Fig. 19.1
Rose diagram. These diagrams are used to visualize data in multiple dimensions allows the human brain to think visually and solve complex problems
These same diagrams are used to visualize data in multiple dimensions allows the human brain to think visually and solve complex problems. Draw the right picture and you can literally transform the way we see the world. Figure 19.2, Your Ideal Future, is an illustration of a mind map that typifies your future.
Fig. 19.2
Your Ideal Future, is an illustration of a mind map that typifies your future
The mind mapping technique can be applied to understanding a schema of care related to a specific drug therapy, refer to Fig. 19.3, Nurse Management for Dextoamphetamine Therapy. This drawing does not show a pathway, a road map or a sequence of related ideas; it is a schema of related elements organized in a meaningful way to describe nursing management for a particular therapy. This mind map suggests the key nursing management activities are: doing, assessing and decision making.
Fig. 19.3
Nurse management for dextoamphetamine therapy
Ahn et al. [5] state that, “[…] mind mapping encourages the nurses to maintain a holistic view of the patient. A complementary approach to the traditional tabular and narrative based nursing care plan is referred to as mind mapping. A mind map [in the context of a nursing plan] is a graphical representation of the connection between concepts and ideas.” Mind mapping is a very effective tool to visually think through large qualities of information and concepts in a framework that has relationship but not necessarily order, which in many ways emulates life itself. Nursing has to deal with many sources of information in many forms: assimilating, discerning and formulating a diagnosis and a nursing care treatment plan.
Five Element Theory
A large organization or business (which healthcare is) takes on the characteristics of a lumbering giant. The view to business whether large or small, public or private, should consider the elemental interaction of the change dynamic formulated by the Ancient Chinese. The current and dominant focus of business function performance management tends to be based on measuring goals and objective within particular disciplines such as: clinical outcomes, financial measures, wait-times, service deliver, and learning and innovation. However, the five element theory formed the fundamental basis of systems thinking of the Ancient Chinese [6].
Figure 19.4 illustrates the five elements and the nourishing effect each element of a strategic balance scorecard category has on each other. The dotted lines illustrate the controlling relationships between the elements and the lines (1), (2) and (3) that govern those relationships related to business growth. Growth is a change to the business and as Wang indicated it is just as important to control the interactions of the five elements as it is the elements themselves [6].
Fig. 19.4
The five elements and the nourishing effect each element of a strategic balance scorecard category has on each other. Five elements: Wood, Fire, Earth, Metal, and Water, [analogous to business functions]
The five element theory is one of the Chinese worldviews and methodologies which most Chinese scholars have recognized over the past millennia. Viewing the universe as revolving around the five basic elements of everyday life—Wood, Fire, Earth, Metal, and Water, [analogous to business functions] (see Fig. 19.4). The five element model reinforces two complimentary and opposite external cycles, one nourishing and the other controlling. Internally each of the five elements maintains harmony through balance, managing the positive and negative forces. Table 19.1 provides a summary and overview of the model.
Table 19.1
Five element theory in a contemporary context
Basic element | Business function | Mind-map affinity | Balanced scorecard |
|---|---|---|---|
Wood | Research and development | Business planning | Mission, strategy and goals |
Water | Innovation, knowledge, information & growth | Information systems and growth transforms | Potential for learning and growth |
Metal | Finance, accounting and purchasing | Finance and balance sheet | Financial performance |
Earth | Operations and human Resources | Organization and change, service delivery | Internal business process indicators |
Fire | Marketing (external change) | Customer/clinical relations and the patient service offering | External, patient service indicators |
The questions that arise are: “Why is this significant?” Why map a contemporary comprehensive management control system such as the balance scorecard [7; p277], to an ancient Chinese model? Wang’s research paper [6] made a compelling case that there is a correlation between present day management systems and the ancient Chinese model. The Chinese model does point out a variation on the balanced scorecard and more recently Program Budgeting/Marginal Analysis in the healthcare field. That is the emphasis on the relationship system determining the impact that one basic element has on the other, essentially the ebb and flow caused by human interaction.
Referring to Fig. 19.4, the relationship that water has on fire [1] is one of profitability and sustainability. Without the ability of an organization to innovate, learn and grow [3] then the marketing or customers will not be satisfied with the product or service [2]. This can be stated affirmatively as well; if the organization has the ability to innovate, learn and grow then the marketing or customers will be more satisfied. Table 19.2, Basic Element Inter-relationships, summarizes the dynamic that exists in the ancient Chinese model that are associated with various lifecycle stages of a business.
Table 19.2
Basic element inter-relationships
Element inter-relationship | Balance Scorecard | Figure | Business impacts | Life-cycle stage |
|---|---|---|---|---|
Water–fire | Knowledge, innovation, growth | Arrow (1) | Profitability and sustainability | Renewal or start-up |
External, customer service | ||||
Fire–metal | External, customer service | Arrow (2) | Competitiveness | Growth or |
Financial performance | Egress growth | |||
Earth–water | Internal process indicators | Arrow (3) | Learning and innovation | Ingress growth |
Potential learning and growth |
While all the other elements, specifically wood, earth and metal, support the maintenance of a healthy organization, it is the dynamic between water, fire, earth and metal that shines the light on what needs to be in place to support transformational change or growth. These dynamics: (1) promote renewal; (2) promote egress change or stabilization; and (3) ingress growth or transformative growth (Table 19.2).
Why is the theory of the five elements significant to the healthcare industry and the characteristics that manifest the change dynamic? These five elements exist in all organizations big and small. Nursing Informatics contributes to the dynamic through facilitation, adaptation and renewal. Further, nursing informatics experts have strong roles in change management and as leaders in supporting information management for clinical data, and clinically-relevant data, they have much to contribute to organizational management and business processes.
Embrace the Change Dynamic: Positive or Negative
The different lifecycle stages include (a) initiation or start-up, (b) expansion with a significant rate of change, (c) maturity establishing consistency and predictability, (d) diversification where the organization develops strength through verity, and (e) decline. The lifecycle stages with their emphasis on control and feedback function as a closed system [similar to the elevator and the passenger and its control systems] that does not interact with the external factors or the environment [8]. The five element model features the relationships of all factors for an organization to survive and thrive.
Organizational change can be both adaptive and transformative. Sundarasaradula and Hasan [9] note that “major transformative change […] involves profound reformulation of the organization’s mission, vision, structure, management, and basic social, political and cultural aspects of the dynamic equilibrium”. Healthcare organizations must be responsive to the need for transformative change, commit to becoming adaptive, and clearly contextualize their transformation within a business perspective to ensure that the implemented approach is proactive, incremental, measureable, and sustainable. Pre-transformation steps to make the environment conducive for transformation include: (a) workforce training, (b) cultural management, (c) strategy formation, (d) key performance indicators, and (e) feedback mechanisms for monitoring key indicators [10, 11]. From these lists, the elements that need to be monitored in healthcare are not just tangible measures but also measures that relate to knowledge, learning and organizational culture for the long term (Fig. 19.5) [12].
Fig. 19.5
Entrepreneurial Facilitator’s Dilemma
Inertial Conflict: Resistance to Change
The attitude or the way of thinking, whether it is the manager-director for the hospital or “group think” of the Board, has the most profound impact on the organization regardless of the level of maturity to which the business has evolved. Around this frame of reference are a number of psychological (psychogenic) and state-of-being (ontological) factors that contribute to the organization change dynamic. These same factors are deeply embedded in the collective culture of the organization (see Fig. 19.6) [13].
Fig. 19.6
Change and frame of reference
There are a number of cultures that can influence the inner workings of an organization especially in the absence of strong leadership [14]. These include: (a) a process culture based on workflow with little feedback, (b) a power culture concentrating power among a few, (c) a role/hierarchy culture delegating authority in a structured organization, (d) a task culture solving a particular problem, (e) a person culture that exists within and individual, (f) a constructive culture encouraging interaction, (g) a market culture a competitive workplace external facing and controlled, and (h) an adhocracy culture a dynamic workplace with leaders that stimulate innovation [14].
Coping with Urgency and Rate of Change
When considering a change dynamic in the workplace, especially in healthcare informatics, the changes tend to vary from urgent with a high rate of change to passive with limited or prescriptive change relating to a specific scope of practice in a specialty, role or discipline. John Boyd, a fighter pilot for the US Air Force in Korea and Vietnam, was puzzled by the acts of war as was Florence Nightingale. Under fire, Colonel Boyd wished to understand the decision making process shaping operations. He developed the OODA Loop that served to explain the nature of surprise and shapes operations in a way that unifies Gestalt psychology, cognitive science and game theory in a comprehensive theory of strategy (Fig. 19.7).
Fig. 19.7
The OODA Loop. The OODA Loop includes sequential activities including Observe (detecting information), Orient (interpret information), Decide (make a clear decision), and Act
The OODA Loop includes sequential activities including Observe (detecting information), Orient (interpret information), Decide (make a clear decision), and Act [15]. The underlying rationale of this model is the concept of agility, which enables rapid response, faster adjustments, and greater success [15]. This model is used by corporations, governments and the military today to cope with urgent and varying degrees of change and requires the organization to be both holistic in its view and tactical in its operations. This dualistic abstraction of the workflow process requires the decision maker to be ambidextrous in decision making.
What does this mean to the nurse and the healthcare workplace?
For a company – including a healthcare organization, to succeed over the long term, it needs to master both adaptability and alignment — an attribute that is sometimes referred to as ambidexterity [16; p50]. Birkinshaw and Gibson [16] developed a model where there exist two types of ambidexterity in business; structural and contextual. The characteristics of each are present in Table 19.3, Organizational Ambidexterity. These two types juxtaposed appear to be mutually exclusive. Herein lies the organizational challenge and the potential for conflict.
Table 19.3
Organizational ambidexterity
Structural ambidexterity | Contextual ambidexterity | |
|---|---|---|
How is ambidexterity achieved? | Alignment-focused and adaptability-focused activities are done in separate units or teams | Individual employees divide their time between alignment-focused and adaptability-focused activities |
Where are decisions made about the split between alignment and adaptability? | At the top of the organization | On the front line – by salespeople, plant supervisors, office workers |
Role of top management? | To define the structure, to make trade-offs between alignment and adaptability | To develop the organizational context in with individuals act |
Nature of roles | Relatively clearly defined | Relatively flexible |
Skills of employees | More specialists | More generalists |
O’Reilly and Tushman [17]; p13] referred to Teece’s tripartite taxonomy of sensing, seizing, and reconfiguring, where ambidexterity requires a coherent alignment of competencies, structures and cultures to engage in exploration, […]focused on exploitation. O’Reilly and Tushman [17] also identified the key factor to success for any organization is organizational discipline and efficiency, and a dedication to innovation and continuous improvement. They distinguish this approach as requiring a short-term approach rather than a longer-term approach, which is required for more research focused companies.
When considering any organization change, management team leadership is essential to showcase a compelling vision and strategic intent with a clear picture of the intra-organizational relationships to leverage skills and infrastructure. Considering this cultural paradox, the need for leadership and vision to shift the focus from the near term to longer term is essential.
Consumerism, Service and Operations
There a number of competing forces impacting the delivery of consistent, high quality, cost effective healthcare. Currently and into the foreseeable future, consumerism will increasingly impact the demands on the system, change clinician roles, and necessitate efficiencies. This will all happen regardless of whether or not the patient perceives a satisfactory level of quality care. Escalating costs and demands on the healthcare systems are exacerbating tensions on available resources that are already stretched to the limit. Embracing health consumerism, being innovative, working within the system as an intrapreneur and showing leadership in the future will be key tenets of the nursing informatics professional.
Health Consumerism
Health consumerism is an interesting word as it relates to healthcare in general and nursing in particular. Commerce is simply the act of a buyer buying something that a seller has for sale. Consumerism is the ever-increasing demand to purchase goods or service or to take part in commerce. Robinson [18] described how consumerism places the needs or priority of the individual above those of the collective, driving decisions based on personal needs rather than the good of society. While the demand for transparency, accountability, and fiscal efficiency is served by individual choice, it concurrently drives the escalation of demand for greater consumption.
How does this apply to healthcare? Translating this concept to both the workplace and the delivery of healthcare services, the patient is encouraged to acquire healthcare service in ever-greater amounts, thus creating a paradox. The “consumer” patient is encouraged to take advantage of a system that is struggling with the demand and the quality of care the patients are getting. Cohen et al. [19] state that, “In healthcare, consumerism is not a product or program. Instead, it is an orientation to new care delivery models that encourage and enable greater patient responsibility through the intelligent use of information technology.”
With Cohen et al. [19], the consumerism definition has taken on the freedom of choice and an invitation to take advantage of alternative approaches to delivering healthcare. They go on to espouse four guiding principles to ensure that next-generation innovation yields the returns that providers, patients, and other stakeholders expect: (1) keep the consumer at the center of innovation, (2) keep it simple, (3) link products and services to a broader “ecosystem” of care, and (4) encourage health in addition to treating illness [19].
The advancements of technologies in mobility, visualization, intelligent databases and social network all contribute to the proliferation of patient centered delivery of healthcare in any location. This does sound like the panacea for all that ails the patient. The caution is that there are always trade-offs and both the informatics professional and digital age nursing practitioners need to understand not only the benefits, but the risks and challenges this emerging context brings to the patient, the providers, and the organizations charged with patient safety. Examples of current consumer health solutions are: mHealth, Personal Health Records, access to reputable online sources of information, life-line for the elderly and infirmed, and remote monitoring of heart rates and other key health indicators. Consumerism is not just for the patient, any participant providing health services can and are consumers.
Upon reflection, consumerism emphasizes the underlying realization that healthcare is actually a business and not an altruistic action. This realization prompts the need for leadership that is not just clinical in nature but understands the different facets of business that provide the framework of a healthy system for service delivery.
Service Management
Service management plans can take many different forms, from a specific problem that needs to be solved to a general strategy to improve service considering: (a) the service or product, (b) the people, (c) the technology, and (d) systems both workflow process related and technology supported [20]; p67]. The best way to illustrate the implementation of a service management plan in healthcare is to provide a good example [21].
The example is the surgical services area. This part of the delivery of health services tends to touch all aspects of acute care across the hospital and in some regards impacts primary care. Ambulatory services and the emergency service also have links to the surgical services area. As healthcare moves toward health consumerism, there will be demands for the system to act more like a business, demonstrating service value, which will require the key care providers and managers to understand service management consideration.
Service Management Case Study
Surgical Service Management
This service plan focuses primarily on the operating rooms and the core services in the surgical area. The other service areas such as: booking and scheduling, labs, diagnostic imaging, pharmacy, equipment and material supply, housekeeping, day surgery clinic, ambulatory care, and post-operative care units (PACU) are services units contributing to the overall delivery of operating room (OR) services.
The strategic goal of this service plan is primarily focused on improving the service quality to the operative patient. The operating room service is a job shop type of service with a high degree of judgement and customization. After assessing the services quality provided to the patients, two areas of variance were revealed. The responsiveness variance for resourcing is based on a lack of information regarding the work process performance measures, and the reliability variance is based on not knowing the reasons for delays, cancellations and inconsistent booking practices.
The surgical area support services blueprint considers: (a) the line of interaction between the customer (patient) and the onstage contact personnel (key contacts in the health care encounter), (b) the line of visibility between the onstage contact personnel and the backstage contact personnel, and (c) the line of internal interaction between the backstage contact personnel and the support processes.
The facility relationships and the process flows give a better understanding of the OR support services area for service planning. The Operating Room Services Context Diagram (Fig. 19.8), illustrates the high-level context of support services to the service plan target area, the OR services unit.
Fig. 19.8
Operating room services context diagram
Facility Relationships
The running of a hospital is a complex environment. There are a number of disciplines, departments, and specialties all with a set of clinical standards and policies, procedures and best practices. The organizational relationship model (Fig. 19.9) depicts the relationships of the various service areas to each other and to the operating rooms. The diagram at a high level also shows the flow of information.
Fig. 19.9
Organizational relationship model
Process Flows
There are a number of steps required to prepare a patient and the OR for the surgical event. The core process areas include: (a) Booking and Pre-Admission, (b) Surgery Pre-diagnosis, (c) OR set-up, (d) Supply to the OR, (e) Pre-surgery, (f) Surgery, and (g) Post-Operative Care. Each of these process areas incorporates a number of processes and sub-processes as depicted by Work Breakdown Structure and Process Flow (Fig. 19.10). The key areas of potential service improvement are external support entities, exchange of information, or a hand-off of responsibility in the service delivery value chain.
Fig. 19.10
Work breakdown structure and process flow
Strategic Goal and Objectives
The strategic goal of this service plan is primarily focused on improving the service quality to the operative patient. The top three objectives in order of importance are as follows:
1.
Objective one: To maintain and gradually improve the flow of information and communication internal and external to the surgical operating room areas, eliminating redundant processes and excess paper processing and improving patient care by providing timely nursing documentation to the post-operative care areas, ER, ICU, PACU and the post-operative care units within 2 min of the patient out of room time;
2.
Objective two: To minimize the time it takes to order, process and provide results to the operating rooms, reducing the resulting time for stat orders to the OR potentially reducing the time the patient is under anaesthesia;
3.
Objective three: To optimize and systematically monitor, evaluate and act on changes that will improve the use of the operating rooms from 60 to 80 % occupancy during prime-time surgical hours of 7:30–16:30. This will be achieved by effective use of an electronic scheduling application to assign, book, shuffle, cancel and confirm surgeries.
Surgical Area Support Services Blueprint
The surgical area support services blueprint considers: (a) the line of interaction between the customer and the onstage contact personnel, (b) the line of visibility between the onstage contact personnel and the backstage contact personnel, and (c) the line of internal interaction between the backstage contact personnel and the support processes, see (Fig. 19.11) [20]; p71].
Fig. 19.11
OR service blueprint
Line of Interaction
The patient line of interaction from the surgical area perspective is with the booking office and the pre-surgical clinics in ambulatory care areas that perform the requested tests and provide the necessary consults. This process is not coordinated and is left to the patient to make sure the tests are performed prior to the date of surgery. The health card, extended health insurance and the validation of patient history and home medications are all points of intersection with the patient. None of these processes are time sensitive for scheduled surgeries but are very time sensitive for emergency surgery.
Line of Visibility
The line of visibility is the internal interface behind the patient contact person and the back stage personnel that prepare the facility, personnel, and the supplies for the surgery. This line of visibility is the highest candidate for process breakdown and slowness as outlined in the process flows. It is also the easiest area in the surgical support model to institute change without directly impacting the surgeons or the front-line patient contacts. The management of the case preparation in the line of visibility is high candidate to improve the service support quality in preparation for surgeries both booked and emergent. This area contributes to deficiencies in responsiveness quality assessment category.
Line of Internal Interaction
The line of internal interaction is the core of the operating room area, the supply and billing for services. The “Surgery” application currently being implemented satisfies the Intraoperative Documentation illustrated by Fig. 19.12. The key to improved service in this case is to ensure the appropriate data is collected, analyzed and reported. Steps are being taken to capture performance measures to understand the gaps related to the internal interaction. This should identify actions that can be taken to improve responsiveness and reliability.
Surgical Area Support Services Plan
The surgical support services plan provides a framework to take advantage of quality and/or productivity improvement opportunities. There are several opportunity areas in the front-line interaction, process flows and the management of the case readiness leading up to a surgical date. Data to interpret the internal interactions need to be evaluated on a regular basis to implement a continuous quality improvement program.
Service Management Model
The service management process in the past for the surgical areas has been process flow driven and the decision-making reactive and based on evidential data that was collected by the core operating services and not based on a holistic view of a service blueprint. No individual stakeholder contributes more or less to the overall performance of the surgical services.
The surgeons are certainly central to the surgical services; however there are a number of other stakeholders involved directly and indirectly in the quality service being provided. Figure 19.8 is a conceptual service management model developed as part of the Service Management Body of Knowledge (SMBOK) [22].
The service management model names three outside-in areas of service management and the three inside-out areas required to create service value. The two service management areas of interest for the surgery area are: the service quality management and service delivery management.
This does not mean that the other areas are not important, service quality management manages things such as capability and performance and delivery management manages continuity, capability and service levels. Both areas ‘shine a light’ on the factors influencing the quality of service in the surgical areas.
Service Support Systems
The service support systems depicted by Fig. 19.13 are delivered by several applications. The system supports the electronic exchange of internal documentation and supports sending lab results to the OR for the anaesthesiologists.
Fig. 19.13
Surgical services support systems
The patient service interface is primarily paper and telephone. There needs to be a system to monitor the readiness and the progress of the pre-admit patient, tracking lab tests, diagnostic imagining and specialty consultations. How will this happen?
The service management plan for the operating room areas is complex, but serves as an excellent illustration of the factors and the details that a health informatician needs to be aware of and to lead or positively influence in the healthcare setting. The health informatics intrapreneur will need to become knowledgeable in the workflow, the objectives, performance indicators, and able to analyze systems and the functionality to support the operational needs of the business.
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