Presentation
Coordination Patterns That Underpin Adaptive Capacity in Complex Systems: A Sterile Processing Department Case Study
DescriptionThe Sterile Processing Department (SPD) in a hospital is responsible for decontamination and sterilization of used surgical instruments, and supplying trays of clean instruments to operating rooms (ORs) for upcoming surgeries. The SPD’s functioning is critical for patient safety, care quality, and efficiency in a health system. For instance, missed or unsterile instruments can result in adverse patient outcomes. The SPD is a large and complex sociotechnical system consisting of multiple sub-departments that service thousands of instruments daily. Addressing the scale and complexity challenges of the SPD requires understanding how stakeholders in the system cope with various pressures and challenges in their everyday work.
Studies on resilient performance in sociotechnical systems have consistently pointed to communication and coordination as key components of adaptive capacity. However, in this context, there are relatively few studies that expand on the characteristics of communication and coordination. Designing for adaptive capacity in complex systems involves designing for coordination.
Aim:
The aim of this study is to identify coordination patterns underpinning adaptive workflows that emerge in response to various pressures across the SPD-OR complex in a large multispecialty hospital. Based on frontline stakeholders’ perspectives, the study seeks to identify factors that shape, enable, and impede effective coordination in the SPD, and to represent the relationship between such factors with a structured approach.
Methods:
In order to elicit the perspectives of stakeholders in the SPD, observations of daily procedures and workflows were conducted, followed by semi-structure interviews. The interview method was based on a synthesis of the Systemic Contributors and Adaptations Diagramming (SCAD) approach (Jefferies et al., 2022) and the knowledge elicitation protocol described in Hegde et al. (2020). Per SCAD, the interview starts with a description of the ‘text-book’ workflow when the system is working as expected, followed by questions about how those workflows would vary under systemic pressures and tradeoffs. Per Hegde et al. (2020), cognitive probes focus on the role of specific capabilities (e.g., monitoring and anticipation, preparedness to respond, and coordination) that support adaptive performance.
Interview transcripts and observation notes were analyzed for themes under three categories: pressures and constraints, adaptations, and information flows (that support adaptations). Next, the data were examined for relationships across the three categories. Pressure themes were linked to the corresponding adaptive workflows, which were mapped with the corresponding information flows. Here, information flows are considered as the ‘currency’ of coordination. The focus of this presentation is specifically on the emergent patterns of coordination, including challenges and strategies, in the context of systemic pressures and adaptive capacity.
Findings:
Salient themes related to coordination are highlighted.
Coordination and Communication Challenges
• Workaround lack documentation, communication protocol: While workarounds are accepted as a characteristic feature of ‘work-as-done’, their ad hoc nature, lacking any supervisory oversight, can create coordination gaps elsewhere in the system. For instance, SPD technicians may sometimes substitute a damaged instrument in a tray with one from another tray without documenting the retrieval, which creates an undocumented missing instrument issue downstream.
• Confusion, ambiguity, or lack of understanding: New SPD employees noted that there were instances where they did not know whom to escalate problems or questions to. As an example, participants described scenarios where new hires would answer the phone and gather the information from the OR but not relay the message to those who are more apt to handle the situation.
• High staff attrition and tightened staff resources: high attrition rates and absenteeism makes it more difficult to divide attention between individual operational tasks, and coordinating other workers’ tasks. For instance, supervisors are often pulled into tray management tasks due to the absence of tray workers, and are therefore unavailable for communication with the ORs.
Adaptive Patterns and Coordination Demands
• Role Evolution: Under various pressures and constraints, staff may ad hoc transition to tasks that are not central to their roles to overcome gaps in workflow, such as a supervisor stepping in to help with tray assembly. However, the study also found that having a formal role exclusively for coordination is highly valuable. Specifically, the SPD had instituted an OR-Liaison (OR-L) role as a dedicated resource for coordinating information between the SPD and ORs, which was frequently mentioned in the interviews as helpful in daily operations.
• Substitute trays/instruments, such as ‘peel-packed’ instruments, are available for use in case of missing instruments due to damage or malfunction. This requires communication from the SPD to the ORs notifying them of peel-packed instruments available in place of missing instruments in the tray.
• Huddles between SPD managers, supervisors, and technicians are held to share information, whether it be shift-to-shift (within-level) or from supervisor to front-line worker (cross-level).
Coordination Cost Matrix
It is important to note that the above challenges and gaps in coordination occur under the overarching time pressure. Given the OR schedule, utilization goals, and criticality of procedures, there is a constant pressure to maintain throughput. Under such severe time constraints, activities related to coordinating and communicating often take a backseat. Time pressure also constricts the room for initiative and reciprocity, key features of adaptive performance in most sociotechnical systems. The propensity for initiative and reciprocity in an adaptive environment is challenged by the ‘cost’ associated with coordination. We characterize this cost qualitatively, in terms of the availability or unavailability of two resource variables: information, and a channel of communication. The relationship between these variables is represented in a 2X2 coordination cost matrix. Each of the four ‘boxes’ in the matrix represents a category of cost, Low, Moderate, Moderate, and High, defined by the specific combinations of the two variables, Information Available/Unavailable, and Channel Available/Unavailable. When both information and a channel of communication are not readily available, the high cost associated with information foraging, i.e. information seeking and ‘wayfinding’, places the highest burden on coordination, and could make coordination gaps more likely. This was seen in the case of technicians new to the SPD not knowing where to ‘look up’ some information and how or whom to ask about it. Conversely, when the information source is well known and there is an easily available channel, as in the case of the SPD conveying to the OR about an expected missing instrument through the OR-L, it is more likely that coordination occurs, and in a timely manner. When either one of information or the channel are not immediately available, there is at least a moderate cost associated with information seeking, or wayfinding, respectively.
The matrix representation could serve as a simple framework for organizations to identify costs of coordination for various workflows. Coordination gaps can be addressed by exploring ways to reduce the cost of coordination by making both information and the channel(s) of communication more readily available or accessible by workers. Strategies could include reducing social gradients of communication by using shared platforms system-wide for workers to raise issues that need redressal from leadership; having redundant channels of communication to avoid information flow bottlenecks; and the use of information visualization toward achieving operational ‘common ground’, or shared awareness across stakeholders.
The presentation will expand on specific instantiations of patterns observed in each of the categories of the coordination cost matrix. Examples of coordination mechanisms evolved bottom-up, such as informal liaising between individual workers across SPD and OR groups, and top-down, such as the OR-L’s workflows, will be discussed in terms of how they support overall adaptive capacity of the SPD. Potential strategies for improving coordination, such as those noted above, will also be discussed.
Studies on resilient performance in sociotechnical systems have consistently pointed to communication and coordination as key components of adaptive capacity. However, in this context, there are relatively few studies that expand on the characteristics of communication and coordination. Designing for adaptive capacity in complex systems involves designing for coordination.
Aim:
The aim of this study is to identify coordination patterns underpinning adaptive workflows that emerge in response to various pressures across the SPD-OR complex in a large multispecialty hospital. Based on frontline stakeholders’ perspectives, the study seeks to identify factors that shape, enable, and impede effective coordination in the SPD, and to represent the relationship between such factors with a structured approach.
Methods:
In order to elicit the perspectives of stakeholders in the SPD, observations of daily procedures and workflows were conducted, followed by semi-structure interviews. The interview method was based on a synthesis of the Systemic Contributors and Adaptations Diagramming (SCAD) approach (Jefferies et al., 2022) and the knowledge elicitation protocol described in Hegde et al. (2020). Per SCAD, the interview starts with a description of the ‘text-book’ workflow when the system is working as expected, followed by questions about how those workflows would vary under systemic pressures and tradeoffs. Per Hegde et al. (2020), cognitive probes focus on the role of specific capabilities (e.g., monitoring and anticipation, preparedness to respond, and coordination) that support adaptive performance.
Interview transcripts and observation notes were analyzed for themes under three categories: pressures and constraints, adaptations, and information flows (that support adaptations). Next, the data were examined for relationships across the three categories. Pressure themes were linked to the corresponding adaptive workflows, which were mapped with the corresponding information flows. Here, information flows are considered as the ‘currency’ of coordination. The focus of this presentation is specifically on the emergent patterns of coordination, including challenges and strategies, in the context of systemic pressures and adaptive capacity.
Findings:
Salient themes related to coordination are highlighted.
Coordination and Communication Challenges
• Workaround lack documentation, communication protocol: While workarounds are accepted as a characteristic feature of ‘work-as-done’, their ad hoc nature, lacking any supervisory oversight, can create coordination gaps elsewhere in the system. For instance, SPD technicians may sometimes substitute a damaged instrument in a tray with one from another tray without documenting the retrieval, which creates an undocumented missing instrument issue downstream.
• Confusion, ambiguity, or lack of understanding: New SPD employees noted that there were instances where they did not know whom to escalate problems or questions to. As an example, participants described scenarios where new hires would answer the phone and gather the information from the OR but not relay the message to those who are more apt to handle the situation.
• High staff attrition and tightened staff resources: high attrition rates and absenteeism makes it more difficult to divide attention between individual operational tasks, and coordinating other workers’ tasks. For instance, supervisors are often pulled into tray management tasks due to the absence of tray workers, and are therefore unavailable for communication with the ORs.
Adaptive Patterns and Coordination Demands
• Role Evolution: Under various pressures and constraints, staff may ad hoc transition to tasks that are not central to their roles to overcome gaps in workflow, such as a supervisor stepping in to help with tray assembly. However, the study also found that having a formal role exclusively for coordination is highly valuable. Specifically, the SPD had instituted an OR-Liaison (OR-L) role as a dedicated resource for coordinating information between the SPD and ORs, which was frequently mentioned in the interviews as helpful in daily operations.
• Substitute trays/instruments, such as ‘peel-packed’ instruments, are available for use in case of missing instruments due to damage or malfunction. This requires communication from the SPD to the ORs notifying them of peel-packed instruments available in place of missing instruments in the tray.
• Huddles between SPD managers, supervisors, and technicians are held to share information, whether it be shift-to-shift (within-level) or from supervisor to front-line worker (cross-level).
Coordination Cost Matrix
It is important to note that the above challenges and gaps in coordination occur under the overarching time pressure. Given the OR schedule, utilization goals, and criticality of procedures, there is a constant pressure to maintain throughput. Under such severe time constraints, activities related to coordinating and communicating often take a backseat. Time pressure also constricts the room for initiative and reciprocity, key features of adaptive performance in most sociotechnical systems. The propensity for initiative and reciprocity in an adaptive environment is challenged by the ‘cost’ associated with coordination. We characterize this cost qualitatively, in terms of the availability or unavailability of two resource variables: information, and a channel of communication. The relationship between these variables is represented in a 2X2 coordination cost matrix. Each of the four ‘boxes’ in the matrix represents a category of cost, Low, Moderate, Moderate, and High, defined by the specific combinations of the two variables, Information Available/Unavailable, and Channel Available/Unavailable. When both information and a channel of communication are not readily available, the high cost associated with information foraging, i.e. information seeking and ‘wayfinding’, places the highest burden on coordination, and could make coordination gaps more likely. This was seen in the case of technicians new to the SPD not knowing where to ‘look up’ some information and how or whom to ask about it. Conversely, when the information source is well known and there is an easily available channel, as in the case of the SPD conveying to the OR about an expected missing instrument through the OR-L, it is more likely that coordination occurs, and in a timely manner. When either one of information or the channel are not immediately available, there is at least a moderate cost associated with information seeking, or wayfinding, respectively.
The matrix representation could serve as a simple framework for organizations to identify costs of coordination for various workflows. Coordination gaps can be addressed by exploring ways to reduce the cost of coordination by making both information and the channel(s) of communication more readily available or accessible by workers. Strategies could include reducing social gradients of communication by using shared platforms system-wide for workers to raise issues that need redressal from leadership; having redundant channels of communication to avoid information flow bottlenecks; and the use of information visualization toward achieving operational ‘common ground’, or shared awareness across stakeholders.
The presentation will expand on specific instantiations of patterns observed in each of the categories of the coordination cost matrix. Examples of coordination mechanisms evolved bottom-up, such as informal liaising between individual workers across SPD and OR groups, and top-down, such as the OR-L’s workflows, will be discussed in terms of how they support overall adaptive capacity of the SPD. Potential strategies for improving coordination, such as those noted above, will also be discussed.
Event Type
Oral Presentations
TimeMonday, March 252:42pm - 3:00pm CDT
LocationSalon A-3
Patient Safety Research and Initiatives