1. Coordination and work flow management in health care Doctoral course held jointly by Prof. Yan Xiao (University of Maryland) and Prof. Gudela Grote (ETH Zürich

2. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 2 Outline Tuesday July 7  9:00 - 10:00Introduction to the course (Xiao & Grote)  10:30 - 12:00 Basic issues in coordination and planning - organizational perspective (Grote & Xiao)  13:00 - 14:30 Basic issues in coordiation and planning - systems engineering perspective (Xiao)  15:00 - 17:00Case study I: Negotiation and conflict in large scale collaboration (Xiao) Wednesday July 8  9:00 - 10:30Case study II: Visualization of uncertainty for planners (Xiao)  11:00 - 12:30Case study III: Surgical work flow (Xiao)  13:30 - 14:30Case study IV: Planning of operating room occupancy (Grote)  14:45 - 16:00Overall discussion (Xiao & Grote)  17:15 - 18.30Talk by Yan Xiao at the University Hospital Zürich: "Simulation, live teams and videotape: all for the sake of patient safety"

3. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 3 Learning objectives  Review concepts and theories on coordination in the literature  Characterize problems and issues in researching coordination and workflow  Review case studies on coordination and workflow in health care  Integrate knowledge into a possible research plan within and/or outside of own dissertation research = Course requirement: 8-10 page report by Aug. 31

4. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 4 Basic issues in coordination and planning - organizational perspective  Coordination and planning in organizations  Linking coordination and planning in view of management of uncertainties  Examples of own research:  Planning in supply chains  Interaction of rules and routines in railway operations  Adaptive coordination in health care teams

5. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 5 Basic issues in coordination and planning - organizational perspective  Coordination and planning in organizations  Linking coordination and planning in view of management of uncertainties  Examples of own research:  Planning in supply chains  Interaction of rules and routines in railway operations  Adaptive coordination in health care teams

6. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 6 Coordination in organization theory (Thompson, 1967; Van de Ven et al., 1976)  Coordination required for management of task interde- pendencies, which are created by task requirements and chosen degree of specialization.  Task interdependencies (TI)  pooled  sequential  reciprocal  Coordination mechanisms  Impersonal (Technology, standards, plans)  pooled/sequential TI  Personal -vertical (Leadership)  sequential/reciprocal TI -lateral (mutual adjustment)  reciprocal TI  Cultural norms - overriding "soft" centralization

7. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 7 Example of interplay between impersonal and personal coordination: Standards as subsitutes for leadership in cockpit crews (Grote et al., 2004)  Good teams used more leadership in phase 2 (low standardization) and less in phases 1 and 3 (high standardization) (n= 42 teams)

8. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 8 Basic issues in coordination and planning - organizational perspective  Coordination and planning in organizations  Linking coordination and planning in view of management of uncertainties  Examples of own research:  Planning in supply chains  Interaction of rules and routines in railway operations  Adaptive coordination in health care teams

9. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 9

10. 10 Basic principles of organization design: Two approaches to managing uncertainties (Grote, 2004, in press) * Uncertainties may stem from the system environment and/or from the transformation processes within the system. Coordination via - technical systems - standards/programs - personal direction Works best with few uncertainties Coordination via - plans - lateral agreement - culture Works best with many uncertainties

11. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 11 Stability Flexibility Loose coupling =Balance between minimizing uncertainty, which creates stability, and coping with uncertainty, which creates flexibility Central planning High standardization High level of automation Little operative freedom Feedforward control

12. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 12 Basic issues in coordination and planning - organizational perspective  Coordination and planning in organizations  Linking coordination and planning in view of management of uncertainties  Examples of own research:  Planning in supply chains  Interaction of rules and routines in railway operations  Adaptive coordination in health care teams

13. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 13 Basic principles of organization design: Two approaches to managing uncertainties (Grote, 2004, in press) * Uncertainties may stem from the system environment and/or from the transformation processes within the system.

14. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 14 Basic issues in coordination and planning - organizational perspective  Coordination and planning in organizations  Linking coordination and planning in view of management of uncertainties  Examples of own research:  Planning in supply chains  Interaction of rules and routines in railway operations  Adaptive coordination in health care teams

15. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 15 The concept of organizational routines  Organizational routines are "repetitive, recognizable patterns of interdependent actions, carried out by multiple actors" (Feldman & Pentland, 2003, p. 95)  Three functions of routines (Nelson & Winter, 1982)  targets for behavior, thereby keeping behavior under control;  organizational memory of the knowledge needed for successful task performance;  truce between conflicting interests of different participants in the organization.

16. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 16 Example of functions of rules in railway operations (Weichbrodt & Grote, 2009)

17. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 17 The relationship between routines and rules Routine in principle Abstract under- standing of certain recurrent behavior pattern Routine in practice Actual recurrent behavior pattern Rule Artefact containing a written-down formal description of certain behavior pattern create establish guide express describe inform

18. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 18 Types of formal rules (Hale & Swuste, 1998)  Rules concerning goals to be achieved (goal rules) "Flights through areas with known or forecast thunderstorms, severe turbulence or wind shear should be avoided whenever possible."  Rules defining the way in which decisions about a course of action must be arrived at (process rules) "In order to complete a replanning, any documented cruise system and all means available may be used, such as flight management systems (where available) and data contained in the respective AOMs."  Rules defining concrete actions (action rules) "Every evacuation must be carried out as quickly as possible. The passengers must be assisted to leave the aeroplane without their belongings and directed to a point at a safe distance from the aeroplane." (Rule examples taken from the flight operations manual of a commercial airline)

19. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 19 Principles for creating flexible routines  Determine desired balance between stability and flexibility  e.g. in view of increasing traffic density  Use goal and process rules for flexibility and action rules for stability  Match responsibility and capabilities for uncertainty handling  e.g. avoid combining centralized capability with local responsibility

20. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 20 Good rule ? "The correct functioning of the train control system and the automatic traffic control system is to be monitored by the signaller. If necessary, he/she has to intervene manually. During normal operation, no monitoring is necessary as long as the operational requirements are met. In the case of disturbances or incidents, the notification of the required services and the required alarm procedures must be guaranteed." (Excerpt from the rule book of a European railway company)

21. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 21 Good rule ? "The correct functioning of the train control system and the automatic traffic control system is to be monitored by the signaller. If necessary, he/she has to intervene manually. During normal operation, no monitoring is necessary as long as the operational requirements are met. In the case of disturbances or incidents, the notification of the required services and the required alarm procedures must be guaranteed." (Excerpt from the rule book of a European railway company) Goal rule  flexibility but: insufficient responsibility/support match Action rule  stability (with decision latitude) Process rule  flexibility

22. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 22 Basic issues in coordination and planning - organizational perspective  Coordination and planning in organizations  Linking coordination and planning in view of management of uncertainties  Examples of own research:  Planning in supply chains  Interaction of rules and routines in railway operations  Adaptive coordination in health care teams

23. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 23 Study setting: Simulated asystole during intubation Preparation Medication Reaction to Asystole Asystole Intubation Additional preparations Debriefing Workload t t

24. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 24 An example of a good team (Kolbe et al., 2009) 17sec. until problem solved; Anaesthetist 1 yr. and nurse 5 yrs. experience

25. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 25 Asystole Physician Nurse During asystole: 1. (nurse) provides unsolicited information ("Asystole") t Coordination in team 2

26. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 26 Asystole Physician Nurse During asystole: 1. (nurse) provides unsolicited information 2. (physician) provides unsolicited action (monitors and fixes tube) Coordination in team 2

27. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 27 Asystole Physician Nurse During asystole: 1. (nurse) provides unsolicited information 2. (physician) provides unsolicited action 3. (nurse) provides unsolicited action (Präkordialschlag) Coordination in team 2

28. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 28 Asystole Physician Nurse 4. (nurse) monitoring (looks at monitor) During asystole: 1. (nurse) provides unsolicited information 2. (physician) provides unsolicited action 3. (nurse) provides unsolicited action Coordination in team 2

29. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 29 Asystole Physician Nurse 4. (nurse) monitoring During asystole: 1. (nurse) provides unsolicited information 5. (nurse) provides unsolicited action (checks whether electrodes are placed correctly) 2. (physician) provides unsolicited action 3. (nurse) provides unsolicited action  Implicit coordination pattern Coordination in team 2

30. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 30 Importance of shared leadership (Künzle et al., 2009) 30 High performing teams Low performing teams p<.05 (n.s) N = 12 teams, Wilcoxon Signed Ranks Test (n.s) Leadership (Mean rate per Minu te)

31. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 31 A personal journey ino planning  The start:How to get rid of planners to free frontline workers  Leg 1: How should planners and operators cooperate  Leg 2: How should planners among themselves cooperate  Leg 3:How should planners across organizations cooperate  Leg 4: Collaborative planning in multi-x networks

32. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 32 Planning  = How to get from the present state to a desired future state  Basic issues:  Knowing/agreeing on the desired state  Knowing the present state  Learning from past states  Basic obstacles:  Uncertainty = lack of knowledge/ambiguous knowledge  Complexity = Multiple interdependencies

33. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 33 Multiple approaches to planning  Feed forward versus feedback  hierarchical versus opportunistic  blueprint versus resource  Loosening versus tightening interdependencies  autonomy for reducing uncertainties  cooperation for coping with uncertainties  power for transfering uncertainties  increasing uncertainty as an unexplored option

34. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 34 Basic principles of organization design: Two approaches to managing uncertainties (Grote, 2004, in press) * Uncertainties may stem from the system environment and/or from the transformation processes within the system.

35. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 35 Bridging the planning-implementation divide: Cooperation between planners and frontline workers  Distribution of autonomy and control as basic conflict (Grote, 2000)  Explicit communication of goal structure and rationale of plans (Hoc, 1988)  Perspective taking and linking (Zölch, 1997)  Willingness for mutual constraining (McKay, 1992)  Linking primary (implementation) and secondary (planning) work systems through shared and higher- order autonomy (Wäfler, 2001, 2002)  Interpersonal and informational role of schedulers (Jackson et al., 2004)

36. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 36 The elusiveness of the common goal: Collaboration among planners  Overcoming power gradients (Jarillo, 1988)  Balancing autonomy-related losses and interdepen- dence-related gains through risk-sharing (Scott, 1981)  Exchanging uncertain information (Loch & Terwiesch, 2005)  General quest for collaborative planning (Danese, 2006)

37. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 37 Model of collaborative planning (Windischer, 2003; Windischer et al., 2009)  Plan creation  Communication of anticipated events  Knowledge of reference field characteristics  Lateral goal agreement  Negotiation of alternatives  Recognition of planning adequacy  Plan execution  Monitoring and diagnosis of errors in common plan  Coordination of individual opportunistic planning  Common reflection/decision on plan cancellation

38. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 38 Characteristics of collaborative planning: Plan creation

39. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 39 Characteristics of collaborative planning: Plan execution

40. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 40 Design-planning-outcome links (Windischer, 2003; Windischer at al., 2009)

41. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 41 The puzzle of the cooperative free spirit: Collaborative planning in networks  Multi-directional influences by multiple power centers in heterarchic networks (Stadtler, 2005)  Interdependence as asset and threat (Gulati & Sytch, 2007)  Collective versus individual autonomy as match to task interdependence (Langfred, 2005)

42. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 42 Example Supply Chain in Forestry (Günter, 2007)

43. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 43 Forest ranger Transportation contractor 29: 3PL providers do not provide transportation contractors with long- and medium term information on planned harvesting processes, hence transportation contractors do not have the opportunity for long- and medium term scheduling of resources. 30: Information on delivery volume or quality is missing or underspecified which affords transportation contractors to get more detailed information from forest rangers and reconfirm information. 31: Truck drivers load timber in accordance with orders given to them by the transportation contractor but do not confirm the quality of the timber – it is not always clear whether truck drivers are responsible for assessing quality of timber at all.

44. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 44 Planning-autonomy-interdependence links (Günter, 2007)

45. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 45 Remaining puzzles in planning  Intricate relationship between autonomy, interdependence and cooperation  Acknowledging limits of planning "at the edge of chaos" (Eisenhardt & Tabrizi, 1995) versus Revival of centralized planning as "more technology allows more management" (e.g. ATM, RFID)  Goal coupling in multi-x networks (x=profession, unit, organization, culture etc.)

46. Prof. Dr. Gudela Grote, ETH Zürich, ggrote@ethz.ch 46 Planning in multi-x networks: Example hospitals  Efficiency through employing operations management methods (Dexter, Xiao et al., 2007)  Standardization as omnibus solution (Naveh, 2008)  Relational collaboration (Gittell et al., 2000)  Intra- and inter-organizational coordination (Gittell & Weiss, 2004)  Pervasive goal conflicts (Gaba, 2000)  Does model of collaborative planning apply?  Replication of moderated autonomy-interdependence- collaboration relationship?