Enhancing hospital care coordination : a resilience-centric approach to challenges and potential strategies

Background: The realms of patient flow management and care coordination, both aiming to optimize care delivery, are governed by distinct operational logics. Patient flow management is primarily a strategic tool concerned with optimising resource utilization via efficient movement of patients through the healthcare system. Care coordination emphasizes a holistic patient-centred approach. It focuses on integrating and coordinating services across the continuum of care to meet the individual patient needs.

Technological improvements, demands for cost control and a shift toward redirecting lower acuity patients to primary and secondary care levels, accentuates the need for specialized staff and equipment in increasingly specialised hospitals. Resource constraints enhances conflicting quality, safety, and production goals as they keep challenging frontline hospital managers to constantly adapt to new situational demands.

The theoretical description of hospitals as complex adaptive systems suggest that resilience is essential for maintaining the systems functions and avoiding loss of control of care delivery. The ability to adapt in response to both critical events and long-term pressures are a hallmark of resilient systems. Adaptations require adaptive capacity, such as extra resources, opportunities, degrees of freedom and/or a flexible goal setting. As well as strategies for control at individual, team, and strategic levels. For this thesis, the system’s ability to adapt is explored through care coordination at the first line management level.

Care coordination has been studied primarily in specific single unit settings or for specific type of management roles such as navigators, nurse coordinators and lead medical doctors. There is a need for studies of how adaptive capacity is realised in-situ from a systems perspective, in highly specialised hospital settings, and to harness first line managers experiences of improvisations and informal practices (Invisible work).

Aim: This thesis aims to contribute to bridging the gap between theory and practice of how first-line hospital managers realise adaptive capacity to avoid loss of control.

Methods: An ethnographic approach that build three cases of care coordination in various in-hospital settings. The studies utilise a broad, inductive-deductive approach to explore how care coordination is realised in-situ using primarily participant shadowing observations and interviews for data collection. Study I. Describes care coordination in a Neonatal Intensive Care Unit. That is an integrated system of intensive care, emergency intake, step down unit and home care nested within one department. This study includes 100 hours of shadowing observations of coordinators, their conversations, tasks, meetings, and artefacts. Data were analysed using an inductive-deductive approach to content analysis from the perspective of resilience engineering. Study II. Explores the intersection of hospital wide patient flow management and care coordination (between wards and units). It incorporates five semistructured individual interviews with high level managers, 56 hours of shadowing observations with hospital bed-coordinators and 14 observations of hospital coordination team huddles. Inductive-deductive content analysis was applied, guided by a framework of Joint Cognitive Systems. Study III. Explores lead-nurses’ strategies and challenges for coordinating care at the emergency department (ED). Data were collected through four focus group interviews guided by a table-top sandbox simulation of the ED. Analysis were conducted using reflexive thematic analysis.

Findings: Study I. Describes a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Everyday work of the management team was characterised by seamlessly and actively organising and reorganising. Sacrificing low level goals based on up-to-date information and making continuous assessments of what would be minimally intrusive for the overall performance of the ward. Study II. Adds to the exploration of care coordination by describing how situations in the hospital’s patient flow is defined as problematic (or disastrous) by being on a course towards unacceptable quality- and safety trade-offs. And additionally, how the hospital management team huddle is an arena for sensemaking and negotiation between wards, but also act as a threshold and delay for information and decisions. Study III. Describes that the “normal state” of the ward is a moving target depending on the current demands. Activities for monitoring the status of the ward are in competition with coordinating activities as they both require managers attention. Coordinating care within the ED extends beyond the boundaries of the physical department within a variety of temporal demands for “on-the-day” adaptations and anticipatory strategies.

Conclusions: The apparent stability of the organisation was found to be a dynamic balance between patient flow and care coordination activities. Care coordination is a team effort that transcend physical or organisational boundaries, teams of managers assert dynamic control as their strategies allow the system to increase the complexity of its control function when needed. The distributed nature of care coordination offers no ‘one point of control’ for tactical or strategic decision makers, which is problematic as a point of control is a common target for patient flow management interventions. Furthermore, frontline managers lacked the aid of tailored decision support systems for matching and visualising current operational stress of their units. It was not obvious outside the head of individual managers what strategies were available for any given situation.

List of scientific papers

I. Hybinette K, Pukk Härenstam K, Ekstedt M. A First-line management team’s strategies for sustaining resilience in a specialised intensive care unit—a qualitative observational study. BMJ Open. 2021;11:e040358.
https://doi.org/10.1136/bmjopen-2020-040358

II. Hybinette K, Praetorius G, Ekstedt M & Pukk Härenstam K. Exploring patient flow management through a lens of cognitive systems engineering. Ergonomics. 2023, 66(12), 2106- 2120.
https://doi.org/10.1080/00140139.2023.2186321

III. Hybinette K, Praetorius G, Ekstedt M & Pukk Härenstam K. Navigating complexity of emergency department care coordination: A qualitative exploration of the use of adaptive capacity. [Submitted]