Why the Plan Doesn’t Hold – a Study of Situated Planning, Articulation and Coordination Work in a Surgical Ward

Jakob E. Bardram & Thomas R. HansenIT University of Copenhagen & Cetrea A/S, Denmark

CSCW 2010 – Everyday Healthcare

07-03-10 · 1

Financial Disclosure

Both authors are co-founders and shareholders in the company Cetrea A/S (Denmark) that produce the technology being studied in this paper.

07-03-10 · 2

Outline

•Background, Motivation, and Research Questions

•Related Studies

•Empirical Background

•Results

•Discussion

Outline of Talk

07-03-10 · 3

Motivation

07-03-10 · 4

Background : Motivation

• Plans, workflows, etc. are coordinative artifacts• Absolutely essential for “complex” work – like

hospitals• However, work is contingent in nature –

especially in hospitals• Several qualitative studies exists• ... but no quantitative evidence exist!• Are all plans subject to change? 50%? 10%? 1%?

What is the relationship between plans and actions?

07-03-10 · 5

Background : Questions

1. What is the nature of the changes to the plan, i.e. how many changes occur and how significant are they?

2. What are the reasons for the changes, i.e. why are plans changed?

3. What are the consequences of these changes, i.e. how are changes experienced and what effect do they have?

4. What are the strategies used for coping with these changes, i.e. how do people handle and accommodate change?

How often, why, consequences, and coping strategies

07-03-10 · 6

• Suchman (1987)

• “plans become resources for work rather than they in any strong sense determine its course”

• Rönkkö, et al. (2005)

• “support the articulation and coordination work necessary in situations where plans do not adequately work out.”

• Schmidt & Simone (1996)

• there is a need for artifacts designed to help “cooperative ensembles [to] articulate their distributed activities more effectively and with a higher degree of flexibility ...”

Related Studies

Qualitative studies

07-03-10 · 7

• Studies of whiteboards in hospitals

• “planning in hospitals is a continuous activity adjusted to the conditions of the specific situation”

• Munkvold et al.

• “[t]here is planning but not plans”

• planning is “a collective, ongoing and heterogeneous achievement”• Bardram & Bossen (2005) : stable coordination mechanisms are

particularly useful

• safety-critical nature of the work,

• distributed and mobile work

• efficient use of scarce and costly resources

Related Studies

Hospital studies

07-03-10 · 8

Empirical Background

07-03-10 · 9

• Operations are subject to extensive scheduling• optimal use of resources• planning staff allocation• equipment allocation

• Operations are subject to extensive changes• acute patients• adjustments during the day• contingencies of all sort

Empirical Background

Scheduling and Execution of Operations in an OR Suite

07-03-10 · 10

• OR Suite on a medium sized Danish hospital

• Organ, orthopedic, and gynecological/obstetric surgery

• 9 ORs, ca. 150 clinicians

• Ca. 8,000 operations/year ≈ 22.4 operations / day, • Using 2 IT systems

• Booking & Planning system

• Peri-operative Coordination and Communication System (PoCCS)

Empirical Background

Research Site

07-03-10 · 11

OP Schedule

Empirical Background

Integration between the two systems

07-03-10 · 12

6 am PoCCS System

Booking & Scheduling

System

07-03-10 · 13

07-03-10

07-03-10

07-03-10

Quantitative Methods• Log file analysis (PoCCS)• 133 days, Oct. 2008 – February 2009• # OPs, # Changes, # Cancelations, Reasons for cancelation

Qualitative Methods• Participant observations; 2 researchers 3 days (plus previous

work)• Semi-structured group interview; 3 charge nurses, 30 min.

Empirical Background

Research Methods

07-03-10 · 17

Results

07-03-10 · 18

Results

07-03-10 · 19

Results

07-03-10 · 20

Results

07-03-10 · 21

Results

07-03-10 · 22

Results

1. Reasons – why are plans changed?

3. Consequences – what happens when plans are changed?

5. Coping strategy – how do you handle changes to the plan?

Quantitative Questions

07-03-10 · 23

Results

Reasons for changing plans

07-03-10 · 24

Results

Consequences of changing plans

07-03-10 · 25

Results

Strategies for handling changes

07-03-10 · 26

• 56% of all operations are planned ahead. • 44% are acute and thus handled ad-hoc.• 8 % of all operations are cancelled.• 31% of all operations are shortened/prolonged > 30 min.• 67% of all planned (“elective”) operations are substantially

changed.

• => only 18% of the operation schedule is enacted as planned.

Summary of Results

Quantitative Results

07-03-10 · 27

Reason?• Incoming acute patients, illness, delays, patient problems, ...• ContingenciesConsequences?• Operations are moved, rescheduled, cancelled, ...• Plans are changed, adjusted, ...Coping Strategies?• Continuous Planning• Articulating Continuous Planning• Negotiation Continuous Planning

Summary of Results

Qualitative Results

07-03-10 · 28

Discussion & Implications for Design

07-03-10 · 29

Continuous Planning

Handling “What-if” scenarios – creating, articulating, negotiating, realizing

07-03-10 · 30

In OR Suite in Denmark...• 56% of all operations are planned• 18% of OPs are executed as planned• Execution is subject to “Continuous

Planning”• ... which has implications for design • ... and for CSCW research

Conclusion

What is the relationship between plans and (situated) action?

07-03-10 · 31

Please ask – or look at www.itu.dk/~bardram

Note! The IT University of Copenhagen has announced several post doc and PhD positions – also within healthcare. Come talk to us or see www.itu.dk

Questions?

07-03-10 · 32