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Background

Efficient use of finite healthcare resources is a central challenge in surgical care. At the same time, perioperative productivity is shaped by organisational conditions that may influence not only efficiency and costs, but also staff work environment and patient-reported outcomes. The overall aim of this thesis was to explore how organisational factors in surgical care relate to productivity, resource use, staff experience, and patient-reported outcomes.

Methods and Results

Study I was a retrospective observational study comparing total case time between two differently organised surgical departments (general surgery and cardiothoracic surgery) at a Swedish university hospital, where the same group of surgeons performed elective surgery for breast cancer and malignant melanoma. After adjustment for patient-, procedure-, and surgeon-related factors, total case time was on average 30.7 minutes shorter at the cardiothoracic department (p<0.001).

Study II was a health-economic evaluation using a bottom-up micro-costing and cost-minimisation approach to compare breast cancer surgery at the same two departments. The cardiothoracic model was associated with lower mean cost per operation, greater procedural efficiency, and shorter simulated waiting times. At the observed annual volume, the point estimate corresponded to an annual cost saving of approximately SEK 681,000, although uncertainty remained around the per-operation cost difference.

Study III used a sequential explanatory mixed-methods design to examine how operating room nurses and anaesthesia nurses at the same two departments perceived productivity and what organisational conditions supported or thwarted a sustainable pace over time. Survey results showed significant between-unit differences in safety climate, stress recognition, and perceptions of management. The interviews identified four cross-cutting categories linked to the three basic psychological needs described in Self-Determination Theory: autonomy, competence, and relatedness. These were predictable workflow and usable tools, psychologically safe teamwork, participatory planning andvisible follow-through, and learning structures for mastery, with workload as a boundary condition.

Study IV was a longitudinal cohort study of 2,906 women using prospective patient-reported outcome measure (PROM) data from the Swedish National Quality Register for Breast Cancer to examine whether patients’ diagnosis-to-surgery lead time was associated with worry about future health. Longer lead time was associated with greater worry about future health (adjusted odds ratio 1.15 per one standard deviation increase; p=0.008), but not with general worry, tension, depressed mood, or overall quality of life.

Conclusions

Taken together, the studies indicate that surgical organisation is associated with perioperative efficiency and costs as well as staff work environment and patient-reported outcomes. Organisational differences were reflected in total case time, resource use, perceived conditions for sustainable work, and patients’ worry during the waiting period before surgery. These findings suggest that surgical productivity should not be understood solely as output or speed, but as a broader organisational phenomenon shaped by structures and processes that are relevant to both staff and patients. Improving surgical care therefore requires attention not only to efficiency, but also to sustainability, coordination, and timely access to treatment.