“They Are Not Going to Be Happy†: An Ethnographic Study of the Prioritization of Patients Awaiting Elective Surgery in an Academic Hospital in the Netherlands

Background To reduce variation in waiting time for elective surgery, a Dutch academic hospital introduced a classification system based on urgency scores to standardize decision making. Physicians, however, retain clinical discretion in assigning urgency scores. This facilitates the provision of personalized and efficient care but may also create variation between patients and lack of transparency. The aim of this study was to describe the prioritization of patients awaiting elective surgery, including the use of urgency scores, and to explore explanations for discrepancies between assigned scores and actual waiting times. Methods We conducted an ethnographic study combining interviews with physicians and observations of elective surgery planners in the academic hospital. Data were analyzed thematically, guided by 3 sensitizing concepts: professional autonomy, emotions, and traditions. Results The prioritization of patients awaiting elective surgery begins with physicians’ assessment of urgency and concludes with planners drafting the schedule. The assessment is guided by clinical parameters, patient- and physician-related factors, and logistical constraints. Importantly, the prioritization of patients for elective surgery is shaped by subjective and affective considerations, customary decision-making practices, as well as the considerable professional autonomy of physicians and planners. Conclusions Standardized prioritization tools, such as urgency scores, may reduce unjustified variation in waiting times, but initial resistance to their implementation can hamper their use in decision-making practice. Moreover, such tools alone may fail to capture the complexity of clinical practice and the importance of the expertise and experience of physicians and planners therein. Rather than relying solely on stricter adherence to urgency scores, prioritization processes may be strengthened by facilitating communication and feedback exchanges to support a more integrated and context-specific approach that considers the complexity of clinical practice. Highlights Standardized decision-making tools are implemented to standardize and support the prioritization of patients awaiting elective surgery. Prioritization decisions are made by different professionals, and nonclinical factors that include subjective perceptions and logistic constraints may guide these decisions. Standardized tools inadequately capture the complexity of clinical decision making and the professional autonomy physicians and planners.