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Connecting for Service Improvement: Understanding departmental and organisational interfaces

High quality healthcare requires coordination of activities between different teams, departments and organisations.  Someone with a broken hip will be taken to Accident and Emergency, be transferred to the Surgical Assessment Unit, admitted to a ward, go to operating theatres for surgery, return to the ward for post-operative care and be transferred to a rehabilitation facility before discharge home where they may require support from primary, community and social care providers.  On the one hand, this division of responsibilities ensures that patients receive specialist care.  On the other hand, it can lead to disconnections between service processes.  Each of the spaces between departments and organisations present potential risks to quality and safety.  The aim of this research is to: (a) deepen understanding of dependency relationships at healthcare interfaces and the range of approaches available to promote service coordination (b) deploy this knowledge to develop tools which can be used to better understand work processes at healthcare interfaces for service improvement purposes (c) promote local learning, through on-going feedback to the service (d) assess the value of this kind of research approach for service improvement purposes.

Work stream 1: An ethnographic study of critical healthcare interfaces

The first work-stream is an in-depth analysis of dependency relationships and coordination processes at critical interfaces, focusing on the specific places where coordination happens.  Fractured neck of femur and dementia care will be used as tracer conditions, selected because they are known to be complex and necessitate management of departmental/organizational boundaries.

Stage 1

Fifteen audio-recorded, semi-structured interviews with patients/carers in each the two tracer conditions will be undertaken to explore how they experienced their journey through the service (n=30).  Focusing on the patient trajectory through the system rather than on the efficiencies of individual units can help to reveal the often uncoordinated steps that can be harmful to the patient and organisation.  The interviews will be analysed for what they reveal about patients/carers’ experience and will inform the selection of critical interfaces in Stage 2 of the study.

Stage 2

Successfully managed interfaces as well as recurrent bottlenecks, crisis points and break downs will be studied.  Data will be generated through observations at critical nodes in the trajectory of care focused initially on the practices and sites of coordination and then working outwards to develop an understanding of the intersecting social worlds though which interfaces are constituted.  Equal weight will be given to formal and informal and human and nonhuman processes to see how they interlock.  Semi-structured interviews with purposively selected service providers will explore perceptions of dependency relations and coordination mechanisms and their impact on service quality (n=80).

Work Stream 2: Realist Synthesis

There is a diverse literature on approaches to coordination in healthcare, spanning science and technology studies, computer supported collaborative work, health services research and organizational studies.  Greater integration would have theoretical and pragmatic value.  Accordingly, a realist synthesis of this literature is proposed.  Unlike conventional systematic review methodology which aims to aggregate evidence of effectiveness, the aim of realist synthesis is theory generation.  Mechanisms are central to such explanations and the aim will be to generate theories about how coordination interventions have their effects in different contexts.  The review process will include the standard stages of realist synthesis: mapping the field, locating the primary studies, quality appraisal, data extraction, data synthesis.  The result will be the production of generic theories of action which can be translated into a practical resource for use by service providers.

Implementation Methodology

As well as being designed to promote global understanding, the study aims to promote local learning through systems of on-going feedback.  This is consistent with the rapid appraisal cycles in which research is folded into action and becomes a catalyst for change.  Previous studies of healthcare interventions have highlighted how summative evaluations miss the opportunity to alert service providers to issues that need to be addressed.  The value of ethnography in supporting quality initiatives will be evaluated. 

Funding Source: The Health Foundation