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

2025-09-27

AI Summary

This study addresses care fragmentation between clinical teams and patients during the post-gastrointestinal-surgery discharge transition, identifying critical gaps in recovery support arising from ambiguous coordination boundaries, nonstandardized handoff procedures, information silos, and misaligned resource allocation between hospital and community/home settings. Using a qualitative approach grounded in human-computer interaction and interprofessional collaboration frameworks, we conducted semi-structured interviews with 13 healthcare professionals and 4 patients. Findings reveal that such fragmentation directly undermines patients’ readiness for home care, fragments clinical data, and delays shared decision-making. Based on these insights, we propose three actionable design opportunities: (1) explicit articulation of task ownership and accountability; (2) standardization of structured, bidirectional discharge handoff protocols; and (3) dynamic alignment of care plans with real-time clinical signals and patients’ evolving home capabilities. The study provides empirically grounded, implementable strategies to strengthen continuity of care in postoperative recovery systems.

Technology Category

• Humans and AI: Planning and Decision Support for Human-Machine Teams
• Search and Optimization: Mixed Discrete/Continuous Search
• Constraint Satisfaction and Optimization: Mixed Discrete/Continuous Optimization

Application Category

• Security and Privacy: Data transparency and provenance
• User Modeling, Personalization and Recommendation: Practical large-scale studies of user experience
• Economics, Online Markets and Human Computation: The sharing economy

Abstract

Post-surgery care involves ongoing collaboration between provider teams and patients, which starts from post-surgery hospitalization through home recovery after discharge. While prior HCI research has primarily examined patients' challenges at home, less is known about how provider teams coordinate discharge preparation and care handoffs, and how breakdowns in communication and care pathways may affect patient recovery. To investigate this gap, we conducted semi-structured interviews with 13 healthcare providers and 4 patients in the context of gastrointestinal (GI) surgery. We found coordination boundaries between in- and out-patient teams, coupled with complex organizational structures within teams, impeded the "invisible work" of preparing patients' home care plans and triaging patient information. For patients, these breakdowns resulted in inadequate preparation for home transition and fragmented self-collected data, both of which undermine timely clinical decision-making. Based on these findings, we outline design opportunities to formalize task ownership and handoffs, contextualize co-temporal signals, and align care plans with home resources.

Problem

• Examining coordination breakdowns between hospital teams and patients
• Identifying communication failures during post-surgery care transitions
• Addressing inadequate home preparation and fragmented patient data

Innovation

• Semi-structured interviews with healthcare providers and patients
• Formalize task ownership and handoffs in care coordination
• Align care plans with home resources for patients