Delicate balance: adaptive support to improve patient safety

Spruit, Shannon; Wauben, L.S.G.L.; Elst, Maarten van der; Doorn, Neelke; Dankelman, Jenny; Dobbelsteen, JJ van den; Klein, Juan-Luís

doi:10.1136/bmjinnov-2016-000150

Cited by 4 publications

(3 citation statements)

References 46 publications

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“…Teams in the OR interact, communicate, adapt, learn and self-organize over time [6,7] which are common determinants of a complex adaptive system (CAS) [7]. From the perspective of complexity there are different strategies for improving patient safety, from attempting to control complexity to embracing it by encouraging flexible behaviors [8]. Complexity requires to wisely balance thoroughness and control with flexibility and adaptations [9].…”

Section: Introductionmentioning

confidence: 99%

Managing complexity in the operating room: a group interview study

Göras

Nilsson

Ekstedt

et al. 2020

BMC Health Serv Res

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Background: Clinical work in the operating room (OR) is considered challenging as it is complex, dynamic, and often time-and resource-constrained. Important characteristics for successful management of complexity include adaptations and adaptive coordination when managing expected and unexpected events. However, there is a lack of explorative research addressing what makes things go well and how OR staff describe they do when responding to challenges and compensating for constraints. The aim of this study was therefore to explore how complexity is managed as expressed by operating room nurses, registered nurse anesthetists, and surgeons, and how these professionals adapt to create safe care in the OR. Method: Data for this qualitative explorative study were collected via group interviews with three professional groups of the OR-team, including operating room nurses, registered nurse anesthetists and operating and assisting surgeons in four group interview sessions, one for each profession except for ORNs for which two separate interviews were performed. The audio-taped transcripts were transcribed verbatim and analyzed by inductive qualitative content analysis. Results: The findings revealed three generic categories covering ways of creating safe care in the OR: preconditions and resources, planning and preparing for the expected and unexpected, and adapting to the unexpected. In each generic category, one sub-category emerged that was common to all three professions: coordinating and reaffirming information, creating a plan for the patient and undergoing mental preparation, and prioritizing and solving upcoming problems, respectively.

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Section: Introductionmentioning

confidence: 99%

Managing complexity in the operating room: a group interview study

Göras

Nilsson

Ekstedt

et al. 2020

BMC Health Serv Res

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“…Generally workarounds are responses to organisational problems ( Lalley and Malloch, 2010 ) (e.g. inter-professional or inter-departmental boundaries, role ambiguity), practical inadequacies of new technologies ( Coiera, 2007 ), over-work ( Guédon et al , 2017 ), inflexible rules or communication blockages ( De Bono et al , 2013 ).…”

Section: Introductionmentioning

confidence: 99%

“…Fourth, the purpose of workarounds is to overcome the aforementioned problems so that the work process achieves its aims more fully and reliably. Some writers describe workarounds as ‘violations' ( Reason, 2005 ), ‘resistance’ ( Reiz and Gewald, 2016 ) or circumventing the systems for maintaining service quality and safety ( Guédon et al , 2017 ), as error-creating ( Koppel et al , 2008 ) or as obstacles to systematic problem-solving. Far from instantiating error, laziness, self-interest, neglect or incompetence, however, many workarounds are ‘reinventions’ ( Barrett and Stephens, 2017 ) which improve work-process resilience ( Alper and Karsh, 2009 ), even at some cost for the improvisers themselves, and if one workaround then necessitates others ( Ellingsen et al , 2013 ).…”

Section: Introductionmentioning

confidence: 99%

Managerial workarounds in three European DRG systems

Sheaff

Morando²,

Chambers

et al. 2020

JHOM

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PurposeAttempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.Design/methodology/approachWe make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010–12, with additional data collection from key informants and administrative documents continuing in 2018–19 to supplement and update our findings.FindingsManagers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load ‘ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed ‘floor' volume.Research limitations/implicationsEmpirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the ‘managerial workaround’ still further.Practical implicationsIn the case of DRGs, the managerial workarounds were instances of ‘constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the ‘managerial workaround'.Social implicationsManagerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.Originality/valueSo far as we are aware, no other study presents and tests the concept of a ‘managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

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