Objectives: The thesis seeks to provide an analysis of surgical work and decision making, to identify the basis of the widely observed variation in surgical practice and to indicate what surgeons see as the source(s) of that variation. Against this background, it examines the strengths and limitations of the approach promoted by the evidence-based medicine movement to surgical work. Methods: A qualitative study of surgical practice by urological and gynaecological surgeons in England and the USA involved in the treatment of female urinary stress incontinence. Depth interviews with 29 English surgeons and five American surgeons. Interviews were recorded and transcribed. Observation of 23 operations and additional ethnographic data collection at the hospitals and clinics where these surgeons worked. The observational data consist of near verbatim notes. All these data were analysed using the constant comparative approach described by Glaser and Strauss (1967). A variant of the split-half technique was used to test emerging themes. Results: Surgical practice is contingent: it is dependent on a range of variables, and, it is serendipitous. Three categories of contingency are identified (case, surgeon and external contingency). It is argued that surgical practice entails the complex interplay of these conditional factors and chance happenings. In order to learn to deal with contingency, surgeons learn or acquire practice skills through first hand experience. The thesis explores the role of the surgical apprenticeship and models of learning used by surgeons. Conclusion: The nature of surgical practice presents some fundamental challenges to EBM. The contingent and experiential features of surgical work raise serious doubts about the applicability of EBM to surgery.

The medical device manufacturing industry has a deficiency in determining how to improve supplier performance for the components and systems they purchase. Many complex medical devices require components from superb suppliers. But how does a medical device manufacturer (MDM) impartially assess supplier performance to know which suppliers to continuing with (or even boost purchase volumes) and which suppliers they should exit? This study describes which supplier-specific metrics are most important to medical device manufacturers (MDMs) so they can utilize this supplier performance scorecard backed by real-world inputs. This research will focus on five categories to measure MDM supplier performance (Quality, Price, Delivery, Customer Service, and Partnership) across twenty-three (23) metrics. Because this is a focus of MDM supplier performance, we are not focusing on analysis of device sales to the final customer (e.g., distributors or group purchasing organizations {GPO}). The study will follow a framework including research analysis of supplier performance management in other industries, methods to attain data from MDMs via survey, results and analysis of the data, conclusions, and an easily understandable MDM supplier performance scorecard. In the survey, 135 MDM professionals replied when asked to rate twenty-three (23) supplier performance metrics, across five (5) categories aggregated from nine (9) different industries. The survey yielded a myriad of results including, weighting factors of each of the metrics, and those data results were used to compile an MDM supplier performance scorecard utilizing real-world feedback. The analysis revealed the ratings of importance of the categories as: Quality (43%), Delivery (24%), Customer Service (4%), Partnership (13%), Price (8%) and associated weights for the twenty-three (23) metrics that matter most to an MDM when creating a performance scorecard for their supplier base. Three contributions that this research will add to the body of knowledge: An in-depth review of supplier performance across many different industries (i.e., non-healthcare and healthcare) for contrasting/comparing evidence. A detailed MDM survey and statistical analysis on the topic of supplier performance management. An easily understandable and useable MDM supplier performance scorecard (via MS Excel) for MDM supply chain and/or operations users and/or managers.