Exploring Collaboration Breakdowns Between Provider Teams and Patients in Post-Surgery Care

Area of Science:

• Health Informatics
• Human-Computer Interaction
• Surgical Care

Background:

• Post-surgery care requires continuous collaboration between healthcare providers and patients, from hospitalization to home recovery.
• Existing research on post-surgery care predominantly focuses on patient challenges at home, with limited understanding of provider coordination during discharge planning and care handoffs.
• Breakdowns in communication and care pathways during discharge can negatively impact patient recovery outcomes.

Purpose of the Study:

• To investigate how healthcare provider teams coordinate discharge preparation and care handoffs for gastrointestinal (GI) surgery patients.
• To identify communication and care pathway breakdowns affecting patient recovery during the transition from hospital to home.
• To explore patient and provider perspectives on discharge and home recovery processes.

Main Methods:

• Conducted semi-structured interviews with 13 healthcare providers and 4 patients involved in gastrointestinal (GI) surgery.
• Analyzed interview data to identify challenges in discharge preparation, care coordination, and patient transition to home recovery.
• Focused on understanding the "invisible work" involved in creating home care plans and triaging patient information.

Main Results:

• Coordination boundaries between inpatient and outpatient teams, along with complex internal team structures, obstructed the preparation of home care plans and patient information triage.
• Patients experienced inadequate preparation for transitioning home and fragmented self-collected data due to these coordination issues.
• Breakdowns in communication and care pathways negatively impacted timely clinical decision-making for patients.

Conclusions:

• Formalizing task ownership and handoffs is crucial for improving discharge coordination.
• Contextualizing co-temporal signals can enhance communication and shared understanding between care teams and patients.
• Aligning care plans with available home resources is essential for successful patient recovery after surgery.