Process support for risk mitigation: a case study of variability and resilience in vascular surgery

Objective: To inform the design of IT support, the authors explored the characteristics and sources of process variability in a surgical care process that transcends multiple institutions and professional boundaries. Setting: A case study of the care process in the Abdominal Aortic Aneurysm surveillance programme of three hospitals in Norway. Design: Observational study of encounters between patients and surgeons accompanied by semistructured interviews of patients and key health personnel. Results: Four process variety dimensions were identified. The captured process variations were further classified into intended and unintended variations according to the cause of the variations. Our main findings, however, suggest that the care process is best understood as systematised analysis and mitigation of risk. Even if major variations accommodated for the flexibility needed to achieve particular clinical aims and/or to satisfy patient preferences, other variations reflected healthcare actors' responses to risks arising from a lack of resilience in the existing system. On this basis, the authors outlined suggestions for a resilience-based approach by including awareness in workflow as well as feedback loops for adaptive learning. The authors suggest that IT process support should be designed to prevent process breakdowns with patient dropouts as well as to sustain risk-mitigating performance. Conclusion: Process variation was in part induced by systemised risk mitigation. IT-based process support for monitoring processes such as that studied here should aim to ensure resilience and further mitigate risk to enhance patient safety.