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

Paper Title

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

Publication Info

• Topic area: Post-surgery care coordination and socio-technical challenges.
• Keywords: Post-surgery care, discharge preparation, care transitions, gastrointestinal surgery, patient-provider collaboration, socio-technical systems, remote patient monitoring, conversational agents, healthcare coordination, boundary objects.

Background and Problem

• Problem / challenge: Existing research has focused on post-surgery challenges at home but has largely overlooked the discharge preparation stage, where coordination breakdowns between provider teams and patients can lead to poor self-care readiness and adverse outcomes.
• Significance: Effective discharge preparation is critical for reducing complications, improving patient safety, and preventing hospital readmissions. Addressing these gaps can enhance both patient outcomes and healthcare efficiency.
• Motivation and related work: Prior studies have documented post-discharge errors, fragmented communication, and the limitations of assistive technologies like remote patient monitoring (RPM). However, the socio-technical mechanisms driving discharge preparation and coordination remain underexplored, particularly in high-risk cases like gastrointestinal (GI) surgery.

Solution

• Proposed approach: A qualitative study investigating the socio-technical mechanisms during discharge preparation for GI surgery patients, focusing on coordination breakdowns and design opportunities for socio-technical systems.
• Novelty:
  1. Identifies systemic coordination breakdowns between provider teams and patients during discharge preparation.
  2. Highlights the role of flawed boundary objects (e.g., discharge summaries) in disrupting care transitions.
  3. Proposes design considerations for context-aware, coordinated technologies to bridge hospital-to-home care gaps.
  4. Explores the role of physical frailty and digital barriers in shaping post-surgery care experiences.
• Procedure and key techniques: Conducted semi-structured interviews with 13 GI care providers and 4 patients to examine workflows, interactions, and challenges during discharge preparation. Thematic analysis was used to identify patterns, breakdowns, and design opportunities.

Results

• Concrete findings:
  • Coordination breakdowns between inpatient and outpatient teams due to flawed discharge summaries and fragmented workflows.
  • Patients often feel unprepared for self-care at home, struggling with tasks like drain management and symptom monitoring due to physical frailty and inadequate training.
  • Digital barriers and misaligned symptom understanding hinder timely reporting and intervention.
• Advantage over baselines: Highlights systemic issues beyond individual errors, offering a holistic view of the discharge preparation stage and its impact on patient outcomes. Proposes actionable design opportunities for socio-technical systems.
• Experiments / evaluation: Semi-structured interviews with 13 GI care providers and 4 patients, focusing on their experiences and challenges during the hospital-to-home transition. Data were analyzed using reflexive thematic analysis.
• Limitations and future work:
  • Small patient sample size limits generalizability.
  • Focused on GI surgery; findings may not generalize to other surgical contexts.
  • Did not implement or evaluate proposed technologies; future work should develop and test these systems.

Summary

This study investigates the socio-technical challenges in the transition from hospital to home for GI surgery patients, identifying critical coordination breakdowns between provider teams and patients. Flawed discharge summaries and inadequate preparation leave patients unprepared for self-care, while systemic resource constraints and digital barriers exacerbate delays in care. The findings highlight the need for context-aware, coordinated technologies that integrate patient-generated data with clinical workflows. Future systems should address these gaps by improving discharge preparation, supporting collaborative care, and tailoring interventions to patients’ physical and digital constraints.