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Enhancements of surgical patient care: perioperative care initiative

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Enhancements of surgical patient care: perioperative care initiative

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Content Running head: PERIOPERATIVE CARE INITIATIVE 1

ENHANCEMENTS OF SURGICAL PATIENT CARE: PERIOPERATIVE CARE
INITIATIVE

by

Alfred Ma

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF EDUCATION

May 2019

Copyright 2019 Alfred Ma

PERIOPERATIVE CARE INITIATIVE 2
Table of Contents
List of Tables 4
List of Figures 5
Abstract 6
Introduction to Problem of Practice 7
Organizational Context and Mission 7
Importance of Addressing the Problem 8
Organizational Performance Status 9
Organizational Performance Goal 10
Stakeholder Group of Focus and Stakeholder Goal 12
Role of Stakeholder Group of Focus 13
Purpose of the Project and Questions 14
Knowledge, Motivation and Organizational Influences Framework 15
Methodological Approach 16
Review of the Literature 17
The United States’ Health Care System 17
Perioperative Fasting Preparations 18
Residency Training 20
Organizational Supports 21
Surgical Residents’ Knowledge, Motivation and Organizational Influences 22
Knowledge Influences 23
Motivation Influences 25
Organizational Influences 28
Conceptual Framework: The Interaction of Knowledge, Motivation, and Organizational
Context 31
Participating Stakeholders: Sampling and Recruitment 35
Recruitment Strategy and Rationale 35
Data Collection and Instrumentation 36
Quantitative Instrumentation and Data Collection 36
Qualitative Instrumentation and Data Collection 37
Data Analysis 38
Results and Findings 38
Quantitative Study 38
Qualitative Study 40
Summary 46
Recommendations for Practice to Address KMO Influences 47
Knowledge Recommendations 48
Organization Recommendations 49
Conclusion 53
References 55
Appendix A: Interview Protocol 68
Appendix B: Credibility and Trustworthiness 71
Appendix C: Reliability and Validity 74
Appendix D: Integrated Implementation and Evaluation Plan 76
Appendix E: Ethics 87
PERIOPERATIVE CARE INITIATIVE 3
Appendix F: Immediate Evaluations (Level 1 and 2) 88
Appendix G: Delayed Evaluations (Levels 1, 2, 3 and 4) 90
Appendix H: Additional Feedback 91

PERIOPERATIVE CARE INITIATIVE 4
List of Tables
Table 1: Organizational Mission Statement and Performance Goal 11
Table 2: Stakeholders and Stakeholders’ Performance Goals 13
Table 3: Knowledge, Motivation, and Organization Influences and Types 30
Table 4: Study Design Chart 37
Table 5: t-Test on Fasting Time Results 39
Table 6: Fasting Time (minutes) 39
Table 7: Summary of Organization Influences and Recommendations 51
Table 8: Outcomes, Metrics, and Methods for External and Internal Outcomes 78
Table 9: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 80
Table 10: Required Drivers to Support Critical Behaviors 81
Table 11: Evaluation of the Components of Learning for the Program. 83
Table 12: Components to Measure Reactions to the Program 84
Table 13: Level 2: During and Immediately Following the Program Implementation 85
Table 14: Level 1. During and Immediately Following the Program Implementation 86

PERIOPERATIVE CARE INITIATIVE 5
List of Figures
Figure 1: Surgical team performance. 34
Figure 2: Boxplot to compare fasting time before and after the APC training. 40

PERIOPERATIVE CARE INITIATIVE 6
Abstract
Prolonged fasting during the perioperative process reflects many problems both in patient
experiences and treatment outcomes that need to be addressed in health care organizations. In
early 2018, one medical center introduced the Accountable Perioperative Care (APC) model to
restructure perioperative practice. The aim of the innovation is to better prepare patients before
surgery by comprehensively communicating the standardization of best practice treatment during
their hospitalization. The study explored resident physicians’ knowledge, motivation and
organizational influences related to implementing the APC. Resident physicians were chosen as
the study population as they are the main work force in teaching medical centers. Under the APC
model of care, residents demonstrated high self-efficacy in providing quality perioperative care
to surgical patients. Residents saw the value of the APC model in improving patient satisfaction
and perioperative outcomes. Residents felt the APC model training was valuable and would like
to champion the process to advocate for better patient care. This study concludes with
recommendations for organizations regarding training on the health agencies guidelines, practice
with the APC model, and supporting stakeholders’ needs.

PERIOPERATIVE CARE INITIATIVE 7
Introduction to Problem of Practice
The following is a question that is commonly heard in a surgical patient waiting room: “I
woke up at 3 this morning to get here at 6 to have my surgery at 9 am. It is now 5 pm. I have not
had anything to eat or drink since 10 last night. I am hungry, worried, and frustrated. What is
going on?” This complaint is reflective of patients’ experiences in public and academic hospitals,
which is the result of inefficiency, lack of empathy, and poor communication. Patients’
experiences are key indicators of health care outcome measures (Manary, Boulding, Staelin, &
Glickman, 2013), and, too often, they are ignored during medical practice (Timmermann,
Uhrenfeldt, & Birkelund, 2017). Fasting is mandatory prior to surgery (Engelhardt, & Webster,
1999), yet, if prolonged, it can result in unnecessary harm to patients and lead to their subsequent
dissatisfaction (Nygren, 2006). The purpose of this study was to determine surgical residents’
knowledge, motivation, and organizational influences needed to mitigate the harm of prolonged
fasting.
Organizational Context and Mission
As one of the remaining county-operated health care facilities, Summer Valley Medical
Center’s mission is to provide superior quality care to Summer Valley County residents with a
special focus on individuals and populations in need. Summer Valley Medical Center will be the
leading academic health system in the region and recognized for transforming care. The medical
center's core values of innovation, collaboration, accountability, respect, and excellence are the
roadmap to organizational mission and vision. These five values convey the philosophy behind
every decision that Summer Valley Medical Center’s leadership and employees make. This
translates into a dedication shared by all members of the community to provide the highest
quality patient care.
PERIOPERATIVE CARE INITIATIVE 8
Summer Valley Medical Center (pseudonym) is in the City of Summer Valley
(pseudonym), centrally located and accessible for all areas of Summer Valley County
(pseudonym) California. The medical center is a teaching hospital accredited by the Joint
Commission and offers training programs for nursing students, medical residents, and allied
health professionals. The medical center is a 500,000-square foot tertiary care facility, licensed
for a total of 400 beds and has 12 operating rooms. There are also adult, pediatric, and neonatal
intensive care units, and a birthing center. The medical center has the capacity to manage
200,000 patient visits in specialty outpatient clinics, and the emergency room/trauma unit has the
capacity to manage 100,000 patient visits annually.
Importance of Addressing the Problem
Initiating and implementing change at a health care organization is an extremely difficult
and complex task. Recent studies show that change resistance is not a norm (Ford, Ford, &
D’Amelio, 2008), yet 70% of major change transformation programs in organizations do not
achieve the objectives they were implemented to achieve (Wiseman, Eseonu, & Doolen, 2014).
People are fearful of the unknown and of lack of choice, causing change to be difficult (Jones,
2016).
In the United States, most health care organizations are still hierarchical and autocratic
(Szekendi et al., 2014). Many workers at all levels do not feel supported or appreciated, and
highly trained professionals work side by side but not together (Isosaari, 2011). This culture is
not conducive to the team-building and collaboration needed to make health care safe. On the
day of surgery, given the unpredictable nature of operating room scheduling and delays, patients
may find themselves anxiously waiting and fasting longer than expected, which often results in
patient dissatisfaction and stress of clinical significance (Brands, Hockey, Sced, & Brennan,
PERIOPERATIVE CARE INITIATIVE 9
2017). However, most surgeons continue to adhere to the tradition of fasting after midnight that
is outdated according to the most recent guidelines (Hamid et al., 2014). Efficient time
management in the operating room helps to give a more predictable fasting time to improve
patients’ experiences. Better communication between stakeholders as well as scheduling realistic
procedure times can help resolve these delays (Murphy, Ault, Wong, & Szokol, 2000).
Due to uncertainty created by the changing nature of delivery services, health care
industry, particularly government-owned hospitals, acknowledge that it will be necessary for
organizations to continually re-evaluate the services provided by some departments.
Government-owned organizations face continuously limited access to capital, and their
operations are also hindered by physician shortages, risk assumption, increasing costs, and
increased payor leverage to name a few.
Organizational Performance Status
As a safety-net hospital and an organization that provides a significant level of care to
low-income and vulnerable populations, Summer Valley Medical Center (SVMC) is a level II
trauma center providing both adult and pediatric trauma services. The medical center is home to
five different specialty residency programs: anesthesiology, general surgery, orthopedics,
internal medicine, and family medicine. SVMC’s operating rooms use block scheduling, where
individual surgical services are assigned to use a number of operating rooms during a certain day
or days of the week. A master operating room schedule is developed on a daily basis. SVMC’s
current perioperative surgical care model is highly fragmented and depicted by average fasting
time double that required in perioperative guidelines. At SVMC, like most teaching health care
organizations, the surgeons’ lack of conceptual knowledge and understanding of perioperative
patient care arrangements is the root cause of present inefficiencies (Regan, Kashiwagi, Dougan,
PERIOPERATIVE CARE INITIATIVE 10
Sundsted, & Mauck, 2017). A previous perioperative care audit demonstrated that average
fasting time at the SVMC was 15 hours. At SVMC, the most commonly cited reason for
disciplinary actions is unprofessional provider behavior rather than insufficient clinical skills. On
many occasions, patients report communication issues as the main reason for pursuing litigation.
The Perioperative Surgical Home Care (PSHC) is a team-based model of care
coordination designed to guide patients through the complete surgical experience, starting with
the decision to undergo surgery and concluding with discharge and return to function (Schimpff,
2007). The PSHC model also promotes communication between care takers and strengthens
continuity of care during the treatment process (Grocott & Pearse, 2012). The PSHC model is a
patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient
care (Spruce, 2015). It is an initiative developed by the American Society of Anesthesiologists
(ASA) and Premier Inc., intended to help physicians retain an emphasis on value, patient
satisfaction, and reduced costs (Cannesson & Kain, 2015). Over the last decade, the development
of the PSHC model of care attempts to decrease the rate of surgical morbidity and mortality by
expanding the anesthesiologist specialty as the surgical patient’s gate keeper, thus becoming a
vital provider from the patient, administrator, and payer perspectives (Grocott & Pearse, 2012).
Unfortunately, at the SVMC, implementation of the PSHC delivery model met with difficulty,
and there are many barriers to the application of this model, which include conflicting financial
interests of surgical specialties and human resources for team development.
Organizational Performance Goal
Building an individualized relationship between patients and health professionals through
tailoring communication of information improves patients’ satisfaction. The current focus of
incentive payment has put the demand on value and quality, which, together, resulted in hospitals
PERIOPERATIVE CARE INITIATIVE 11
constantly looking to improve and maintain high patient satisfaction to compete in the industry.
Thus, the goal for every hospital is to deliver high-value health care with quality outcomes
produced at low cost.
On April of 2016, SVMC tasked clinical leaders of different surgical service lines to
develop multi-disciplinary best-practice pathways to improve patient care and satisfaction. In the
operating room, this goal was achieved by transitioning to a newly developed Accountable
Perioperative Care (APC) model (derived from the PSHC model of care) in early 2018. In
practice, what this means is that, when the decision is made for a patient to undergo surgery, the
patient is placed on a plan for communication regarding all areas of their care. This aim is to
better prepare patients before surgery by comprehensively communicating the standardization of
best-practice treatment during their hospitalization. The overarching organizational goal of the
APC model is to ensure that communication is efficient and effective during perioperative
processes. As such, better scheduling practice and elimination of surgical delays can reduce
prolonged perioperative fasting to improve patients’ satisfaction. Table 1 identifies the
organizational mission and organizational performance goals.
Table 1
Organizational Mission Statement and Performance Goal
Organization Mission Statement
The mission of the Summer Valley Medical Center is to improve the health of the individuals
and diverse communities we serve through the integration of outstanding patient care,
education, research, and community partnerships.
Organizational Performance Goal
The overarching organizational goal of the APC model is to ensure that communication is
efficient and effective during perioperative processes. In such, better scheduling practice and
elimination of surgical delays can abolish prolonged fasting during the processes.
Stakeholder Goal
By April 2018, surgical residents will implement the APC model to achieve 100% compliance
for a perioperative fasting time not to exceed 10 hours and improved patient satisfaction
outcomes.
PERIOPERATIVE CARE INITIATIVE 12
Stakeholder Group of Focus and Stakeholder Goal
Although a complete analysis would involve all stakeholder groups (administrations,
patients, attending physicians, and residents), for practical purposes, the stakeholder group of
focus for this dissertation is the residents. The reason for selecting residents is that they are the
work force in teaching hospitals and have the first-line duty to know and be responsible for
rendering direct care on many medical issues. Residents have clear insight on many patient care
activity processes, both positive and negative.
In medicine, residency is a stage of clinical education. A resident is a medical school
graduate accepted to a resident teaching program in their preferred specialty and practice
medicine under the direct supervision of an attending physician. A senior resident is in his or her
last year of training in the program and is capable of both supervising junior residents’ activities
and conducting administrative management in the department.
Resident physicians are the main work force in teaching medical centers, and motivated
resident physicians are key parts of high-quality health care delivery at SVMC. Surgical
specialties are constantly busy; it is, therefore, difficult for surgical residents to handle both the
preparation of surgery and performing the surgery. With the APC model, patient preparation is
delivered through constant communication between operating room personnel and the surgical
resident to assure the appropriateness of scheduled orders. The APC model initiative is meant to
educate and motivate surgical residents to effectively adhere to the ASA fasting guidelines and
subsequently reduce morbidity among surgical patients. This study was designed to examine the
surgical residents’ knowledge, motivation, and organizational influences related to achieving the
organization’s goal of improving perioperative patient care and experiences. Perioperative
fasting time is a viable indicator of surgical residents’ motivation, metal effort, and empathy in
PERIOPERATIVE CARE INITIATIVE 13
this study. Currently, ASA guidelines set perioperative fasting at 8 hours. The goal of
stakeholders in this study is to promote perioperative care efficiency by attaining 100%
compliance for a perioperative fasting time not to exceed 10 hours (Table 2).
Table 2
Stakeholders and Stakeholders’ Performance Goals

Role of Stakeholder Group of Focus
Resident physicians commonly work 80 hours a week to prepare patients and take part in
surgical interventions (Asch, Bilimoria, & Desai, 2017). Scheduling surgery is the responsibility
of resident physicians. They coordinate the surgery schedules with attending physicians, patients,
operating room availability and with anesthesia providers. Thus, motivation of resident
physicians to engage in the APC model was a key component in the success of the initiative.
Resident physicians’ learning attitudes are significantly influenced by their supervisors. The
attributes of clinical supervisors in the program could significantly impact the outcomes of
training and patient care in an academic medical setting (Rosenstein & O’Daniel, 2008). The
successful implementation of a process requires both motivation and accountability by the
resident physicians. Because surgical specialties are constantly busy, it is difficult for surgical
departments to handle both the preparation of surgery and conducting the surgery. With the
newly proposed APC model, surgical services had the option to op-out patient’s preparation and
Transformation Officer Surgical Residents
By December 2017, the Training Program
Director will complete the development of the
Accountable Perioperative Care (APC)
learning plan and begin the training for 100%
of operating room administrators and surgical
residents to familiar with the initiative.
By April 2018, surgical residents will
complete the training on the APC model and
participate in the implementation of the APC
model to achieve 100% compliance for a
perioperative fasting time not to exceed 10
hours.
PERIOPERATIVE CARE INITIATIVE 14
optimization. The APC team then assumed the responsibility of perioperative patient preparation
and communication.
Purpose of the Project and Questions
Traditionally, the United States health care system has prioritized the interest of
physicians over that of patients. Institutions would cater to physicians to boost their market share
(Aveling, Parker, & Dixon-Woods, 2016). Thus, the traditional calculation for an institution was
a balance between physician satisfaction and operational efficiency, which ignored patient needs
and comforts.
Too often, we, as operating room personnel, witness patient frustration, anxiety, and
anger with operating room delays. According to Mendelson (1946), prolonged fasting may alter
medication absorption and have an adverse impact on high-risk patients. This is particularly true
for babies and elderly patients, who may become dehydrated, hypoglycemic, hypovolemic or
experience other adverse metabolic reactions from prolonged fasting (Søreide & Ljungqvist,
2006). These changes in medical condition may result in occasional cancelation of surgeries and
significantly affect the daily scheduling of operating rooms and surgeons’ practices. This study
was designed to show the fasting time patients must endure on the day of surgery at SVMC and
the reflection of fasting time to the consideration of good clinical practices. As patient
satisfaction is a key determinant of care quality and a key component of the Patient Protection
and Affordable Care Act’s pay-for-performance metric, the duration of fasting can be a good
measurement of medical care quality, institution efficiency, and patient satisfaction.
At SVMC, surgery delays often occur in the operating room and have a significant effect
on patient flow and resource use. Many times, cases are canceled and re-scheduled because there
is simply not enough time left in the day to finish them (Chon, Ma, & Mun-Price, 2017). There
PERIOPERATIVE CARE INITIATIVE 15
are no consequences for surgeons for delaying or canceling surgery due to poor scheduling and
planning. Again, as patient satisfaction is a key determinant of care quality included in Joint
Commissions metrics, the following questions guided the study:
1. What are the surgery residents’ knowledge and motivation related to implementing the
APC model to achieve 100% compliance for a perioperative fasting time not to exceed 10
hours?
2. What is the interaction between the organization and surgery residents’ knowledge and
motivation to implement the APC model to achieve 100% compliance for a perioperative
fasting time not to exceed 10 hours?
3. What is the recommended knowledge, motivation, and organizational solutions?
Knowledge, Motivation and Organizational Influences Framework
In order to explore stakeholders’ performance in implementing the APC model, this study
employed Clark and Estes’ (2008) gap analysis framework. Clark and Estes suggest that
measuring the gap between benchmark and current performance is critical for supporting
organizational performance. The framework for performance improvement strategies involves
examining stakeholders’ knowledge, motivation, and organizational influences. Stakeholders’
knowledge contains clear understanding of functional skill sets (factual, conceptual, and
procedural) and cognitive development (Cooke, 2016; Klehe & Anderson, 2007). Along with
knowledge, stakeholders also need the motivation to engage with tasks in the context of their
goals. Too often, stakeholders are more likely to assume others are like them when thinking
about their own groups (Robbins & Krueger, 2005). Thus, organizational influences play a
crucial role in ensuring worker morale and motivation. This study explored surgical residents’
PERIOPERATIVE CARE INITIATIVE 16
knowledge, motivation, and organization influences related to the implementation of the APC
model of care.
Methodological Approach
Research methodology is a strategy to postulate the logic or master plan of research,
which includes methods of data collection and analysis (McEwan & McEwan, 2003). The
strategy is an attempt to answer the underlying assumptions of the research question. There are
many distinct ways of conducting research; the most common methods for conducting research
are quantitative, qualitative, and a mix of both (Creswell, 2014). This study utilized mixed
methods in explanatory sequential design.
Mixed methods research involves collecting, analyzing, and mixing both quantitative and
qualitative data in a study or series of studies. The aim is to provide a better understanding of
research problems than can be presented using either approach alone (Creswell, 2014). When
one approach to data analysis is not enough to explain the initial results, a second method is
needed to enhance the primary approach, and the project then has multiple phases. Explanatory
sequential design is quantitative analysis followed by qualitative explanations (Ivankova & Stick,
2007). In this study, quantitative data were used for the purpose of triangulation to increase the
credibility and validity of the results and to strengthen the qualitative section of the study. This
study examined the feasibility of the APC model to reduce perioperative fasting time to under 10
hours through Clark and Estes’ (2008) gap analysis model, which asserts that deficits in
performance are the result of lack of knowledge, lack of motivation, and organization behavioral
barriers.
In this study, under the newly assembled APC initiative, one month of orthopedics’
surgery surgical patients’ fasting data were collected and compared quantitatively between
PERIOPERATIVE CARE INITIATIVE 17
before and after training of the initiative to determine if the APC model mitigates prolonged
fasting time. Residents’ experiences during training and implementation of APC model were
qualitatively evaluated by interviews of orthopedics senior residents.
Review of the Literature
The US health care scape has evolved dramatically in the last decade to counter the need
of access and ever-rising costs of health care. In this section, I will discuss the United States
health care system and health care organization. I will also review the elective surgical
preparation practices and the role of resident physicians in surgical services at academic teaching
medical organizations. I will discuss further the necessary knowledge, motivation, and
organization influences that are required to improve performances in these organizations alike.
The United S tat e s’ Health Care System
The foundations of the United States health care system are shifting to new models of
care. In 2008, the Institute for Healthcare Improvement focused attention on three aims:
improving the patient care experience, moving beyond the individual to improve the health of
populations, and reducing per capita cost (Berwick, Nolan, & Whittington, 2008). To achieve
these aims, communication and accountability are key. Recently, to promote change,
organizations have paid more attention to professional development of their medical staff (Nica,
2015). This training has included knowledge and skills outside their medical competencies, and
concentrated on understanding organizational goals, job performance and responsibilities
(Brown, Belfield, & Field, 2002). Health care is unique in part because patients cannot easily
observe the quality of care they receive (Collier, 2015). To think about quality, patient safety is
antecedent to health services and needs responsible providers to better inform and communicate
with patients.
PERIOPERATIVE CARE INITIATIVE 18
Patient safety has become a key driver on health care quality (Schimpff, 2007). As
medicine intersects with information technology in recent decades, it has been found that many
patients were being harmed during the process of treatment (Classen et al., 2011).
Professionalism underlies the notion that physicians ought to serve as agents for their patients,
regardless of their economic interests and that they have a duty to deliver high-quality care
(Mason, 2017). To provide a good patient experience, the organization must have processes to
properly coordinate delivery of care (Manary et al., 2013). In health care, accountability seems
straightforward, but it is accompanied by a high degree of complexity.
Perioperative Fasting Preparations
Proper preparation of patients undergoing surgical procedures may include patient-
centered shared decision-making, proper and timely obtainment of informed consent,
standardized acknowledgement of surgical site, and accurate transfer of surgical information.
These components can only be achieved by effective team communication and coordination.
There is a wealth of scholarship on patient-focused care delivery systems, especially in operating
room management, generated in the past decade (Cook et al., 2014). The efficiency of
operational management in the operating room is critical for both health organization and
provider productivity (Crenshaw & Winslow, 2002).
The practice of fasting prior to surgery began with Dr. Curtis Mendelson’s observation in
1946. He reported that surgery patients who ingested food shortly before surgery were more
likely to regurgitate their stomach contents with severe consequences (Mendelson, 1946). The
practice of fasting patients for a period of time preoperatively is based on the premise that fasting
allows time for gastric emptying to occur, thereby reducing the risk of aspiration pneumonitis
during anesthesia. While prolonged fasting time is not better or safer, it could cause an increase
PERIOPERATIVE CARE INITIATIVE 19
gastric pH that may result in significant pneumonitis if aspirated (Engelhardt & Webster, 1999).
Fasting can have short-term side effects even in healthy people, such as headaches, dizziness,
abnormal heart rhythm and low blood pressure (Søreide & Ljungqvist,, 2006). Improper fasting
instructions before surgery can lead to lack of compliance with preoperative fasting orders
because of the discomfort that ensues. Fasting can also raise the risk of an attack in people with
gout and worsen the symptoms of gallstones (Nygren, 2006). Fasting can quickly result in
dehydration and require fluid replacement during anesthesia in addition to potential replacement
of blood lost during surgery (Nygren, 2007). Dehydration and blood lost during surgery reduce
blood volume and alter drugs’ kinetics, which can lead to more side effects (Anastasio, Cornell,
& Menscer, 1997).
Standard preparation for many surgeries requires patients to fast. Patients are instructed
that nothing should be consumed by mouth past midnight on the day of their scheduled surgery
to avoid the possibility of pulmonary aspiration of stomach contents during surgery (Maltby,
2006). In 2011, the ASA (2011) published an updated version of anesthesia practice guidelines.
The purpose of the guidelines was to enhance the quality and efficiency of perioperative care,
stimulate evaluation of clinical practices, and reduce the severity of complications related to
perioperative pulmonary aspiration of gastric contents. The intended patient populations for these
guidelines are limited to healthy patients of all ages undergoing elective procedures. From the
ASA’s 2011 guidelines, highlighted recommendations for perioperative assessment were a
thorough history, examination, and interview that includes pertinent assessment of
gastroesophageal reflux disease, dysphagia symptoms, and other gastrointestinal motility
disorders; potential for difficult airway management; and metabolic disorders (i.e., diabetes
mellitus) that may increase the risk of regurgitation and pulmonary aspiration. Patients should be
PERIOPERATIVE CARE INITIATIVE 20
informed of fasting requirements sufficiently in advance of their procedure. Verification of
patient compliance with fasting requirements should be assessed at the time of their procedure.
Mandatory fasting before surgery is not only clinically critical, it is also a good reflection
of patient education, communication, and provider-patient relationship. Again, fasting is crucial
prior to elective surgery, yet, if prolonged, can result in harm and lead to patient dissatisfaction
(Nygren, 2006). In an academic teaching medical center, such practice is part of the many
responsibilities resident physicians need to follow.
Residency Training
Specific knowledge, skills, behaviors and attitudes and educational experiences are
required of residents to complete specialty graduate medical education programs. These include
patient care, medical knowledge, practice-based learning and improvement, interpersonal and
communication skills, professionalism, and system-based practice. The United States residency
training programs have more than 100 years of history, yet innovation in clinical education has
been ignored for many years, and training styles remain that of the original (Harding, Akabas, &
Andersen, 2017). Factors related to the success of clinical training include the trainee’s mental
effort, motivation and character, clearness of mission and follow-up of knowledge transferred
(Grossman & Salas, 2011). Unfortunately, residency programs often formed for wrong reasons
(Lloyd & Kriegerlos, 1997). Often, residency training programs form due to the potential cost
saving of using resident physicians for demanding clinical work. Not only is the intention
problematic, but assessment of knowledge transferred and motivation is not adequately
monitored. It is well known that, despite established policies and standards, patient care and
experiences continue to suffer (Saddawi-Konefka, Schumacher, Baker, Charnin, & Gollwitzer,
PERIOPERATIVE CARE INITIATIVE 21
2016). Patients’ experiences are a key indicator of health care outcome measures (Manary et al.,
2013), and, too often, this is ignored during medical practice (Timmermann et al., 2017).
Organizational Supports
The U.S. health care landscape has evolved dramatically in the last decade to counter
rising costs and access needs (Organization for Economic Co-operation and Development,
2012). Today’s political environment creates many uncertainties in the health care industry
(Oberlander, 2018). Sustaining operational survival and balancing revenue with the cost of doing
business has become the priority in health care organizations (Traynor, 2018). Fresh thinking is
required to compete in the market place. In the past, health care innovation was often attached to
clinical functions and rarely involved managerial insights (Hage & Hollingsworth, 2000). In
recent years, clinical leaders have recognized that operational innovation is governed by a
different set of rules than the everyday clinical practice (Lang, 2018). Many physicians tackle
these challenges by obtaining business administrative education and training, yet the value added
by such efforts were not fully recognized.
Beyond motivating change for success under the APC model, leaders can shift surgeons’
motivational paradigm by focusing on reducing cost, improving quality and reshaping the
dynamics of surgeon motivation away from a traditional volume-driven fee-for-service payment
system toward a broader range of motivators, including greater mastery of clinical medicine and
social purpose in meeting patient needs (Judson, Volpp, & Detsky, 2015). It is the self-motivated
sense of purpose that drives physicians to join academic medical organizations. It is the sense of
mission that attracts physicians to these organizations (Grant & Hofmann, 2011). However, too
often, the cultural model of most academic medical organizations masks that purpose
(Bunderson & Thompson, 2009). Maintaining that line of sight, reinforcing, and recognizing the
PERIOPERATIVE CARE INITIATIVE 22
purpose, and helping stakeholders with their roles reconnect everyone with that purpose
(Cerasoli & Ford, 2014).
To sustain stakeholder’s high level of engagement, maintaining intrinsic motivation,
sense of purpose, relevancy, and meaning is critical. Balancing intrinsic motivation with
extrinsic motivating forces to align with goals and rewards is also critical (Johnson, Nguyen,
Groth, & White, 2018). One of the most common problems in organizations is that rewards are
not aligned with desired behavior. Organization should not ignore social comparison and fairness
concerns to ensure that stakeholders feel fairly treated.
Surgical Re sid e n ts’ Knowledge, Motivation and Organizational Influences
Medicine is a profession and a culture that is considered defensive and intolerant of
mistakes (Bakanas, 2013). It is, therefore, unusual for surgeons to admit if there is, for example,
a scheduling error which results in case cancelation and requires rescheduling. To improve the
performance of patient care in surgery, adopting a new initiative, such as the APC model, is
critical. The use of fasting status provides an accurate measure of patient experience, patient
safety, and operational efficiency. Residents’ knowledge and motivation have significant practice
implications for the perioperative medical care of surgical patients. Due to the multi-disciplinary
nature of the residency training, performance in perioperative care of patient is challenging.
Organizational culture influences and shapes residency training programs and, ultimately, the
care of patients. Organizational supports are deemed useful by residents in developing value,
teamwork and leadership skills during the training.

PERIOPERATIVE CARE INITIATIVE 23
Knowledge Influences
Education is the key purpose of residency training. Through this educational process, the
residents gain the knowledge and practical clinical skills of medicine. Senge (1999) defines
knowledge as the ability to make effective decisions and take effective action. In health care,
proper preparation of patients undergoing a surgical procedure may include patient-centered
shared decision-making, proper and timely obtaining of informed consent, standardized
acknowledgement of the surgical site, accurate surgical information transfer, and effective team
communication and coordination (Contono, 2004). Thus, clinical skills and non-clinical
knowledge are both important within the process of perioperative care.
To engage in the APC model, residents require knowledge and skills in the subject matter
and in responsibly performing the task. This knowledge includes factual knowledge of
terminology related to the APC model, conceptual knowledge of fasting guidelines, knowledge
of skills involved and steps necessary to implement the APC model. Lastly, residents require
willingness and insight regarding perioperative processes. Assessing value of learning through
surveys provides insight into participants’ performance on tasks and reflection on satisfaction
and mental effort (Deveney, 2015).
Factual knowledge. Factual knowledge, in this study, refers to the basic elements and
major facts of the APC model. Such knowledge requires the external resources in the form of
structured training and the internal resource of self-learning. Implementation of initiatives should
be aligned with the organization’s policies and procedures (Wachter, 2013), and use of data
should be transparent for the sustainability and spread of the initiative (Vetter, Barman, Hunter,
Jones, & Pittet, 2016).
PERIOPERATIVE CARE INITIATIVE 24
Conceptual knowledge. Most knowledge structures require conceptual elements, which
is an organized form of knowledge that, usually, can be compared (Krathwohl, 2002). These
elements are key to the understanding the construction of useful new knowledge from experience
and prior knowledge (Arslan, 2010). Ability to provide evidence and generate examples of the
APC model concepts reflects understanding and use of knowledge. In order to implement it
effectively, residents are required to know the benefits of the APC model. This is important for
resident buy-in to the perioperative change process. Information and education sessions are
required for residents to familiarize themselves with the implications of the APC model.
Procedural knowledge. Procedural knowledge is the most critical part of performance.
Procedural knowledge can be mechanical, which involves sometimes only memorizing
operations without understanding underlying meanings (Arslan, 2010). This is knowledge of how
and the skills necessary to perform a task (Rueda, 2011). The development of the APC model
involves numerous policies and procedures to align with guidelines provided by regulatory
agencies. Implementors of the APC model are required to be familiar with step-by-step
procedural knowledge, both to disseminate information and to execute the APC model of care.
Metacognitive knowledge. The term “metacognition” was a coined by John Flavell
(1979) and consists of both metacognitive knowledge and metacognitive experiences or
regulation (Flavell, 1979). Metacognition refers to higher order thinking, which involves active
awareness and control over the cognitive processes engaged in learning. This type of knowledge
includes self-knowledge and knowledge and awareness of one’s own cognition (van Velzen,
2012). Metacognitive knowledge can be divided into three variables on behalf on learning
processes. First, person variables include how one views oneself as a learner and thinker.
Knowledge of person variables refers to knowledge about how one learns and processes
PERIOPERATIVE CARE INITIATIVE 25
information as well as individual knowledge of one’s own learning processes. Second, task
variables include knowledge about the nature of the task as well as the type of processing
demands it will place upon the individual. It is about knowing what needs to be accomplished
and knowing the kind of effort it will demand. Third, strategy variables involve awareness of the
strategy used in learning a topic and evaluating if it is effective. Metacognitive knowledge is
knowledge of general strategies used for different tasks (Pintrich, 2002). This is a particularly
important knowledge type for the development of the APC model initiative.
Residents within the APC model are highly educated and heavily invested in clinical
knowledge and skills that sometimes blind them from learning other knowledge. Providing
residents with direction in order to engage self-knowledge in learning new knowledge become
key to the success of the APC innovation. Surgical staff and residents need to have
comprehensive knowledge of perioperative preparation and fasting protocol to better prepare
patients for elective surgery. It is critical for residents to manage the time that can be utilized
during the perioperative period and schedule elective surgeries accordingly. Efficiently
managing the time of surgery allows appropriate fasting time schedule and avoids prolonged
patient suffering.
Motivation Influences
The APC model requires residents to change how they deliver care. This is particularly
true at SVMC due to the growing number of surgical patients’ dissatisfaction reports and the
apparent loss of market share. Learning how the APC model motivates residents to make such
changes is, therefore, of immense importance at SVMC. Why is motivation important for
education? In learning, outcomes are predicated on a motivated learner interested in engaging
with learning activities until they accomplish the goals (Tennyson & Rasch, 1988). One way to
PERIOPERATIVE CARE INITIATIVE 26
think about motivation is that it is not about learning per se but, rather, a prerequisite for learning
(Bandura, 2000). In the context of this study, without motivation, no resident will engage in the
learning that brings them into the APC model training session.
Extrinsic and intrinsic motivation. As health care financing evolves toward
reimbursement schemes in which physicians assume risk (Judson et al., 2015), there are
important questions to consider regarding the balance of extrinsic motivators (financial
reimbursement or other forms of recognition such as awards) and intrinsic motivators (personal
satisfaction or internal desire to achieve an objective). By default, physicians have little to no
control over the extrinsic return, which is mostly controlled by the payors in the form of
contracts and agreements. The industry’s current strategies to generate improvements, such as
pay-for-performance, suggest that focusing on clinicians’ self-determination can help improve
quality in health care delivery.
Motivation can be viewed as intrinsic and extrinsic. Perkins’s (1993) four elements of
effective pedagogy are clear information, thoughtful practice, informative feedback and
fundamental to any good learning environment is intrinsic and extrinsic motivators or either
(Perkins, 1993). An instructor can shape learners’ motivation extrinsically by offering incentives
or punishments to incentivize or disincentive learner’s behaviors. Intrinsic motivation comes
from within. It is self-motivation to pursue things that interest the learner. Here, administration
of the APC model can provide residents with external motivation by rewarding them with, for
example, additional free time to study, and ensure alignment of rewards with performance.
Self-determination to perform. Achievement goal theory is a descriptive theory of how
learners motivate and orient themselves towards performance (Senko, Hulleman, &
Harackiewicz, 2011). There are two basic orientations: mastery orientation and performance
PERIOPERATIVE CARE INITIATIVE 27
orientation. The goal of mastery orientation is to master the material, and the goal of
performance orientation is either to perform adequately or to avoid performance altogether,
which is performance avoidance orientation, to avoid failures (Treasure & Roberts, 1995).
Residents involved in the APC model need to be familiar with the knowledge to conduct the task
and efficacies to achieve the goal. They need to know that closing the gap between current
perioperative fasting time and that outlined in the guidelines is an asset rather than a prerequisite
to make a good impression of their superiors.
Self-determination motivation was developed first by two scholars at the University of
Rochester, Ryan and Deci (2000), and is studied broadly for how it is related to learners' intrinsic
versus extrinsic motivation (Ryan & Deci, 2000). Self-determination theory consists of three
major components: a learner's sense of autonomy, sense of belongingness, and sense of
competence. In this sense, autonomy component is putting some of the sense of agency and
choice on the learner, as opposed to having a learning environment designed with the instructor
as the sole determiner of how learning occurs (Orsini, Evans, Binnie, Ledezma, & Fuentes,
2015). As learners gain more knowledge, allowing them to create tasks or design assignments
will provide them and their peers a chance to demonstrate the tasks or assignments’ value both
individually and as a team. Involving the residents from the beginning of the APC model design
provided them with a sense of ownership. This sense of value and autonomy provides residents
with the drive to ensure the success of the APC model.
The second element mentioned here is belongingness or relatedness (Coffey, 2012).
Residents thrive in a social context and feeling like they are a part of a professional community
can create the sense of support they need to thrive and to feel motivated. Sometimes, this feeling
PERIOPERATIVE CARE INITIATIVE 28
is set up as accountability to their calling. Having residents feel like they are part of a
professional sphere with similar goals can nurture their intrinsic motivation.
The third component is competence. Learners need to feel a challenge, but a challenge
that is achievable, a stretch goal that comes with the supports they need (Deveney, 2015). This is
about giving residents realistic and authentic feedback about their performance during
implementation of the APC model and allowing residents to see how every effort, even if it is a
failure, will get them closer to their goal. Failure is an important part of the learning process and
is an indication that residents are trying to implement the APC model.
Feedback is part of the sense of competence. It gives learners choice in how they
demonstrate their learning because that gives them a chance to recover from failures (Shweiki et
al., 2015). Feedback is just as important, if not more important, as it is in a traditional classroom
because the learners actually pay much attention to it. During the implementation of the APC
model, communication with the residents in the form of feedback can be short and needs to be
timely. It is essential to have a feedback process that is specific and actionable (Diehl & Sterman,
1995). Often, quick feedback can be as impactful as longer marginal comments on a paper. This
study explored participants’ willingness to take part in the initiative, commitment to the initiative
and self-efficacy in terms of factors related to the initiative.
Organizational Influences
Change requires the support of the organization. The APC model of care needs to break
away from the status quo of practice, which is deeply rooted in most health care organizations. In
the process, the organization needs to constantly align communication between administrators
and clinical providers on the organization’s vision as a foundation for reducing fasting time and,
through that, improving patient care. Organizations need to focus both on measurable elements
PERIOPERATIVE CARE INITIATIVE 29
such as resources and processes and to people-oriented determinants of the culture, which are
more difficult to measure (Loewe & Dominiquini, 2006).
Breaking the status quo. Cultural-model influenced behavior among health care
providers has been linked to patient safety and outcomes (Samenow, Worley, Neufeld, Fishel, &
Swiggart, 2013). High-stress locations within the organizations, including the perioperative
setting, are especially prone to disruptive physician behavior (Small, Porterfield, & Gordon,
2015). Balancing extrinsic and intrinsic motivations allows for leveraging the need for status,
value of autonomy, and meaning of work that providers demand (Grant & Hofmann, 2011).
Though most health care professionals are motivated extrinsically (income, recognition, and
status), residents are generally intrinsically motivated, such as by valuing a learning opportunity
and personal altruistic intent. Thus, it is important that the organization provide residents with an
encouraging environment to pursue the success of initiative improvements.
In health care, there is professional purpose and a moral duty that physicians rely on, and
they, therefore, support academic medical organizations (Grant & Hofmann, 2011). Too often,
however, the cultural models of most academic medical organizations do not take that purpose
into account (Bunderson & Thompson, 2009). To sustain residents’ high level of engagement,
maintaining intrinsic motivation, such as a sense of purpose, relevancy, and meaning, is critical.
Balancing intrinsic and extrinsic motivation is beneficial, as one of the most common problems
in organizations is that rewards are not aligned with desired behaviors. In addition, organizations
should not ignore social comparison and fairness concerns.
Setting the stage. The systems improvement goals of the APC model are to increase
operating room efficiency, enhance patient safety and experience, improve surgical outcomes,
and meet the future goals of coordination before and after surgery. While strong organizational
PERIOPERATIVE CARE INITIATIVE 30
supports are beneficial for development and implementation of the APC model initiative, many
environmental influences, levels of ability, and cultural backgrounds should be taken into
consideration when designing the stakeholders’ learning environment (Samenow et al., 2013).
Clinical leaders’ professional competencies require cross professional knowledge, such as
business knowledge and skills (Garman, Burkhart, & Strong, 2006). Application of these
competencies is relevant to executive level management positions but is distant and very limited
for clinical leaders. Incorporating business knowledge and skills competency during training of
the APC model initiative can be beneficial for residents to gain business perspective and
proactively contribute to management of the APC model. An organizational culture setting that
empathizes with employees is helpful to promoting new innovations that can improve patients’
satisfaction and treatment outcomes.
Table 3 presents a description of the knowledge, motivation, and organizational
influences that are relevant to residents and their ability to retain the information necessary to
safely execute the APC model. The intent of the table is to categorize the influences that directly
affect the residents and their ability and desire to learn and retain the knowledge.
Table 3
Knowledge, Motivation, and Organization Influences and Types
Knowledge Types Knowledge Influences
Declarative Surgical residents need to understand the difficulties facing the
organization, especially in the surgical arena.
Declarative Surgical residents need the knowledge of the functionality and
conceptual foundation of the APC model.
Procedural Surgical residents need to know the American Society of
Anesthesiologists perioperative fasting and perioperative
evaluations guidelines.
Metacognitive Surgical residents need to know how to reflect on their own
effectiveness under the guidelines on organizational altruism,
empathy, and ethical policies.

PERIOPERATIVE CARE INITIATIVE 31
Table 3, continued
Motivation Variables Motivation Influences
Efficacy Surgical residents need to feel confident about their ability to
accurately implement both physical and psychological
preparation of patients prior to surgery and fully confident to
advocate the activity through the APC model of care.
Value Surgical residents need to value the benefit of the APC model to
achieve better perioperative patient care goal.
Organizational Variables Organizational Influences
Culture Model Influence/
Organizational Culture
Change requires the support of organization. The APC model of
care needs to break away from the status quo of practice, which
is deeply rooted in the organization.
The organization needs to constantly align communication
between administrations and clinical providers on organization’s
vision as a foundation for reducing fasting time and through
that, improving patient care.
Culture Setting Influence/
Resources
The organization needs to provide the necessary resources in
order to conduct the training of the APC model of care.
The organization needs to provide adequate time for surgical
residents to study despite demanding clinical workloads.

Conceptual Framework: The Interaction of Knowledge, Motivation, and Organizational
Context
A conceptual framework is an analytical tool with many variations and contacts. It is
used to make conceptual distinctions and organize ideas (Bailin, Case, Coombs, & Daniels,
1999). A conceptual framework is particularly useful as an organizing devise in empirical
research. Likewise, conceptual frameworks are abstract representations connected to research
project goals that direct the collection and analysis of data based on observations (Creswell,
2014).
During training, residents will receive progressively increasing levels of responsibility in
caring for patients under faculty supervision. Providing safe and effective patient care is of
utmost importance. The faculty attending physician is responsible for evaluating the progress of
each resident in acquiring the skills necessary for the resident to progress to the next level of
training. Factors considered in this evaluation include the resident’s clinical experience,
PERIOPERATIVE CARE INITIATIVE 32
judgment, professionalism, cognitive knowledge, and technical skills. At each level of training,
there is a set of competencies that the resident is expected to master.
Supportive organizational learning environments may lead learners to value and engage
in activities. Thus, many environmental influences, such as levels of ability and culture of
practice, should be considered when designing the learning environment (Samenow et al., 2013).
Knowledge is defined as the ability to make effective decisions and take effective action (de
Brabander, 2000). To engage in the APC model, residents are required to possess knowledge and
skills pertaining to the subject matter and to performing the task responsibly (Vetter et al., 2016).
This knowledge includes factual knowledge of facts and terminology related to the APC,
knowledge of skills involved and steps necessary to implement the APC, and lastly, willingness
and insight. Assessing the value of learning through interviews provides insight into the
participant’s performance of tasks and reflection on satisfaction and mental effort.
Improper instructions prior to surgery lead to lack of compliance with perioperative
requirements (Schimpff, 2007). Implementation of the APC is an opportunity to present
evidence-based best practices and standardize care for surgical patients. Learners’ attributes can
be difficult to standardize and require a qualitative measuring tool to assess results. Both clinical
reviews and administrative monitors for accountability are necessary prior to designing such
programs (Wilensky, 2016). The efficiency of the APC process relies on participants’ training
and motivation. Most residents are familiar with the fasting guidelines, yet surgical attending
physicians’ preference in terms of the order of surgery becomes a priority because going against
the attending’s will may affect the resident’s evaluation and grades. Residents’ lack of
motivation to properly manage surgery schedules may be related to the attending physician’s
behavior in the perioperative process. The APC model is meant to address issues of both surgery
PERIOPERATIVE CARE INITIATIVE 33
scheduling and communication between stakeholders to mitigate prolonged fasting time.
Maintaining interest of authorities within the organization in the initiative is critical for the
success of the APC model.
Organizations in every field are rushing to make organizational changes to compete in
today’s marketplace. However, the health care industry has lagged behind most and is using
innovative ideas borrowed from other sectors, such as the airline industry, to bolster performance
and respond to increased environmental rules and the need for further cost savings. Residents are
providers with medical degrees who spent much of their time alone in their respective
specialties. Organization leaders seem to know residents’ ability and duty, but do not know about
their troubles and frustrations. The path to future success entails continuously scanning the
organization’s environment, viewing challenges with fresh eyes and a willingness to rethink past
assumptions. Principally, leaders and employees must develop new mindsets and capabilities that
can differ markedly from before. In addition, leaders must manage output by defining the goal.
In the last decade, health care organizations have paid more attention to the professional
development of their medical staff in order to improve patient care (Brown et al., 2002). This
training has included knowledge and skills outside of their medical competencies, concentrating
on understanding organizational goals, job performance and responsibilities. The framework of
surgical team performance is depicted in Figure 1.

PERIOPERATIVE CARE INITIATIVE 34

Figure 1. Surgical team performance.

PERIOPERATIVE CARE INITIATIVE 35
Participating Stakeholders: Sampling and Recruitment
As mentioned, surgical residents are the center of patient care at the SVMC, and they
were also the key stakeholders of the APC initiative. Orthopedics residents were familiar with
the APC model of care before the study was implemented as they had been provided two
sessions of training in March of 2018. After analysis of quantitative data, five senior orthopedics
residents were interviewed. The qualitative data gathered via interviews provided insight that
helped explain the quantitative data by providing understanding of the surgical residents’
experience implementing the APC perioperative model. Orthopedics surgery services at SVMC
perform approximately an equal number of surgery cases each year. Without the APC initiative
training, one month of orthopedics surgery perioperative fasting times were examined and
compared quantitatively to those in orthopedics surgery perioperative fasting time after the
implementation of the APC model.
Recruitment Strategy and Rationale
Triangulating of quantitative study results prompted follow-up qualitative interviews with
residents in orthopedics service to evaluate both the significance of the APC training and the
implementation process the residents experienced. Orthopedic surgical services have five senior
residents (resident physicians in their last year of training). Due to the small size of residency
programs, qualitative interviews were conducted in census format, meaning all five senior
residents in the orthopedics services were invited to participate. In May 2018, orthopedic senior
residents were about to graduate from the program and had less, if any, concern and fear of
retaliation from the program. A senior resident at the department of anesthesia conducted the
interviews after completing the quantitative data analysis to avoid power dynamic concerns
related to having the interviews conducted by me. Interview protocols are listed in Appendix A.
PERIOPERATIVE CARE INITIATIVE 36
The following criteria guided the selection of interview participants:
Criterion 1: Senior residents are directly involved in daily activities of perioperative
care.
Criterion 2: Senior residents are familiar with the perioperative care model at SVMC
before and after the implementation of the APC model.
Data Collection and Instrumentation
Orthopedics surgery services at SVMC perform approximately an equal number of
surgery cases each year. One month of orthopedic surgery perioperative fasting times prior to
APC model implementation were examined and compared quantitatively to perioperative fasting
time after implementation of the APC model.
Quantitative Instrumentation and Data Collection
In this study, through the Epic Electronic Scheduling Data System at SVMC, one month
of surgery cases involving resident training were collected from a pool of weekday elective
surgeries in April 2018. Excluding all emergency cases performed in April, five hundred cases
were reviewed and studied. The cases were further subdivided into first cases of the day in each
operating room and then subsequent elective cases. Data collection excluded first cases in each
operating room. The attempt was to observe more predictable surgery scheduling and eliminate
potential outliers that would skew the numeric representation of fasting status during standard
scheduling protocol. The study design is shown in Table 4.

PERIOPERATIVE CARE INITIATIVE 37
Table 4
Study Design Chart
Total Cases Involving Resident Training During April 2018
First elective cases of the day Other elective cases
First cases, urgent and emergency cases On time and delayed elective cases
Exclude from the study Include in the study

During April 2018, quantitative fasting data were obtained after the implementation of the APC
model and compare to those fasting time before the APC training.
Qualitative Instrumentation and Data Collection
The main task in interviewing was to understand the participants’ experiences while
implementing the APC model. The interviews were structured in a general interview guide
approach. Qualitative analysis of interview data served to evaluate the orthopedics senior
residents’ experiences and performance on the APC model of care. Evaluation of APC initiative
performance was based on subjective reflections and suggestions. To ensure the stability of the
interview questions, I piloted the interview template with anesthesia residents at the hospital
because they were accustomed to perioperative care processes. As direct care providers,
anesthesia residents were very much concerned with the ability of surgical residents to
implement the APC model. Interviews of orthopedics residents were conducted following
analysis of quantitative data. A senior resident from anesthesia department conducted the
interviews to avoid the power dynamics that may exist during the interviews if conducted by
myself. Qualitative analysis results were made available for participants to review and confirm.
Interview-generated data were secured to protect the resident physicians’ identity, and the data
were solely used for this dissertation. This measure was taken to protect the privacy of
participants and for the protection of the surgical residents from their superiors and program
directors. Informed consent was obtained from targeted surgical residents, and they had the
PERIOPERATIVE CARE INITIATIVE 38
option to not participate in the interview. Principles of credibility and trustworthiness discussed
above were explicitly followed (Appendix B).
Data Analysis
In this study, orthopedics surgical patients’ fasting data were collected and transferred to
statistical tolls for quantitative analysis. To analyze the data in an interval way of measurement, I
used the measures of central tendency: the mean, median, and mode. Variability measurements,
such as the range and the standard deviation, were used to measure the dispersion or distribution
of the responses. To determine whether there were statistically significant differences between
subgroups in data, a t-test was used. The confidence level was set at 95% (p < 0.05). Qualitative
textual data were examined through coding, categorizing, interpretation of patterns and themes to
help answer the research questions. This was an ongoing and cyclical process that happened
throughout data collection. After identifying the themes, data were compressed into a display
that enabled conclusions to be drawn.
Results and Findings
To investigate whether the APC model can have a positive impact on patient care, a study
was performed to determine if surgical patient fasting times could be reduced to less than 10
hours. To answer this question, 148 elective cases involving orthopedics were studied during the
month of April 2018. Because first case delays are minimal, first cases of the day were excluded
from the study. Among the 148 cases, 94 cases were included in the study based on the inclusion
and exclusion criteria as indicated above.
Quantitative Study
There was a significant difference in the fasting times for orthopedics after training (M =
643.99, SD = 106.69) and before training (M = 879.21, SD = 90.11) condition; t (93) = 1.99, p =
PERIOPERATIVE CARE INITIATIVE 39
2.32346E-30. The results suggest that the APC model improves the perioperative fasting times as
depicted in Table 5 and 6.
Table 5
t-Test on Fasting Time Results
Orthopedics Surgery Before Training After Training
Mean 879.212766 643.988768
Variance 8120.448868 11382.31258
Observations 94 94
Pearson Correlation 0.083074625
Hypothesized Mean Difference 0

df 93

t Stat 17.04329497

p(T<=t) one-tail 1.16173E-30

t Critical one-tail 1.661403674

p(T<=t) two-tail 2.32346E-30

t Critical two-tail 1.985801814

Table 6
Fasting Time (minutes)
Orthopedics Surgery Before Training After Training
Mean 879.21276 643.988768
Standard Deviation 90.11353321 106.6879214
Sample Variance 8120.448868 11382.31258
Range 638 414
Minimum 645 476
Maximum 1283 890
Count 94 94

Prolonged fasting has an adverse impact on high-risk patients during the perioperative
period. The APC model of care mitigated the orthopedics fasting time, yet, statistically, it failed
to reject the hypothesis. The fasting times were higher than that of the alternative hypothesis of
less than 600 minutes in both findings. Further, in the boxplot below, I visualized and compared
the fasting times before and after implementation of the APC model (Figure 2). APC model
PERIOPERATIVE CARE INITIATIVE 40
implementation resulted in significant difference in length of fasting time orthopedics surgical
patients had to endure during the perioperative process. The ASA’s recommended fasting
guideline for surgery is 8 hours, yet the average fasting time for orthopedics surgery patients
having surgery in this study was more than 10.5 hours, significantly longer than that of the ASA
guideline.

Figure 2. Boxplot to compare fasting time before and after the APC training.
Qualitative Study
The purpose of the qualitative component was to provide evidence to assess residents’
experiences after conducting education sessions and the implementation of the APC model.
Interviews were conducted with residents in orthopedics service to evaluate both the significance
of the APC training and the implementation process the residents experienced. Five senior
residents from orthopedics service were interviewed by a peer, a senior resident from anesthesia,
to avoid the power dynamic that may be expected if the interview were conducted by me as the
department chair of anesthesia. Individual interviews were carried out at the department of
anesthesia conference room and average time to conduct them was 24 ± 8 minutes. One resident
PERIOPERATIVE CARE INITIATIVE 41
provided follow-up comments 24 hours after the interview. One resident engaged the interview
with some reservation and concern; he gave short answers and was reluctant to elaborate on
some subjects.
Knowledge. As a safety net health care facility, SVMC’s mission statement is simple. In
short, it is to serve community members’ health care needs regardless of their ability to pay.
SVMC has imprinted the hospital mission on employee identity badges to remind staff members
of their accountability and responsibility. Transparency officers at SVMC are constantly
updating clinical providers with organizational performance, opportunities, and available
resources through newsletters and emails. These reports are also available to residents and
nursing staff. The surgical arena is both a major financial burden and the most important revenue
generator in a hospital (Shamayleh, Fowler & Zhang, 2012).
Residents have in-depth knowledge about organization difficulties. In an organization
that continuously endures budget neutrality, having a culture of transparent communication helps
to promote organizational awareness. Surgical residents need to understand the difficulties facing
the organization, especially in the surgical arena. During the training, Participants 2 and 3
expressed that, “we are well aware of the hospital’s mission and of influences on organizational
operations.” They continue responding to question like, “we are not the highest pay residents in
California,” and “we know what we are getting into, our training is bundled to the survival of the
hospital.” They have strong willingness to participate in the APC model to be more efficient,
costs-aware, and patient-centered.
Residents are familiar with the APC conceptual knowledge. The purpose of the APC
model of care is to promote fluent communication between care providers and the patient. In
general, residents have the most direct contact with patients. Conceptual knowledge regarding
PERIOPERATIVE CARE INITIATIVE 42
the key components of the fasting protocol was not a major issue that concerned participants,
“the fasting protocol is something that we have to deal all the time, it is basic, every surgical
resident should know.” Participant 3 said. Residents’ willingness to participate in the initiative
were high, Participant 3 continued “we want to treat our patients with respect, they give us the
opportunity to learn.” During training, residents expressed full understanding of the APC model
of care without difficulty. They were familiar with procedural knowledge of the ASA 2011
fasting guidelines and welcomed the development of a new initiative to guide them and promote
better perioperative patient care. Participant 1 provided comments, “we learned about
perioperative fasting guidelines in medical school.” and “unfortunately, we are unable to follow
the guidelines in practice.”
Residents reflect and want to be successful. Interview data demonstrated that surgical
residents reflect on their own effectiveness under organizational guidelines and policies. All
interviewees expressed their intention to complete the program and strive to learn the knowledge
and skills of orthopedic surgery by responding with, “we desire health, safety, knowledge, and
competence” to secure their own wellness, knowledge gains, and professional conduct during the
training. They expressed strong motivation on maturing both personally and professionally and
readiness to serve the community ethically with answers like, “we want a meaningful connection
to patients by providing them the best care that we know and capable to give.” and “we seek
recognition of our contributions in the community.” To address their status in the organization,
Participant 1 stressed, “we want to make meaningful difference to serve our altruistically purpose
as physicians.” It was concerning when Participant 5 expressed, “I am here to count my days
until the finish line. This is just a part to the process to become an orthopedic surgeon.” and “it is
not much a resident can do if our boss is not supporting the APC model.” SVMC’s leaders say
PERIOPERATIVE CARE INITIATIVE 43
that, “we strive for excellence and take pride in our accomplishments” to value their
achievements. However, the rewards are not aligned with contributions across people especially
to the residents. This highlights questions regarding fairness of values in the organizational
environment and culture.
Motivation. Prior to the implementation of the APC model, residents expressed their
frustration when the attending physicians directed them to disrupt the surgery schedule by
changing the order of patients, Participant 4 conveyed that “how to proceed the day is not our
control, the attending decides what they want,” which often resulted in prolonged fasting time.
The traditional hierarchy organizational structure prevented residents from disobeying or
discussing the attending physician’s intention with Participant 4 continued comment such as,
“we want to avoid being enlisted in the attending black list” and “our evaluations is our survival
in the program.” Conversely, the implementation of the APC model increased communication
among the stakeholders: the residents, the attendings, and the nursing staff.
Resident self-efficacy. Surgical residents need to feel confident in their ability to
accurately implement both physical and psychological preparation of patients prior to surgery
and fully confident to advocate the activity through the APC model of care. Residents expressed
that the delivery of high-quality care provided them with sense of achievement and increased
both their self-confidence and their ability to empathize with their patients, Participant 3
mentioned that “patients appreciate more than ever!” “I want to continue the APC model in my
own practice!” Residents felt that their feelings were validated by the fact that they were on the
front lines of patient care and heard first-hand from the patients as they went through the
operative experience, Participant 1 said that “my awareness of time improved, it seems I look at
the clock more often than before.” Residents were motivated to care for their patients in the best
PERIOPERATIVE CARE INITIATIVE 44
possible way during the perioperative period, Participant 1 continued to say that “patient
remembers my name, I am not just “the young doc” anymore.” Good patient feedback gave them
a sense of profound altruistic achievement.
Value of the APC model to residents. Surgical residents need to value the benefit of the
APC model to achieve better perioperative patient care goal. Residents positively valued the
APC model because they felt it elevated the level of care that the patients received. Participant 2
stated, “I believe that the APC model really work, patients were complaint less since we begin
the APC model.” Residents recognized the value of the APC model and were positively
motivated through feedback from patients and nursing staff regarding their conscientious and
empathy actions. Participant 1 quoted a nurse and say, “your patients really like you, you are a
good doctor, your patient is lucky.” Participant 1 expressed, “we seek freedom in our actions and
decisions for our patients to receive the best care from us.” This sense of achievement and
autonomy were indicative of the value that the APC model brought by residents in patient care
through the implementation of the APC model.
Organization. Many academic health care organization residency programs train medical
specialty knowledge and skills in a programmatic manner without depth of communication for
the residents to express their feelings in a safe and healthy environment, such as open forum
discussion on medical ethics or topics on professional wellness during residency training.
Without depth in communication with their supervisors, residents struggle in the clinical
relationships with their patients. The success of the APC model initiative requires focus on the
residents at SVMC who are trying to drive change across the perioperative process. The
organization should initiate programs to educate both faculty and residents on the common
barriers to communication that potentially endanger patient care and patient safety.
PERIOPERATIVE CARE INITIATIVE 45
Lack of organizational support to implement the APC model. Skepticism was strongly
expressed by the interviewed residents in that there was not adequate organizational support,
which may result in a barrier to the implementation of the APC model, Participant 5 stated that
“our attendings are in the hospital once or twice a week. They also have their own practice
outside this hospital. It is not much that you can expect from them.” Participants perceived that
their supervising attendings had minimal knowledge of the patient experience because they did
not directly interact with the patients in the immediate perioperative period. Participant 4 stated,
“there are many personalities that we have to deal with; this is what we need to deal with all the
time.” Participant 5 continue mentioned, “they are not all teacher material, you know.”
The traditional hierarchical environment pitfall. The power dynamic between the
supervising attending and the subordinate resident was also a key barrier to implementation of
the APC model. Participant 4 said, “making sure the day went well for the attending is priority
one. They don’t know us that well, you know, yet my evaluation is in their hand.” Residents
struggled to balance patient care with their need to impress their attending to gain favorable
evaluations. Attending physicians were concerned only with having a smooth surgery schedule
and ability to flex the schedule to best accommodate their busy practices and other obligations.
Taken together, the burden of power dynamics is a clear obstacle to change. The patient’s
experience during perioperative process directly conflicted with the attending’s individual
motivations.
Participant 2 noted the “culture model of individual program varies according to
leadership in the department” and “going to an outside rotation is a break for us.” These
expressions suggested that cultural model and setting in a training program dictated by a power
dynamic and lack of safe communication often disrupted the residents’ morale and motivation.
PERIOPERATIVE CARE INITIATIVE 46
Many times, residents mentioned the lack of time to study and exercise for wellness. Participant
5 said, “we desire quality not quantity.” As mentioned above, residents were strongly motivated
to achieve the best for the care of patients, yet “the hospital worried more about ‘numbers’ and
‘surveys’ outcomes than us.” Unfortunately, their perception was that the organization was
concerned more with the residents’ labor and productivity than with their capacities of learning
medicine and patient care, Participant 1 concluded his interview with “knowing your attending
mindset on approaching issues are critical to your learning.” Politics constantly affect
implementation of necessary changes within the organization and keep residents from
developing within a healthy educational environment. Nevertheless, 215 expressions mentioned
in the interviews were categorized and listed in phrase format that yielded 35 categorical barriers
and approaches.
Summary
In the quantitative study, while results did not meet the expectation to keep fasting time
under 10 hours, orthopedics department fasting times were reduced by 32%. In the qualitative
study, a surprisingly high percentage of residents saw the importance of establishing peer and
patient understanding through better communication and empathy. According to the interview
data, all interviewed residents strongly agreed that organization needs to provide the resources
for patient care activities among stakeholders.
Orthopedics residents felt the APC model training was valuable and would like to
champion the process to advocate for better patient care. Individual residents noted that patient
understanding had improved, and the majority of residents reduced perioperative fasting time
and narrowed the gaps related to prolonged patient suffering. Residents also expressed increased
PERIOPERATIVE CARE INITIATIVE 47
sense of altruistic purpose and achievement. Lastly, residents mentioned the importance of the
training and suggested extending the program for attending physicians and leadership personnel.
Knowledge of the fasting guidelines was an asset to most participants. In general, the
interview data suggested that participants were familiar with the ASA fasting guidelines and
easily understood the newly learned perioperative initiative process. They were enthusiastic
about the APC model and believed the initiative improved communication with patients and was
improving relationships among stakeholders. All interviewees believed that the APC model was
helping organization-wide communication and were more likely to say that collaboration with
other specialty partners was more efficient. Interestingly, among the respondents who strongly
agreed that the APC model was improving patient care, residents also strongly agreed that the
use of the APC model was changing the way the department conducted their practices. Just one
among the five interviewees was skeptical that the APC model had changed their department
practice.
Recommendations for Practice to Address KMO Influences
The results from the quantitative study indicated a significant difference between
experimental and control group. The APC model reduced orthopedics perioperative fasting time
by three and a half hours compared to the general surgery group. Based on the interview data
analysis, this section provides recommendations to reduce the gap that continues to exist after the
implementation of the APC model and includes an integrated implementation and evaluation
plan (Appendix D) that utilized the New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick,
2016).
Clinical residency education takes place after a medical student obtains a medical degree,
and it is considered the most important part of medical education. Residents need to work hard
PERIOPERATIVE CARE INITIATIVE 48
and take and devote much time and effort to acquire both the didactic knowledge and the clinical
sense expected of them by their profession and patients. Self-efficacy, even driven by fear, is a
powerful motivating factor that recognizes the responsibility that residents have: the
responsibility for the life of another human being. The APC model promotes better
communication in residents’ learning. Residents are highly motivated during the implementation
of the APC initiative and value their patient care experiences.
Knowledge Recommendations
In the interviews, residents demonstrated they were familiar with the ASA (2011) fasting
practice guidelines. Providing residents with training regarding the ASA guidelines will refresh
their knowledge and enhance the efficiency of perioperative care in the patient care process. It is
beneficial to partner with organizational stakeholders at SVMC to promote an integrated
approach to perioperative care and build capacity for better informed and participatory policy
processes.
“Attending physicians should receive training in the APC model,” a resident said. This is
particularly helpful for dealing with transference and countertransference in supervision. It may
also help to avoid intentional abuse in supervision. Training should include supervisors and
trainees in conflict resolution. Conflicts occurred due to the supervisor’s lack of professionally
and clinical knowledge. Conflicts occurred also when an attending has motivational issues, such
as lack of interest, resentment, and misuse of power. Individual and cultural differences and
administrative constraints also limited supervisors’ performance. It is difficult for attendings to
accept and support the APC initiative unless they are familiar with content of the APC initiative
and subjectively empathize with the suffering of prolonged fasting that patients incur during
perioperative process. Residents are very concerned about their attending’s impression of them,
PERIOPERATIVE CARE INITIATIVE 49
which deeply influenced their perception of the evaluation process and its impact on their career.
The APC model is going to limit the attendings’ ability to change the order of surgery on the day
of surgery, and residents are struggling to prioritize the patient experience as this may displease
the attending and his desire to manipulate of the surgical schedule.
Organization Recommendations
Organizational leaders can influence the surgeon’s motivational paradigm by focusing on
both cost reduction and quality improvement and reshaping the dynamics of surgeon motivation
away from the traditional volume-driven, fee-for-service payment system toward a broader range
of motivators, including greater mastery of clinical medicine and social purpose in meeting
patient needs (Judson et al., 2015). To sustain the stakeholder’s high level of engagement,
maintaining intrinsic motivation, such as a sense of purpose, relevance, and meaning, is critical.
Balancing intrinsic motivation with extrinsic motivating forces is important, as one of the most
common problems in health care organizations is that rewards are not aligned with desired
behavior. Organizations should not ignore the social comparison and fairness concerns to ensure
that stakeholders feel fairly treated.
In health care, studies show 60% of incidences reported involve only 5% of staff
members in a hospital, and these individuals are responsible for 30% of medical malpractice
cases in the organization (Stamm, Korzick, Beech, & Wood, 2016). The health care industry can
no longer ignore patients’ experiences during medical care. Health care organizations routinely
conduct patient experience surveys, and leaders need to make medical providers aware of survey
results and feedback. By establishing an active communication path, the organization can
encourage reporting of both emotional and clinical events from patients and staff members. The
PERIOPERATIVE CARE INITIATIVE 50
report will be reviewed and shared with involved parties within a safe communication
environment to induce positive self-awareness and, ultimately, self-correction.
To transform communication in the hospital, organizational support in the form of
necessary financial and human resources is a must. The process of change can be informal but
serious; the goal is clearly to establish self-awareness and self-correction in professional
development. The organization needs to provide training on patient-outcome reporting processes,
peer interventions, data collection, and event evaluation. Constantly identifying champions and
motivating individuals to engage in the transformation is critical. Establishing an accountable
professional culture will ensure sustainability. Organizational influences and recommendations
are presented in Table 7.

PERIOPERATIVE CARE INITIATIVE 51
Table 7
Summary of Organization Influences and Recommendations
Assumed
Organization
Influence
Principle and Citation Context-Specific
Recommendation
Organization
needs to require
clinical providers
to use the new
APC model of
care to break
away from the
status quo of
practice to
improve patient
care (Culture
Model).
Medical practice culture is a very
complex element reflected by the
health care’s organizational culture
and by its components, such as the
ethical approach in medicine. Thus,
provider’s behavior is conditioned by
the health care organization’s
structure, which depends on policy and
hierarchical emotional relationships
established inside the organization
(Militaru, Zanfir, Baltaretu, & Stefan,
2012).

Cultural model influenced behavior
among health care providers has been
linked to patient safety and outcomes
(Samenow et al., 2013). Yet the
cultural models of most academic
medical organizations lose sight of
that purpose (Bunderson & Thompson,
2009).
The organization needs to
constantly align communication
between administrations and
clinical providers on the
organization’s vision.

The organization needs to make
medical providers aware and
introduce a mechanism on how
to address patient complaints.

To benefit from the APC
initiative, organization needs to
introduce new policies to
uniformly structure fasting
protocol for residents to follow.
Organization
needs to provide
the necessary
resources to
conduct the
training of the
APC model of
care (Culture
setting).
Health care organizations have paid
more attention to the professional
development to improve patient care
(Brown et al., 2002).

Task participation increases when
organization stakeholders agree on
alignment of resources to complete the
goals (Clark & Estes, 2008).
The organization needs to
provide adequate time for
surgical residents to participate
in the APC initiative despite
demanding clinical workloads.

Increasing the visibility of organizational support. Medicine is a profession and a
culture that is considered defensive and intolerant to mistakes (Bakanas, 2013), which has been
PERIOPERATIVE CARE INITIATIVE 52
linked to patient safety and outcomes (Samenow et al., 2013). There is professional purpose and
a moral duty that physicians rely on, and they, therefore, support academic medical organizations
(Grant & Hofmann, 2011), yet the cultural models of most academic medical organizations do
not consider that purpose (Bunderson & Thompson, 2009).
. Organizational tangible support is critical for the success of the APC initiative. Medical
practice culture is a very complex element reflected by organizational culture and by its
components, such as an ethical approach. Providers’ behavior is conditioned by the
organization’s structure and policy, and it highly depends on hierarchical and emotional
relationships (Militaru, Zanfir, Baltaretu, & Stefan, 2012). High-stress locations within the
organization, including the perioperative setting, are especially prone to disruptive physician
behavior (Small et al., 2015). Balancing the organizational extrinsic and intrinsic motivations
allows for leveraging the need of status, value of autonomy, and meaning of work that
stakeholders demand (Grant & Hofmann, 2011). In this case, organization requires residents to
use the new APC model of care to improve patient care. The APC framework for performance
improvement strategies involves residents’ knowledge, motivation, and organizational
influences. A shared vision between an organization and its workers is then imperative to
achieve the goals (Clark & Estes, 2008).
Provide the necessary resources to conduct training. Herzberg (1968) emphasized the
importance of organizational management’s knowledge and expertise. His two-factor model
(hygiene and motivating factors) enables an organization to make sure employees are satisfied at
work and leverage the motivating factors to ensure employees are motivated, engaged, and want
to go above and beyond to contribute to the organization (Herzberg, 1968). Task participation
PERIOPERATIVE CARE INITIATIVE 53
increases when organizational stakeholders agree on alignment of resources to achieve goals
(Clark & Estes, 2008).
Surgical specialties are constantly busy; it is, therefore, difficult for surgical
departments to handle both the preparation of surgery and conducting APC model training. The
recommendation is to provide adequate time for surgical residents to participate in the APC
initiative despite demanding clinical workloads. Supportive organizational learning
environments may lead learners to value and engage in activities. Thus, many environmental
influences, such as levels of ability and culture of practices, should be considered when
designing a health care professional development learning environment (Samenow et al., 2013).
The successful implementation of the APC process requires both external motivation and
accountability of the resident physicians, and also motivations from intrinsic perspectives, such
as altruistic intent and saving lives.
Conclusion
During surgery, the patient does not really know if a long delay is a necessity due to a
legitimate reason or if they are just another victim of poor management and careless behavioral
culture within the organization. Here, professionalism underlies the notion that physicians ought
to serve as agents for their patients, regardless of their economic interests, and that they have a
duty to deliver high-quality care to their patients. If a provider’s interest is to preserve his market
share in the industry, providers should know that consumers or policy makers will only pay for a
good outcome and a good patient experience. In order to provide a good patient experience, the
organization must have processes to ensure delivery of care is properly coordinated. To improve
the quality of care, organizations could begin by focusing on performance on structure and on
process. Together with structural engineering processes, empowering clinical medical educators
PERIOPERATIVE CARE INITIATIVE 54
and management leaders to revamp curricula and culture are keys to success and sustainable
solutions.
The process of change can be informal, but the goal must be clear in order to achieve
self-awareness and self-correction (Saddawi-Konefka et al., 2016). To achieve the goal in this
study, training in the APC model must include the patient-outcome reporting process and the
provider understanding that to attain a fasting time of less than 10 hours is reasonably a good
perioperative practice compared to the status que. Establishing an accountable professional
culture will ensure sustainability of the APC model of practice. Every hospital worker, no matter
his or her rank, should be held to the same ambitious standards. The APC initiative will succeed
only if every staff member believes it is the right thing to do.

PERIOPERATIVE CARE INITIATIVE 55
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Appendix A
Interview Protocol
I would like to first begin with expressing my gratitude for agreeing to participate in my
study. Thank you for taking some time out of your extremely busy schedule to meet with me and
answer some questions. This interview will take about an hour, although we have allocated an
hour and half for some cushion time.
I am currently enrolled in a doctoral program at USC, and I am conducting a study on the
implementation of newly developed perioperative care initiative attempted to reduce the
significantly prolonged fasting time prior to surgery at the hospital. Today, I am not here as an
executive of this organization to make a professional assessment or judgment of your
performance as a surgical resident. I would like to emphasize that, today, I am only here as a
researcher collecting data for my study. The information you share with me will be placed into
my study as part of the data collection. In addition, this interview is completely confidential, and
your name or responses will not be disclosed to anyone or anywhere outside the scope of this
study and will be known only to me specifically for this data collection. While I may choose to
utilize a direct quote from you in my study, I will not provide your name specifically and will
make the best effort possible to remove any potential identifying data information. I will gladly
provide you with a copy of my final product upon request.
During the interview, I will be utilizing a recording device to assist me in capturing all of
your responses accurately and completely. This recording will not be shared with anyone outside
the scope of this project. The recording will be transferred to my password-protected files in my
computer and deleted from the recording device immediately upon transfer. The recording will
then be destroyed after two years from the date my dissertation defense is approved. With that,
PERIOPERATIVE CARE INITIATIVE 69
do you have any questions about the study before we get started? If not, I would like your
permission to begin the interview. May I also have your permission to record this conversation?
The following are areas of questions for the interview:
1. Describe your knowledge about the surgical practice at the hospital.
a. Describe your duties and working hours.
b. What parts of the surgical practice do you find redundant and lack efficiency?
2. Please explain what you understand to be the reason for shifting to the new Accountable
Perioperative Care (APC) model.
a. Can you explain the foundation of the APC model?
b. Please highlight some of the American Society of Anesthesiologists perioperative
fasting and evaluations guidelines.
3. Describe your training experiences in the context of the APC initiative.
a. Which aspects of the training did you find to be effective?
b. Are there any aspects of the training that can be enhanced?
4. Describe how your scheduling practice has changed after the training, if at all.
5. Describe the difference between current practice vs. the APC model.
6. How do you feel about your ability to implement the APC model?
7. Describe how the patient’s experience has changed since implementation of the initiative,
if at all.
8. What is your level of participation in the initiative?
a. What feedback do you have to offer about the implementation of the initiative?
9. What barriers have you met in the change process, if any?
10. To what degree do you see value in shifting to the APC model of care?
PERIOPERATIVE CARE INITIATIVE 70
a. What is that value?
b. If you do not perceive this shift to be valuable, please explain why.
11. What organizational level change, if any, have you observed since the implementation of
the initiative?
12. Tell me about how you reflect on your effectiveness in the context of the hospital’s
empathy and ethics policies?
13. Describe the leadership’s participation in the APC model initiative.
a. What is the impact of leadership’s actions?
b. What organizational level support, if any, do you see in the implementation of the
APC initiative?
14. How would you educate your peers and medical students about fasting time?
15. What is your opinion on the viability of the initiative?
16. How would you improve the initiative?

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Appendix B
Credibility and Trustworthiness
In regard to qualitative analysis, it is a unique challenge to draw trustworthy conclusions
from data that is often rich, specific, ambiguous and highly context-dependent. Quantitative
concepts such as validity, bias and objectivity become less pertinent. Trustworthiness can be
described as ways in which qualitative researchers ensure that transferability, credibility,
dependability, and confirmability are evident in their research (Merriam & Tisdell, 2016).
Moving away from quantitatively oriented concepts allows qualitative researchers the freedom to
describe their research in ways that highlight the overall rigor of qualitative research without
trying to force it into the quantitative model (Given & Saumure, 2008). Lincoln and Guba (1985)
argue that ensuring credibility is one of most important factors in establishing trustworthiness
(Lincoln & Guba, 1985). Yet Glaser (2004), one of the founders of the concept of grounded
theory, argue that naturalistic inquiry should include criteria that go beyond accuracy, and
suggest criteria of authenticity is fairness (Glaser, 2004). The final proposal is that this
authentication should be effective in creating desired change (Schwandt, Lincoln, & Guba,
2007), which suggests that a trustworthy qualitative analysis will have the following
characteristics:
Reactivity of approach. Reactivity refers to the extent to which the researcher is
attentive to their own position and the potential effects of this position on all aspects of the
research. This includes the analysis, and what conclusions are being drawn (Thomson, 2013). In
this study, I challenged my assumptions in data analysis, as mentioned in Trochim, by referring
to the research participants for discussion and to confirm their interpretation of the data
PERIOPERATIVE CARE INITIATIVE 72
(Trochim, Cabrera, Milstein, Gallagher, & Leischow, 2006). Trochim argues that the key here is
whether the research findings are credible from the perspective of participants in the research.
Confirmability of interpretation. Beyond credibility to participants, confirmability
refers to the ability of others to understand and engage with the research findings and to clearly
understand how they were arrived at (Merriam & Tisdell, 2016). However, there is a very
important connection between the claims made by the researcher and the data used to illustrate
those claims. Confirmability is a way of describing the strength of this connection. For example,
am I able to support my interpretation of an excerpt (e.g., benefit of APC training) from an
interview with my own observations from the setting? Can I make useful and credible links and
comparisons between the accounts of the interviewees? In this study, I ensured confirmability by
piloting the interview questions with anesthesia residents and rechecking the data during the
entire research.
Richness and liveliness of data. When presenting qualitative data, the researcher should
make several examples to illustrate key themes or ideas to show the variety of responses, or to
express the complexity of a narrative account (Merriam & Tisdell, 2016). The impact of these
examples can greatly enrich qualitative analysis and provide a sense of the researcher's
understanding of and interaction with the data.
Transferability and criticality of analysis. For Trochim, the role of the researcher is not
to make claims for how the research will apply to other settings, but to give enough information
about the research context and assumptions to allow the reader or research user to determine its
applicability (Trochim et al., 2006). A hallmark of transferability is an interpretative approach
that offers one, but not the only, interpretation of a given situation. Criticality here refers to the
ability of other surgical departments at the hospital to be open to better time management. While
PERIOPERATIVE CARE INITIATIVE 73
a large amount of filtering and organizing of data is an inevitable and a desirable part of
interpretative analysis, a trustworthy account will not oversimplify the perspectives, tensions and
ideas encountered. In this study, I ensured transferability by and criticality of analysis by piloting
the study with residents at anesthesia department to facilitate transferability of the inquiry.
Sensitivity to context. Dependability could be defined as sensitivity to context. For
example, does my interpretation of a specific interview excerpt or document demonstrate an
understanding of the wider context of the operating room? Context can include local factors like
organizational culture, but also social, political or historical factors that have shaped the time and
place of the research (Merriam & Tisdell, 2016). To ensure sensitivity to context, I have my
senior resident to conduct the interview. This is an attempt to deal with potential fear of
stigmatization.

PERIOPERATIVE CARE INITIATIVE 74
Appendix C
Reliability and Validity
Validity refers to whether the instruments accurately measure the concept they are
supposed to (Salkind, 2015). There are three types of validity. Content validity refers to whether
the measurements include all the types and items needed to measure the broader construct or
concept. Secondly, criterion validity refers to whether the instrument can accurately predict or
forecast the outcome measures of the construct. Thirdly, construct validity refers to weather the
researcher is using the right instrument, and discernibly measuring the correct construct to
answer the intended research questions (Purpura, Brown, & Schoonen, 2015). Time
measurement is daily entered into the electronic medical record system by operating room staff.
In this study, data were extracted from the medical record system and were approved by the
information department to ensure the validity of the data. Content, criterion, and construct
validity were evaluated to ensure the richness of the instruments and to cover the broader
construct of the concept to answer research questions correctly. Tests were conducted
anonymously.
Reliability refers to consistency or repeatability in measurements (Salkind, 2015). To
avoid measurement error during quantitative research, it is important to pay attention to what
constructs of research questions a researcher is interested in. The measurements may not reflect
the true underlying value of the construct that a researcher is interested in, but it produces
consistent and repeatable values. To improve reliability, clear conceptualization and
standardization of categorical rating are important. Increasing the number of items in the
instrument or using ratio scale measurement in the instrument can give more precise
measurements on physical quantities (Woodcock, Pullin & Kaiser, 2014). Pilot testing and
PERIOPERATIVE CARE INITIATIVE 75
retesting is useful in preparation to set up proper and reliable questions in a survey. To ensure the
reliability of the instrument, continuous data of surgery schedules is collected from the electronic
medical record system at the hospital. Proved schedule time, starting time, and ending time of
surgery were entered into excel. Data analysis tools in excel were used to examine both central
of tendency and variances measurements of the data.

PERIOPERATIVE CARE INITIATIVE 76
Appendix D
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
Program directors in anesthesia training like to use flying a plane as a metaphor to
describe the process of providing anesthesia service; it is the take-off and landing that is critical.
Training in the APC model of care is not difficult; it is like coasting during flight. It is the
motivational and implementation plan of the initiative that is critical. Motivating stakeholders to
engage in the APC model of care is the first step of evaluation. Through training, familiarization
with the APC model by stakeholders determines how successful the initiative will be. As
mentioned by Kirkpatrick and Kirkpatrick (2016), the behavior of the stakeholders’ participation
is the most important level because training alone is not enough to be viewed as successful. The
challenge here is how to engage stakeholders to live the mindset so that they persist with
behavior that survives, sustains, and scales. It is important to think through how to implement
and Kirkpatrick’s model and build accountability and a shared mindset of belief.
Organizational Purpose and Expectations
Summer Valley Medical Center’s (SVMC) mission is to provide superior quality health
care to county residents with a special focus on individuals and populations in need. On the day
of surgery, given the unpredictable nature of operating room scheduling and delays, patients may
wait and fast longer than expected, which often results in patient dissatisfaction and stress of
clinical significance (Brands et al., 2017). Having the knowledge and skills of perioperative care
processes is essential for operating room personnel to better manage their time and promote self-
awareness. This can lead to increased efficiency of operating room usage. In the operating room,
the goal is to be carried out by transitioning to a newly developed Accountable Perioperative
PERIOPERATIVE CARE INITIATIVE 77
Care (APC) model in early 2018. In practice, what this means is that, when the decision is made
for a patient to undergo surgery, the patient will be placed on a plan of communication regarding
all areas of their care. This care is to better prepare patients before surgery by comprehensively
communicating the standardization of best practice treatment during their hospitalization. The
overarching goal of APC model is to ensure that communication is efficient and effective during
perioperative processes. In such, better scheduling practice and elimination of surgical delays can
abolish prolonged fasting.
Resident physicians are the main work force in teaching medical centers, and motivated
resident physicians are key parts of high-quality health care delivery at SVMC. Because surgical
specialties are very busy; it is difficult for surgeons and the residents to handle both the
preparation of surgery and performing the surgery. With the APC model, patient preparation is
delivered through constant communication between the operating room personnel and the
surgical resident to ensure the proper scheduled orders. The goal of the APC model initiative is
to educate and motivate resident providers to effectively adhere to the ASA fasting guidelines
and subsequently reduce the unnecessary morbidity of surgical patients. Currently, the
perioperative fasting guideline set by ASA is eight hours. The goal of stakeholders in this study
is to promote perioperative care efficiency by attaining 100% compliance for a perioperative
fasting time not to exceed 10 hours.
Under my recommendations, constantly communicating the mission and goals of the
organization can increase stakeholders’ awareness of organization directives. Providing residents
with time to engage in the APC model and reducing their cognitive loads can mitigate challenges
on implementation of the APC model.

PERIOPERATIVE CARE INITIATIVE 78
Level 4: Results and Leading Indicators
Delays of surgery are common and unpredictable prior implementation of the APC
model. The APC model should improve scheduling and mitigate surgery order changes.
Development of measurements to observe scheduling error and surgery order changes on the day
of surgery would indicate that the stakeholder is achieving the desired outcomes. Comparing the
multiform measures within patient satisfaction data before and after implementation of the APC
model provides a clear measure of patient care improvement.
Table 8
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metrics Methods
External Outcomes
Patient satisfaction 100% patient survey Patient experiences
survey
Review 100% surgery scheduling 2
weeks prior to day of surgery
Review surgery
scheduling 2 weeks in
advance
All surgical patients receive a survey for
perioperative experiences.
Patient experiences
survey
Resident Experience Residents comments regarding their
perioperative process experiences
Resident survey
Patient treatment
outcomes
Continuous review of data Organization and
government data
collection and analysis
Continuous review on mortality and
morbidity rates
Mortality and morbidity
reporting
Hospital reputation Continuous review of reflection from
community and media
Public ranking on hospital
and provider

PERIOPERATIVE CARE INITIATIVE 79
Table 8, continued
Outcome Metrics Methods
Internal Outcomes
Surgery residents
persist in initiatives
to attain 100%
fasting time not to
exceed 10 hours
100% review on training participation Data collection and
analysis on training
participation
6-month follow-up on engagement in the
APC model of care, percent of fasting
less than 10 hours
Fasting time data
collection and analysis
Surgery residents
communicate
effectively to
achieve the goal
6-month follow-up on perioperative
readiness
Data analysis on case
cancelation and delay
Numbers of cross departments meeting Data analysis on
department consults

Level 3: Behavior
Critical behaviors. A critical behavior checklist consists of a list of specific behaviors
required to complete a task. It provides information on whether each behavior is performed
competently or incompetently. Performance cannot improve without behavior-based feedback,
and feedback is often most informative when linked to observations. The critical behavior
checklist can be used to help achieve the vision of an organization. Key to effective application
of a critical behavior checklist is the selection and definition of the target behaviors.

PERIOPERATIVE CARE INITIATIVE 80
Table 9
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metrics Methods Timing
1. Surgical residents’
engagement
Training participation

Residents’
performance
Review all sign in
sheets collected and
department promotion
Data collection on
patient fasting time of
each responsible
resident
One
month

Three
months
2. Surgical residents’
motivation to participate
in the initiative
100% reviews on
feedback from training
and operating
procedures
Communication effort,
observation and
analysis of participants
feedbacks
One
month
3. Surgical department’s
leadership
encouragement
Number of
presentations of the
APC initiative in the
department
Data on invitation of the
APC initiative
presentation to various
departments
One
month
4. Surgical residents’
willingness to champion
in the APC model
initiative.
Residents’
participation and
outcomes scorecards
and patient
satisfactions.
Surveys, feedbacks and
reflections from all
stakeholders (residents
and patients)
Three
months

Required drivers: Surgical residents need the support of APC model program staff and
their division supervisors to reinforce learning and provide motivational encouragement to
mitigate prolonged fasting time. The drivers are listed in Table10.

PERIOPERATIVE CARE INITIATIVE 81
Table 10
Required Drivers to Support Critical Behaviors
Methods Timing
Reinforcing
Enhancement of organization mission and goals during
medical executive meetings
Monthly
Formation of champion users of the APC model to reinforce
the implementation of the initiative
Continuous
Reinforce the residents’ awareness on the most recent
guidelines on perioperative fasting
Two weeks of perioperative
guidelines training
Encouraging
Provide surgical residents time necessary to review
information and data on patients’ feedbacks
Continuous
Provide surgical residents time to participate and master the
APC model of care
Continuous
Rewarding
Structure reward systems at department level to encourage
participations of the initiative
Monthly
Reward efficiencies with more operating time Continuous
Monitoring
The organization needs to constantly align communication
between administrations and clinical providers on
organization’s vision
Continuous
The organization needs to provide adequate time for surgical
residents to participate in the APC initiative despite
demanding clinical workloads
Continuous

Organizational support. Evaluation is an important tool for organizations to improve
management (Wiseman et al., 2014). Due to uncertainty created by the changing nature of health
care delivery services, the health care industry, particularly government ownership hospitals
must continually re-evaluate the services provided at some departments. Because of limited
PERIOPERATIVE CARE INITIATIVE 82
access to capital, budget neutrality is commonly mentioned in government-owned health care
organizations. When such organizations’ leaders are concerned with their stakeholders’
commitment to the organization, perceived organizational support can be critical for them to
observe (Eisenberger & Adornetto, 1986). Perceived organizational support increases
stakeholders’ feelings of obligation to help the organization reach its objectives, their affective
commitment to the organization, and their expectation that improved performance will be
rewarded. Perceived organizational support has been found to have important consequences for
stakeholders’ performance and well-being.
Level 2: Learning
Learning goals. Most residents felt that they were familiar with the perioperative process
and there were no barriers and challenges to learn the newly developed APC model. Residents
are required to inform patients about the perioperative process prior to surgery. The knowledge
of the APC model of care will simplify their communication on perioperative process and benefit
their relationship with patients. The APC model is targeted to increase patient satisfaction,
which, in turn, provides feedback to residents on their performance in patient care and
commitment. The learning goals are listed below.
1. Explain the principles that guide The APC model of care.
2. Describe the APC model implementation of the guiding principles.
3. Demonstrate the benefits of the APC model to ensure program alignment.
4. Allocate time strategically to meet the needs of program.
5. Create an appropriate timeline for engaging the residents and departments.
6. Plan and monitor their work to ensure compliance.
7. Indicate confidence that surgical residents can execute the APC model.
PERIOPERATIVE CARE INITIATIVE 83
8. Value the engagement and monitoring of surgical residents’ work.
Program. The program includes allocation of residents’ time to participate in learning
and relearning of the APC model. During the 2-week training, two sessions of interactive
didactic and discussion forum training will be conducted each day during lunch hours. Lunch
will be provided during learning sessions to encourage participation and engagement. Pre- and
post-tests of training materials will be given to participants for evaluation of their understanding
and training progress. The program also provides residents the organization’s mission and vision
statements on stickers to adhere to the back of their ID cards to remind them at all times.
Evaluation of the components of learning: Evaluation of sessions’ effectiveness will be
conducted by pre- and post-test during sessions. Tests will be evaluated to see the progress and
levels of confidence residents have after learning.
Table 11
Evaluation of the Components of Learning for the Program.
Methods Timing
Declarative Knowledge “I know it. ”
Pre- and post-tests During 2 weeks learning sessions
Procedural Skills “I can do it right now. ”
Observation during perioperative clinical activities

Pre- and post-tests
After the implementation of
program

During 2 weeks of learning
sessions
Interviews After training sessions completed
Attitude “I believe this is worthwhile.”
Pre- and post-tests During learning sessions
Interviews After training sessions completed

PERIOPERATIVE CARE INITIATIVE 84
Table 11, continued
Methods Timing
Confidence “I think I can do it on the job. ”
Pre- and post-tests During learning sessions
Interviews After training sessions completed
Performance evaluation during perioperative clinical
activities
During implementation
Commitment “I will do it on the job. ”
Pre- and post-tests During learning sessions
Performance evaluation during perioperative clinical
activities
During implementation
Interviews After training sessions completed
Patients’ feedback Continuous

Level 1: Reaction
Questions regarding residents’ satisfaction on learning sessions are included in the pre-
and post-test. External reaction to the success of the program will be measured with patients’
satisfaction surveys that contain perioperative-related questions. Observations by the nursing
staff can be useful to measure residents’ engagement with the APC model.
Table 12
Components to Measure Reactions to the Program
Methods Timing
Engagement
Residents’ post-training survey Promptly after training
Prolonged fasting study. Continuous

PERIOPERATIVE CARE INITIATIVE 85
Table 12, continued
Methods Timing
Relevance
Pre and post-test during learning sessions. 2 weeks during the training
Performance evaluation on perioperative activities 2 months during implementation

Evaluation Tools
Immediately following program implementation. Both formal and informal
evaluations are subject to the performance of residents in the pre- and post-tests, patient surveys,
observations of resident’s participations and residents’ self-reflections. Analysis of perioperative
fasting times data will be useful to triangulate the result of program implementation and
residents’ engagement (Appendix F).
Table 13
Level 2: During and Immediately Following the Program Implementation
Declarative knowledge Item
Knowledge on perioperative care process in the
APC model
Pre-implementation test on the APC
model knowledge
Identify knowledge deficit during the
implementation of the APC model
Post-test following the implementation
of the APC model
Procedural knowledge
Time management in the perioperative
environments
Facts improvement survey of the APC
model process
Attitude
Levels of engagement in the implementation of
the APC model
Data analysis on perioperative process
completion

PERIOPERATIVE CARE INITIATIVE 86
Table 13, continued
Confident
Understanding of the APC model
implementation processes
Survey of ability to complete the task
Commitment
Sense of success in the implementation of the
APC model
Self-reflection on the implementation
of the APC model

Table 14
Level 1. During and Immediately Following the Program Implementation
Engagement Item
Participant training and implementation of the
APC model
Attendance rate and passing the pre- and
post-test during training
Champion the process during the
implementation
Review of execution and completion of
the APC process during implementation
Relevance
Residents evaluation during the
implementation of the APC model
Residents’ self-reflection and survey
during implementation
Customer Satisfaction
Residents’ scorecard Feedback on patients’ satisfaction survey
and fasting time study

Delayed for a period after the program implementation. At the three-month
timeframe, the implementation of the APC model will be evaluated through an anonymous
survey that covers all levels of Kirkpatrick and Kirkpatrick’s (2016) model with a response
options ranging from strongly disagree to strongly agree (Appendix G)

PERIOPERATIVE CARE INITIATIVE 87
Appendix E
Ethics
Ethical consideration in research is identifying potential problems and risks produced by
the methodology. The key here is potential risks to research participants, which are the
responsibility of every researcher, funder, and commissioner of IRBs. Informed consent for
medical research is rooted in the Nuremberg code of 1947 (Herbert, 1996). Adopted by the 18th
World Medical Association (WMA) General Assembly on June 1964 in Helsinki, Finland, and
last amended by the 64th WMA General Assembly on October 2013 in Fortaleza, Brazil, the
WMA developed the Declaration of Helsinki as a statement of ethical principles for medical
research involving human subjects, including research on identifiable human material and data
(Morris, 2013). The declaration binds physicians with the words, “The health of my patient will
be my first consideration,” and it is the duty of the physician researcher to promote and
safeguard patients’ health, wellbeing and rights. Participants must be informed appropriately and
consent must be obtained. My dissertation does not involve patient treatment nor interview. The
research is of explanatory sequential design. On the quantitative side, I obtained unidentifiable
data from the hospital operating room database. The qualitative study involved interviews of
surgical residents from department of orthopedics at the hospital. I obtained informed consent
from residents to ensure participation is voluntary and that participants have the right to
discontinue at any time without penalty. Opinions and the confidentiality of their personal
information are protected, and the research protocol was submitted to hospital’s institutional
review committee for consideration.

PERIOPERATIVE CARE INITIATIVE 88
Appendix F
Immediate Evaluations (Level 1 and 2)
Directions: Thank you for attending today’s APC model training session. The medical center and
our patients appreciate your commitment and willingness to learn more and provide better medical
care to our community. To help ensure the quality of future training sessions, please truthfully
respond to the following items. You also can provide additional feedback or suggest topics for
future training and implementation at the end of this feedback form. These feedback forms are
anonymous. However, if you would like to provide one-on-one additional feedback please contact
the training administrators.

Pre-Test

Item 1: I am familiar with the updated perioperative guidelines provided by the American Society
of Anesthesiologists.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 2: I am following the updated perioperative guidelines provided by the American Society of
Anesthesiologists.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 3: I am aware about the value of efficient perioperative processes.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 4: My department encouraged me to participate in the APC model training with incentives.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 5: I volunteered to participate in the APC model training.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Post-Test

Item 1: I was satisfied with the APC model training session arrangement.

Strongly Disagree Disagree Neutral Agree Strongly Agree

PERIOPERATIVE CARE INITIATIVE 89
Item 2: As a resident/operating room administrator, I found the content presented valuable.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 3: The materials and information learned during the APC training session gave me
confidence to become an advocate for reducing perioperative fasting time toward the guidelines.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 4: It is likely that I would advise my peers to participate in the APC model training.

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 5: It is likely that I would be the champion user of the APC model of practice at my
department.

Strongly Disagree Disagree Neutral Agree Strongly Agree

PERIOPERATIVE CARE INITIATIVE 90
Appendix G
Delayed Evaluations (Levels 1, 2, 3 and 4)
Directions: Thank you for attending today’s APC model training session. The medical center and
our patients appreciate your commitment and willingness to learn more and provide better medical
care to our community. To help ensure the quality of future training sessions, please truthfully
respond to the following items. You also can provide additional feedback or suggest topics for
future training and implementation at the end of this feedback form. These feedback forms are
anonymous. However, if you would like to provide one-on-one additional feedback please contact
the training administrators.

Item 1: The APC model training was valuable to mitigate perioperative fasting time (Level 1).

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 2: The APC model provided knowledge to improve patient care (Level 2).

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 3: Patient satisfaction during the perioperative care process is my goal for my everyday
practice (Level 3).

Strongly Disagree Disagree Neutral Agree Strongly Agree

Item 4: Do you participate in and have confidence in achieving 100% of the APC model of practice
and reduced fasting time to less than 10 hours (Level 4).

A. Yes, I participated in the APC model of practice and reduced fasting time below 10 hours.

B. Yes, I participated in the APC model of practice but unable to reduce fasting time below 10
hours.
C. No, I did not participate in the APC model of practice.

Item 5: Through implementation of the APC model of practice, I found a strong sense of altruistic
value and achievement (Level 4).

Strongly Disagree Disagree Neutral Agree Strongly Agree

PERIOPERATIVE CARE INITIATIVE 91
Appendix H
Additional Feedback
Additional Feedback: In the space below please provide additional feedback about the APC model
initiative that you took part in 2018. What would you like to see more of next year? Please provide
us with your reflections regarding the training and implementation of the APC model

Abstract (if available)

Abstract Prolonged fasting during the perioperative process reflects many problems both in patient experiences and treatment outcomes that need to be addressed in health care organizations. In early 2018, one medical center introduced the Accountable Perioperative Care (APC) model to restructure perioperative practice. The aim of the innovation is to better prepare patients before surgery by comprehensively communicating the standardization of best practice treatment during their hospitalization. The study explored resident physicians’ knowledge, motivation and organizational influences related to implementing the APC. Resident physicians were chosen as the study population as they are the main work force in teaching medical centers. Under the APC model of care, residents demonstrated high self-efficacy in providing quality perioperative care to surgical patients. Residents saw the value of the APC model in improving patient satisfaction and perioperative outcomes. Residents felt the APC model training was valuable and would like to champion the process to advocate for better patient care. This study concludes with recommendations for organizations regarding training on the health agencies guidelines, practice with the APC model, and supporting stakeholders’ needs.

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Asset Metadata

Creator Ma, Alfred C. (author)

Core Title Enhancements of surgical patient care: perioperative care initiative

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 02/04/2019

Defense Date 12/14/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag fasting,implementation,initiative,OAI-PMH Harvest,perioperative,Training

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Seli, Helena (committee chair), Datta, Monique (committee member), Nichol, Michael (committee member), Ninan, David John (committee member)

Creator Email alfredma@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-117361

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Legacy Identifier etd-MaAlfredC-7043.pdf

Dmrecord 117361

Document Type Dissertation

Format application/pdf (imt)

Rights Ma, Alfred C.

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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