Bridging the divide between standardisation and individualisation of care to minimise on-the-day surgery cancellations.

Samarasinghe, Buddhika (2025). Bridging the divide between standardisation and individualisation of care to minimise on-the-day surgery cancellations. University of Birmingham. Ph.D.

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Abstract

Reasonably high levels of unintended outcomes (e.g., hospital-acquired infections, delayed discharges, wrong diagnosis, surgery cancellations) in Healthcare Delivery Systems (HDSs) are a global problem. Standardisation of care has been seen as a panacea to minimising unintended outcomes and improving healthcare. Care delivery in modern HDSs has become dominated by various forms of standardised care, such as care pathways, interventions, terminology, protocols, checklists, targets and best practice guidelines. Nonetheless, finding a ‘standard patient’ in a real care setting is hard. Individualised care delivery approaches, careful understanding of patient needs, and individualised diagnoses and treatment plans are fundamental to minimising unintended outcomes and improving healthcare quality.

To understand how standardisation and individualisation of care influence unintended outcomes, the thesis investigates On-The-Day Surgery Cancellations (OTDSCs), a widely reported long-standing problem in Scheduled Surgical Care Systems (SSCSs). An OTDSC is defined as any surgery appointment cancelled on the scheduled day. The study design comprises five phases and uses a realist methodology. The study used a multi-method approach for theory gleaning and refining: incorporating examining literature related to OTDSCs (n=55), findings on the feasibility study including results from eight NHS trusts, two feedback events with patient representatives (n=6), eight expert practitioners (n=8), and 28 semi-structured interviews conducted in a “teacher–learner style” with healthcare professionals.

The iterative analysis identified OTDSCs resulting from clinical reasons as a complex phenomenon dependent on closely connected variables: micro-context (i.e., clinical autonomy), standardised clinical care planning interventions, individualisation of care related to clinical care planning, and behavioural mechanisms (i.e., compassion, self-efficacy, trust and situational awareness). The realist investigation found that OTDSCs resulting from clinical reasons were preventable through minimising tensions between the standardisation and individualisation of care. The study contributes to knowledge by developing a taxonomy and transferable explanations of how and in what contexts OTDSCs, for clinical reasons, are reduced, developing a reporting tool to categorise OTDSCs that can be useful in minimising OTDSCs.

By using findings relating to OTDSCs for clinical reasons, the thesis contributes to knowledge in academic research about the impact on standardisation and individualisation of care in HDSs. The thesis synthesises a theory explaining how individualisation and standardisation of care work together to minimise unintended outcomes that could be used in other HDSs. Behavioural mechanisms activated by the clinical autonomy of clinical actors, namely compassion, self-efficacy and situational awareness, play a vital role in enabling standardisation and individualisation of care to work together.

Despite the polarised nature of standardisation and individualisation of care, the thesis findings are associated with the concept of “individualised standardisation” Despite the significant reliance on standardisation of care, it is not a ‘universal’ or simple solution to minimise unintended outcomes. One of the main recommendations emerging from the study highlighted the need to caution policymakers on over relying on the standardisation of care to minimise unintended outcomes and improve quality instead of maintaining a judicious balance between standardisation and individualisation of care delivery in HDSs.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):