=Paper=
{{Paper
|id=None
|storemode=property
|title=Coordination in Perioperative Systems - A Tacit View
|pdfUrl=https://ceur-ws.org/Vol-727/eics4med7.pdf
|volume=Vol-727
|dblpUrl=https://dblp.org/rec/conf/eics/DittmarKF11
}}
==Coordination in Perioperative Systems - A Tacit View==
https://ceur-ws.org/Vol-727/eics4med7.pdf
Coordination in Perioperative Systems – A Tacit View
Anke Dittmar, Robert Kühn and Peter Forbrig
Department of Computer Science
University of Rostock
A.-Einstein-Str. 21
D-18051 Rostock, Germany
{anke.dittmar,robert.kuehn,peter.forbrig}@uni-rostock.de
ABSTRACT to achieve this goal. By using “Treatment Patterns”, the
Coordination of perioperative systems is a deeply collabo- system is able to plan even before the admission of the
rative process, distributed over time and space. The paper patient to the clinic. (Treatment patterns are simplified
analyses coordination in a perioperative centre along the clinical paths reduced to the description of the medical
three temporal levels suggested in [1]: allocation, service and needed resources). The Patient Manager
scheduling, and synchronization. In particular, the tension allocates automatically beds and time slots for examina-
between schedules and actual demands in synchronization tions and operations. The system automatically fills in a
work is reflected by looking at example situations. It is variety of forms. Algorithms guarantee the availability of
shown how dedicated coordination workers try to find a time slots and the absence of conflicts (translated from [4]).
balance between different co-existing values and goals of {F3} The mother of the first author told her that their
all stakeholders. Their abilities to analyze a situation, to neighbour, a 69-year old woman, had to undergo a surgery
negotiate problems and to react flexibly are needed in this winter. She packed her bag and went by taxi (paid by
systems such as modern hospitals. It has to be taken into the health insurance) to the hospital in the other town.
account in systems design. However, after the examinations for the operation the
Keywords following day she was told to go home and then come back
Collaborative and distributed healthcare, temporal coordi- next morning. She was not prepared for this situation, had
nation, invisible work, resilience. to call another taxi (and a third one next morning) and
spent an uneasy night alone at home. When talking with the
nurses about these new practices they told her about a man
FRAGMENTS...
in a similar situation whose bus was too late. When he
{F1} “Perioperative systems design describes a rational
finally arrived at the hospital he was chilled to the bone and
approach to managing the convergent flow of patients from
not ready for operation. It had to be rescheduled.
disparate physical and temporal starting points (frequently
home), through the operating room (OR), and then to such {F4} “Well-defined processes enhance mutual understan-
a place and time (home or hospital bed) where future events ding of all parties involved in the perioperative care. When
pertaining to the patient have no further impact on OR each person involved has a clear understanding of his re-
operations. This process for an individual patient can be sponsibilities and duties, the process can run efficiently”
envisioned as a nested set of timelines: a coarse-grained [5].
timeline beginning with the decision to perform an {F5} “Operating rooms are regarded as the most costly
operation and ending when the patient definitively leaves hospital facilities. In this context several strategies have
the postoperative experience, and a fine-grained timeline been proposed that optimize patient throughput by
encompassing the immediate pre-, intra-, and postoperative redesigning perioperative processes. The successful
course... Perioperative systems design can be concep- deployment of effective practices for continuous process
tualized, studied, and optimized like any industrial process improvements in operating rooms will require that
in which many materials, actors, and processes are brought operating room management sets targets and monitors
together in a coordinated workflow to achieve a designed improvements throughout all phases of process
goal” [7]. engineering. Simulation can be used to study the effects of
{F2} According to the business manager of OR Soft process improvements through novel facilities, techno-
Jänicke GmbH, business directors of big hospitals wish to logies and/or strategies” [2].
consider the throughput at a hospital in a holistic way to {F6} “According to Valgårda (1992), the arguments behind
aim for meeting lower length of stay during planning at the evolution of the modern Danish hospital organisation
least. This can be achieved if data are promptly recorded. have been based on the production factory as an equivalent
The application of the “Patient Manager” makes it possible analogy. Hence, a rationalistic approach to organisations –
Copyright © 2011 for the individual papers by the papers' as evident in Weberian bureaucracies, Tayloristic
authors. Copying permitted only for private and academic management theories, and Fordist rationalization of the
purposes. This volume is published and copyrighted by production of goods – has also been one of the most
the editors of EICS4Med 2011. influential conceptualisation of organisations and
36
cooperation within hospitals. This rationalistic organisation complications during an operation or patients who are not
of collaborative work emphasises that (i) there is a ready for the operation. They may be confronted with
functional division of work, (ii) the responsibility for staffing shortages1 or a lack of resources. Last but not least,
organising work should be shifted from workers to they may be confronted with a mismatch of organisational
management, hence separating planning from goals and their own values. We were particularly interested
implementing work, (iii) control of time becomes the key to in how people who perform coordination work actually
control labour, by paying salaries in based on workhours, cope with these tensions. How do they use their skills to
and (iv) work is production-oriented” [1]. coordinate the work as smoothly as possible?
{F7} “The presence or participation of a resident physician The analysis was based on an activity-oriented, tacit
prolongs the duration of the surgery up to 70% increasing conception of work2. This view was not fully shared by all
costs accordingly. Adequate resident training, possibly with participants of the project but helped to counterbalance
the aid of a simulator and experienced assistance should be other interpretations of data. Just to give a small example,
provided to the residents starting to operate more we could observe several “methods” the operation manager
independently. Even small reductions in operative time can applied to track the situation in the first floor of the
increase OR throughput...Teaching a resident seems to operation suite. For example, she explained: “The first
delay the anesthesiologist only by 2–3 min. Covering more point in room 1 is finished now. I heard the anaesthetist
than one room statistically causes a delay of 6 min” [5]. talking”. She asked the storage male nurse to do her a
{F10} “Intra-organisational coordination requires planning, favour and check whether room 4 is already dark (meaning
and sophisticated schedules become necessary to provide a here that the operation is almost finished). She was also
degree of predictability. The operation schedule is clearly aware of equipment and patients passing her open office.
an indispensable mediator for temporal coordination at the One interpretation was that this behaviour is error-prone
surgical clinic. However, as pointed out by Zerubavel and should be replaced by reliable tracking mechanisms
(1981), one of the most significant consequences of the automatically recording relevant points of time 3.
invention of the schedule has been the consolidation of the Our work was influenced by studies grounded in
element of routine in collaborative work, which is essential conceptual frameworks such as activity theory or
antithetical to spontaneity. In general, there is an inherent distributed cognition, e.g. [1,6,10]. Data collection was
trade-off between the static quality of pre-set plans and conducted from spring 2009 to fall 2010. It involved
schedules and the dynamic quality of ongoing participative observations (e.g. of the operation manager,
collaboration” [1]. the head nurses, the head anaesthetist, a storage male
…of an Introduction nurse), interviews at workplaces (e.g. anaesthesia
Hospitals are sensitive and well-studied working environ- consultation, central patient management of the general
ments. The above fragments show that they are studied by
people with different backgrounds, assumptions, methods
and intentions. And of course, they are reflected by people
in their everyday life (e.g. {F3}). This paper adds a report 1
“In many countries shortage of anesthesiologists or
about an analysis of coordinating activities in a peri- anesthesia nurses restricts the availability of ORs.” [6]
operative centre where different surgical departments share 2
ten operating rooms. Perioperative systems, their under- In [9] an “organizational, explicit view” and an “activity-
lying rationale and assumptions are explained in {F1}, oriented, tacit view” on work are distinguished. While the
{F2}, {F4} and {F5}. Their development is critically first perspective conceptualizes work in terms of defined
reflected in {F6} and {F8}. The case study shows how tasks, processes, and work flows to achieve business goals,
important it is in the current system that coordination a tacit perspective focuses on analyzing everyday work
workers are able to negotiate and solve problems and to practices. Sachs shows general design implications from
react flexibly to unexpected or only vaguely expected taking one or the other view. For example, people are rather
situations. Improvements to the system will have to take considered as producing errors and deskilling is desirable in
into account these aspects. an explicit view. Social interaction is seen as nonpro-
ductive. In contrast, people are considered as able to
THE CASE STUDY discover and solve problems and skill development is
The analysis was conducted as part of the Perikles project desirable in a tacit view. Communities are seen as funds of
with two other partners to support “flexible work knowledge and a system is flexible if people are skilled.
processes” in perioperative systems. Sachs argues that a balance of the two views is needed but
Objective and Research Approach rarely achieved in design activities.
The goal of the analysis was to gain a deeper understanding 3
In [10], the interweaving of coordination and control in
of coordination in perioperative systems. On the one hand,
computer-based information systems and possible effects
such systems need a sophisticated scheduling of operations
are discussed. “Resources for action should be separated
and examinations and are mainly measured in terms of
from accounts of action” is recommended in [3]. However,
operation room throughput. On the other hand, the
operation management systems such the one in this study
personnel have to react flexibly to emergencies,
show an opposing trend.
37
surgery unit) and studies of documents4. Audio tapes were Figure 2 partly illustrates the specific situation in the
transcribed. Photographs were taken. Information artefacts analyzed perioperative centre which is part of clinical
such as schedules and allocation plans were collected. centre with different locations. The OR-suite consists of
Visual materials were processed to remove any patient two floors with four and six ORs respectively. The physical
identifying information. Accumulated data were discussed layout of an OR and of the first floor is to be seen in the
and analysed in individual work and in group meetings. figure. The centre is at the main location of the clinical
ANALYSIS centre and accommodates many surgical departments, the
Within this paper, we focus on some aspects of the analysis radiology and the anaesthesiology department with two
only. First, perioperative processes and the studied system ICUs. The anaesthetists are in charge of five functional
are briefly described. Second, the distributed nature of areas spread around the whole clinical centre. Bottlenecks
coordination work is described along three temporal levels in this system are shortages of nurses, anaesthetists and
as suggested in [1]. Third, a glimpse of the work of the beds in the ICUs.
operation manager in the study is given by a reflection of
situations where she used her skills and spontaneity to
respond to actual demands during continuous temporal
coordination. We argue that dedicated workers try to find a
balance between different co-existing values and goals of
all stakeholders. The paper closes with a discussion of how
to support the flexibility of systems such as modern
hospitals.
Description of the Analyzed System
In perioperative systems, the treatment of patients follows a
scheme called perioperative process. A short explanation
of this model is already given in fragment {F1}. Figure 1
shows typical ‘patient movements’ with a focus on the fine-
grained timeline (see {F1}). The perioperative process in a Figure 2. The perioperative centre – overview.
hospital includes all clinical steps from admission of the
patient on the ward, examinations and anaesthesia The coordination of the perioperative system is a deeply
consultation through surgery (including premedication and collaborative process, distributed over time and space.
anaesthesia care) to care and patient release from hospital. Some members of the staff are exclusively concerned with
coordination tasks to ensure a proper treatment of all
However, the treatment of a single patient is seen through patients. Other people such as the head surgery nurse, the
the lenses of the whole perioperative system which aims to head anaesthetic nurse and the head anaesthetist in the OR-
reduce costs. The main goals are maximizing the use of suite coordinate the work of their co-workers but are also
operating rooms (OR) and reducing staff. Hence, most involved in the actual surgeries.
perioperative systems have OR-suites and so called nurse
pools for a shared use by different surgical departments. In At the time the participative observations were conducted,
addition, single ORs consist of different areas for an operation manager (OP-manager) was responsible for
anaesthetic preparation, the actual surgery and emergence the coordination of work in the OR-suite. She was directly
from anaesthesia to allow an overlapping of surgeries. responsible to the head of the clinical centre. For reasons of
brevity, the description of coordination work is mainly
restricted to the central patient management (CPM) of one
department with two wards (called department 1, ward A
and ward B), to the anaesthesia consultation (AC) and to
the work of the OP-manager. This is indicated in Figure 2.
Distributed Coordination of Perioperative Processes
On the one hand, distributed collaborative coordination
helps to consider multiple interests by gradually shaping
future activities in a working system. On the other hand,
coordination is an activity itself and participants develop
activity rhythms which have to be coordinated as well. This
also includes the development and appropriation of
Figure 1. Perioperative movement of patients, in [7]. artefacts. In the example, all coordination work is
constrained by the organisational goal to achieve a high
4
Interviews were conducted in other hospitals as well. throughput through the ORs. More specifically,
They are not subject of this paper but helped to understand – Two nurses in the CPM are responsible for the inpatient
the impact of the specific constraints on the overall planning of department 1. This includes appointments for
perioperative system (e.g. physical constraints, permanent necessary examinations and anaesthesia consultations, if
staff shortage and actual division of labour). possible prior admission at the ward.
38
– The nurse in the AC has to organize appointments with weekly lists of admissions to the wards A and B. “Always
anaesthetists for the perioperative centre and other only for the next week...Something can change though. A
departments of the clinic to ensure that all patients had a new patient can come. Okay, the ward will tell her [the OP-
consultation at least 24 hours before the operation. manager] that. Or, a doctor realizes that he doesn’t need to
– The OP-manager has to schedule operations for the next operate this patient. This is only a preview. She gets the
day and to synchronize actual activities in the OR-suite. real [plan] every day from the wards.” (nurse CPM)
In the first case, the urgency of an operation is considered (3),(4) The wards inform the OP-manager every day
but also time constraints of doctors and patients. It is aimed (officially until 11:00, often between 11:00 and 12:00 due
for reduced costs of the wards and less waiting time for to work overload) about their surgeries planned for the next
patients. In the second case, the safety of the patients day by registering them in the central management system
during the surgery is in the focus of interest. The OP- (called CoMed here).
manager has to consider, for example, the demands of all (5) The OP-manager uses CoMed to create the next day’s
surgery departments but also has to act in the interests of schedule for OR-suite usage (day plan). A first and second
the staff in the OR-suite5. version is given e.g. to the wards, the AC, labs (fax), head
We apply the approach taken in [1] and describe aspects of anaesthetist, head nurses, storage male nurses and cleaning
coordination along three macro-temporal levels of service (printout). She pins a printout to the wall outside
collaborative work: synchronization (continuous temporal her office. “There, the nurses already take a look and
coordination), scheduling (planned temporal coordination), prepare themselves for tomorrow. And also the surgeons,
and allocation (coordination temporal motives). when they have a break, take a look at tomorrow.”
Scheduling Allocation
Figure 3 sketches some schedules with different time Allocations can be considered as long-term agreements on
granularities and different level of detail as they are created the usage of shared resources. They often have a rhythmic
and used by different stakeholders. They are indicated by structure to support their internalization by collaborators.
encircled numbers. An example is the allocation plan of the OR-suite which
has existed for many years. It says, for example, that
trauma surgery can use OR1 on Mondays from 8 to 14, that
OR3 and OR4 are always reserved for heart surgery, that
OR6 is a “long table” every Thursday and so on. An
exemplar of this plan hangs in the office of the OP-manager
(Figure 4) but is internalized by her.
Allocation is important for constraining scheduling
problems. Another example is reflected in the following
explanation of a CPM nurse: “Monday is visceral
consultation, Dr. X cannot be in the OR then. Dr. Y is here
in the consultation on Tuesday. He makes small surgeries,
laparoscopic galls, hernia and so on, we cannot check in
him on Tuesday...” Due to their stability allocation plans
can also cause permanent conflicts. For example, a
mismatch between the OR allocation plan and the actual
needs of a surgery department developed in the studied
system because that department grew larger.
Figure 3. Different schedules in use: long-term schedules, weekly
schedules, and days schedule of the OR-suite.
(1) is a long-term schedule maintained by the nurses in the
CPM. It contains appointments for operations of depart-
ment 1 planned up to several months in advance because
this department has many elective patients. The nurses use
a blackboard, their own software system, printouts and
paper for scheduling. (Other departments use e.g. operation
books as described in [1] and Excel for planning.)
(2) Every Friday, the CPM nurses send their operation
schedule of next week to the OP-manager (by fax) and the
Figure 4. Artefacts of the OP-Manager. Top: CoMed system,
preview of weekly schedule of a department (Excel), OR
5 allocation plan. Bottom: paper calendar for prebookings (e.g. ICU
A big calendar sheet is pinned to the wall in her office
beds), notes, “done”.
quoting Laurence Sterne: “The art of drawing up a budget
is to spread the disappointments evenly.” (transl.)
39
Synchronisation point 3.3 to OR4. “I would call him [the patient] then. OK,
Synchronisation is fine-grained temporal coordination and let’s say he will be in the room at three quarter to or even at
is prepared by scheduling. For example, the nurse in the one. Thanks. Bye.”
AC is waiting for the day plan at lunchtime (first version) – OM calls a ward but the patient is at a different ward.
in order to select at least those of the patients waiting for an – OM calls and asks whether OR4 is now ready.
– OM calls the other ward and asks them to premedicate the
anaesthesia consultation who will be operated the following patient and bring him to the OR-suite7.
day. “That’s why I always push a little bit. With her [OP- – OM goes to OR4 and informs them about the movement of
manager] it works very well. If she has a substitute, I have 3.3 to OR4.
to push sometimes. OK, they are substitutes.” – Head nurse and OM are looking for a team for OR4.
In Figure 5, three “instances” of the day plan are shown – OM is back in her office and enters the movement of 3.3 into
the CoMed system.
which serve to coordinate the actual events in the OR-suite.
On the left, part of the day plan is hanging in an OR. The Situation 2: “Emergency heart”
printout was annotated and copied by anaesthetists during OM sees in the morning that the heart surgery expects to
their afternoon meeting the other day to convey important operate an “emergency heart” today. She opens the weekly
information about patients to colleagues. The screenshot plan of the department to get more information about
detail in the middle illustrates how the CoMed system helps patient H who will come by helicopter. She looks for H in
to keep track of events. The staff members have to enter the CoMed system but can’t find the patient. She knows
relevant points of time of each perioperative process (e.g. from experience that there can be a spelling mistake in the
patient enters OR suite, patient in OR, surgeon arrived, name. She thinks that she will need an additional ICU bed.
begin blood arrest...). – [9:30] OM talks with the head anaesthetist (HA) about “the
heart” and that the arrival is not to be expected too soon.
– [10:30] OM calls ward W and ICU, but H is not there.
– [11:30] OM calls ward W, H hasn’t arrived yet. But the
nurses will call her back.
– [12:05] A doctor calls OM and tells her that he can hear the
helicopter. OM tells him to bring H to the ward for
preparation. OR5 will be ready soon.
Figure 5. “Instances” of the day plan for synchronization. – [12:30] OM calls ward W to be sure that H has arrived.
– [12:34] HA comes and asks OM whether H is at ward W or
The picture on the right shows the so called “table of
at the ICU.
anaesthetists” in the floor of the OR-suite with different – OM calls a doctor for the surgery of H.
forms and a printout of the day plan which is continuously – OM (still at the phone) and HA decide to premedicate H in
annotated by the OP-manager to show the course of events. the OR-suite and not send an anaesthetist to the ward in order
A Glimpse of Continuous Temporal Coordination to save time.
Although the actual course of events in a perioperative – OM explains to the doctor on the phone their decision to
have him earlier in the OR suite.
system is shaped a great deal by schedules, there are often
unexpected or only vaguely expected situations. Emer- – [12:39] OM calls the nurses in OR5 and prepares them for
the next steps.
gencies and complications during a surgery can happen
anytime. As another example, schedules are known as In the first situation, the OP-manager knows that the late
being too optimistic very often [5]. Communication plays point in OR3 will likely result in the cancellation of an
an important role for establishing relationships, shared operation. She also knows that this department generally
understanding and commitment. This is needed to be able needs more OR capacity. When the surgeon calls her she
to respond adequately to the demands in this working initiates the formation of an OR team. She knows that this
environment. Two interleaved “small” situations which means extra work for the nurses and helps them.
required flexible behaviour are described from the perspec- In the second situation, the OP-manager needs to coordi-
tive of the OP-manager (in the following called OM). nate an additional operation with a high priority. She has to
Situation 1: Rescheduling of 3.3 keep track of the situation to prepare her colleagues. The
Five surgeries were planned in OR3: point 3.1 at 7:006, doctor who informs her about the arrival of the helicopter is
point 3.2 at 9:30, 3.3 at 12:30, 3.4 at 14:00 and 3.5 at 15:00. aware of her role in the overall process. The OM and HA
All surgeries were planned by the department which decide to modify the premedication process in the interest
permanently lacks of OR capacities. The second point of the patient and the nurses who otherwise will probably
started very late. OM was called at 12 o’clock by the have to work overtime. They have to do it too often.
surgeon of point 3.3 asking her whether they couldn’t DISCUSSION
operate this patient in parallel in another OR. Flexibility by or despite Information Technology?
– [12:20] OM calls the head nurse. She tells her that the point At the time of the analysis, a central management of
in OR4 is almost finished and asks whether they could move patients and the coordination of perioperative processes
were partly supported by the system CoMed. The nurses in
6
A surgery in the OR-suite is also called point. 3.1 refers to
7
the first surgery of the day in OR3, 3.2 to the second etc. Normally, the nurses would call the ward.
40
the CPM of department 1 and in the anaesthesia consul- SUMMARY
tation were promised to get access to the system as well. Surgery environments are dynamic and high risk. “They
The information system’s infrastructure was heterogeneous. require coordination across multiple groups whose incen-
For example, anaesthetists had to enter some data multiple tives, cultures, and routines can conflict” [6]. Perioperative
times into different information systems (additionally, systems even increase the coordination effort and the
handwritten documents are required in some cases). They potential for conflict. A system can be considered as
had no direct access to archived data of patients. We often flexible if it allows achieving multiple goals with varying
observed that people were wondering what of the priorities according to the actual context. The presented
information they have access to can be accessed by study analysed coordination work in a concrete periopera-
colleagues using CoMed in a different role. For each tive system. The need for workers who are able to react
perioperative process relevant points in time had to be flexibly and negotiate problems has been revealed. We
recorded, but were sometimes not promptly entered. think that a too strong focus on the improvement of
information systems does not necessarily result in more
A more homogeneous information structure certainly
flexible systems. This requires the co-development of
improves the quality of the whole system. The operation
skilled and dedicated workers and technology.
manager may work more efficiently if CoMed would
record some more relevant points of time. The nurses in the ACKNOWLEDGMENTS
CPM and AC criticized that they did not get enough We are grateful to the staff at the hospital supporting us.
information about cancellations of operations. In a more We thank the reviewers for their useful comments. The
matured management system, such information could “flow work was partly funded by the BMBF grant 01IS099009.
back” to them. However, flexible systems require a healthy REFERENCES
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41