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Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare

Cognition, Technology & Work volume 9, pages 139–148 (2007)Cite this article

Abstract

The flow of technical work in acute healthcare varies unpredictably, in patterns that occur regularly enough that they can be managed. Acute care organizations develop ways to hedge resources so that they are available if they are needed. This pragmatic approach to the distribution of work among and across groups shows how rules can be used to manage a response to irregular demands for care. However, no rule set can be complete enough to cover this setting’s variety of care demands. Expertise is also needed to tie together the loose ends of conflicts that remain where rules no longer suffice. Many informal solutions to systemic problems go unnoticed unless they are the subjects of study. Naturalistic decision making (NDM) methods such as observational study, interviews, and process tracing reveal the activities of workers in their natural settings. Results of findings from such explorations of technical work can improve understanding of large scale work processes and, ultimately, patient safety. We have explored how practitioners cope with the demands that the system presents to them. While not all succeed, successful initiatives workers have developed demonstrate how their solutions create resilience at large scale.

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References

  • Andorre-Gruet V, Quenniec Y, Concordet D (1998) Three-process model of supervisory activity over 24 hours. Scand J Work Environ Health 24(Suppl 3):121–127

    Google Scholar 

  • AORN (2005) Guidance statement: Safe on-call practices in perioperative practice settings. AORN J 81(5):1054–1057

    Google Scholar 

  • Ashby WR (1956) An introduction to cybernetics. Chapman & Hall, London

    MATH  Google Scholar 

  • Bardram JE (2000) Temporal coordination: on time and coordination of collaborative activities at a surgical department. Computer-supported cooperative Work 9. Kluwer Academic Publishers, Amsterdam, pp 157–187

  • Barley SR, Orr JE (eds) (1997) Between craft and science: technical work in US settings. Cornell University Press, Ithaca, NY

  • Brandwijk M, Nemeth C, O’Connor M, Kahana M, Cook R (2003) Distributing cognition: ICU handoffs conform to Grice’s maxims. SCCM, San Antonio

  • Conant RC, Ashby WR (1970) Every good regulator of a system must be model of that system. Int J Syst Sci 1(2):89–97

    MATH  Article  Google Scholar 

  • Cook RI, Render M, Woods DD (2000) Gaps in the continuity of care and progress on patient safety. BMJ 320:791–794

    Article  Google Scholar 

  • Cook R, Nemeth C (2005) Taking things in stride: cognitive features of two resilient performances. In: Hollnagel E, Woods D, Leveson N (eds) Resilience engineering: concepts and precepts. Ashgate, Aldershot, UK pp 205–221

  • DeRosier JM, Taylor L (2005) Analyzing missing patient events at the VA. Topics in patient safety. VA National Center for Patient Safety 5(6):

  • Drew P, Heritage J (1992) Talk at work. Cambridge University Press, New York, pp 3–100, 331–358

  • Fisne J (1999) What works: ER tracking systems prevent “lost” patients. Health Mana Technol 20(10):52–53

    Google Scholar 

  • Goldstein MJ, Kim E, Widmann WD, Hardy MA (2004) A 360-degree evaluation of a night-float system for general surgery: a response to mandated work hours reduction. Curr Surg 61(5):445–451

    Article  Google Scholar 

  • Grice HP (1975) Syntax and semantics. In: Cole P, Morgan J (eds) Speech acts. Academic Press, New York, pp 41–58

    Google Scholar 

  • Hendey GW, Barth BE, Soliz T (2005) Overnight and postcall errors in medication orders. Acad Emerg Med 12(7):629–634

    Article  Google Scholar 

  • Hollnagel E (2006) Resilience-The challenge of the unstable. In: Hollnagel E, Woods D, Leveson N (eds) Resilience engineering: concepts and precepts. Ashgate, Aldershot, UK

  • Hutchins E (1995) Cognition in the Wild. MIT Press, Cambridge, MA

    Google Scholar 

  • Kerr MP (2002) A qualitative study of shift handover practice and function from a socio-technical perspective. J Adv Nurs 37(2):125–134

    Article  Google Scholar 

  • Klein G (2000) Sources of power. The MIT Press, Cambridge, MA

    Google Scholar 

  • Kowalsky J (2004) PICU hand-offs: characterizing the technical work context of intensive care units. Report available from the cognitive technologies laboratory, University of Chicago, 5841 S. Maryland Avenue, MC4028, Chicago, IL

  • Kowalsky J, Nemeth C, Brandwijk M, Cook RI (2004) Understanding sign outs: conversation analysis reveals ICU handoff content and form. Critical Care Med 32:12. (A29)

    Google Scholar 

  • Matthews AL, Harvey CM, Schuster RJ, Durso FT (2002) Emergency physician to admitting physician handovers: an exploratory study. Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting, Baltimore

  • Mittal V, Salem M, Tyburski J, Brocato J, Lloyd L, Silva Y, Silbergeit A, Shanley C, Remine S (2004) Resident’s working hours in a consortium-wide surgical education program. Am Surg 70(2):127–131

    Google Scholar 

  • Nemeth C, Nunnally N, O’Connor M, Klock PA, Cook R (2005) Getting to the point: developing IT for the sharp end of healthcare. J Biomed Inform 38:1, 18–25

    Google Scholar 

  • Nemeth C (2003) The master schedule: how cognitive artifacts affect distributed cognition in acute care. Dissertation abstracts international 64/08, 3990, (UMI No. AAT 3101124)

  • Nemeth C (2004) Human factors methods for design. Taylor and Francis/CRC Press, New York

    Google Scholar 

  • Nemeth C (2005) Large scale coordination: Studying groups at work. Proceedings of the human factors and ergonomics society national conference, Orlando

  • Perrow C (1999) Normal accidents. Princeton University Press, Princeton, NJ

    Google Scholar 

  • Patterson E, Roth E, Render M (2005, September) Handoffs during nursing shift changes in acute care. Proceedings of the human factors and ergonomics society 49th annual meeting, Orlando, pp 1057–1061

  • Patton M (2002) Qualitative research and evaluation methods. 3rd edn. Sage Publications, Thousand Oaks, CA

    Google Scholar 

  • Rasmussen J (1988) Merging paradigms: decision making, management, and cognitive control. In: Flin R, Salas E, Strub M, Marton L (eds) Decision-making under stress: emerging themes and applications. Ashgate, Brookfield, VT, pp 67–81

  • Sawyer RG, Tribble CG, Newberg DS, Pruett TL, Minasi JS (1999) Intern call schedules and their relationship to sleep, operating room participation, stress, and satisfaction. Surgery 126(2):337–342

    Google Scholar 

  • Wainwright M (2003) Shakeup after “lost” patient. The guardian. March 28. Retrieved from The Guardian web site http://www.society.guardian.co.uk. Cited 27 February 2006

  • Woods DD (1993) Process tracing methods for the study of cognition outside of the experimental psychology lboratory. In: Klein G, Orasanu J, Calderwood R (eds) Decision making in action: models and methods. Ablex Publishing, Norwood, NJ, pp 228–251

  • Woods D, Roth E (1988) Cognitive systems engineering. In: Helander M (ed) Handbook of human-computer interaction. North-Holland, Amsterdam, pp 3–43

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Acknowledgments

Dr. Nemeth’s work is supported by a grant (LM007947) from the National Library of Medicine, NIH (Valerie Florance, Ph.D., Deputy Director). Dr. Cook’s work is supported by a grant (HS11816) from the Agency for Healthcare Research and Quality.

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Authors and Affiliations

  1. Cognitive Technologies Laboratory, Department of Anesthesia and Critical Care, The University of Chicago, 5841 S. Maryland Avenue, MC4028, Chicago, IL, 60637, USA

    Christopher P. Nemeth, Mark Nunnally, Michael F. O’Connor & Richard I. Cook

  2. Department of Pediatrics, The University of Chicago, 5841 S. Maryland Avenue, MC1051, Chicago, IL, 60637, USA

    Marian Brandwijk

  3. Pritzker School of Medicine, The University of Chicago, 5841 S. Maryland Avenue, BSLC, Chicago, IL, 60637, USA

    Julie Kowalsky

Authors
  1. Christopher P. Nemeth
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  2. Mark Nunnally
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  3. Michael F. O’Connor
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  4. Marian Brandwijk
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  5. Julie Kowalsky
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  6. Richard I. Cook
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Correspondence to Christopher P. Nemeth.

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Nemeth, C.P., Nunnally, M., O’Connor, M.F. et al. Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare. Cogn Tech Work 9, 139–148 (2007). https://doi.org/10.1007/s10111-006-0058-4

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  • DOI: https://doi.org/10.1007/s10111-006-0058-4

Keywords

  • Cognition
  • Cognitive systems engineering
  • Resilience
  • Technical work
  • Healthcare