Coordination and work flow management in health care Doctoral course held jointly by Prof. Yan Xiao (University of Maryland) and Prof. Gudela Grote (ETH

Coordination and work flow management in health care

Doctoral course

held jointly by Prof. Yan Xiao (University of Maryland) and Prof. Gudela Grote (ETH Zürich

2Prof. Dr. Gudela Grote, ETH Zürich, [email protected]

Outline

Tuesday July 7 9:00 - 10:00 Introduction to the course (Xiao & Grote) 10:30 - 12:00 Basic issues in coordination and planning -

organizational perspective (Grote & Xiao) 13:00 - 14:30 Basic issues in coordiation and planning -

systems engineering perspective (Xiao) 15:00 - 17:00 Case study I: Negotiation and conflict in large scale

collaboration (Xiao)

Wednesday July 8 9:00 - 10:30 Case study II: Visualization of uncertainty for planners (Xiao) 11:00 - 12:30 Case study III: Surgical work flow (Xiao) 13:30 - 14:30 Case study IV: Planning of operating room occupancy (Grote) 14:45 - 16:00 Overall discussion (Xiao & Grote) 17:15 - 18.30 Talk by Yan Xiao at the University Hospital Zürich:

"Simulation, live teams and videotape: all for the sake of patient safety"


Learning objectives

Review concepts and theories on coordination in the literature

Characterize problems and issues in researching coordination and workflow

Review case studies on coordination and workflow in health care

Integrate knowledge into a possible research plan within and/or outside of own dissertation research

= Course requirement: 8-10 page report by Aug. 31


Basic issues in coordination and planning - organizational perspective

Coordination and planning in organizations Linking coordination and planning in view of

management of uncertainties Examples of own research:

Planning in supply chains Interaction of rules and routines in railway operations Adaptive coordination in health care teams







Coordination in organization theory (Thompson, 1967; Van de Ven et al., 1976)

Coordination required for management of task interde-pendencies, which are created by task requirements and chosen degree of specialization.

Task interdependencies (TI) pooled sequential reciprocal

Coordination mechanisms Impersonal (Technology, standards, plans) pooled/sequential TI Personal

- vertical (Leadership) sequential/reciprocal TI

- lateral (mutual adjustment) reciprocal TI Cultural norms - overriding "soft" centralization

Prof. Dr. Gudela Grote, ETH Zürich, [email protected] 7

Flight phase

1

Take-off

2

Preparation

Clean approach

3

Approach and Landing

Average duration (min.) 3 10 3

Task load Low Low High

Standardization High Low High

Communication units (CU) overall 840 3514 1429

CU standardized communication 52% 9% 28%

CU explicit 66% 81% 60%

CU implicit 34% 19% 40%

CU leadership 2% 14% 3%

CU Heedful interrelating 2% 18% 19%

Example of interplay between impersonal and personal coordination: Standards as subsitutes for leadership in cockpit crews (Grote et al., 2004)

Good teams used more leadership in phase 2 (low standardization) and less in phases 1 and 3 (high standardization) (n= 42 teams)







Process upset in a polyethylen plant (taken from an obs ervat ion study during a sa fety man age ment aud it) In a plant of a la rge pert roche mica l compan y, po lyethy len is pro duced from ethy len disso lved in isobuta ne and a nun ber of other c hemica ls inc lud ing hexane. The react ion takes plac e und er high temperat ure and pressure in loop rea ctors. An opera tor in the contro l room of the plan t mon itors two such reactor s by means of a number of scre ens an d process record ers on a contro l pane l. Looking at one of th e process record ers, another sh ift ope rator exp la ins to the observ er that when two of the curves on the line record er do no t run in para lle l any more , extra caut ion is ne eded, an d when the cruves cross the process has to be s toppe d immediate ly. Those two curve s conc ern the press ure in the react or and the en ergy consu mption in a g roup of p umps. The cro ss ing of t he curves indicates lumping of t he po lyethy len in the rea ctor, which increases the pressur e in the react or and the energy consu mption by the pumps becaus e more energ y is nee ded to pump the finished product out of the react or. Next to the pro cess rec order, a p iece of p aper is taped to the contro l pane l, stat ing critica l va lues for these two par ameters, dis tingu ish ing between va lues whe n the shift superv isor has to be informed an d when the process has to be stop ped. Stopp ing the process implies the imm ediate emptying and rins ing with water of the reacto r and an inte rrupt ion of product ion for severa l hours. An hour later dur ing the obser vat ion, the curves do indeed beg in to move towards ea ch other. The pa ne l oper ator not ices the change imm ed ia te ly an d cha nges the se t va lues for he xan e after hav ing checked a numbe r of other process par ameter s and a lso hav ing ver ified the set va lues for he xane in the standa rd ope rat ing proced ures. This action causes the process con trol syste m to redu ce the influx of he xane which redu ces the pres sure in the reac tor due to a s maller volume of react ing substances . At the sa me time , the operato r has informed the shift su perv iso r who leaves a meet ing to join him a t the cont rol pane l where he remains during the course of the process ups et. The first act ions taken by the operat or have not been ab le to reverse the tr end in the two para mters. On ly after further redcut ion of he xane influx an d faster e mptying of the reactor the va lues turn back to no rmal. In the f ifteen minu tes that this course of events takes, the curves disp layed on the pro ce ss record er have briefly cros sed. Trust ing his own competence in ha ndling the proces s upse t and supp orted by the sh ift superv isor , the ope rato r dec ide d aga inst stopp ing the process comple te ly. Instead of caus ing a s ign ificant interr uption of product ion, the ope rator succe eds in nor malizing the process in the cours e of ha lf an ho ur, with a lso the resu lts from qua lity contro l be ing pos itive aga in a little while later. His sh ift co lleague comm ents: „I def inite ly wou ld have stopped the process complete ly“, but admirat ion for the other` s co mpetence can be sensed. Your task: Did the operat or act correct ly? Why?


Basic principles of organization design: Two approaches to managing uncertainties (Grote, 2004, in press)

Minimizing uncertainties • complex, central planning systems

• reducing operative degrees of freedom through procedures and automation

• disturbances as to be avoided symptoms of inefficient system design

Co ping w ith un cer taintie s • plann ing as re sourc e for s ituated act ion

• maximizing operat ive degree s of freed om throu gh complete tasks and la tera l coope rat ion

• distu rbances a s opp ortun ity for us e and deve lopment of compe tenc ies and for syste m ch ange

Dependence /

feedforward control

Autonomy /

feedback control

Balance through loose coupling Motivation through task orientation

Higher order autonomy Flexible changes between organizational modes

Culture as basis for coordination/integration * Uncertainties may stem from the system environment and/or from the transformation processes within the system.

Coordination via- technical systems- standards/programs- personal directionWorks best with few uncertainties

Coordination via- plans- lateral agreement- cultureWorks best with many uncertainties


Stability

Flexibility

Loose coupling

= Balance between minimizing uncertainty, which creates stability, and coping with uncertainty, which creates flexibility

Central planning

High standardization

High level of automation

Little operative freedom

Feedforward control














Dependence /

feedforward control

Autonomy /

feedback control










The concept of organizational routines

Organizational routines are "repetitive, recognizable patterns of interdependent actions, carried out by multiple actors" (Feldman & Pentland, 2003, p. 95)

Three functions of routines (Nelson & Winter, 1982)

targets for behavior, thereby keeping behavior under control;

organizational memory of the knowledge needed for successful task performance;

truce between conflicting interests of different participants in the organization.


Example of functions of rules in railway operations (Weichbrodt & Grote, 2009)

Signalling Shunting Construction

Density of regulation

high low medium

(increasing)

Level and type of risk

personal risk: none for others: high

personal risk: high for others: medium

personal risk: high for others: high

Amount of conflict around rules

low high medium

Handling of rule breaking

mostly peer control mostly supervision peer control and

supervision

Function of rules (interviewee’s perspective)

providing support, especially in

unusual situations

control by management and identifying culprit

control by management and providing support

fi Rule as

organizational memory

fi Rule as truce

fi Rule as target


The relationship between routines and rules

Routine in principleAbstract under-standing of certain recurrent behavior pattern

Routine in practice Actual recurrent behavior pattern

RuleArtefact containing a written-down formal description of certain behavior pattern

crea

tees

tabl

ish

guide

express

describeinform


Types of formal rules (Hale & Swuste, 1998)

Rules concerning goals to be achieved (goal rules) "Flights through areas with known or forecast thunderstorms, severe turbulence or wind shear should be avoided whenever possible."

Rules defining the way in which decisions about a course of action must be arrived at (process rules) "In order to complete a replanning, any documented cruise system and all means available may be used, such as flight management systems (where available) and data contained in the respective AOMs."

Rules defining concrete actions (action rules)"Every evacuation must be carried out as quickly as possible. The passengers must be assisted to leave the aeroplane without their belongings and directed to a point at a safe distance from the aeroplane."(Rule examples taken from the flight operations manual of a commercial airline)


Principles for creating flexible routines

Determine desired balance between stability and flexibility e.g. in view of increasing traffic density

Use goal and process rules for flexibility and action rules for stability

Match responsibility and capabilities for uncertainty handling e.g. avoid combining centralized capability with local

responsibility


Good rule ?

"The correct functioning of the train control system and the automatic traffic control system is to be monitored by the signaller. If necessary, he/she has to intervene manually. During normal operation, no monitoring is necessary as long as the operational requirements are met. In the case of disturbances or incidents, the notification of the required services and the required alarm procedures must be guaranteed."

(Excerpt from the rule book of a European railway company)


Good rule ?

"The correct functioning of the train control system and the automatic traffic control system is to be monitored by the signaller. If necessary, he/she has to intervene manually. During normal operation, no monitoring is necessary as long as the operational requirements are met. In the case of disturbances or incidents, the notification of the required services and the required alarm procedures must be guaranteed." (Excerpt from the rule book of a European railway company)

Goal rule flexibility

but: insufficient responsibility/support match

Action rule stability

(with decision latitude)

Process rule flexibility







Study setting: Simulated asystole during intubation

Preparation Medication Reaction to Asystole

Asystole

Intubation Additional preparations

Debriefing

Workload

t

t


An example of a good team (Kolbe et al., 2009)

17sec. until problem solved; Anaesthetist 1 yr. and nurse 5 yrs. experience

Zur Anzeige wird der QuickTime™ Dekompressor „“

benötigt.


AsystolePhysician

Nurse

During asystole:

1. (nurse) provides unsolicited information ("Asystole")

t

Coordination in team 2


AsystolePhysician

Nurse

During asystole:

1. (nurse) provides unsolicited information

2. (physician) provides unsolicited action (monitors and fixes tube)



AsystolePhysician

Nurse

During asystole:


2. (physician) provides unsolicited action

3. (nurse) provides unsolicited action (Präkordialschlag)



AsystolePhysician

Nurse

4. (nurse) monitoring (looks at monitor)

During asystole:



3. (nurse) provides unsolicited action



AsystolePhysician

Nurse

4. (nurse) monitoring

During asystole:


5. (nurse) provides unsolicited action (checks whether electrodes are placed correctly)


3. (nurse) provides unsolicited action

Implicit coordination pattern



Importance of shared leadership (Künzle et al., 2009)

30

High performing teams Low performing teams

p<.05

(n.s)

N = 12 teams, Wilcoxon Signed Ranks Test

00.5

11.5

22.5

33.5

44.5

Nurses Residents

Content-oriented Structuring

00.5

11.5

22.5

33.5

44.5

Nurses Residents

Content-oriented Structuring

(n.s)(n.s)

Lead

ersh

ip (

Mea

n ra

te p

er M

inut

e)

Lead

ersh

ip (

Mea

n ra

te p

er M

inut

e)


A personal journey ino planning

The start: How to get rid of planners to free frontline workers

Leg 1: How should planners and operators cooperate

Leg 2: How should planners among themselves cooperate

Leg 3: How should planners across organizations cooperate

Leg 4: Collaborative planning in multi-x networks


Planning

= How to get from the present state to a desired future state

Basic issues: Knowing/agreeing on the desired state Knowing the present state Learning from past states

Basic obstacles: Uncertainty = lack of knowledge/ambiguous knowledge Complexity = Multiple interdependencies


Multiple approaches to planning

Feed forward versus feedback hierarchical versus opportunistic blueprint versus resource

Loosening versus tightening interdependencies autonomy for reducing uncertainties cooperation for coping with uncertainties power for transfering uncertainties increasing uncertainty as an unexplored option









Dependence /

feedforward control

Autonomy /

feedback control





Bridging the planning-implementation divide: Cooperation between planners and frontline workers

Distribution of autonomy and control as basic conflict (Grote, 2000)

Explicit communication of goal structure and rationale of plans (Hoc, 1988)

Perspective taking and linking (Zölch, 1997) Willingness for mutual constraining (McKay, 1992)

Linking primary (implementation) and secondary (planning) work systems through shared and higher-order autonomy (Wäfler, 2001, 2002)

Interpersonal and informational role of schedulers (Jackson et al., 2004)


The elusiveness of the common goal: Collaboration among planners

Overcoming power gradients (Jarillo, 1988)

Balancing autonomy-related losses and interdepen-dence-related gains through risk-sharing (Scott, 1981)

Exchanging uncertain information (Loch & Terwiesch, 2005)

General quest for collaborative planning (Danese, 2006)


Model of collaborative planning(Windischer, 2003; Windischer et al., 2009)

Plan creation Communication of anticipated events Knowledge of reference field characteristics Lateral goal agreement Negotiation of alternatives Recognition of planning adequacy

Plan execution Monitoring and diagnosis of errors in common plan Coordination of individual opportunistic planning Common reflection/decision on plan cancellation


Characteristics of collaborative planning: Plan creation

Characteristic Definition Example Communication of anticipated events

Explicit mentioning of expected events; communication of uncertain information regarding proba-bility of occurrence of events

Early warnings regarding anticipated delivery problems; Communication of expected, but uncertain orders

Knowledge of reference field characteristics

Exchanging information on conditions in own and other`s field of action; trying out actions

Providing background infor-mation on delivery problems; Providing information on own capacities, time manage-ment etc.

Goal agreements Common definition of goals and reciprocal commitment to achieving the goals

Agreements on safety margins; Agreements on frozen zones for demand changes

Negotiation of alternatives Agreement on a deviation from the original plan

Agreement on express delivery; Agreement on taking back unnecessary material

Recognition of planning adequacy

Avoiding unnecessary restrictions in the other`s decision latitude

Sufficient detail and time span of demand forecast; Sufficient stability of planning


Characteristics of collaborative planning: Plan execution

Characteristic Definition Example Monitoring and error diagnosis

Checking the status of execution of the common plan; Exchanging information on discrepancies between planned and actual situation

Checking with production that a delivery date can be kept; Identifying problem zones in a shared plan

Co-ordination of opportunistic planning

Informating others about implemented deviations from original plan; Explicit common decision on modifications

Early information on changes in demands; Common decision on plan changes due to an express order

Common reflection / decision for plan cancellation

Recognizing when a plan cannot be executed; Reflection on improvement potential

Information on inability to keep delivery date; Common reflection on problems in the planning process


Fit regulation requirements / possibilities

Collaborative planning

Outcome- Variables

Company A Low fit due to high task inter-dependence and uncertainty com-bined with feed-forward single-department plan-ning

Few goal agree-ments Little recognition of adequacy of com-mon plan, co-ordination of oppor-tunistic planning, and monitoring and error diagnosis

Low satisfaction with inter-departmental communication Low delivery effi-ciency Medium forecast ac-curacy

Company B High fit due to high task inter-dependence and uncertainty com-bined with inte-gral process-oriented feedback planning

Good knowledge of reference field, co-ordination of modifi-cations, and reflec-tion on planning process

Medium to high sat-isfaction with inter-departmental com-munication High delivery effi-ciency Low forecast accu-racy

Design-planning-outcome links (Windischer, 2003; Windischer at al., 2009)


The puzzle of the cooperative free spirit:Collaborative planning in networks

Multi-directional influences by multiple power centers in heterarchic networks (Stadtler, 2005)

Interdependence as asset and threat (Gulati & Sytch, 2007)

Collective versus individual autonomy as match to task interdependence (Langfred, 2005)


Main process stages

Fagus network

First stage : Long -and medium term planning Second stage : Bid processing Third stage : Harvesting and hauling Fourth stage : Transporting wood Fifth stage : Measuring wood and billing

Forest ranger

Service provider (harvesting )

Public forest owner

Service provider

(hauling )

Third party logistics provider ( 3PL )

Industry customer

( paper and pulp mills )

Regional customer ( saw mills )

Private forest owner

Forest administration ( canton / district )

Association of forest owners

Service provider( freight carrier )

Developing annual plan ( financial

budgeting )

Approving annual plan

Demand planning (12 months

demand )

Demand planning (12 months demand )

Requesting for quotations

( maximum delivery volume ? )

Requesting maximum delivery volume (for one

year )

Requesting customer’s annual

need

Notifying about maximum volume

Notifying about annual delivery

volume

Supply =

demand ?

Reducing delivery

volume per supplier

Ad -hoc decision -making with forest

owners and 3PL

Re -requesting whether delivery

volume can be increased

Evaluating

harvesting sites by sight

Medium - term plannig of harvesting and hauling processes

Assessing what (manual ) site preparation is needed for mechanical harvesting

Marking out trees to be felled at harvesting sites

Order releasing for the coming month

Briefing machine

operator on harvesting site

Enquiring take -over sequrity

Reconfirming take -

over sequirity with customer

Scheduling resource

availability and attandance

Setting up machinery (for mechanical

harvesting ) at sites

Harvesting process

Short -term planning , reservation , and setting up machinery (for

mechanical hauling ) at sitesHauling process

Storing wood according customer orders

( „poltern“ )

Requesting information on

transport volume for the coming two weeks

Informing about delivery

volume

Communicating information on stacked

roundwood ( site , volume , quality , assortments ) to 3PL

Formulating transfer order

Customer owns trucks

Scheduling truck drivers

Picking up wood from forest storage locations

Delivering wood to

customers

Unloading wood

Measuring wood

Short -term planning of hauling process

Notifying about annual demand

Formulating blanket order

Fomulating blanket order

Collating information on

stacked roundwood

Formulating transfer order

Invoicing

Invoicing

Medium -term planning of plantation , maintenance ,

and harvesting

Medium -term planning of plantation , maintenance ,

and harvesting

Providing customers from timber industry with

information on maximum delivery volume in the

coming month

Short term planning (monthly

basis ): Information on timber supply is exchanged with 3 PL

Short -term planning

of hauling process

Cross - banding harvesting sites

Sending delivery permits

to forest rangers

Truck driver is familiar with

harvesting sites Collating information on forest districts , storage

locations , and identification numbers

Collating identification

numbers of timber for each forest district

Developing pf operating plan based on guidelines given by forest

administration

Assisting the forest ranger with developing the

operating plan

Collating information on storage locations , quality

and volume of timber

Medium - term planning , i.e . plan development based on

physical inventory data , information on tree

population etc .

Informing about delivery

volume

Operating plan , defines maximum harvesting volume

for coming ten years

Operating plan Annual plan

Demand plan

Demand plan

yes

noSupply > demand

yes

no

Customer blanket order ( for one year )

Customer blanket order ( for one year )

Medium -term planning of resources

Evaluating harvesting sites

by sight

Short term planning (monthly basis ): Information on timber

supply is gathered from forest rangers

Medium - term plannig

of harvesting and hauling processes

Medium - term plannig of harvesting and hauling processes

Delivery permit (fixed volume per supplier )

Short -term scheduling of

service providers based on delivery permit

Attendance and resource availability

information

Rough routing

and scheduling

Routing information

Invoice

Information on harvesting site ,

volume , and quality

Documenting information on

harvesting

Hauling information (site , volume , assortments )

Hauling information (site , volume , assortments )

Invoices from different forest

districts

Invoice

Invoice

Invoice

Invoices from different forest

districtsInformation on timber

stores in forests

Wood transportation organized by customer

yes

no

yes

no

Information on identification numbers

Information on forest districts , storage

locations , and identification numbers

Information on forest districts , storage locations , and identification numbers

Routing and scheduling

yes

Detailed routing and scheduling

no

Transfer order (delivery due date )

Transfer order (delivery due date )

Transportation order

Sending credit notes to forest owners and service providers

Invoicing

Transfer of sums of money to 3 PL

Information on volume , quality , and

resulting price

Payment recipe

Invoice

Invoice

Legend

Process step

Document , information carrier

Decision

Flow of materials or information (one .way or both - way )

Ad -hoc decision -making with forest

owners and 3PL

Example Supply Chain in Forestry (Günter, 2007)


Forest ranger

Transportation contractor

Scheduling truck drivers

Picking up wood from forest storage locations

Delivering wood to

customers

Collating identification numbers of timber for each

forest district

Information on forest districts, storage locations, and identification numbers

Detailed routing and scheduling

30

29

31

29: 3PL providers do not provide transportation contractors with long- and medium term information on planned harvesting processes, hence transportation contractors do not have the opportunity for long- and medium term scheduling of resources.

30: Information on delivery volume or quality is missing or underspecified which affords transportation contractors to get more detailed information from forest rangers and reconfirm information.

31: Truck drivers load timber in accordance with orders given to them by the transportation contractor but do not confirm the quality of the timber – it is not always clear whether truck drivers are responsible for assessing quality of timber at all.


Planning-autonomy-interdependence links (Günter, 2007)

Interactive effects of outcome interdependence and individual autonomy

Low autonomy

High autonomy

3,0

3,2

3,4

3,6

3,8

4,0

4,2

4,4

Low High

Outcome interdependence

Collaborative planning

Step and variable

B

SE B

ß

∆R2

Step 1

Length of relationship .004 .012 .025

Interaction .410 .088 .384** .238**

Step 2

Task interdependence (centred) .115 .072 .151

Outcome interdependence (centred) .200 .087 .227*

Autonomy (centred) .197 .083 .196* .143**

Step 3

Task interdependence * Autonomy .046 .081 .072

Outcome interdependence * Autonomy -.199 .092 -.263* .043*


Remaining puzzles in planning

Intricate relationship between autonomy, interdependence and cooperation

Acknowledging limits of planning "at the edge of chaos" (Eisenhardt & Tabrizi, 1995)

versus

Revival of centralized planning as "more technology allows more management" (e.g. ATM, RFID)

Goal coupling in multi-x networks

(x=profession, unit, organization, culture etc.)


Planning in multi-x networks:Example hospitals

Efficiency through employing operations management methods (Dexter, Xiao et al., 2007)

Standardization as omnibus solution (Naveh, 2008)

Relational collaboration (Gittell et al., 2000)

Intra- and inter-organizational coordination (Gittell & Weiss, 2004)

Pervasive goal conflicts (Gaba, 2000)

Does model of collaborative planning apply?Replication of moderated autonomy-interdependence-

collaboration relationship?

Documents

Coordination and work flow management in health care Doctoral course held jointly by Prof. Yan Xiao (University of Maryland) and Prof. Gudela Grote (ETH