a subsystem within the healthcare "system", though the usage is strained in both instances. System implies orderly linkages between intercommunicating parts. The word derives from Greek roots for standing together. The Canadian Oxford Dictionary defines a system as a complex whole; a set of connected things, parts, or institutions ... functioning together.

The recent development of the Toronto Academic Health Sciences Network (TAHSN) has helped to systematize approaches to educational experience in our hospitals. Participants are enthusiastic about the results. Similar efforts are underway to harmonize the remarkably disparate approaches of Research Ethics Boards across the city. Both of these efforts indicate recognition of the need for "standing and functioning together to improve complex processes".

The Senior Advisory Committee of our Department includes the surgeons-in-chief of our affiliated hospitals along with university division chairs. Its valued role is advisory to the chair. Perhaps a more focused management role for SICs or their delegates could help bring surgical care closer to a coherent system.

Ethical Standards for Healthcare Systems

Competent systems should meet the standards of care appropriate for organizations or jurisdictions of comparable size, mission, attributes and assets. The standard of knowledge requires the system to assure timely knowledge among caregivers and to maintain nimble, effective information systems. The standard of skill includes the ability to give access to those in need of care (e.g. by ambulance, aircraft, water transport), and to take them through the entire process of care, providing relief, security and appropriate treatment without compromising their dignity.

The brilliant book Redefining Health Care by Harvard Business School University Professor Michael Porter, presents a value based vision of how this can be accomplished - by competing on results of the overall course of care, not just individual procedures. The standard of judgement requires healthcare systems to choose and provide the right facilities, personnel and policies to the right patients at the right time. As in the dyadic relationship of individual caregivers to their patients, the systems of care should inform the larger populace of appropriate treatments and preventive measures, including current advances and warnings of significant health hazards.

Martin McKneally


Letters to the Editor are welcomed to keep the community informed of opinions, events and the activities of our surgeons, friends and alumni.

Dear Martin:
I enjoyed your column in the Winter Surgical Spotlight. I was surprised that you did not make reference to the well known comment regarding good judgement: "Good judgement is the result of experience. Experience is the result of bad judgement".
I enjoyed the column; I thought it was timely and relevant. Thank you.
Yours truly,
James P. Waddell, MD, FRCSC
Professor, Division of Orthopaedic Surgery
University of Toronto

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