When routines are not so routine: Exploring coordination work in hospitals

Date of Award

2010

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Information Science and Technology

Advisor(s)

Carsten Osterlund

Keywords

Routines, Coordination work, Hospitals, Workflow, Medical errors

Subject Categories

Library and Information Science

Abstract

Many work processes take place through routines, or recurrent patterns of action. These activities involve individuals from several occupations working across spatial, temporal, and organizational boundaries. Crossing these professional, temporal and spatial boundaries has unique challenges which can lead to coordination failures. In these conditions, facilitating communication and relationships between team members can improve coordination and prevent errors.

This is of particular importance in healthcare provider organizations, where coordination and communication failures are a common cause of medical errors. The healthcare industry is characterized by increased specialization of work, hierarchy, shifts and various organizational affiliations. Thus, patient care occurs through a series of interconnected coordination routines. These routines often involve handoffs of the patient across boundaries. Thus, the staff must also work across these boundaries in the course of providing patient care. If this is not done effectively, this can lead to errors.

In order to address these issues, a multi-method, single-site case study was conducted in the interventional cardiology unit of a community hospital. Ideal type routines were identified through document review and interviews. They were validated with the participants and changed as necessary. Observations were conducted of the routines in practice. Differences between the ideal routine and routines in practices were identified and analyzed using a coding scheme adopted from the coordination, routine and boundary literature. Issues in the observed routines were also identified and categorized. The relational coordination survey was also administered to determine if there were cross-functional differences in communication and relationships throughout the routine.

Differences between the ideal routine and routines in practice were often due to systemic factors. These included different understanding of the routines by staff, inconsistent documentation, and lack of exception procedures. Differences between the ideal routine and routine in practice resulted in changes in workflow that had impacts beyond the coordination routine. For coordination routines with high variability and good communication and relationships between the participants, differences from the ideal-type routine were less likely to lead to issues. In coordination routines with less expected variability and poor communication and relationships, differences from the ideal-type routine are more likely to lead to issues. This means both the variability and the quality of communication and relationships served as mediating factors for issues.

The study utilized concepts from the routines, boundary theory and coordination theory literatures. While this is useful to inform interdisciplinary work, this is particularly valuable for healthcare informatics because much of the literature in this area is descriptive. Thus, the conceptual framework can be used to inform future study of interdisciplinary work in and out of healthcare. This also furthers the work that has been previously done about routines. The findings can also be used by managers and team members to develop and implement flexible standards to serve as coordination mechanisms across temporal, spatial and occupational boundaries.

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