Intended for healthcare professionals

Analysis

Role of routines in collaborative work in healthcare organisations

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2448 (Published 17 November 2008) Cite this as: BMJ 2008;337:a2448
  1. Trisha Greenhalgh, professor
  1. 1UCL Research Department of Primary Care and Population Health, University College London, London N19 5LW
  1. Correspondence to: p.greenhalgh{at}pcps.ucl.ac.uk
  • Accepted 6 September 2008

Work routines are often viewed negatively, but Trisha Greenhalgh reviews evidence showing that they can be the key to maintaining and improving quality of care

We all know that health care is becoming more complex. This complexity carries risks. The US Institute of Medicine report Crossing the Quality Chasm and an international overview by the Organisation for Economic Cooperation and Development identified poor coordination and collaboration as a major (and growing) weakness of healthcare systems.1 2 Although the organisation and delivery of health care have been widely studied, the question of how to improve collaborative health care—that is, people working together around a common task or goal—has rarely been addressed either theoretically or empirically. Existing work on coordination of care is typified by “black box” studies that measure inputs and outcomes without examining the process of coordination.3

When undertaking a systematic review on the spread and sustainability of innovation in health care,4 I discovered a novel theoretical perspective on organisational routines.5 6 7 A subsequent search uncovered some important empirical work in healthcare settings that had been published in organisational sociology journals.8 9 10 11 12 13 14 15 16 Here, I synthesise the findings to consider how key theories, methods, and findings might be adapted and applied in a wider healthcare context.

What is a routine?

An organisational routine is “a repetitive, recognizable pattern of interdependent actions, involving multiple actors.”17 Becker suggested that the routine may be the most fruitful unit of analysis when researching organisational change and set out its defining characteristics (box 1).5 One purpose of routines in organisations is to reduce uncertainty (and hence, cognitive dissonance and stress). On our first day in a new job, for example, we experience confusion because we do not “know the ropes.” Work gradually becomes less stressful as we learn whom to interact with, when, where, and how. Another purpose is governance or control—a routine shapes and constrains the behaviour of people and makes some actions and processes impossible.5

Box 1 Key characteristics of organisational routines 5

  • Routines are recurrent, collective, interactive behaviour patterns

  • Routines are specific (they have a history, a local context, and a particular set of relations)—hence, there is no such thing as universal best practice

  • Routines coordinate (they work by enhancing interaction among participants)

  • Routines have two main purposes—cognitive (knowledge of what to do) and governance (control)

  • Routines, by allowing actors to make many decisions at a subconscious level, conserve cognitive power for non-routine activities

  • Routines store and pass on knowledge (especially tacit knowledge)

  • The knowledge for executing routines may be distributed (everyone has similar knowledge) or dispersed (everyone knows something different; overlaps are small)

  • Routines reduce uncertainty, and hence reduce the complexity of individual decisions

  • Routines confer stability while containing the seeds of change (through the individual’s response to feedback from previous iterations)

  • Routines change in a path dependent manner (depending on what has gone before)

  • Routines are triggered by actor related factors (aspiration levels) and by external cues

The development and delivery of effective routines depends on at least three things: structuring devices, people, and organisational learning (box 2). I consider these in turn below.

Box 2 A theory of collaborative work in health care

Effective and efficient collaborative work in health care is achieved by the development, refinement, and continual renegotiation of organisational routines, which requires attention to three domains:

Structuring devices
  • Time

  • Space

  • Artefacts (eg documents or technologies)

  • Roles and responsibilities

People
  • Capability

  • Mindfulness

  • Identity

  • Agency

Organisational learning
  • A sense making perspective

  • Understanding the organisational grammar of key routines: who, where, when, what, to/for whom, and with which documents and technologies?

  • Encouraging reflection and negotiation

  • Avoid overemphasising standard operating procedures; encourage creative improvements from front line staff

Structuring devices

Organisational life is highly structured.18 This structuring is achieved through devices such as time, space, artefacts (documents or technologies), and roles and responsibilities. Consider a new doctor who is told by a colleague, “We all gather round the notes trolley at 8.30 am for the ward round.” This simple example shows how collaborative work is supported by the coming together of people at particular times and in particular places for an agreed set of tasks delivered through agreed roles and responsibilities, and that particular artefacts may serve as focal points for such complex, collaborative tasks.19 Pentland described this structuring process as a grammar of organisational life.6

An increasingly popular structuring device in healthcare organisations is the integrated care pathway—a predefined management plan for a particular symptom cluster, diagnosis, or intervention, which aims to make care more consistent and efficient.20 Although integrated care pathways have been widely researched in the medical literature,4 theoretical insights on routines have yet to be systematically applied to this particular approach.

Technological artefacts such as the telephone, desktop computer, and personal digital assistant (PDA) can add to the structuring of routines—and sometimes subtract from them—by allowing communication to become placeless. Østerlund, who did a detailed ethnographic study of the use of documents (paper and electronic) in healthcare settings, showed that health professionals tend to gather in information dense spaces such as “by the notes trolley” or “under the white board” when high levels of collaboration are required.12 The physical presence of documentation structures key moves in the routine such as the transfer of a patient from one part of the healthcare system to another (for example, without an admission sheet, the patient cannot leave the accident and emergency department to go to the ward).

The introduction of electronic patient records (widely assumed to increase efficiency, quality, and safety) removes a key material structuring device (the paper document) and the face to face communication that often happens around it—a fact that accounts for some unanticipated failures in electronic record projects. For example, Obstfelder and colleagues studied the introduction of an electronic record system in a care home. The main goal was to improve handovers between nursing shifts, but the new system was subsequently abandoned because crucial information in the handover was actually conveyed verbally and by informal notes (such as sticky notes) when nurses convened around a trolley of paper documents.11 Tellingly, the authors observed: “To maintain continuity of care, the nurses reintroduced these [former] routines spontaneously and ad hoc.”

Østerlund showed that entries on the medical record (whether paper or electronic) are written not merely—or even primarily—to store data but to orient different members of the team to the roles and inputs of others. All documents in organisations have a particular intended audience, are constructed in a particular style, and are stored in a particular place for that audience.13 The apparent duplication of effort in recording data (for example, multiple clinicians each taking a history from a patient on admission and recording it in different places) was accounted for by the need to structure several collaborative tasks involving different individuals and teams.13 14 If the medical record is seen as a simple container, the fact that several people document the “same” information in different places is inefficient; if the record is seen as a structuring device for collaborative work, the duplication is a subtle and paradoxical example of how efficiency can be achieved.13 14 21

People and routines

The human action and interaction that make up an organisational routine depend on key personal qualities of individuals. People must be capable of undertaking the role that is expected of them—including communicating with, and handing over to, other individuals. I have called this quality capability to highlight the need for flexibility, sensitivity to context, and responsiveness to the input of others—which is what distinguishes it from competence (knowledge and skills).22

Another requirement of individuals is an awareness of how the collaborative work of the whole team contributes to the patient’s (or the population’s) overall care. This can be thought of in terms of what Epstein called mindfulness: critical awareness of our own performance, limitations, and needs in the context of clinical work.23 In a recent analysis of key determinants of quality in high performing US hospitals, Bate et al described a culture of mindfulness keeping “staff constantly vigilant and alert as to their personal and group standards and practices—being ‘awake’ to quality and safety concerns, and avoiding ‘automatic’ or ‘standard cookbook’ practice.”24

Braithwaite and colleagues have extended the concept of mindfulness to what they call theory of mind (the capacity to “understand others’ behaviours, mental states and intentions, and use this knowledge to advantage”) and Machiavellian intelligence (the capacity to “solve social problems, including to befriend others for our own purposes, manipulate social situations, benefit from social alliances, and to deceive and outwit when necessary”).25 These uniquely human abilities form the basis of positive intangibles in organisations such as trust, team spirit, and reciprocity and negative ones like suspicion and blame.

Another human element in successful routines is identity—the self that individuals actively construct to present to the world.26 Demarcation of roles and responsibilities is not a simple matter of seeing who is able and available to perform a particular role—it also reflects what that role says about whom they are.27 The general practitioner who says that shared electronic templates for chronic disease management have “reduced me to a data entry clerk” is less likely to contribute enthusiastically to collaborative work than one who feels that the templates have helped him or her to “do my bit for interdisciplinary, holistic care throughout the patient journey.”

A final dimension of the individual’s contribution to organisational routines is agency. As Feldman put it, “Routines are performed by people who think and feel and care. Their reactions are situated in institutional, organisational and personal contexts. Their actions are motivated by will and intention. All of these forces influence the enactment of organisational routines and create in them a tremendous potential for change.”28

The above quote highlights the theoretical tension in routines between preserving past practice and embodying scope for change. Routines are sustained and evolve through the agency and choice of individuals, especially in response to failure or in a turbulent or threatening external environment.17 29 The term routine refers to both the abstract understanding of what should happen in the routine (ostensive aspects) and also to what people actually do (performative aspects).17 30 Pentland’s organisational grammar offers a repertoire of choices that could be made in particular circumstances, but the final decision of what to do must be made judiciously by the actor.6 Importantly, it is here that the scope for incremental change (and hence quality improvement) lies.17 31 To use a somewhat oversimplified example, if everyone is repeatedly late for the ward round and delivers their allotted contribution half heartedly, its start time will slip, some people may not turn up at all, and quality of care will fall. If, on the other hand, people take it on themselves to be punctual and prepared for the ward round, and to suggest ways of making it work better, it sharpens as a collaborative activity, and quality of care is likely to improve.

Organisational learning and routines

All organisations need to learn—that is, to capture knowledge about their activity, reflect on that knowledge, and adjust their systems and processes accordingly.32 This principle underpins much quality improvement work in health care.33 Organisational members are active framers, cognitively making sense of the events, processes, objects, and issues that make up organisational life in a way that links with their personal and professional identity.34 In a learning organisation, people’s cognitive frames are continually shared and negotiated, enabling them to accommodate the frames of others and allow the organisation to better embrace innovation and change.34 Conversely, where organisational learning is underdeveloped or suppressed, counterproductive defensive routines become entrenched.35

Organisational learning is important both for embedding and refining helpful routines and also for negotiating and changing unhelpful ones. For example, if a multidisciplinary team is required to collaborate on the care of clinical cases, questions might be asked such as, Where, when, and by whom will complex cases be discussed? Are all key players free at the stipulated time (or might the time be changed)? Are paper and electronic documents fit for purpose and accessible (who writes what, where, in what format, for what audience)? Do technologies assist, rather than detract from, collaborative moves such as communication, orientation and handovers? And, Is everyone clear and comfortable about their roles and responsibilities and how these interface with those of others? More radically, organisational learning may allow staff to challenge a routine and renegotiate the accepted ways of working (do we always need five people to have input in cases such as Mrs X?).

Unpacking the organisational grammar of routines in health care has many parallels to process mapping, which has shown considerable promise in quality improvement initiatives in health care.36 37 This is no easy task—nor is it likely to suggest simple or resource neutral solutions. Routines are almost never performed in a vacuum but overlap with other routines.5 Overlapping routines are especially hard to align if they occur at different speeds or frequencies5 or cross organisational boundaries.38

Failed routines

There may be several explanations at different levels for a new intervention (for example, a care pathway) not becoming part of a routine. At the individual level, people on whom the routine depends may not know what needs to be done or may lack the ability to do it.39 Alternatively, they may know what is required of them but choose not to do it because it does not fit with their identity, values, or goals.15 At the interpersonal level, they may fail to interact effectively with others—because they lack social skills or organisational power, or through lack of trust in individuals (perhaps because of clashes of professional culture).8 At organisational level, there may be a variety of problems such as: the routine is under-resourced or poorly coordinated, the technology is inadequate, the new routine conflicts with other more established or critical routines, key actors lack the necessary autonomy, or leaders create a weak or inappropriate framing for the routine and fail to invest in team training.10 29 At the level of institutional structures, there may be constraints or drivers such as laws, codes, and expectations of how a good clinician would behave.40 Finally, wider environmental forces (such as economic pressure) may creative incentives or disincentives for particular routines (figure).

Figure1

Multiple levels of influence on development and implementation of organisational routines

My team has shown how the strength of organisational routines explains why patients with limited English have little difficulty in getting a professional interpreter for a consultation in some general practices but find it impossible in others.41 A detailed mapping of the interpreter booking routine showed that the practices with good access were characterised by strong and successful routines, which sharpened over time and consisted of mindful, coordinated execution by staff who made effective use of time, space, documents, and technologies. Those with difficult access were characterised by failed routines with weak or uncoordinated execution of key steps by unmotivated staff, ambiguity of roles (some steps in the routine were nobody’s job), and ineffective use of time, space, documents, or technologies.

Making the most of routines

The flexible and emergent nature of organisational routines, and the fact that they are always enacted by thinking agents in particular contexts, means that while an organisation’s routines should be mapped and understood, they should not normally be formalised through detailed written rules. A ward round undertaken under standard operating procedures would surely be a nightmare—but a mindful team that actively seeks to contribute to, make sense of, and learn from its ward rounds will refine and improve this routine every time it is enacted.

Almost all empirical research on organisational routines has been done in the commercial and manufacturing sectors. Most academic writing on the organisation and management of health care focuses on what organisational members should do rather than studying in detail what they actually do.16 Routinisation theory opens up an exciting new agenda for empirical research in healthcare organisations that links human action and interaction with organisational and institutional change.18 Box 3 gives examples of preliminary questions for this agenda.

Box 3 Examples of research questions on collaborative routines in healthcare organisations

  • How do collaborative routines emerge and how does their emergence link to the embedding of complex innovations?

  • How are these routines shaped and sustained by the purposive action of individuals—and how does this process link to wider themes of organisational learning and quality improvement?

  • What is the nature of the work which individuals and teams need to do to keep routines alive and adapt them responsively to change—and how can this process be optimised and supported?

  • How is the enactment of particular routines by individuals influenced by such things as professional identity, capability, organisational power, and access to resources?

  • How might systems and technologies intended to support collaborative healthcare routines actually interfere with them?

  • Could the systematic study of existing routines be a useful starting point for the design of collaborative technologies (such as electronic records)?

  • What is the link between failed routines and the risk and safety agenda?

Notes

Cite this as: BMJ 2008;337:a2448

Footnotes

  • Contributors and sources: TG is an academic general practitioner with an interest in the organisation and delivery of health services and in the systematic review of complex and heterogeneous evidence.

  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References

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