Manda Broekhuis

Sociotechnical systems: towards an organizational learning approach

Abstract By means of three design principles (the sociotechnical criterion, the principle of minimal critical specification and the principle of joint optimization of the technical and social system), STS as a design theory is related to four organizational performance indicators (price, quality, flexibility and innovation). As a diagnostic theory, STS helps to find contingencies between environmental demands and work design. The diagnoses result in sets of STS practices. It is argued that as long as price and quality are the only important performance criteria, STS practices have little to offer and their contributions will be only at the job level. If flexibility is of importance, STS has much more to offer, on the job level as well as the organizational level. The same is true for when innovation is a relevant indicator, in which case STS practices may also help to ‘design’ processes, such as mutual trust among workers and diversity with respect to attitudes, abilities and cognitions. It is argued that the dominant performance indicators have changed in a cumulative way from efficiency, via quality and flexibility towards innovation and learning. In accordance with these changes, the STS principles are extended with the concept of organizational learning.

How Health Care Complexity Leads to Cooperation and Affects the Autonomy of Health Care Professionals

Health professionals increasingly face patients with complex health problems and this pressurizes them to cooperate. The authors have analyzed how the complexity of health care problems relates to two types of cooperation: consultation and multidisciplinary teamwork (MTW). Moreover, they have analyzed the impact of these two types of cooperation on perceived professional autonomy. Two teams were studied, one team dealing with geriatric patients and another treating oncology patients. The authors conducted semi-structured interviews, studied written documents, held informal discussions and observed the teams at work. Consultation was most likely to take place when a patient had multiple problems. However, if these problems were interrelated, i.e. the solution for one problem interfered with solving another, then MTW was favored. The same was true when the available information was equivocal such that there were conflicting interpretations of a problem. How the professionals perceived the relationship between complexity and the need to cooperate depended on their expertise, their occupational background, and their work orientation. Consultation did not affect the professional autonomy of the health care professionals. MTW however did decrease the perceived level of professional autonomy. The extent to which this occurred seemed to depend on the quality of the interpersonal relations within the team. The findings can help in selecting the most appropriate and efficient type of cooperation based on the complexity of a patient’s problems. They can also help team leaders to stimulate reflection and feedback processes, and medical trainers to develop competencies among students related to such teamwork behaviors.

Complexity of health care needs and interactions in multidisciplinary medical teams

By using an information processing and social identity approach, this study examines the relationships between the complexity of the health care needs of a patient and (1) the interactions among physicians during team meetings and (2) how the meeting participants evaluate the discussion. Three dimensions of the complexity of the health care needs are related to the interactive behaviour of medical specialists during meetings of multidisciplinary medical teams. Three medical teams from a Dutch university hospital, each discussing a total of 40 patients, were observed. The results show that component complexity was positively related to the amount of information team members exchanged, to positive reactions, and to the positive evaluation of the discussion. Two other dimensions (interrelatedness of needs and ambiguity) have to be considered in concert: interrelatedness was positively related to negative reactions but only if ambiguity was low; and, further, ambiguity was positively related to evaluative behaviour and to positive reactions, and negatively to the evaluation of the discussion, but only if interrelatedness was low.

Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety

BackgroundPracticing safe behavior regarding patients is an intrinsic part of a physician’s ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians’ risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians’ behaviors.MethodsWe carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach.ResultsWe identified four factors that could affect the relationship between malpractice litigation risk and physicians’ behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals’ response to physicians following incidents.ConclusionIn complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

Service decomposition: a conceptual analysis of modularizing services

Purpose – Applying “modularity” principles in services is gaining in popularity. The purpose of this paper is to enrich existing service modularity theory and practice by exploring how services are being decomposed and how the modularization aim and the routineness of the service(s) involved may link to different decomposition logics. The authors argue that these are fundamental questions that have barely been addressed. Design/methodology/approach – The authors first built a theoretical framework of decomposition steps and the design choices involved that distinguished six decomposition logics. The authors conducted a systematic literature search that generated 18 empirical articles describing 16 service modularity cases. The authors analysed these cases in terms of decomposition logic and two main contingencies: modularization aim and service routineness. Findings – Only three of the 18 articles explicitly addressed the service decomposition by reflecting on the underlying design choices. By unravelling...

Consequences of Participating in Multidisciplinary Medical Team Meetings for Surgical, Nonsurgical, and Supporting Specialties

This study examines the consequences for medical specialists of participating in multidisciplinary medical team meetings in terms of perceived clinical autonomy, domain distinctiveness, and professional accountability. These consequences may influence their willingness to cooperate and the quality of teamwork. The authors hypothesized that multidisciplinary medical team meetings would be more of a threat to the professional identity of surgical specialists than to the professional identity of nonsurgical and supporting specialists. A survey among 1,827 Dutch medical specialists supported the authors’ hypotheses. However, a few specific specialties had response patterns that deviated from our expectations. The results are related to specialty choice, to the training of medical specialties, and to having a role in leading team meetings.

Actionable indicators for short and long term outcomes in rectal cancer

AIM OF THE STUDY Although patient and tumour characteristics are the most important determinants for outcomes in rectal cancer care, actionable factors for improving these are still unclear. Therefore, the purpose of this study was to assess the impact of surgeon and hospital factors which can actually be influenced to improve on postoperative complications, disease-free survival (DFS) and relative survival (RS) in rectal cancer. METHODS For 819 curatively operated rectal cancer patients, staged I-III and diagnosed between 2001 and 2005, data were derived from the population-based Cancer Registry of the Comprehensive Cancer Centre North East and supplemented by medical record examination. (Multilevel) Logistic regression analysis was performed to examine the influence of relevant factors on postoperative complications and time from diagnosis to first treatment. Besides, Cox regression analysis for DFS and relative survival analysis was performed. RESULTS Postoperative complications were dependent on type of surgery (p=0.024) and hospital volume (p=0.029). DFS was mainly influenced by stage (p<0.001) and time to treatment (p=0.018). Actionable indicators related to RS were type of surgery (p=0.011) and time to treatment (p=0.048). Time to treatment was found to be related to co-morbidity (p=0.007), preoperative radiotherapy (p=0.003) and referral for operation (p=0.048). Nevertheless, 18.2% unexplained variation in time to treatment remained on hospital level. CONCLUSIONS We conclude that optimal outcomes for rectal cancer care can be achieved by focusing on early detection and timely diagnosis, as well as adequate choice and timeliness of treatment in hospitals with optimal logistics for rectal cancer patients.

The role of individual accountability in promoting quality management systems

Abstract Workers sometimes violate, more or less deliberately, Quality Management System (QMS) procedures and rules, and two of the most essential causes of such violations are the attitude and motivation of the workers. The effectiveness of a QMS may therefore benefit from management tools aimed at promoting desired behaviour. The result could then be a behaviour-oriented frame for the QMS. The concept of individual accountability, a pivotal concept in performance management models, may serve to develop such a frame. In this study, the relationship between individual accountability factors and the effectiveness of a QMS is investigated. Individual accountability is conceived of as the interplay among three factors: system clarity, social support and personalized responsibility. Data were obtained by conducting a survey and by interviewing employees of a large gas company. We found positive relationships between all three accountability factors and belief in the QMS as well as use of the QMS. Personalized responsibility and social support appeared to strengthen the relationship between system clarity and belief in the QMS, whereas the same factors appeared to weaken the relationship between system clarity and use of the QMS. Apart from being motivators in themselves, the three accountability factors thus seem to form a system of interrelated factors.

Is Telecare Feasible? Lessons from an In-depth Case Study

This paper describes the empirical findings of a large-scale telecare pilot implementation, called KOALA. The pilot is based on video interaction of clients with a medical service centre of a home care provider. The purpose of the project was to gain experience with telecare and to measure the effects in terms of costs and perceived well-being. The expected effects were that clients’ well-being would be increased and overall costs of health care would be reduced. The results of this study are:• the positioning of the medical service centre in the care provider’s network and the organization of the centre are crucial for attaining acceptance and cost effectiveness;• introduction of a telecare program needs careful preparation with clients and employees, and alignment with existing care;• there is substantial difference in the use of telecare and its advantages for different groups of clients; this is especially relevant when using proprietary technology.

What professionals consider when designing a modular service architecture

Purpose The purpose of this paper is to explore how functional and appropriateness arguments influence the adoption of modularity principles during the design of a professional service architecture. Design/methodology/approach Action design research was conducted to examine the design process of a modular service architecture for specialised elderly care by a multi-professional group. Data collection methods included, partly participatory, observations of the interactions between professionals during the design process, interviews and document analysis. Data analysis focussed on the emerging design choices and the arguments underlying them. Findings A wide range of both functional and appropriateness considerations were enlisted during the design process. The three core modularity principles were adapted to varying degrees. In terms of the design outcome, the interdependencies between the modularity principles necessitated two trade-offs in the modular design. A third trade-off occurred between modularity and the need for professional inference where services were characterised by uncertainty. Appropriateness was achieved through the professionals reframing and translating the abstract modularity concept to reconcile the concept’s functionality with their professional norms, values and established practices. Originality/value The study adds to service modularity theory by formulating three trade-offs that are required in translating the core modularity principles into a functional set of design choices for a multi-professional service environment. Moreover, the inherent intertwinedness of the core modularity principles in professional services requires an iterative design process. Finally, the authors saw that the ambiguity present in the service modularity concept can be used to develop a design that is deemed appropriate by professionals.