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A model for interpreting work and information management in process-oriented healthcare organisations
International Journal of Medical Informatics (2003) 72, 47—56
A model for interpreting work and information management in process-oriented healthcare organisations Anna Andersson a,*, Niklas Hallberg a,c , Toomas Timpka a,b a
Department of Computer and Information Science, Linköping University, SE-581 83 Linköping, Sweden Department of Health and Society, Linköping University, SE-581 83 Linköping, Sweden c Department of System Analysis and IT Security, Swedish Defence Research Agency, Box 1165, SE-581 11 Linköping, Sweden b
Received 9 October 2002 ; received in revised form 25 February 2003; accepted 8 September 2003
KEYWORDS Process-oriented healthcare organisation; Health information system (HIS); Healthcare management; Care process; Case study methods
Summary Background: To increase productivity, management in healthcare organisations have introduced different types of process-oriented organisational configurations. Few studies have addressed clinical practice and information management in these settings. Methods: A case study was performed at a paediatric clinic. Data was collected from archives, through interviews, by participatory observation, and by performing a focus group session. The collected data was analysed using a qualitative and interpretative research strategy. Results: A model was developed of care practitioners’ daily work in process-oriented organisations. The model shows that clinical work was deeply integrated; the care activities were dependent on supply activities and tightly connected to management routines. Conclusion: The resulting model can be used to support development of health information system (HIS) embedded in process-oriented healthcare work. © 2003 Elsevier Ireland Ltd. All rights reserved.
1. Introduction To perform their services, modern healthcare organisations are profoundly dependent on rich and accurate information collected and shared between multiple organisational levels. However, to be able to manage large amounts of data, the organisations need an integrated structure and a health information system (HIS) to rapidly spread the information among managers and care providers [1]. The information systems should also be able to handle the maintenance of this critical mass of integrated *Corresponding author. Tel.: +46-13-281000. E-mail addresses: [email protected] (A. Andersson), [email protected] (N. Hallberg), [email protected] (T. Timpka).
information over time [2]. Non-integrated organisational structures and information systems entail that care providers spend time searching for misplaced information, instead of taking care of their patients. One related difficulty within existing information systems is finding a connection between used resources and actual costs [3]. To come to terms with budget cuts, management of many healthcare organisations have recently introduced process-oriented organisational forms [4], that are based on reengineering the organisational structure [5]. One of the purposes is to collect data about how resources invested in the organisations are used and to feed the information back to health-service management [6]. Due to the
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48 additional complexity, it can be assumed that management in process-oriented healthcare organisations are particularly inclined to support HIS development [7]. The objectives of the HIS are to increase efficiency by reducing costs and improving patient care [8]. Nevertheless, healthcare information is bound to the context of its production [9]. Therefore, it is essential that both managers and developers share an understanding of the work routines, information demands, and other central preconditions at the clinical level before the development of information systems is initiated. Furthermore, healthcare managers at different management levels require divergent information [10]. The next generation of HIS will be embedded in the organisation’s processes, and will be dependent on meeting the care providers’ contextual information needs [11]. One precondition for successfully introducing HIS is to consider social, organisational and cultural issues in the design process [12]. Further, achieving close collaboration and mutual understanding between the system developers involved in the development process and the involved care providers has been found to be a good investment [13].
1.1. Organisational and work process models In the 1990s, several new approaches to organisational development were introduced, ranging from reengineering [5,14—16] and quality systems [17], to organisational learning [18], along with new ways of measuring organisational activities [6]. The main idea of reengineering was to focus on organisational processes instead of organisational functions. By using process-oriented models in combination with statistical control and other quality assurance methods in integrated quality systems, such as Total Quality Management (TQM), further enhancement could be achieved. The intentions of TQM are to change the organisational culture, work routines and leadership in an integrated manner, as to produce services that are appreciated more by the consumers. Another strategy to improve quality is by changing the culture in the organisation towards a learning organisation [18]. One example of a new way to measure organisational activities, e.g., in the financial area, the Balanced Scorecard has been used to translate mission and strategy statements into operational objectives and variables suitable for measurement [6]. In medical informatics, attempts have been made to establish different kinds of organisational models, e.g., socio-technical modelling [19]. The rationale for introducing these models is to gain an understanding of how a new HIS will affect the
A. Andersson et al. distribution and content of work tasks. Changes in work activities require modification of information management [7]. Aarts et al. [20] define three domains that need to be effectively integrated, i.e., clinical work, HIS, and the organisation of medical and healthcare systems. The model (which model?) is focused on identifying the relevant domains for organisational change and patterning the interaction that each of the domains can have with clinical work and the healthcare system. The two-way dependence of the organisational structure and the infrastructure of the HIS are also in focus [21]. The reason for this is that the validity of any technology is not only concerned with meeting the specifications of functions, but also with the interaction of the technical system with its organisational environment [22]. Theories, such as the Cultural-Historical Activity Theory (CHAT) have been used to perform contextual analyses of clinical cognition and activity [23]. In CHAT, it is argued that it is not enough to just study the present healthcare setting, the researcher must also have knowledge about the setting’s history, because clinical cognition takes place embedded in broader institutional structures and the long-term history of development and change [23]. One weakness of the theory is that the analysis is restricted to the reconstruction of actions and the theory cannot explain why people act as they do in the first place. Other researchers argue for a framework that allows for movement between models, theories and perspectives [24]. Based on the fact that healthcare is a complex and socialised environment, the framework should not impose a singular model of clinical thought and action. For instance, one strategy is to combine two or more approaches in the development of HIS, e.g., a combination of use cases originating in object-oriented development with Dynamic Essential Modelling of Organisations (DEMO), which has its roots in the Speech Act Theory [21,25]. The benefits of integrated frameworks are that methods and models can be optimised in the development process and a method that has a specific weakness can be supported by another method that compensates the weakness. Finally, there are approaches to exploring how providers of healthcare reason in clinical contexts, e.g., situated action, which is an emerging perspective for studying human cognition and behaviour as a basis for developing intelligent systems [26]. The process of medical decision-making is here reassembled in an incremental, sequential-refinement planning algorithm, in which a complex decision is broken into a sequence of choices made from a limited number of alternatives [27]. One application is
A model to support develop HIS embedded in process-oriented health care organisations modelling Clinical Practice Guidelines [28]. Here, models address the clinical tasks that should be performed in a specific context of a guideline, and define the criteria for selecting appropriate options when there are a set of potential options.
1.2. Study aims The aim of this study is to model health managers’ and care providers’ work in process-oriented healthcare organisations. To improve the potential to develop HISs that meet users’ needs and that work properly, the results should facilitate the understanding of process-oriented healthcare organisations by visualising the conceptual level of the work activities [29]. Specifically, the objective is to present the internal and external dependencies related to the clinical work tasks? and the kind of work routines in functional units in the hospital that HIS should support. For study purposes, an organisational process is defined as a sequence of work procedures that together constitute complete healthcare service. A work activity is defined as a set of work procedures closely related through their purpose and means of performance. A functional unit is the organisational venue responsible for a certain set of work activities [30].
2. Methods To achieve the objectives of the study, a case study was conducted, based on an interpretative research strategy [31]. Data was collected: (1) from archives, (2) through interviews, (3) by participatory observation, and (4) by conducting a focus group session.
2.1. Case study site The setting for the study was a paediatric clinic at a Swedish county council-owned hospital, with about 30 clinics and 3200 employees. The main organisational objectives for the hospital were delivery of emergency care and specialist medical care, and to produce rehabilitation and habilitation services at the county level. Habilitation is defined as support to a person with a congenital impairment to gain ability, in contrast to rehabilitation where the target is to regain ability. The paediatric clinic was also working in cooperation with maternity wards and Child Health Centres (CHCs) throughout the county. Thirteen CHCs were located at different sites in the county. The clinic was involved in a network of specialist clinics in Southern Sweden, to share knowledge and experience. At the time of the study (2000), the paediatric clinic employed 12 senior physicians, 21 physicians, 91 nurses, 77
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paediatric nurses (specialised nurse’s aides) and 13 secretaries. The management group consisted of six senior physicians, seven nurses and one secretary from the clinic. During the time of the study, the paediatric clinic supplied approximately 16,000 bed-days to inpatients, performed 5000 scheduled surgical interventions and managed 6000 emergency room visits by children. The functional organisation at the paediatric clinic comprised one surgery and three wards, each with a physician responsible for medical matters and a nurse as ward manager. The ward for neonatal patients had eight beds for intensive care and ten beds for prenatal care. The ward for infected patients had 16 isolation rooms for newborn babies and infected children. The ward for institutional care for children older than 1 year had 18 beds. In 1996, the hospital adopted a broad quality program, based on TQM and a Plan-Do-Check-Act (PDCA)-cycle. Therefore, in addition to the work assigned by managers from the functional structure, the clinic developed work processes related to specific patient groups. These work processes, called Patient Need-Group Processes (PNGPs), were organised around individual patient’s medical care. The main objective of the processes was to develop and maintain a high level of knowledge about medical care. The size of the PNGP units differed, but always included at least one physician, one nurse and one secretary. However, if necessary, several clinics, hospitals and county councils could be involved in the development of a process. To evolve nursing care, development teams were established. The participants on the development teams were selected from practitioners who had expressed interest in development work. Specific development areas for these teams were, e.g., palliative care and use of technical equipment. These teams developed, e.g., new work routines for the nursing care and activities that indirectly interfere with the patient-care process, such as delivering food, ordering medicine and play therapy. New developed routines and activities were documented and presented to the other colleagues. The management of the development teams varied from physicians to nurses. The development teams had a representative at each ward that could be contacted if anyone experienced a problem related to nursing care. The group members mostly used their own spare time for meetings or used overlapping time when two shifts were on duty.
2.2. Data collection The interpretation of the clinical setting started with a study of three official forms of documentation
50 of the paediatric clinic: (1) a declaration of quality, development and leadership, from the county council; (2) the report from a survey of the physical and psychological environment; and (3) the clinic’s annual report for 2000. Thereafter, four physicians and four nurses were interviewed. The interviews were semi-structured with open questions that addressed daily work routines and communication patterns. To further improve understanding work situations and to construct descriptions of work practices as accurately as possible, the third step was to observe and interact with the care providers at the paediatric wards before and after rounds. Parallel to observations, the clinical staff were once again interviewed about what they were doing, why they were doing it, what they wanted to obtain from the presumed HIS and what benefits they expected [32]. Field notes were taken in a log during the observation study [33]. To understand how the work in providing care at a ward unit was perceived, a ward nurse’s diary notes for one week were used to obtain information about managing a ward. Finally, a focus group was formed, with seven nurses and three paediatric nurses selected by a ward nurse. The participants were all women with various roles at the clinic and they had worked at the paediatric clinic from 9.5 to 32 years. Five nurses were ward managers and two of them were also in charge of development teams. They all had experience from all of the ward units and the surgery. The first author (AA) prepared the moderator of the focus group with guidelines and questions. The moderator was a researcher who was not involved in the research project [34]. The questions the moderator asked the participants were based on the clinic’s self-presentation structure, which included administrative work, care providing and development work at the clinic. Questions were also asked concerning work activities and information exchange with external units. Furthermore, questions were asked about patients’ relations to the care providers, the physical location and the time set for performing care activities. The focus group session was recorded using a video camera. The first author (AA) also observed the whole session. The recording was used to transcribe selected parts of the conversation.
2.3. Data analysis Data from participant observation and semi-structured interviews, typically used to illuminate the elements of an organisational culture, can readily be handled via categorisation [35]. In this study, all collected empirical material was scrutinised and themes were identified. These themes were there-
A. Andersson et al. after classified and organised into categories. The categories were cross-compared and clustered so that new, abstract categories could be defined [36]. By constantly comparing category with category, it is possible to identify core categories. These core categories were then presented for personnel at the paediatric clinic as a preliminary report for comments and criticism [37]. Based on these comments and criticism, a final modification of the categories was made. The categorisation of the data provided an inductive and contextual analysis with an interpretative rather than positivist orientation. The focus here was on developing a context-based description and explanation of the phenomenon, rather than an objective, static description expressed in terms of causality [38]. In the last step in the data analysis, a preliminary model was produced, sent to the paediatric clinic for criticism and feedback, and thereafter finalised.
3. Results The analysis identified three main work activities and within these, three work procedures each (Fig. 1). The work activities were: (1) co-ordination activities for managing the exchange of information; (2) care activities, which included documentation of the care provided and practice development at the clinic; and (3) supply activities, which included patient assistance and psychosocial support. Specific work procedures in the different activities are often related to and dependent on each other. For instance, the internal co-ordination work is the foundation of external and patient co-ordination in the communication activity. In the care activity, documentation is the foundation of care providing and development of the activity. The supply activity has patient assistance as a basis for structuring materials provision and psychosocial support.
3.1. Co-ordination activity The co-ordination activity deals with managing the wards and the clinic. This activity is focused on co-ordinating different types of information to support care provision. 3.1.1. External co-ordination External co-ordination concerns the exchange of information between the paediatric clinic and other care units. Patients arrived from different types of functional units, such as the emergency unit, other hospitals and by remittance from other physicians working for the county council. For this
A model to support develop HIS embedded in process-oriented health care organisations
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Care activity
Care provision
Care Documentation
Practice development
Co-ordination activity
External Co-ordination
Supply activity
Internal Co-ordination
Patient Co-ordination
Fig. 1
Material provision
The information flow in institutional care
Patient assistance
Psychosocial support
A model of the work structure in the process-oriented healthcare setting.
reason, the co-ordination of documentation had to be done rapidly. As a result, planning for the patients started before the patients arrived at the paediatric clinic. More than one functional unit was often simultaneously involved in the care of a patient, e.g., the orthopaedic and the child psychiatric clinic. Therefore, it was urgent for the nurses to know the ‘‘right’’ phone numbers to be able to get in touch with the ‘‘right’’ persons to co-ordinate the patient’s care. Problems related to the exchange of information between units forced nurses to spend a considerable amount of time making calls and tracing information. Further, problems with providing information, for instance, to surgical staff occurred because patient information had been misplaced. Papers that concerned anaesthetic procedures could disappear between the paediatric clinic and the surgical theatre. One nurse in the focus group explained this dilemma as It is easier to guide the patient right than to get the patient’s records to the right place! External co-ordination continued after the patients had been discharged from the paediatric clinic. For instance, by informing the Well-child
Centre so that they knew about what had happened with the patients and what kind of after-care the patients were in need of. Hence, the coordination of external resources and inter-organisational collaboration was vital to the management of the clinic, but still it was full of problems. 3.1.2. Patient co-ordination Patient co-ordination started before the patient entered institutional care and it included phone and personal contact with patients and their relatives. The care providers had different kinds of supportive equipment for informing the patient, such as radiology films and folders with informative pictures. These were supposed to support the patients and their families by providing them with an understanding of how, for example, a surgical procedure was performed and the amount of recovery time required. All this interaction with the patient and the family was done before the patient was admitted. There were two reasons for such actions. First, the time patients stayed at the wards was expensive for the healthcare organisation. Hence, the actions saved money for the organisation as compared to previous situations, when the patient was provided
52 with information at the clinic. Second, the actions enhanced the relationship between care providers and caretakers as patients and their relatives became well informed. 3.1.3. Internal co-ordination Internal co-ordination concerned managing and planning activities at the clinic and on the wards. These activities were connected to external and patient co-ordination, because in order to manage the ward, the care providers had to co-ordinate activities with other units and patients. However, unlike external co-ordination, internal co-ordination received some support from computer-based systems. Patient records could be ordered via a system aimed at keeping track of the location of patient records. Unfortunately, patient records were not always located where the system stated. In such cases, detective work was required to find the missing patient records. Another computer system kept track of appointments, e.g., the patients’ next appointment with a physician or a nurse. Co-ordinating schedules to give patients new appointments was experienced as a time-consuming task. Further, the ward managing nurses had computer-based systems for scheduling staff at the wards. The staff had some potential to influence their own work schedule but the ward nurse was responsible for both the schedule and updating the system. One important aspect of this scheduling was to assign patients a personal nurse, or paediatric nurse, who was responsible for planning and following the patient through care activities. Furthermore, the ward nurse also had a statistics system for how many patients there were at the clinic. This system was one way for management to measure the performance of the clinic.
3.2. Care activity The care activity had its underpinnings in what had been agreed upon in the co-ordination of work activities and the information that was supposed to be used in different co-ordination procedures. 3.2.1. Care provision Care provision concerned physicians, nurses and paediatric nurses performing care activities. The care activities were clearly distinguished among the different professions, but from a patient perspective, care was teamwork. Different professions assisted each other, especially nurses and paediatric nurses. For example, when a nurse was taking a laboratory test the paediatric nurse assisted, by making the situation less painful and frightening
A. Andersson et al. for the patient. Hence, the different professions’ work tasks together became what are referred as the outcome of care provision. 3.2.2. Practice development Practice development included PNGP units and development teams. These units represented the workflow at the clinic and were connected to local development efforts. Development efforts were divided into medical and nursing care matters, but both interacted with each other. The knowledge and information that was developed in practice development was assumed to be implemented into the paediatric clinic’s ordinary work routines. Practice development was in need of information systems that could be used for distribution of information to the clinic’s care providers. The easiest way was to use the patient records, i.e., to distribute the information using the same information structures that were used for day-to-day care documentation. 3.2.3. The care documentation The care documentation activity was connected to care provision and development efforts. According to Swedish law, all care providers are obligated to document all care treatment. The purpose is to be able to follow-up how the patient has been treated. When a patient has been subject to malpractice or when the patient claims to have been subject to malpractice all information will be available in the care document. Thus, documentation is a source of protection for both care providers and patients. In care documentation, all medical actions performed and observations made by care providers are documented, in terms of patient and point of time. Furthermore, work routines and medical treatment that have been developed at the clinic are also documented, as well as how care providers, in practice, use them. Care documentation is used as a communication medium between care providers. Accordingly, less time is spent on oral briefing. An opinion of the nurses was that documentation of their work routines should be used for teaching new nurses about existing experience. It is a means to share existing experience with new nurses. The nurses also suggested that the same terminology in nursing care should be used so that different hospitals could share documentation.
3.3. Supply activity Supply activity procedures were not directly connected to the medical or the nursing care activities but were still very important for the patients’
A model to support develop HIS embedded in process-oriented health care organisations wellbeing. The personnel that performed the supply activity were, e.g., nurses, paediatric nurses, kitchen and cleaning staff, play therapists and teachers. 3.3.1. Material provision Material provision supported the care activity with pharmaceutics, equipment and material. The resources provided by material provision on a daily basis to the care activity, formed the basis for estimating how much resources care activity required over time. In material provision, pharmaceuticals had a specific position. The drugs look alike and the work conditions are hectic. If rigorous attention was not paid to the administration of drugs, mistakes could easily be made. The clinic did not have any administrative system for how often medical equipment was used, but on the other hand, the machines were always in use. Supplying material, such as bandages, diapers and injections was also a part of material provision. An important procedure in materials provision was handling waste products. Furthermore, equipment and material for play and school activities–—such as games, videotapes and schoolbooks–—as well as kitchen and cleaning materials were also included in material provision. 3.3.2. Psychosocial support Psychosocial support was related to the care providers’ feeling of ‘‘laying themselves open’’ to the patients, which gave returns both to the patients and the care providers. However, it was experienced as emotionally difficult. One tangible example of a psychosocial activity that assisted in smoothing the relationship between care providers and caretakers was providing access to a phone. The phone made it possible for the patients to call and feel close to their relatives, thereby, unwanted tension between care providers and patients was avoided. The information flow within psychosocial support was of a different kind than in supply provision and patient assistance. Nevertheless, the psychosocial support activity needed an information system to support the emotional dimension in the process, such as administrative support for providing patients with a personal phone. Consequently, psychosocial support depended on patient co-ordination working smoothly, so that the patients and their relatives were well informed. 3.3.3. Patient assistance Patient assistance includes both material provision and psychosocial activities. The main purpose was to assist care provision in care activities. The activities included were related to supporting patients’ physical and psychological wellbeing in medical and
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nursing care. Examples of activities are changing nappies, patient transportation, washing and feeding patients and preparing patients for operations by applying anaesthetic cream. These activities were taken for granted, and were not included in the clinic’s ordinary documentation of work activities. However, both medical care and nursing care are dependent on these activities in treating patients.
4. Discussion A model that describes performed activities and their relationships in functional units within process-oriented healthcare organisations has been developed. It is based on an analysis conducted in a well-defined healthcare setting. The motivation for the study was the growing need for understanding the relationship between work activities and information management in process-oriented healthcare. The purpose was to establish a model that can be used for information system development in these contexts. By using such a model, first, the information demands of both healthcare organisation managers and care providers can be more efficiently addressed within the development of HIS. Second, the model enhances the potential to consider organisational and cultural issues early in the development process, while the risk of being stranded in details is avoided. Senge [18] puts forth ‘system thinking’ as a key concept in organisational development. In healthcare, the use of this view demands a shared understanding of information management among healthcare managers and care providers. In the process-oriented healthcare setting, the specific process definitions describe where information is produced and how healthcare management can obtain information about particular work activities and resource use. Most organisational development methods used in healthcare today, such as reengineering and quality management, include process definitions. However, the interaction between different groups of processes has seldom been analysed. In this study, the nature of these interactions is visualised in the model of activities in a functional unit. The model of the work in a functional unit provides an overview of the generic activities related to a process-oriented organisation. To health informatics practitioners, the results provide empirical underpinnings for identifying which kind of work routines in functional units should be supported by information systems and for what reason. The model identifies the particularity of internal and
54 external dependencies and displays the network of heterogeneous healthcare practices [11]. Consequently, it provides an overview of how a functional unit’s work routines are related. For instance, internal co-ordination in the co-ordination activity was found to be directly related to documentation in the care activity, while the latter was related to how supply activity assisted care activity. This implies that issues, which are related to the patients’ psychosocial wellbeing, can be improved with information systems. The psychosocial aspect is an important dimension in any healthcare setting, but psychosocial support functions are seldom included as a main objective in HIS development. Nevertheless, even though such functions are not included, the results of this study suggest that HIS developers should be fully aware of the psychosocial processes that go on among and between care providers and caretakers so that forthcoming HIS does not interfere with these. Several recent organisational methods, such as the Balanced Scorecard [6], address the problem of relating cost to resources [3]. This study indicates that internal co-ordination is informed and thereby dependent on the documentation in the care activity, specifically by showing how human resources are used in caring for patients. In addition, internal co-ordination is achieved by using information about material resource use, i.e., about the use of durable equipment and disposables. Internal co-ordination is thus critically dependent on information from the care activity to enable both co-ordinating clinical work, as well as detecting the cost accrued in the care and supply activities. In this context, the present model provides a tool that can be used during the development of HIS to better identify and follow a process-oriented healthcare organisation’s resources and factual cost. In the different processes, the allocated resources and costs are detected and related to the kind of care activities that have been produced. The present study points out where information can be found in the care activities. Subsequently, the description in the model of how specific activities are related to the different processes can assist methods, such as the Balanced Scorecard. Thus, the Balanced Scorecard can be used to identify the activities that should be measured and the model of work in process-oriented healthcare can be used to define how the organisation should be measured, in practice. The study was based on an interpretative research approach. According to Kaplan [39], contextual studies are still rare, even though knowledge from such approaches is widely requested. The analysis approach to creating the model for
A. Andersson et al. process-oriented organisations differs from, for instance, CHAT and medical cognitive science, which are both based on theoretical concepts [23,26]. The intention of the presented model is to provide contextual knowledge for the development of HIS, for healthcare management and care providers, instead of producing a clinical decision-support system [40,41] or a digital patient record [19,42]. Meanwhile, the present analysis has similarities to socio-technical studies of clinical work. Without using static theoretical frameworks, the resulting model points out generic relations and activities in the process-oriented healthcare setting. The case study analysis method also has similarities to Grounded Theory development, but without the philosophy behind the latter analysis method [43]. The intention was to categorise empirical material, while being aware of the controversy concerning the theoretical background of Grounded Theory analyses [44]. Nevertheless, the model of healthcare work that has been described is based on an inductive approach through which the categories for the model were identified based on data and not on a pre-existing theory.
5. Conclusions The model of work activities in functional units describes how the healthcare practitioners in a process-oriented healthcare organisation handle a large amount of data. The study can be summarised in terms of three conclusions. (1) The model of work in process-oriented healthcare organisations addresses the work activities in an institutional care setting. It can be used to support the early HIS development stages with information concerning organisational culture and contextual issues. (2) The healthcare organisation is bound to the context of its production [9]. Therefore, medical care and nursing care are not separated in practical care provision. Instead, the care provision is one integrated activity centred on the patient. It is supported by supply activity and is reported to healthcare management through co-ordination activities. (3) The resulting model can be used together with methods, such as the Balanced Scorecard [6] to address the problem of relating resources to factual cost [3]. The method points out that which should be measured and the model can be used to suggest how the healthcare organisation can organise the measurements. Future studies have to further address where, in the care providers’ daily routines, information about processes can be identified and collected for the management information system.
A model to support develop HIS embedded in process-oriented health care organisations
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[20] J. Aarts, V. Peel, G. Wright, Organizational issues in health informatics: a model approach, Int. J. Med. Info. 52 (1998) 235—242. [21] E. Maij, P.J. Toussaint, M. Kalshoven, M. Poerschke, J.H.M. Zwetsloot-Schonk, Use cases and DEMO: aligning functional features of ICT-infrastructure to business processes, Int. J. Med. Info. 65 (2002) 179—191. [22] J. Brender, Trends in assessment of IT-based solutions in healthcare and recommendation for the future, Int. J. Med. Info. 52 (1998) 217—227. [23] Y. Engenström, Objects, contradictions and collaboration in medical cognition: an activity-theoretical perspective, Art. Intel. Med. 7 (1995) 395—412. [24] T. Timpka, Situated clinical cognition, Art. Intel. Med. 7 (1995) 387—394. [25] J. Ljungberg, P. Holm, Speech act on trial, in: M. Kyng, L. Mathiassen (Eds.), Computers and Design in Context, The MIT Press, Cambridge, 1997, pp. 317—347. [26] V.L. Patel, D.R. Kaufman, J.F. Arocha, Steering through the murky waters of a scientific conflict: situated and symbolic models of clinical cognition, Art. Intel. Med. 7 (1995) 413— 438. [27] B. Kuipers, A. Moskowitz, J. Kassirer, Critical decisions under uncertainty: representation and structure, Cognitive Sci. 12 (1988) 177—210. [28] D. Wang, M. Peleg, S.W. Tu, A.A. Boxwala, R.A. Greenes, V.L. Patel, E.H. Shortliffe, Representation primitives, process models and patient data in computer-interpretable clinical practice guidelines: a literature review of guideline representation models, Int. J. Med. Info. 68 (2002) 59—70. [29] L. Suchman, Making work visible, Commun. ACM 38 (1995) 56—64. [30] T.W. Malone, K. Crowston, What is coordination theory and how can it help design cooperative work systems? in: Proceedings of CSCW’90, ACM, Los Angeles, 1990. [31] N.K. Denzin, Y.S. Lincoln, Introduction: the discipline and practice of qualitative research, in: N.K. Denzin, Y.S. Lincoln (Eds.), Handbook of Qualitative Researchers, Sage, Thousand Oaks, 2000, pp. 1—28. [32] B. Kaplan, Addressing organizational issues into the evaluation of medical systems, J. Am. Med. Inform. Assoc. 4 (1997) 94—101. [33] M. Ely, Kvalitativ forskningsmetodik i praktiken–—cirklar inom cirklar, Studentlitteratur, Lund, 1993 (in Swedish). [34] T.L. Greenbaum, The Handbook for Focus Group Research, Lexington Books, New York, 1993. [35] P.Y. Martin, B.A. Turner, Grounded theory and organizational research, J. Appl. Behav. Sci. 22 (2) (1986) 141— 157. [36] A. Strauss, J. Corbin, Basics of Qualitative Research–— Techniques and Procedures for Developing Grounded Theory, Sage, California, 1990. [37] B.B. Glaser, Theoretical Sensitivity, The Sociology Press, California, 1978. [38] W.J. Orlikowski, CASE tools as organizational change: investigating incremental and radical changes in systems development, MISQ 17 (1993) 309—340. [39] B. Kaplan, Evaluating, informatics applications–—some alternative approaches: theory, social interactionism, and call for methodological pluralism, Int. J. Med. Info. 64 (2001) 39—56. [40] B. Kaplan, Objectification and negotiation in interpreting clinical images: implications for computer-based patient records, Art. Intel. Med. 7 (1995) 439—454. [41] C. Safran, P.C. Jones, D. Rind, B. Bush, K.N. Cytryn, V.L. Patel, Electronic communication and collaboration in
56 a health care practice, Art. Intel. Med. 12 (1998) 137— 151. [42] G. Mikkelsen, J. Aasly, Concordance of information in parallel electronic and paper based patient records, Int. J. Med. Info. 63 (2001) 123—131.
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A model for interpreting work and information management in process-oriented healthcare organisations Anna Andersson a,*, Niklas Hallberg a,c , Toomas Timpka a,b a
Department of Computer and Information Science, Linköping University, SE-581 83 Linköping, Sweden Department of Health and Society, Linköping University, SE-581 83 Linköping, Sweden c Department of System Analysis and IT Security, Swedish Defence Research Agency, Box 1165, SE-581 11 Linköping, Sweden b
Received 9 October 2002 ; received in revised form 25 February 2003; accepted 8 September 2003
KEYWORDS Process-oriented healthcare organisation; Health information system (HIS); Healthcare management; Care process; Case study methods
Summary Background: To increase productivity, management in healthcare organisations have introduced different types of process-oriented organisational configurations. Few studies have addressed clinical practice and information management in these settings. Methods: A case study was performed at a paediatric clinic. Data was collected from archives, through interviews, by participatory observation, and by performing a focus group session. The collected data was analysed using a qualitative and interpretative research strategy. Results: A model was developed of care practitioners’ daily work in process-oriented organisations. The model shows that clinical work was deeply integrated; the care activities were dependent on supply activities and tightly connected to management routines. Conclusion: The resulting model can be used to support development of health information system (HIS) embedded in process-oriented healthcare work. © 2003 Elsevier Ireland Ltd. All rights reserved.
1. Introduction To perform their services, modern healthcare organisations are profoundly dependent on rich and accurate information collected and shared between multiple organisational levels. However, to be able to manage large amounts of data, the organisations need an integrated structure and a health information system (HIS) to rapidly spread the information among managers and care providers [1]. The information systems should also be able to handle the maintenance of this critical mass of integrated *Corresponding author. Tel.: +46-13-281000. E-mail addresses: [email protected] (A. Andersson), [email protected] (N. Hallberg), [email protected] (T. Timpka).
information over time [2]. Non-integrated organisational structures and information systems entail that care providers spend time searching for misplaced information, instead of taking care of their patients. One related difficulty within existing information systems is finding a connection between used resources and actual costs [3]. To come to terms with budget cuts, management of many healthcare organisations have recently introduced process-oriented organisational forms [4], that are based on reengineering the organisational structure [5]. One of the purposes is to collect data about how resources invested in the organisations are used and to feed the information back to health-service management [6]. Due to the
1386-5056/$ — see front matter © 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2003.09.001
48 additional complexity, it can be assumed that management in process-oriented healthcare organisations are particularly inclined to support HIS development [7]. The objectives of the HIS are to increase efficiency by reducing costs and improving patient care [8]. Nevertheless, healthcare information is bound to the context of its production [9]. Therefore, it is essential that both managers and developers share an understanding of the work routines, information demands, and other central preconditions at the clinical level before the development of information systems is initiated. Furthermore, healthcare managers at different management levels require divergent information [10]. The next generation of HIS will be embedded in the organisation’s processes, and will be dependent on meeting the care providers’ contextual information needs [11]. One precondition for successfully introducing HIS is to consider social, organisational and cultural issues in the design process [12]. Further, achieving close collaboration and mutual understanding between the system developers involved in the development process and the involved care providers has been found to be a good investment [13].
1.1. Organisational and work process models In the 1990s, several new approaches to organisational development were introduced, ranging from reengineering [5,14—16] and quality systems [17], to organisational learning [18], along with new ways of measuring organisational activities [6]. The main idea of reengineering was to focus on organisational processes instead of organisational functions. By using process-oriented models in combination with statistical control and other quality assurance methods in integrated quality systems, such as Total Quality Management (TQM), further enhancement could be achieved. The intentions of TQM are to change the organisational culture, work routines and leadership in an integrated manner, as to produce services that are appreciated more by the consumers. Another strategy to improve quality is by changing the culture in the organisation towards a learning organisation [18]. One example of a new way to measure organisational activities, e.g., in the financial area, the Balanced Scorecard has been used to translate mission and strategy statements into operational objectives and variables suitable for measurement [6]. In medical informatics, attempts have been made to establish different kinds of organisational models, e.g., socio-technical modelling [19]. The rationale for introducing these models is to gain an understanding of how a new HIS will affect the
A. Andersson et al. distribution and content of work tasks. Changes in work activities require modification of information management [7]. Aarts et al. [20] define three domains that need to be effectively integrated, i.e., clinical work, HIS, and the organisation of medical and healthcare systems. The model (which model?) is focused on identifying the relevant domains for organisational change and patterning the interaction that each of the domains can have with clinical work and the healthcare system. The two-way dependence of the organisational structure and the infrastructure of the HIS are also in focus [21]. The reason for this is that the validity of any technology is not only concerned with meeting the specifications of functions, but also with the interaction of the technical system with its organisational environment [22]. Theories, such as the Cultural-Historical Activity Theory (CHAT) have been used to perform contextual analyses of clinical cognition and activity [23]. In CHAT, it is argued that it is not enough to just study the present healthcare setting, the researcher must also have knowledge about the setting’s history, because clinical cognition takes place embedded in broader institutional structures and the long-term history of development and change [23]. One weakness of the theory is that the analysis is restricted to the reconstruction of actions and the theory cannot explain why people act as they do in the first place. Other researchers argue for a framework that allows for movement between models, theories and perspectives [24]. Based on the fact that healthcare is a complex and socialised environment, the framework should not impose a singular model of clinical thought and action. For instance, one strategy is to combine two or more approaches in the development of HIS, e.g., a combination of use cases originating in object-oriented development with Dynamic Essential Modelling of Organisations (DEMO), which has its roots in the Speech Act Theory [21,25]. The benefits of integrated frameworks are that methods and models can be optimised in the development process and a method that has a specific weakness can be supported by another method that compensates the weakness. Finally, there are approaches to exploring how providers of healthcare reason in clinical contexts, e.g., situated action, which is an emerging perspective for studying human cognition and behaviour as a basis for developing intelligent systems [26]. The process of medical decision-making is here reassembled in an incremental, sequential-refinement planning algorithm, in which a complex decision is broken into a sequence of choices made from a limited number of alternatives [27]. One application is
A model to support develop HIS embedded in process-oriented health care organisations modelling Clinical Practice Guidelines [28]. Here, models address the clinical tasks that should be performed in a specific context of a guideline, and define the criteria for selecting appropriate options when there are a set of potential options.
1.2. Study aims The aim of this study is to model health managers’ and care providers’ work in process-oriented healthcare organisations. To improve the potential to develop HISs that meet users’ needs and that work properly, the results should facilitate the understanding of process-oriented healthcare organisations by visualising the conceptual level of the work activities [29]. Specifically, the objective is to present the internal and external dependencies related to the clinical work tasks? and the kind of work routines in functional units in the hospital that HIS should support. For study purposes, an organisational process is defined as a sequence of work procedures that together constitute complete healthcare service. A work activity is defined as a set of work procedures closely related through their purpose and means of performance. A functional unit is the organisational venue responsible for a certain set of work activities [30].
2. Methods To achieve the objectives of the study, a case study was conducted, based on an interpretative research strategy [31]. Data was collected: (1) from archives, (2) through interviews, (3) by participatory observation, and (4) by conducting a focus group session.
2.1. Case study site The setting for the study was a paediatric clinic at a Swedish county council-owned hospital, with about 30 clinics and 3200 employees. The main organisational objectives for the hospital were delivery of emergency care and specialist medical care, and to produce rehabilitation and habilitation services at the county level. Habilitation is defined as support to a person with a congenital impairment to gain ability, in contrast to rehabilitation where the target is to regain ability. The paediatric clinic was also working in cooperation with maternity wards and Child Health Centres (CHCs) throughout the county. Thirteen CHCs were located at different sites in the county. The clinic was involved in a network of specialist clinics in Southern Sweden, to share knowledge and experience. At the time of the study (2000), the paediatric clinic employed 12 senior physicians, 21 physicians, 91 nurses, 77
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paediatric nurses (specialised nurse’s aides) and 13 secretaries. The management group consisted of six senior physicians, seven nurses and one secretary from the clinic. During the time of the study, the paediatric clinic supplied approximately 16,000 bed-days to inpatients, performed 5000 scheduled surgical interventions and managed 6000 emergency room visits by children. The functional organisation at the paediatric clinic comprised one surgery and three wards, each with a physician responsible for medical matters and a nurse as ward manager. The ward for neonatal patients had eight beds for intensive care and ten beds for prenatal care. The ward for infected patients had 16 isolation rooms for newborn babies and infected children. The ward for institutional care for children older than 1 year had 18 beds. In 1996, the hospital adopted a broad quality program, based on TQM and a Plan-Do-Check-Act (PDCA)-cycle. Therefore, in addition to the work assigned by managers from the functional structure, the clinic developed work processes related to specific patient groups. These work processes, called Patient Need-Group Processes (PNGPs), were organised around individual patient’s medical care. The main objective of the processes was to develop and maintain a high level of knowledge about medical care. The size of the PNGP units differed, but always included at least one physician, one nurse and one secretary. However, if necessary, several clinics, hospitals and county councils could be involved in the development of a process. To evolve nursing care, development teams were established. The participants on the development teams were selected from practitioners who had expressed interest in development work. Specific development areas for these teams were, e.g., palliative care and use of technical equipment. These teams developed, e.g., new work routines for the nursing care and activities that indirectly interfere with the patient-care process, such as delivering food, ordering medicine and play therapy. New developed routines and activities were documented and presented to the other colleagues. The management of the development teams varied from physicians to nurses. The development teams had a representative at each ward that could be contacted if anyone experienced a problem related to nursing care. The group members mostly used their own spare time for meetings or used overlapping time when two shifts were on duty.
2.2. Data collection The interpretation of the clinical setting started with a study of three official forms of documentation
50 of the paediatric clinic: (1) a declaration of quality, development and leadership, from the county council; (2) the report from a survey of the physical and psychological environment; and (3) the clinic’s annual report for 2000. Thereafter, four physicians and four nurses were interviewed. The interviews were semi-structured with open questions that addressed daily work routines and communication patterns. To further improve understanding work situations and to construct descriptions of work practices as accurately as possible, the third step was to observe and interact with the care providers at the paediatric wards before and after rounds. Parallel to observations, the clinical staff were once again interviewed about what they were doing, why they were doing it, what they wanted to obtain from the presumed HIS and what benefits they expected [32]. Field notes were taken in a log during the observation study [33]. To understand how the work in providing care at a ward unit was perceived, a ward nurse’s diary notes for one week were used to obtain information about managing a ward. Finally, a focus group was formed, with seven nurses and three paediatric nurses selected by a ward nurse. The participants were all women with various roles at the clinic and they had worked at the paediatric clinic from 9.5 to 32 years. Five nurses were ward managers and two of them were also in charge of development teams. They all had experience from all of the ward units and the surgery. The first author (AA) prepared the moderator of the focus group with guidelines and questions. The moderator was a researcher who was not involved in the research project [34]. The questions the moderator asked the participants were based on the clinic’s self-presentation structure, which included administrative work, care providing and development work at the clinic. Questions were also asked concerning work activities and information exchange with external units. Furthermore, questions were asked about patients’ relations to the care providers, the physical location and the time set for performing care activities. The focus group session was recorded using a video camera. The first author (AA) also observed the whole session. The recording was used to transcribe selected parts of the conversation.
2.3. Data analysis Data from participant observation and semi-structured interviews, typically used to illuminate the elements of an organisational culture, can readily be handled via categorisation [35]. In this study, all collected empirical material was scrutinised and themes were identified. These themes were there-
A. Andersson et al. after classified and organised into categories. The categories were cross-compared and clustered so that new, abstract categories could be defined [36]. By constantly comparing category with category, it is possible to identify core categories. These core categories were then presented for personnel at the paediatric clinic as a preliminary report for comments and criticism [37]. Based on these comments and criticism, a final modification of the categories was made. The categorisation of the data provided an inductive and contextual analysis with an interpretative rather than positivist orientation. The focus here was on developing a context-based description and explanation of the phenomenon, rather than an objective, static description expressed in terms of causality [38]. In the last step in the data analysis, a preliminary model was produced, sent to the paediatric clinic for criticism and feedback, and thereafter finalised.
3. Results The analysis identified three main work activities and within these, three work procedures each (Fig. 1). The work activities were: (1) co-ordination activities for managing the exchange of information; (2) care activities, which included documentation of the care provided and practice development at the clinic; and (3) supply activities, which included patient assistance and psychosocial support. Specific work procedures in the different activities are often related to and dependent on each other. For instance, the internal co-ordination work is the foundation of external and patient co-ordination in the communication activity. In the care activity, documentation is the foundation of care providing and development of the activity. The supply activity has patient assistance as a basis for structuring materials provision and psychosocial support.
3.1. Co-ordination activity The co-ordination activity deals with managing the wards and the clinic. This activity is focused on co-ordinating different types of information to support care provision. 3.1.1. External co-ordination External co-ordination concerns the exchange of information between the paediatric clinic and other care units. Patients arrived from different types of functional units, such as the emergency unit, other hospitals and by remittance from other physicians working for the county council. For this
A model to support develop HIS embedded in process-oriented health care organisations
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Care activity
Care provision
Care Documentation
Practice development
Co-ordination activity
External Co-ordination
Supply activity
Internal Co-ordination
Patient Co-ordination
Fig. 1
Material provision
The information flow in institutional care
Patient assistance
Psychosocial support
A model of the work structure in the process-oriented healthcare setting.
reason, the co-ordination of documentation had to be done rapidly. As a result, planning for the patients started before the patients arrived at the paediatric clinic. More than one functional unit was often simultaneously involved in the care of a patient, e.g., the orthopaedic and the child psychiatric clinic. Therefore, it was urgent for the nurses to know the ‘‘right’’ phone numbers to be able to get in touch with the ‘‘right’’ persons to co-ordinate the patient’s care. Problems related to the exchange of information between units forced nurses to spend a considerable amount of time making calls and tracing information. Further, problems with providing information, for instance, to surgical staff occurred because patient information had been misplaced. Papers that concerned anaesthetic procedures could disappear between the paediatric clinic and the surgical theatre. One nurse in the focus group explained this dilemma as It is easier to guide the patient right than to get the patient’s records to the right place! External co-ordination continued after the patients had been discharged from the paediatric clinic. For instance, by informing the Well-child
Centre so that they knew about what had happened with the patients and what kind of after-care the patients were in need of. Hence, the coordination of external resources and inter-organisational collaboration was vital to the management of the clinic, but still it was full of problems. 3.1.2. Patient co-ordination Patient co-ordination started before the patient entered institutional care and it included phone and personal contact with patients and their relatives. The care providers had different kinds of supportive equipment for informing the patient, such as radiology films and folders with informative pictures. These were supposed to support the patients and their families by providing them with an understanding of how, for example, a surgical procedure was performed and the amount of recovery time required. All this interaction with the patient and the family was done before the patient was admitted. There were two reasons for such actions. First, the time patients stayed at the wards was expensive for the healthcare organisation. Hence, the actions saved money for the organisation as compared to previous situations, when the patient was provided
52 with information at the clinic. Second, the actions enhanced the relationship between care providers and caretakers as patients and their relatives became well informed. 3.1.3. Internal co-ordination Internal co-ordination concerned managing and planning activities at the clinic and on the wards. These activities were connected to external and patient co-ordination, because in order to manage the ward, the care providers had to co-ordinate activities with other units and patients. However, unlike external co-ordination, internal co-ordination received some support from computer-based systems. Patient records could be ordered via a system aimed at keeping track of the location of patient records. Unfortunately, patient records were not always located where the system stated. In such cases, detective work was required to find the missing patient records. Another computer system kept track of appointments, e.g., the patients’ next appointment with a physician or a nurse. Co-ordinating schedules to give patients new appointments was experienced as a time-consuming task. Further, the ward managing nurses had computer-based systems for scheduling staff at the wards. The staff had some potential to influence their own work schedule but the ward nurse was responsible for both the schedule and updating the system. One important aspect of this scheduling was to assign patients a personal nurse, or paediatric nurse, who was responsible for planning and following the patient through care activities. Furthermore, the ward nurse also had a statistics system for how many patients there were at the clinic. This system was one way for management to measure the performance of the clinic.
3.2. Care activity The care activity had its underpinnings in what had been agreed upon in the co-ordination of work activities and the information that was supposed to be used in different co-ordination procedures. 3.2.1. Care provision Care provision concerned physicians, nurses and paediatric nurses performing care activities. The care activities were clearly distinguished among the different professions, but from a patient perspective, care was teamwork. Different professions assisted each other, especially nurses and paediatric nurses. For example, when a nurse was taking a laboratory test the paediatric nurse assisted, by making the situation less painful and frightening
A. Andersson et al. for the patient. Hence, the different professions’ work tasks together became what are referred as the outcome of care provision. 3.2.2. Practice development Practice development included PNGP units and development teams. These units represented the workflow at the clinic and were connected to local development efforts. Development efforts were divided into medical and nursing care matters, but both interacted with each other. The knowledge and information that was developed in practice development was assumed to be implemented into the paediatric clinic’s ordinary work routines. Practice development was in need of information systems that could be used for distribution of information to the clinic’s care providers. The easiest way was to use the patient records, i.e., to distribute the information using the same information structures that were used for day-to-day care documentation. 3.2.3. The care documentation The care documentation activity was connected to care provision and development efforts. According to Swedish law, all care providers are obligated to document all care treatment. The purpose is to be able to follow-up how the patient has been treated. When a patient has been subject to malpractice or when the patient claims to have been subject to malpractice all information will be available in the care document. Thus, documentation is a source of protection for both care providers and patients. In care documentation, all medical actions performed and observations made by care providers are documented, in terms of patient and point of time. Furthermore, work routines and medical treatment that have been developed at the clinic are also documented, as well as how care providers, in practice, use them. Care documentation is used as a communication medium between care providers. Accordingly, less time is spent on oral briefing. An opinion of the nurses was that documentation of their work routines should be used for teaching new nurses about existing experience. It is a means to share existing experience with new nurses. The nurses also suggested that the same terminology in nursing care should be used so that different hospitals could share documentation.
3.3. Supply activity Supply activity procedures were not directly connected to the medical or the nursing care activities but were still very important for the patients’
A model to support develop HIS embedded in process-oriented health care organisations wellbeing. The personnel that performed the supply activity were, e.g., nurses, paediatric nurses, kitchen and cleaning staff, play therapists and teachers. 3.3.1. Material provision Material provision supported the care activity with pharmaceutics, equipment and material. The resources provided by material provision on a daily basis to the care activity, formed the basis for estimating how much resources care activity required over time. In material provision, pharmaceuticals had a specific position. The drugs look alike and the work conditions are hectic. If rigorous attention was not paid to the administration of drugs, mistakes could easily be made. The clinic did not have any administrative system for how often medical equipment was used, but on the other hand, the machines were always in use. Supplying material, such as bandages, diapers and injections was also a part of material provision. An important procedure in materials provision was handling waste products. Furthermore, equipment and material for play and school activities–—such as games, videotapes and schoolbooks–—as well as kitchen and cleaning materials were also included in material provision. 3.3.2. Psychosocial support Psychosocial support was related to the care providers’ feeling of ‘‘laying themselves open’’ to the patients, which gave returns both to the patients and the care providers. However, it was experienced as emotionally difficult. One tangible example of a psychosocial activity that assisted in smoothing the relationship between care providers and caretakers was providing access to a phone. The phone made it possible for the patients to call and feel close to their relatives, thereby, unwanted tension between care providers and patients was avoided. The information flow within psychosocial support was of a different kind than in supply provision and patient assistance. Nevertheless, the psychosocial support activity needed an information system to support the emotional dimension in the process, such as administrative support for providing patients with a personal phone. Consequently, psychosocial support depended on patient co-ordination working smoothly, so that the patients and their relatives were well informed. 3.3.3. Patient assistance Patient assistance includes both material provision and psychosocial activities. The main purpose was to assist care provision in care activities. The activities included were related to supporting patients’ physical and psychological wellbeing in medical and
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nursing care. Examples of activities are changing nappies, patient transportation, washing and feeding patients and preparing patients for operations by applying anaesthetic cream. These activities were taken for granted, and were not included in the clinic’s ordinary documentation of work activities. However, both medical care and nursing care are dependent on these activities in treating patients.
4. Discussion A model that describes performed activities and their relationships in functional units within process-oriented healthcare organisations has been developed. It is based on an analysis conducted in a well-defined healthcare setting. The motivation for the study was the growing need for understanding the relationship between work activities and information management in process-oriented healthcare. The purpose was to establish a model that can be used for information system development in these contexts. By using such a model, first, the information demands of both healthcare organisation managers and care providers can be more efficiently addressed within the development of HIS. Second, the model enhances the potential to consider organisational and cultural issues early in the development process, while the risk of being stranded in details is avoided. Senge [18] puts forth ‘system thinking’ as a key concept in organisational development. In healthcare, the use of this view demands a shared understanding of information management among healthcare managers and care providers. In the process-oriented healthcare setting, the specific process definitions describe where information is produced and how healthcare management can obtain information about particular work activities and resource use. Most organisational development methods used in healthcare today, such as reengineering and quality management, include process definitions. However, the interaction between different groups of processes has seldom been analysed. In this study, the nature of these interactions is visualised in the model of activities in a functional unit. The model of the work in a functional unit provides an overview of the generic activities related to a process-oriented organisation. To health informatics practitioners, the results provide empirical underpinnings for identifying which kind of work routines in functional units should be supported by information systems and for what reason. The model identifies the particularity of internal and
54 external dependencies and displays the network of heterogeneous healthcare practices [11]. Consequently, it provides an overview of how a functional unit’s work routines are related. For instance, internal co-ordination in the co-ordination activity was found to be directly related to documentation in the care activity, while the latter was related to how supply activity assisted care activity. This implies that issues, which are related to the patients’ psychosocial wellbeing, can be improved with information systems. The psychosocial aspect is an important dimension in any healthcare setting, but psychosocial support functions are seldom included as a main objective in HIS development. Nevertheless, even though such functions are not included, the results of this study suggest that HIS developers should be fully aware of the psychosocial processes that go on among and between care providers and caretakers so that forthcoming HIS does not interfere with these. Several recent organisational methods, such as the Balanced Scorecard [6], address the problem of relating cost to resources [3]. This study indicates that internal co-ordination is informed and thereby dependent on the documentation in the care activity, specifically by showing how human resources are used in caring for patients. In addition, internal co-ordination is achieved by using information about material resource use, i.e., about the use of durable equipment and disposables. Internal co-ordination is thus critically dependent on information from the care activity to enable both co-ordinating clinical work, as well as detecting the cost accrued in the care and supply activities. In this context, the present model provides a tool that can be used during the development of HIS to better identify and follow a process-oriented healthcare organisation’s resources and factual cost. In the different processes, the allocated resources and costs are detected and related to the kind of care activities that have been produced. The present study points out where information can be found in the care activities. Subsequently, the description in the model of how specific activities are related to the different processes can assist methods, such as the Balanced Scorecard. Thus, the Balanced Scorecard can be used to identify the activities that should be measured and the model of work in process-oriented healthcare can be used to define how the organisation should be measured, in practice. The study was based on an interpretative research approach. According to Kaplan [39], contextual studies are still rare, even though knowledge from such approaches is widely requested. The analysis approach to creating the model for
A. Andersson et al. process-oriented organisations differs from, for instance, CHAT and medical cognitive science, which are both based on theoretical concepts [23,26]. The intention of the presented model is to provide contextual knowledge for the development of HIS, for healthcare management and care providers, instead of producing a clinical decision-support system [40,41] or a digital patient record [19,42]. Meanwhile, the present analysis has similarities to socio-technical studies of clinical work. Without using static theoretical frameworks, the resulting model points out generic relations and activities in the process-oriented healthcare setting. The case study analysis method also has similarities to Grounded Theory development, but without the philosophy behind the latter analysis method [43]. The intention was to categorise empirical material, while being aware of the controversy concerning the theoretical background of Grounded Theory analyses [44]. Nevertheless, the model of healthcare work that has been described is based on an inductive approach through which the categories for the model were identified based on data and not on a pre-existing theory.
5. Conclusions The model of work activities in functional units describes how the healthcare practitioners in a process-oriented healthcare organisation handle a large amount of data. The study can be summarised in terms of three conclusions. (1) The model of work in process-oriented healthcare organisations addresses the work activities in an institutional care setting. It can be used to support the early HIS development stages with information concerning organisational culture and contextual issues. (2) The healthcare organisation is bound to the context of its production [9]. Therefore, medical care and nursing care are not separated in practical care provision. Instead, the care provision is one integrated activity centred on the patient. It is supported by supply activity and is reported to healthcare management through co-ordination activities. (3) The resulting model can be used together with methods, such as the Balanced Scorecard [6] to address the problem of relating resources to factual cost [3]. The method points out that which should be measured and the model can be used to suggest how the healthcare organisation can organise the measurements. Future studies have to further address where, in the care providers’ daily routines, information about processes can be identified and collected for the management information system.
A model to support develop HIS embedded in process-oriented health care organisations
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