I Thought I Was Rebuilding Operating Theatres

A hospital executive sets out to replace a 25-year-old operating theatre — and discovers that the real rebuild is training, roles and culture.

When I started planning a new operating theatre suite, I thought the biggest challenge would be the construction.

I was wrong.

Our main operating theatre was more than 25 years old. It had served us well over the years, but it desperately needed refurbishment. The problem was that it also handled the majority of our surgical workload. Closing it wasn’t an option.

So we made the difficult decision to build an entirely new operating theatre suite in another part of the hospital.

It meant relocating housekeeping, laundry, inventory, physiotherapy, the staff lunchroom and several other services just to create enough space to build. It became a project that lasted close to two years.

While we were busy building the future, the existing operating theatres continued to deteriorate.

Then we started seeing surgical site infections.

One case has always stayed with me. An orthopaedic surgeon came to us as a patient for a knee replacement. Unfortunately, he developed an infection afterwards and eventually had to have the implant removed.

Whether or not the infection was directly related to our systems, it forced us to stop and ask some uncomfortable questions.

Was it the environment?

Was it our infection prevention practices?

Or was something else happening that we hadn’t recognised?

As we started looking more closely, the problem wasn’t as straightforward as I had expected.

Our staff weren’t careless.

They weren’t refusing to follow procedures.

They simply hadn’t had the opportunity to formally update their knowledge over the years.

New equipment had been introduced. Technology had changed. Infection prevention practices had evolved. Yet much of the theatre team’s knowledge had been passed from one generation of staff to the next. Their original training had been built on excellent foundations, but healthcare had moved on.

Our training hadn’t kept pace.

That was probably the moment the project changed. Our nurse manager was instrumental in that shift. Rather than jumping straight into teaching, she first assessed the team, identified knowledge gaps and developed learning objectives. From there we built an in-house education programme around what the department needed.

Doctors from different specialties came to teach the theatre staff. Equipment vendors demonstrated the correct use, cleaning and maintenance of their equipment and certified that the training had been completed. They talked about anatomy, physiology, infection prevention and the expectations different specialties had of the theatre team.

The more we learned, the more questions we started asking.

One ongoing issue I remember well was about shaving patients before surgery.

Management wanted patients shaved on the ward before coming to theatre. Some surgeons preferred the shaving to be done in theatre.

At first, it sounded like a disagreement over policy.

It really wasn’t.

From a management perspective, our concern was that shaving in theatre introduced loose hair into what was supposed to be a clean surgical environment. I was also thinking about the patient. If someone was shaved after they were asleep, had we explained that beforehand? Would they wake up understanding what had happened, or would they feel that something had been done without their knowledge?

The easy option would have been to write another policy.

But I had already realised that policies weren’t really the problem.

If management said one thing and a surgeon said another, staff ended up caught in the middle.

I didn’t want them following whichever person had spoken last.

I wanted them to understand the reasoning well enough to have an informed conversation.

If I wasn’t there, I still wanted the right conversation to happen. If they believed shaving should happen before the patient entered theatre, I wanted them to be able to explain why. If a surgeon challenged them, I wanted that discussion to be based on knowledge—not hierarchy.

That was also when I recognised something else. I was tired of being the person who had to make every decision.

Every time there was a disagreement, someone would come looking for management to provide the answer. That wasn’t sustainable, and it certainly wasn’t helping the staff develop confidence in their own judgement.

I didn’t want a department that depended on me to solve every problem.

I wanted a department where people understood the reasoning behind what they were doing, felt confident enough to ask questions and could have professional discussions with each other without management stepping in every time.

For me, that was the real value of education.

It wasn’t just about improving knowledge. It was about giving people the confidence to think differently: understand the evidence, ask questions and explain the reasoning behind their decisions.

That was the culture I was trying to build.

While all this was happening, I was also trying to learn an entirely new world myself.

Building three new operating theatres meant understanding theatre design, workflow, pre-operative care, intra-operative care, post-operative recovery, CSSD (Central Sterile Services Department), anaesthetic nursing, attendants, equipment flow, clean air systems and what a modern operating department should look like.

We couldn’t afford to hire consultants to do any of that for us.

So I visited other hospitals, spoke with doctors, read everything I could find and learned as I went.

As I learnt more about operating theatre design, I was also thinking strategically about the future of the hospital.

This wasn’t just about replacing an old operating theatre. We were designing a department that needed to support the surgical specialties we had at the time, while also creating the infrastructure to attract new specialties in the future.

Every design decision mattered—patient flow, staff movement, infection prevention, communication, equipment placement and, ultimately, the patient experience.

The physical layout had to support the way we wanted the department to function, not recreate what we already had.

I found myself asking a different question throughout the project:

If a new surgeon walked into these theatres five or ten years from now, would they feel confident operating here?

That process exposed another problem.

Our roles had gradually become blurred.

Everyone did a bit of everything. It worked because people helped each other, but over time responsibilities became less clear.

The new theatres gave us an opportunity to redefine those roles and build clearer workflows.

Then we hit another challenge.

We knew exactly what people needed to learn.

Finding somewhere for them to learn it was much harder.

I often say, “We don’t know what we don’t know.” That’s why exposure is important.

If you’ve never experienced a department functioning differently, you don’t even know what questions to ask.

Access to specialised operating theatre education was limited. Recruiting experienced staff was equally challenging. We recruited both internally and externally, but regardless of where someone came from, they still had to learn our theatre policies, workflows and expectations.

Like many healthcare organisations across the Caribbean, we were trying to improve services while working within a very limited training ecosystem.

So we built what we could ourselves, invited clinicians into the department to teach and equipment vendors to train and certify staff.

And we started looking outside the organisation for ideas we couldn’t find at home.

We identified an accredited local programme for operating theatre personnel, and some of our staff attended. However, it also highlighted another challenge. Like many specialised programmes in small countries, the programme had to deliver highly specialised practical training with limited resources and opportunities for clinical exposure.

It reinforced for me that sending staff on a course was only one part of the solution. We still needed to provide ongoing in-house education, mentoring and practical experience within our own department.

I also reached out to a respected hospital system in the United States to explore observership opportunities. The project never came to fruition, but the thinking behind it stayed with me. It wasn’t about learning one new technique. It was about seeing how a busy, accredited operating department functioned behind the scenes—how roles were defined, departments communicated and patients, instruments and information flowed through the system.

Once you’ve seen what is possible, you start asking different questions.

When I started this project, I genuinely believed I was solving a building problem.

Instead, I uncovered a training problem, a workforce problem and, ultimately, a culture problem.

The new operating theatres and equipment were important. They positioned the hospital for future growth and new surgical specialties. But they would never have transformed the department on their own.

The biggest change was watching people grow in confidence. Watching them ask questions, explain their reasoning and make difficult decisions based on what they genuinely believed was right for the patient.

I realised I wasn’t trying to build a department that followed rules because management said so. I was trying to build a department that understood why it did what it did.

In the end, that wasn’t just good for the staff or the hospital. It was good for every patient who placed their trust in us.

About the Author

Tricia Medford MSM-DTH, MScPH(LSHTM), PgDip HSM, BA, is a Healthcare Management Consultant with more than 25 years of experience in private healthcare operations in Trinidad and Tobago. Her work spans healthcare operations, quality improvement, workforce development and digital transformation, with extensive experience leading organisational change and implementing healthcare systems. She holds postgraduate qualifications in Public Health and Health Systems Management from the University of London, and a Master in Management in Digital Transformation in Healthcare from Northeastern University. She works with healthcare organisations to strengthen operations, develop their teams and improve the patient experience.

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