META-COORDINATION ACTIVITIES: EXPLORING ARTICULATION WORK IN HOSPITALS

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META-COORDINATION ACTIVITIES: EXPLORING ARTICULATION WORK IN HOSPITALS

ABSTRACT

Coordination of distributed activities is central to organizational work. The effective functioning of organizations hinges on their ability to manage interdependencies both within (intra-) and between (inter-) various departments. However, more than just the management of these individual dependencies is required for smooth coordination in organizations. Organizations must also manage the interactions between intra- and inter-departmental coordination activities. In this thesis, I investigate a certain set of interactions which I refer to as negative cross-level interactions. These interactions often result in poor performance, increased errors and higher coordination costs. Consequently, in order to achieve organizational goals, workers must perform a certain type of articulation work – meta-coordination activities – to manage and mitigate the effects of these negative cross-level interactions.

To examine negative cross-level interactions and how they are dealt with in an organizational setting, I conducted a year-long qualitative research study of the patient transfer process at a large academic hospital in the Northeastern United States. Patient transfers are particularly appropriate to study because they require both intra- and inter-departmental coordination activities to be successful. I focused on the patient transfer activities between two clinical departments (emergency department and neurosciences department) and the role of a nonclinical department (inpatient access department) in facilitating the patient transfer process. I utilized standard qualitative methods including observations, shadowing and interviews. Through this study, I provide a detailed understanding of patient transfer process, with a particular emphasis on (a) the challenges that lead to negative cross-level interactions and its effect on both inter-departmental coordination and on overall hospital workflow, and (b) the meta-coordination activities that are performed to mitigate the effects of these negative cross-level interactions, and (c) the relationship between meta-coordination activities and articulation work.

The findings from this study will make contributions to research in the fields of Computer Supported Cooperative Work (CSCW) and Medical Informatics (MI). The main contributions to the CSCW field include (a) examining a unique set of coordination challenges – negative cross-level interactions that occur at the intersection of intra- and inter-departmental coordination activities; (b) uncovering a particular type of work activities – meta-coordination activities – that are performed to mitigate the effects of negative cross-level interactions; (c) developing a conceptual and empirical understanding of meta-coordination activities; (d) identifying meta-coordination activities as a type of articulation work focused on fixing breakdowns that occur when intra- and inter-departmental coordination activities affect each other; (e) providing deeper insights on organizational articulation work across multiple levels; (f) developing a framework of inter-departmental coordination work that highlights the relationship between the concepts of negative cross-level interactions and meta-coordination activities.

The main contributions to the MI field include (a) drawing attention to the role of nonclinical staff during patient transfers; (b) providing detailed understanding about an interdepartmental workflow (e.g. patient transfer) that depends on the coordination between clinical and non-clinical departments; and (c) informing the design of systems that can support interdepartmental workflows.

 

Chapter 1 

Introduction

This chapter introduces the problem and research motivation of the thesis. I also present the research objectives and questions that I answer through this thesis. Furthermore, the research approach that is adopted to address my research objectives is briefly described. Finally, an outline of the dissertation is highlighted.

Problem Motivation

Hospital environments are highly dynamic in nature, characterized by rapidly changing information needs, time-pressured decision making, distributed activities and functionally diverse teams. The vignette provided below captures some of the coordination challenges during patient transfers that take place in most hospitals in the U.S. This vignette illustrates a transfer process of a trauma patient from the emergency department (ED) to the operation room (OR).

The ED has reached its critical capacity of seventy one patients. The ED staff is overwhelmed with the constant influx of patients. During this chaos, a trauma patient is brought to the ED. The ED attending, based on his evaluation of the patient, decides that the patient needs to undergo a surgery sometime that day. After consulting with the OR attending (on OR schedule and staff availability), the patient is directly sent to the OR from the ED.

Later that evening, the admissions department staff responsible for bed placement gets a phone call from the charge nurse of the OR requesting an ICU (intensive care unit) bed for the trauma patient. Since the admissions staff member was not notified of the prior transfer sequence of this patient, she had no updates regarding the status or the physical location of this patient. Because the hospital was at critical capacity, the admissions staff member was unable to immediately locate an available ICU bed for the patient. This consequently created bed assignment delays and other bottlenecks in patient flow which in turn had a detrimental effect on the goals of the hospital.

As the vignette highlights, coordination is a prominent aspect of collaborative work in organizations [1] , [2] , [3] . Organizational work is characterized by interactions between individuals and teams in different departments that result in the need for coordination of their activities to ensure seamless and efficient work processes. Effective organizational coordination results in streamlined work processes, increased performance and effectiveness, higher productivity, and effective resource management [4] .

The smooth functioning of an organization hinges on its ability to manage the coordination of distributed activities both within (intra-) and between (inter-) the various departments. The seamless management of organizational work requires intra- and interdepartmental coordination activities to be synchronized with each other. This requires the management of coordination activities (at intra- and inter -departmental levels) in such a way that they do not have a detrimental effect on each other. However, organizations find it extremely difficult to balance these intra- and inter-departmental coordination activities. This is because often times intra-departmental activities negatively influence the inter-departmental coordination activities and vice versa. As a result, conflicts arise at the intersection of intra- and interdepartmental coordination activities (where intra- and inter-departmental coordination activities interact with each other) which impact the overall workflow, consequently disrupting the organizational performance and success. Failure to address these conflicts and breakdowns in coordination activities can potentially result in poor performance, increased errors and higher coordination costs.

In healthcare, hospitals are a prime example of large-scale organizations that have to deal with these types of coordination breakdowns on a daily basis. They have wide number of functionally diverse departments that support a variety of related patient care activities. Consequently, characteristics such as increased complexity and uncertainty of work, hierarchical and distributed organizational structures, heterogeneous teams, distributed decision making, uncertainty of patient conditions, and dispersed information makes hospitals susceptible to a variety of intra- and inter-departmental coordination breakdowns. Hospitals have to deal with these breakdowns in a timely manner because they can become detrimental to patient safety, sometimes even resulting in the death of patients. For example in the vignette above, coordination breakdowns occurred when decisions made to facilitate one type of coordination activity within a department negatively impacted other types of coordination activities between departments.

  • The ED staff failed to notify the admissions staff about the transfer (ED to OR) due to the chaotic and time-pressured nature of the ED environment. They decided to send the patient to the OR to temporarily solve the crowding crisis within the ED, thereby achieving the coordination of care and patient flow activities within the ED at the expense of inter-departmental coordination activities between the OR and IPA.
  • The lack of notification about the patient transfer from ED to OR (i.e. inter-departmental coordination activities) affected the intra-departmental activities of the IPA department, i.e., bed management.

The major consequence of this type of coordination breakdown that occurs at the intersection of intra- and inter-departmental coordination activities is the use of additional resources such as the time and effort required by the IPA departmental staff to switch patients around to find an appropriate bed, to contact physicians in the ED and OR requesting them to enter admit and transfer orders of the ED trauma patient, to cancel a hospital transfer of a patient who was pre-assigned the last ICU bed and also to try to convince the PACU (post-anesthesia care unit) CN to accommodate and temporarily board an OR patient.

Thus the vignette raises some interesting issues about coordination activities in organizations: the breakdowns that arise at the intersection of intra- and inter-departmental levels, the factors contributing to these breakdowns, the effects of these coordination breakdowns on organizational goals, and finally, the mechanisms to mitigate the effects of the breakdowns in order to maintain the smooth coordination of the organization. Understanding these issues can help address the breakdowns, thus leading to better coordination support in organizations such as hospitals.

Research Motivation

Coordination has been a prominent topic of research in a variety of domains including maritime operations and software development [5] civil work [6] , electronic commerce [4] , and healthcare [7] . Coordination has been studied at various levels including team [8] , departmental [9] and organizational levels [10] . Studies of organizational coordination have examined both intra-departmental and inter-departmental coordination practices. While intra-departmental coordination studies investigate the local departmental work practices; specifically focusing on the interdependencies between teams within a department [7] , [11] , [12] , inter-departmental coordination studies examine the global organizational work practices; specifically focusing on the interdependencies between teams from different departments [13] , [14] , [15] , [16] , [17] , [18] . Although coordination has been the focus of much research [1] , [2] , [3] , researchers have not examined the effects of intra- and inter-departmental coordination practices on each other.

Furthermore, most of these studies have investigated how the seamless integration of distributed work activities results in significant problems affecting coordination. They highlight that some problems are caused by the specialization and decomposition of activities [19] , [20] , while other problems arise due to the presence of interdependencies among activities and the need to integrate and align these interdependencies to achieve organizational goals [2] , [21] . Especially, within the healthcare domain, [22] , researchers have investigated the coordination problems of clinical departments. Some of the coordination problems that are investigated in healthcare are related to information breakdowns [23] , [24] , process bottlenecks [25] , and patient handoff [26] challenges that result in medical errors and poor quality of care. However, these problems are specifically related to coordination of patient care activities of clinical staff in clinical departments. Although the coordination of non-patient care activities (i.e. organizational activities such as hospital resource management) has an effect on clinical outcomes, there is still a lack of research that examines the challenges that affect the seamless coordination of activities between staff from clinical and non-clinical departments.

Besides, despite the vast amount of research on coordination problems in a variety of domains, there is still a lack of understanding of the coordination challenges that occur when intra- and inter-departmental coordination activities negatively affect each other. To address these coordination problems in organizations, researchers have investigated the role of several coordination strategies and mechanisms [21] , [24] , [27] . One particular approach that has received much attention is articulation work. Central to articulation work is the need to manage interdependencies among various coordination activities and their related consequences. As an “informal” mechanism for sustaining coordination and the continuity of work,  researchers have been focusing a great deal of attention on articulation work [28] . CSCW (Computer Supported Cooperative Work) researchers have interpreted this particular aspect of coordination in different ways. For example, Strauss [29] defines articulation work as “the coordination of lines of work”. Star et al. [30] describe articulation as the work that “gets things back on track in face of unexpected contingencies”. However, these perspectives do not highlight the specific characteristics of the articulation work that is done to manage the negative effects of the coordination challenges that arise at the intersection of intra- and inter-departmental coordination activities.

Moreover, despite the research examining the role of articulation work in managing the consequences of coordinated work in variety of settings [31] , [32] , there is limited knowledge on articulation work in the healthcare setting [33] , [34] . Besides, these studies in the healthcare setting are primarily focused on articulation work done by clinical departments to maintain the continuity of clinical work; it fails to identify the articulation work of non-clinical departments which play a vital role in maintaining hospital coordination. Consequently the overall body of knowledge in this research space is considerably limited.

I have identified three important gaps in coordination research that need to be addressed:

  1. There is limited research on the coordination problems that occur at the intersection of intra- and inter-departmental coordination activities. Although researchers have identified various challenges to organizational coordination, the conflicts that occur when intra- and inter-departmental coordination activities affect each other is an important issue that needs to be examined in greater detail.
  2. There is little empirical understanding about coordination mechanisms used to mitigate the coordination problems that occur when intra- and inter-departmental coordination activities affect each other. Researchers have investigated a number of coordination mechanisms that help mitigate coordination breakdowns. However, it is important to understand what types of mechanisms can be used to mitigate the coordination problems that occur at the intersection of intra- and inter-departmental coordination activities.
  3. There is a lack of understanding about the nature of articulation work done to alleviate the coordination problems that occur when intra- and inter-departmental coordination activities affect each other. Researchers have investigated the role of articulation work in different domains. In particular they have explored the nature of articulation work used to alleviate consequences of distributed collaborative work. It is also important to examine the unique nature and type of articulation work used to mitigate the coordination challenges that occur at the intersection of intra- and interdepartmental coordination activities.

Research Approach

To address these gaps in research, I investigated the patient transfer process in a hospital. Hospitals are a natural site for investigating coordination activities because there are a wide variety of activities that requires seamless coordination between individuals, teams, and departments to maintain continuity of care. A patient transfer process is a paradigmatic example of a coordination activity for a number of reasons. First, it requires ad-hoc collaboration among hospital departments because of the dynamic and rapid nature of events. Second, its success depends on effective management of both intra-departmental and inter-departmental coordination activities. Third, patient transfers involve both clinical and non-clinical departments that have varied and constantly changing coordination needs and goals. Finally, effective patient transfers is instrumental in realizing organizational goals such as improving access to care, minimizing the length of patient stay and reducing the wait times for patients [35] .

To examine the coordination practices during patient transfers, I conducted a year long qualitative research study at the Penn State Milton S. Hershey Medical Center. These methods allowed for a situated in-depth evaluation of the healthcare practices by focusing our attention on the interaction of people, information technologies, and organizational structures. In particular, I investigated the conflicts that occur when intra- and inter-departmental coordination activities affect each other which I label as “negative cross-level interactions” and also the activities that are preformed to mitigate their effects, which I label as “meta-coordination activities”. To collect this data, I focused on patient transfer activities between two clinical departments (emergency department and neurosciences department) and investigated the role of a non-clinical department (inpatient access department) in managing these activities. The three departments were selected because of the large number of patient transfers that take place between the ED and NSD and the prominent role played by IPA in facilitating hospital transfers. I used standard ethnographic methods such as general observations, patient transfer activity shadowing, formal and informal interviews, and artifact identification & collection to gather data. These methods have been widely used in computer supported cooperative work [36] and the medical informatics domains [37] to gain meaningful insights on the nuances and complexities of work practices. For instance, these methods can help identify and provide a detailed understanding of complex interactions of technical and organizational issues. I adopted a grounded theory approach [38] and the concept of articulation work [28] to analyze the data.

Research Objectives and Questions

The three main research objectives of this dissertation study are (a) to explore negative cross-level interactions that occur between intra- and inter-departmental coordination activities; (b) to develop a conceptual and empirical understanding of the nature of meta-coordination activities; (c) to provide insights on the relationship between meta-coordination activities and articulation work (Table 1-1).

The three main research questions that will help address the research objectives of the study include:

RQ 1: How do negative cross-level interactions affect organizational workflow? 

  • What are negative cross-level interactions?
  • What are the challenges that lead to negative cross-level interactions?

RQ 2: What are the meta-coordination activities employed by organizational staff to alleviate the effects of negative cross-level interactions? 

  • What are the unique features of meta-coordination activities?
  • How does meta-coordination manifest itself in hospital work?

RQ 3: How is meta-coordination activity an aspect of articulation work? Answering RQ 1 will help achieve the first research objective, (a) of the study. The second and third objectives, (b) and (c) will be addressed by answering RQ 2 and RQ 3.

 

 

 

 

 

 

Table 1-1. Mapping the Research Gap to the Research Objectives and Questions

RESEARCH GAP RESEARCH OBJECTIVE RESEARCH QUESTIONS
Limited research on the coordination problems that occur at the intersection of intra- and inter-departmental coordination activities To explore negative crosslevel interactions that occur between intra- and interdepartmental coordination

activities

How do negative cross-level interactions affect organizational workflow?
Little empirical understanding on coordination mechanisms used to mitigate the coordination problems that occur when intra- and interdepartmental coordination activities affect each other To develop a conceptual and empirical understanding of

the       nature       of       meta-

coordination activities

What       are       the       meta-

coordination activities employed by organizational staff to alleviate the effects of negative cross-level interactions?

Lack of understanding on the nature of articulation work done to alleviate the coordination problems that occur when intra- and interdepartmental coordination activities affect each other To provide insights on the relationship between metacoordination activities and articulation work How is meta-coordination activity an aspect of articulation work?

 

RQ 1 investigates the various challenges that lead to negative cross-level interactions that are caused by the interplay of coordination activities both within and across departments. Answering RQ 1 will also provide insights on how negative cross-level interactions affect organizational coordination goals.

RQ 2 explores the meta-coordination activities employed that will mitigate the effects of negative cross-level interactions. Answering RQ 2 will contribute to a stronger understanding on meta-coordination activities including its basic nature, features and characteristics. This understanding will provide a broader perspective on the role of meta-coordination activities in organizational work. Subsequently, this understanding will be instrumental in the design of healthcare information systems that can support meta-coordination activities.

RQ 3 describes the aspects of meta-coordination activities that allow it to be categorized under articulation work. Addressing this question will help identify a particular type of articulation work that mitigates coordination challenges that occur at the intersection of intra- and inter-departmental coordination activities which has been little explored.

By answering these research questions, I provide a detailed understanding of (a) how interdependencies among activities within and between departments (clinical and non-clinical departments) are managed in order to achieve organizational goals; (b) the challenges caused when intra-departmental activities and inter-departmental coordination activities negatively affect each other; and (c) a type of articulation work used to mitigate the effects of the coordination challenges that arise when intra-departmental and inter-departmental activities negatively affect each other.

Dissertation Overview

The structure of the dissertation is as follows:

  • Chapter 2 Background – This chapter presents a review of coordination research including the coordination theories and models, coordination problems, strategies and mechanisms and modes of coordination. It also highlights prior research on patient flows and transfers.
  • Chapter 3 Study Design and Methodology – This chapter provides an overview of the research methodology, specifically focusing on the data collection and analysis methods.
  • Chapter 4 Organizational Background – This chapter describes the research setting and participants involved in the patient transfer process.
  • Chapter 5 Findings: Patient Transfer Work – This chapter presents the main findings on coordination of patient transfers: sequence of steps in the patient transfer process and the types of interdependencies in patient transfer work.
  • Chapter 6 Findings: Coordination Challenges during Patient Transfers – This chapter highlights the coordination challenges that lead to negative crosslevel interactions. A variety of examples, vignettes and quotations from the field data are used to highlight the negative cross-level interactions.
  • Chapter 7 Discussion: Negative Cross-level Interactions – This chapter describes the various levels of factors that lead to negative cross-level interactions; specifically focusing on the organizational issues that create challenges for effective management of interdependencies resulting in coordination challenges which in turn lead to negative cross-level interactions. In addition, the consequences of the negative cross-level interactions on two important hospital goals: effective patient flow and effective patient colocalization are also discussed.
  • Chapter 8 Discussion: Meta-Coordination Activities – This chapter presents the different meta-coordination activities used to mitigate the effects of negative cross-level interactions in patient transfers. It also describes the relationship between meta-coordination activities and articulation work. In particular, I highlight how the concept of meta-coordination activities help improve our understanding of articulation work by (a) identifying the nature and characteristics of a type of articulation work that aims at mitigating the challenges at the intersection of intra- and inter-departmental coordination activities and (b) examining organizational articulation work in complex settings.
  • Chapter 9 Discussion: Informing Design – This chapter first highlights a framework of inter-departmental coordination work that ties the concept of negative cross-level interactions and meta-coordination activities. Then, I discuss the socio-technical design issues that need to be considered when designing informatics tools to support effective inter-departmental coordination based on the analysis drawn from Chapter 5 and 6.
  • Chapter 10 Conclusion – This chapter discusses the major contributions of this dissertation, future research directions and some final concluding remarks on the dissertation.

META-COORDINATION ACTIVITIES: EXPLORING ARTICULATION WORK IN HOSPITALS

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