Enabling the Continuous Improvement of
Healthcare Work Systems By Building
Awareness of Workarounds: The
Workaround Snapshot Approach
Enabling the Continuous Improvement of
Healthcare Work Systems By Building
Awareness of Workarounds: The
Workaround Snapshot Approach
Iris Beerepoot Student number: 10309071
University of Amsterdam Faculty of Science
Thesis Master Information Studies: Business Information Systems Final version: 30 June 2017
Supervisor: Inge van de Weerd Second examiner: Vanessa Dirksen
Abstract. The complex and variable nature of healthcare work makes alignment of
health information systems to healthcare processes a major challenge. Awareness of workarounds provides a means to address this misalignment. This paper proposes to take the workaround as a trigger that initiates the development of workaround snapshots, in which all of the necessary information about a workaround is captured: e.g. motivation, the impact of the workaround on the work system, and possible actions that can be taken. These workaround snapshots provide the core to the Workaround Snapshot Approach (WSA) that is proposed in this study, together with the activities of monitoring and evaluating the identified workaround. In accordance with the principles of design science, the WSA is demonstrated and evaluated in the form of a case study at a Dutch hospital, where twelve workarounds have been identified and examined. The approach has proven to enable the organisation to make well-informed decisions on actions to be taken, which at times result in direct improvement to the work system. The research contributes to existing research in moving past the identification and categorisation of workarounds, towards how awareness of workarounds can be utilised to improve the work system. It also contributes by proposing the creation of workaround snapshots, and based on these snapshots, to continuously monitor and evaluate workarounds. Future research may include longitudinal studies in other (healthcare) settings and may focus more on the monitoring side of the approach.
Keywords. Workarounds, work system, process improvement, workaround snapshot,
Table of Contents
Table of Contents ... 3
1. Introduction ... 5
2. Theoretical Background ... 5
2.1. Definitions and Perspectives on Workarounds ... 5
2.2. Achieving Continuous Awareness of Workarounds ... 6
2.3. Taking Action to Improve the System ... 6
3. Research Method ... 7
3.1. Design Science ... 7
3.2. Case Study: Context ... 8
3.3. Case Study: Data Collection ... 8
3.4. Case Study: Data Analysis ... 9
4. The Workaround Snapshot Approach to the Improvement of Work Systems ... 9
4.1. Snapshot Components ... 9
4.1.1. General Information ... 9
4.1.2. Description and Model ... 10
4.1.3. Impact ... 10
4.1.4. Motivation ... 10
4.1.5. Possible Actions ... 11
4.1.6. Monitoring ... 11
4.2. From Snapshot to Improvement ... 11
5. Case Study Results ... 12
5.1.1. Model ... 12
5.1.2. Impact ... 13
5.1.3. Motivation ... 14
5.1.4. Possible Actions ... 14
5.1.5. Monitoring ... 15
5.2. Improvement of the Work System: the Decision ... 15
5.3. Generalising Beyond The Ward ... 16
6. Discussion ... 16
6.1. Using the Workaround Snapshot Approach ... 16
6.2. Identifying and Examining Workarounds on the Ward ... 17
6.3. Practical Implications and Limitations ... 18
Acknowledgements ... 20
References ... 20
Appendices ... 22
Appendix 1 – Individual Workaround Evaluation Questions ... 22
Appendix 2 – General Evaluation Questions ... 25
Appendix 3 – Workaround Modelling: Addition and Omission ... 26
Appendix 4 – Workaround Snapshots ... 27
Appendix 5 – Individual Workaround Evaluation Answers ... 28
Appendix 6 – General Evaluation Answers ... 35
1. Introduction
A concept that has gained attention in Information Systems research recently is
workarounds. Yang et al. (2012) define workarounds as “alternative procedures employed
by users to accomplish a task in response to a misfit between computer-based and existing work processes”. One area where the misfit between computer-based and existing work processes is especially evident and workarounds are common, is healthcare (Kobayashi et al., 2005; Nadrah & Michell, 2013; Safadi & Faraj, 2010; Vogelsmeier et al., 2008). In healthcare, workarounds are the norm, rather than an exception (Koppel et al., 2008; 2015). The complex and variable nature of healthcare work (Ash et al., 2004; Cresswell et al., 2016; Kobayashi et al., 2005; Koppel et al., 2008), makes alignment of health information systems to healthcare processes a major challenge (Lenz & Kuhn, 2004). Although information technology is seen as a key factor in providing healthcare professionals access to the needed information and thereby improving the quality of healthcare, the existence of IT-related workarounds may have a negative effect on patient safety and security (Koppel et al., 2008; Röder et al., 2015; Vogelsmeier et al., 2008).
Additionally, work processes are subject to change because of new technologies and changing responsibilities, leading to a need for health information systems to continuously adapt to new conditions (Berg, 1999; Lenz & Kuhn, 2004). Awareness of workarounds potentially offers a means to do so. Whereas the perspective on workarounds has for the most part been negative in the past, it is increasingly believed that knowledge of workarounds can signal important issues in process alignment, can help mitigate risks and may even offer a blueprint for identifying misfits that need to be resolved (Petrides et al., 2004; Safadi & Faraj, 2010; Vogelsmeier et al., 2008). To discover how addressing and monitoring workarounds can aid healthcare organisations in adapting processes to changing circumstances, this research asks the following question: how can awareness of workarounds in healthcare processes enable the continuous improvement of work systems?
A work system is defined here as: “a system in which human participants and/or machines perform work (processes and activities) using information, technology, and other resources to produce specific products/services for specific internal and/or external customers” (Alter, 2013). Therefore, it includes both the healthcare professionals carrying out their work and the health information systems. To answer the main research question, two sub-questions are asked, namely: how can awareness of workarounds in healthcare processes be achieved? And: how can this awareness of workarounds consequently be used to bring about continuous improvement of the work system?
The paper starts by sketching the theoretical background, after which the methodology and the results are discussed and a discussion and conclusion are presented.
2. Theoretical Background
2.1. Definitions and Perspectives on Workarounds
Besides the definition of Yang et al., there exist many other definitions of workarounds. A clear and general one comes from Halbesleben et al. (2008), and describes a workaround as a “deviation from the prescribed plan of action”. In practice, three types of workarounds can be defined: omission of process steps, steps performed out of sequence, and unauthorised process steps (Koppel et al., 2008). Halbesleben et al. state that a process containing workarounds is not necessarily inferior to the prescribed process, but may
actually be of higher quality. Thus, whereas workarounds have mostly been viewed as negative phenomena (Outmazgin & Soffer, 2013), especially in terms of compliance (Röder et al., 2014a), they are more and more seen as potentially beneficial activities (Cabitza & Simone, 2013; Cresswell et al., 2016; Nadrah & Michell, 2013; Röder et al., 2014a; Safadi & Faraj, 2010). Workarounds related to information systems are believed to enable the identification of gaps between work processes and their representation in the information system (Petrides et al., 2004) and draw attention to things that need fixing (Lalley & Malloch, 2010). Being aware of workarounds allows for the redesign of processes such that these gaps can be resolved (Cresswell et al., 2016).
Attention to workarounds also allows for the bottom-up involvement of process participants (Azad & King, 2011). According to Safadi and Faraj (2010), “workarounds encode rich knowledge about the needs of users and the required customizations of the system”. They contain information about actual behaviour of users, thus acting as a feedback resource that may be used to improve the system (Cresswell et al., 2016). Several authors believe the involvement of users is crucial in developing an information system that fits the work processes well (Helfert, 2009; Lalley & Malloch, 2010; Safadi & Faraj, 2010). Awareness of workarounds can enable this involvement of users by monitoring their behaviour.
2.2. Achieving Continuous Awareness of Workarounds
Awareness of workarounds can be achieved by identifying process deviations: the activities that differentiate prescribed processes from the actual processes. Therefore, to discover workarounds, the prescribed and the actual process need to be defined. Workarounds are tangible and can be observed, which makes them suitable for identification and analysis (Safadi & Faraj, 2010). However, they will only surface when the information system is in active use (Ash et al., 2004). Therefore, the examination of workarounds is especially useful in the post-implementation phase of the information system. As work processes change, new requirements will surface and thus new workarounds will emerge. Gaps between the work process and the information system will always remain present (Petrides et al., 2004). Hence, the fit between work processes and information systems must be evaluated continuously (Koppel et al., 2008). Constant vigilance is crucial (Ash et al., 2004). When the work system is continuously monitored, any underlying problems can be addressed and resolved (Koppel et al., 2008; Vogelsmeier et al., 2008).
2.3. Taking Action to Improve the System
Up until now, research related to workarounds has been centered on how and why people work around. How knowledge of workarounds can lead to improvement of work systems, is still unclear, although it is believed that by addressing workarounds, it has the potential to do so. To move from knowing that people work around and how they do it, towards improving the work system, well-informed decisions need to be made about the workarounds. Previous researchers have mentioned a number of actions that can be taken regarding workarounds. For example, ignoring workarounds is in many cases harmful (Alter, 2015), while formalising or institutionalising is believed to be advantageous (Azad & King, 2011; Cresswell et al., 2016; Koppel et al., 2008; Yang et al., 2012). The different types of action mentioned in literature can be clustered into four groups (Figure 1). Organisations may decide to prohibit (Röder et al., 2014b), prevent (Nadrah & Michell, 2013), eliminate (Vogelsmeier et al., 2008) or demonise (Cresswell et al., 2016) the
workaround. They may also adopt (Vogelsmeier et al., 2008), formalise (Cresswell et al., 2016) or institutionalise (Azad & King, 2011) workarounds. Another stance is to intervene (Cabitza & Simone, 2013), fit (Yang et al., 2012), redesign (Cresswell et al., 2016) or take measure (Röder et al., 2014b), which can be done by either embellishing the process or modifying the IT (Yang et al., 2012). Lastly, the organisation may choose to ignore (Alter, 2015) or tolerate (Röder et al., 2014b) the workaround.
Figure 1. Actions mentioned in literature.
This research aims to find out whether a level of workaround awareness can be achieved that enables an organisation to make a well-informed decision on an action to be taken, e.g. to prevent, formalise, redesign or tolerate, and whether this awareness enables the organisation to improve the healthcare work system.
3. Research Method
3.1. Design Science
The research is carried out according to the principles of design science (Peffers et. al, 2007). Design science is about creating artefacts that provide solutions to organisational problems. Such artefacts can include informational resources, models, methods, innovations, or any other object that offers a solution to a problem. The problem that aims to be solved in this study is the alignment of Health Information Systems (HIS) to complex healthcare processes that are continuously changing. The objective for a solution to this problem is to enable the continuous improvement of healthcare work systems. For the purpose of this research, a new approach is designed and developed: the Workaround Snapshot Approach (WSA). As per the principles of design science, this approach is drawn from existing theories and knowledge, in order to provide a solution to the defined problem. As several researchers have proposed to study workarounds in relation to health information systems, the WSA is largely based on theories about workarounds, implementation of health information systems and related concepts. It is presented in Section 4.
As an important part of design science entails the demonstration and evaluation of an artefact, this research contains a case study of the application of the WSA. The details of the case study are explained below and the results are presented in Section 5. The case study allows for the carrying out of a detailed and intensive analysis of the case, examining the complex environment a healthcare organisation often is (Bryman, 2015). The case type is representative (Yin, 2013): a hospital that is in the midst of a digital transformation, representing many other hospitals and hospital departments in the post-implementation phase of a HIS. The discussion in Section 6 contains an evaluation of the designed approach.
Adopt/ Formalise/ Institutionalise Intervene/ Fit/ Redesign/ Take measure Ignore/ Tolerate Prohibit/ Prevent/ Eliminate/ Demonise
3.2. Case Study: Context
To carry out the case study, a consultancy company specialised in HIS, ICTZ, offered to make their knowledge and facilities available to the researcher. ICTZ proposed to execute the case study at a specific Dutch peripheral hospital, as the HIS implementation of this hospital was known to be problematic. The data was collected at one ward of the hospital, during the months of April, May and June 2017. At the time of the research, the hospital was amid the implementation phase, as the first hospital in the Netherlands to move to this particular HIS. The implementation process of the HIS consists of three phases, of which the third and final phase was still ahead at the time of the research.
The researcher received full access to the ward, which consists of around 30 clinical beds and is run by a team of nurses, carers and helpers. Also working on the department are surgeons, orthopaedists, physicians and physiotherapists. The team lead of the ward allowed the researcher to talk to everyone there and sit with both the nurses and physicians. A nursing suit was provided to not draw attention to the research being done.
3.3. Case Study: Data Collection
Data gathering mainly took the form of ethnographic observations and interviews. Secondary data in the form of internal documents were provided by the ward’s team lead. Initially, interviews with the team lead were planned to uncover the prescribed processes. Interviews and observations with nurses and physicians would follow afterwards, through which the actual process would be discovered. However, the discovery of workarounds turned out to be more of an iterative process where interviews and observations merge. To decide whether a nurse’s or physician’s activities were indeed workarounds, regular visits to the team lead were necessary. Interviews turned into observations when participants eagerly showed how they worked around an obstacle in the process or when they were asked by a colleague to perform a task. Active observations, where the researcher asked the participant to show the execution of a specific task, alternated with passive observations, for instance when a physician was busy and did not have time to be interviewed.
Data on workarounds were collected from eight nurses, five physicians, one pharmacist, and the team lead. Twelve workarounds were identified and worked out in detail. One HIS consultant from ICTZ who played a large role in the previous phases of the HIS implementation and with a background in nursing was consulted during two sessions in order to gain additional information about the problems underlying the different workarounds and the possible actions that can be taken to improve the work system. An information architect was consulted to discover the ways the workarounds can be monitored using the information stored in the HIS, which is part of the WSA.
As soon as the workarounds were worked out sufficiently according to the researcher and other participants, they were presented to the team lead. After discussing each workaround, the team lead was encouraged to answer a set of questions (Appendix 1 and 2), with the aim of verifying the used approach. A second team lead from another ward was provided the same information and asked for a reaction, in order to verify the application of the approach and recognition of the workarounds outside the ward of the case study. In Table 1, an overview of the data collection is given.
Table 1. Overview of data collection
Date Type of Data Collection Informant(s) Time
12/04 Interview Team lead 50 mins
26/04 Interview Team lead 37 mins 26/04 Passive observations Physicians 3 and 4 (& team lead), nurse 7 4¼ hrs
26/04 Interview/active observation Nurse 1 1 hr
03/05 Passive observation Physicians 4 and 5 (& nurse 8, pharmacist) 3½ hrs
10/05 Interview Information architect 72 mins
12/05 Interview HIS consultant 45 mins
18/05 Interview HIS consultant 74 mins
01/06 Interview/survey Team lead 51 mins
07/06 Interview/survey Second team lead 45 mins
3.4. Case Study: Data Analysis
The interviews were recorded and transcribed. During observations, notes were taken. All transcripts, documents and articles were collected in qualitative analysis software Atlas.ti and coded there. Coding of the interview transcripts and observation notes was done on the basis of the components of the WSA.
4. The Workaround Snapshot Approach to the Improvement of Work Systems
Alter (2015) proposed a method to capture knowledge of a work system in the form of a ‘work system snapshot’. A work system snapshot is a summary of different elements of a work system: customers, products/services, major activities and processes, participants, information and technologies. It forces one to only include the essential information about the work system and allows for quick analysis. This paper proposes the creation of ‘workaround snapshots’ to generate awareness of workarounds. A workaround snapshot contains the essential information about a workaround and forces the creator to keep the information concise.
4.1. Snapshot Components
The included components of the workaround snapshot are shown in Table 2 and explained in more detail below.
Table 2. The Workaround Snapshot. Snapshot Component Content
Date of Snapshot Date the snapshot was created.
Workers Roles that are involved in the workaround.
Degree of Distribution Indication of how often the workaround was mentioned or spotted. Description Concise textual description of the workaround.
Model Process model of the workaround
Impact Impact of the workaround in terms of the devil’s quadrangle. Motivation Description of the worker’s motivation to work around. Possible Actions Inventory of actions that can be chosen.
Monitoring Ways the workaround can be monitored.
4.1.1. General Information
The creation date of the snapshot is included to enable systematic monitoring and evaluation of the workaround, based on the time passed since identification. The types of workers are listed to enable filtering. The degree of distribution aims to give an indication of the degree of usage of the workaround within the department, as how workarounds are proliferated within the organisation is a major concern for organisations (Halbesleben et al., 2008).
4.1.2. Description and Model
The snapshot also includes a concise textual description of the workaround, which is to be readable by someone without extensive knowledge of IT and/or healthcare. A model of the workaround is included in the workaround to illustrate both the activities of the prescribed model and the workaround activities. Process modelling of healthcare processes is especially difficult because of complex roles and decision-making (Berg, 1999). However, workaround modelling allows for targeted identification of the prescribed activities and workaround activities. Business Process Model and Notation (BPMN) is used to model the workaround, as this is a clear and intuitive notation for both end users and IT professionals (Cabitza & Simone, 2013; Röder et al, 2015). To enable the representation of both the prescribed process and the workaround activities in one model, a construct proposed by Röder et al. (2015) is used. By using one lane for activities that are part of the prescribed process, and one for activities that are part of the workaround, extra activities and omitted activities can easily be read off. Appendix 3 illustrates this construct. When a workaround includes a reordering of activities, this can be modelled by using a combination of the two, where an activity is first omitted and later added or the other way around.
4.1.3. Impact
After identifying a workaround, it is important to evaluate its impact on the work system (Ignatiadis & Nandhakumar, 2009; Nadrah & Michell, 2013; Yang et al., 2012). However, the impact of workarounds on business processes is hard to measure (Cabitza & Simone, 2013; Röder et al., 2015). Workarounds can impact factors such as quality and time and can have either a positive or negative influence (Alter, 2015; Azad & King, 2008; Halbesleben et al., 2008). Especially those with a negative nature need to be addressed and mitigated (Niazkhani et al., 2011). Interestingly, a workaround can simultaneously have a positive effect on one factor, and a negative effect on another (Andrade et al., 2016). To illustrate this trade-off, the workaround snapshot includes a devil’s quadrangle of impacts. The devil’s quadrangle was proposed by Dumas et al. (2013) to illustrate the effect of a business process redesign on four performance dimensions: time, cost, quality and flexibility. A process redesign is usually considered an improvement when time and cost decrease, and quality increases. The flexibility dimension concerns the ability of the business process to react to changes, such as a sudden increase in demand of a product. According to Dumas et al., there is often a trade-off to be considered in terms of these four dimensions. The authors state it is important to be aware of this trade-off when choosing to redesign a process.
For the purpose of the workaround snapshot, the devil’s quadrangle is used to illustrate the impact of the workaround in terms of time, cost, quality and flexibility, which can be either positive, negative or neutral. The impact on time thus relates to the impact of the workaround on the duration of the process, the impact on cost to the impact of the workaround on the cost of executing the process, and the impact on quality to the impact of the workaround on the quality of the process in terms of patient care and safety. The last dimension, flexibility, is defined differently to the original devil’s quadrangle. Here, it relates to the impact of the workaround on the flexibility of the workers involved.
4.1.4. Motivation
Researchers agree that there is a need to identify the motivation underlying a workaround (Azad & King, 2008; Cresswell et al., 2016; Ferneley & Sobreperez, 2006; Halbesleben et al., 2008; Ignatiadis & Nandhakumar, 2009; Koppel et al., 2015; Lalley & Malloch, 2010; Nadrah & Michell, 2013; Outmazgin & Soffer, 2013; Vogelsmeier et al., 2008; Yang et al.,
2012). There is often a barrier that workers perceive and they try to avoid (Nadrah & Michell, 2013). When they come across a barrier, they weigh the benefits and risks of working around (Röder et al., 2014a). If they determine that the benefits outweigh the risks, they work around. As this rationale behind negative and positive defiance (Ferneley & Sobreperez, 2006) drives behaviour, it is important to include in the analysis and addressing of a workaround. Without knowing the underlying reason to work around, it is difficult to make a well-informed decision about the workaround.
4.1.5. Possible Actions
Creating awareness of workarounds also entails including an inventory of possible actions to be taken, which is considered important in order to correctly address them (Cresswell et al., 2016; Ignatiadis & Nandhakumar, 2009; Kobayashi et al., 2005; Nadrah & Michell, 2013; Niazkhani et al., 2011; Röder et al., 2014a; Röder et al., 2015; Vogelsmeier et al., 2008; Yang et al., 2012). The workaround snapshot thus contains a list of possible actions that can be taken in relation to the identified snapshot, based on the actions mentioned in
Figure 1. Actions belonging to the prevent cluster are actions where a decision is made to
actively prevent the workaround from happening. Actions belonging to the formalise cluster are actions where the workaround is considered the best available way of performing a task and this workaround is actively distributed. The redesign cluster includes actions that redesign either the work process or the information system, resulting in the prescribed process being altered. The last cluster, tolerate, includes actions that leave everything as-is.
4.1.6. Monitoring
According to Cresswell et al. (2016), there is a need to monitor workarounds over time. When tracking workarounds over the period of years, both short-term and long-term issues can be spotted and the effect of actions taken can be observed. A HIS contains event data related to healthcare processes, making it possible to mine knowledge about possible process deviations, thereby giving insight into the actual processes, as opposed to the prescribed processes (Mans et al., 2008). Monitoring workarounds through observations is time-consuming, whereas automatic monitoring can save time after an initial investment is made (Rebuge & Ferfeira, 2012). The workaround snapshot therefore contains a description of the ways the workaround can be automatically monitored using HIS logs, as this would help enable an organisation to make a well-informed decision on an action to be taken.
4.2. From Snapshot to Improvement
The workaround snapshot is a central idea in the approach, but it is not sufficient to develop snapshots and leave it at that. To enable continuous improvement, there needs to be a continuous workflow of evaluating and addressing workarounds. At the start of this is the identification of a workaround: the trigger. A workaround is identified when workaround activities are spotted in an observation or interview. A snapshot is subsequently created for this workaround, which is iteratively improved through discussions with all those involved. When all components of the snapshot are filled in, a well-informed decision can be made about the action to be taken. The chosen action is recorded, after which the workaround is monitored for the agreed time-frame. At the end of this period, the workaround is evaluated. The snapshot is adjusted accordingly and a decision is made whether the action needs to be changed. The workaround is again monitored, evaluated, etc., resulting in the model illustrated in Figure 2.
Figure 2. The Workaround Snapshot Approach to the Improvement of Healthcare Work Systems.
5. Case Study Results
Workaround snapshots are created for all twelve identified workarounds from the case study. Table 2 lists the found workarounds, including the sources from which the information was collected. The complete snapshots can be found in Appendix 4. Below, illustrative examples are given regarding the snapshot components Model, Impact, Motivation, Possible Actions and Monitoring. The general information about workarounds and their descriptions are believed to speak for itself, but can also be found in Appendix 4. Table 2. Identified workarounds (N = Nurse, P = Physician, Pha = Pharmacist, T = Team lead).
ID Title Source
WA1 Incomplete medication information after OR N1, N3, N8, P4, T WA2 Inputting patient checks on paper instead of COW N1, N2, T
WA3 Logging in as physician as co-assistant P3
WA4 Alternative use activity plan N1, N3, T
WA5 Incomplete and overdue execution of dismissal checklist N1, N3, N4, N5, T WA6 Inadequate second check during administering medication N1, N3, T WA7 Extra check during printing of home medications P1, P2, P3
WA8 Walking away from computer without locking Spotted 4x in one day
WA9 Overdue execution of rush order N1, N3
WA10 Checking of occupancy other departments N3, T
WA11 Home medications not received by pharmacy N1, Pha, P3, P5, T WA12 Post-OR medication in activity plan instead of administration register N3, N4, T
5.1.1. Model
Figure 3 shows the workaround model for the first workaround, WA1. This workaround
involves incomplete information about medication of a patient that has returned from the operating room:
“The physician is responsible for settling everything related to medications, but they don’t, causing the nurses to constantly be confronted with questions about pills, things that are incomplete, so they need to call after it. And then the physician says: I just got my hands covered in blood, so it will take half an hour.”
- Team lead
The physician who is responsible for inputting this information, does not do so sufficiently, forcing the nurse responsible for administering the medication to call the physician for more information and subsequently inputting the information ad-hoc.
Develop snapshot Observe and interview
Decide on action Monitor workaround Evaluate workaround Identify workaround
The first difference between the prescribed activities and the workaround activities is that in the latter, the physician does not input the medication information completely. This affects the activities later in the stream, as the nurse notices the information is not present. Because of this, s/he needs to ask for the information, an activity that is not necessary in the prescribed process. The physician is then interrupted in his/her work, which would not happen if the information was inputted correctly. Lastly, the nurse needs to perform another activity: inputting information ad-hoc. Therefore, by working around the inputting of information at the start, new activities are added later in the stream.
Figure 3. Workaround Model WA1.
5.1.2. Impact
An illustrative example of the impacts trade-off is WA6. When one nurse administers certain medication to a patient, a second nurse is required to check whether the right medication is given to the right patient at the right time. However, it happens that the second nurse simply gives his or her personal code, so that the order can quickly be signed off without the actual check executed:
“It is about trusting each other. If someone needs to walk along every time until you lay that pill there… we won’t be able to do our jobs.”
- Nurse
The impact on cost in this case is neutral, as there are no costs involved in not checking the medication, unless the hospital is caught and fined. The impact on time is clearly positive, as all activities involved in the check are omitted. The impact on the flexibility of the worker
is positive as well, as the second nurse is available to do other tasks. The impact on quality is negative, as errors may not be identified in administering medication.
WA10 concerns the checking of patient occupation at other departments. It is necessary for nurses to view information on their direct patients, but they are technically able to view information on patients within the whole ward, and on a few other departments as well. They use this occasionally to see which patients might come to the ward and to prepare themselves for those patients. The impact of this workaround on cost is neutral, but the impact on time is negative, as it costs the nurses time to spot patients that may come to the ward. Quality is positive, as it allows for the preparation of coming patients, and flexibility is positive as well, as a nurse is able to act faster when the patient indeed comes.
5.1.3. Motivation
WA2 relates to the entering of information about the regular patient check-up. Five Computers on Wheels (COWs) are present at the ward, to enable immediate input of information after each patient. However, many nurses choose not to use the COW and write the information on a piece of paper, after which they input it in the system all at once:
“I need to do more things at once, and people ask a lot of questions during checks. So I rather do my checks and write them down, do my stuff and if I have some time I sit down for a while and fill them in quietly.”
- Nurse
When asked for their motivation to work around, they say they prefer to input the data in a quiet place, as it allows them to concentrate better. Inputting the data using the COW means they spend more time at a patient’s bedside, resulting in other patients asking them for help.
5.1.4. Possible Actions
WA3 concerns a co-assistant in the last stage of his study, who occasionally logs in on another physician’s account:
“So every morning, I log in as one of the physicians. […] Imagine I would just have that co-assistant login… Well, I wouldn’t be able to do anything.”
- Co-assistant
His own user account does not allow him to do anything other than view information and perform the most basic tasks, although he is entitled to perform other tasks for physicians. Four actions can be performed here. The first is to consider a new system role. This role can be attributed to all co-assistants in the last stage of their studies and equipped with the specific capabilities they need. This action is a form of prevention, as the aim is to prevent the co-assistant from logging in with someone else’s account. By creating a new system role, there is no more need to log in with the physician’s account and the workaround can be prevented. Another prevention option is to prohibit the workaround, by actively monitoring and prohibiting the logging in on someone else’s account. This, however, is labour-intensive, difficult to monitor and denies co-assistants the possibility of performing their work. A third option is to formalise the workaround, where co-assistants are explicitly asked to log in via a physician’s account, as this allows them to perform their work. This is not recommended either, as logging in as someone else is prohibited according to
regulations and his/her activities cannot be traced back to the co-assistant. A last option is to tolerate the workaround: leaving the process as-is and not performing any action.
Another example is WA5. This concerns nurses not executing the patient dismissal checklist completely and/or in time. Redesign may entail the development of a new checklist. The hospital makes use of standard content, which means that this content is supplied by the HIS provider and based on a default hospital. Therefore, the standard patient dismissal checklist includes tasks that are not relevant for the nurses of the wards, which results in them not really following the checklist at all. It also means that the checklist cannot be edited. However, it is possible to create a new list from scratch and add just the elements that this ward needs. The workaround may also be prevented by organising a meeting in which attention is paid to the checklist and the tasks that should be completed. Such a meeting may increase understanding and increase compliance. Finally, the workaround may be formalised by asking nurses to perform what and when they deem necessary, or it may be tolerated by not undertaking any action.
5.1.5. Monitoring
WA1, for instance, can be monitored in different ways by analysing data from the HIS.
“In the mutation log this is tracked: who put it in? Is it approved by the physician? When is it approved? Is it approved by the pharmacy? Is it done ad-hoc?”
- Information Architect
By analysing these data, an indication can be given of how often this workaround occurs, how much time it costs before ad-hoc medication inputted by a nurse is approved by the physician, whether the number of ad-hoc administrations has risen since last month, and more. This information is helpful in deciding on an action to be taken.
5.2. Improvement of the Work System: the Decision
The answers to the questions that were asked to the team lead are included in Appendix 5 and 6. According to the team lead, all workaround snapshots are clear and understandable (Q1). Not once did he find the snapshot lacking essential information (Q9). He was already aware of 11 out of 12 workarounds (Q2), since almost all identified workarounds had been mentioned in the earlier sessions with the team lead. Many snapshots did however provide the team lead with new information, especially regarding the possible actions that can be taken (Q3). For example, the team lead was unaware of the possibility of using the HIS on a tablet, making him consider the purchase of tablets in favour of COWs. He was also unaware of the possibility of developing an entirely new patient dismissal checklist that is tuned specifically for the ward. A last example is the possibility of facilitating the physicians in keeping track of their patients through the development of a convenient layout in the HIS. Many workarounds cause the team lead concern, and urge him to undertake action (Q4 & Q5). For 11 out of 12 workarounds, one of the presented actions was chosen (Q6, Table 3). Both formalise and tolerate were not once chosen: it was always either prevent or
redesign or a combination of the two. Crucial factors for the team lead in terms of impact
are quality and flexibility. Time and cost are important, but not as much. Notable is that the two workarounds where he said not to take action, were indeed one where flexibility was positive and quality was neutral (WA2), and one where both flexibility and quality were positive (WA10). All other workarounds had a devil’s quadrangle where flexibility or quality were negatively impacted, therefore it was deemed necessary to undertake action.
Apart from WA2, WA3 and WA10, the team lead expressed interested in monitoring workarounds by using data from the HIS. He also believes the information from the workaround snapshots enables the organisation to improve the work system (Q1 General), and when asked whether he sees value in a re-inventory of the workarounds after a year, he answered with: “Yes, absolutely!” (Q2 General).
Table 3. Actions chosen.
Action Prevent Redesign & prevent Redesign None
Frequency 6x 2x 3x 1x
5.3. Generalising Beyond The Ward
In order to get an idea of the generalisability of the approach, a second team lead was interviewed. This team lead was given a general presentation of the snapshots, after which the first three snapshots were discussed in detail. The snapshots are considered clear and comprehensive. The issues related to medication are recognised beyond the ward and are considered a top priority. There is great interest in monitoring these, as medication errors are a cause of major concern. Nurses using paper instead of COWs are generally not considered concerning, especially if it helps them concentrate better. Employees logging in under another name is not unique to the one ward either, as on others it also happens that new nurses have already worked for two weeks before they get a HIS tutorial. Nurses generally do not get an account before they have had the tutorial, so they work on someone else’s account for the time being.
The general belief is that the creation of workaround snapshots enables team leads to improve their work systems. The approach is considered a very ingenious way of looking at processes, which yields value for the organisation. Interest is expressed in performing another analysis after the final stage of the implementation has finished, perhaps followed by two more after three and six months.
6. Discussion
6.1. Using the Workaround Snapshot Approach
With little time on site, a comprehensive picture of issues could be drawn by encouraging workers to talk about their usage of the system and applying the Workaround Snapshot Approach. However, the creation of the workaround snapshots turned out to be much more of an iterative process than expected beforehand, introducing the need to repetitively speak to different participants in order to confirm the information about the workaround. This corresponds to the guidelines for process modelling by Dumas et al. (2013), who recommend the involvement of different types of domain experts, as one person is rarely aware of an entire business process. This involvement of different experts does not only apply to modelling a process or workaround, it applies to the entire development of snapshots. By developing workaround snapshots, one gathers knowledge of different domain experts: the workers that partake in executing the workaround, the person responsible for those workers, the people with knowledge of the hospital’s IT infrastructure and those with specific knowledge of the HIS and of implementing such a system in other hospitals. By presenting this combined knowledge in a clear and concise snapshot such as Alter’s work system snapshot (2015), this holds great value for the organisation. Whereas a HIS vendor is often unaware of many obstacles end users of a HIS come across, end users
and decision-makers are often unaware of the possible solutions to these issues. In most cases, a very understandable motivation underlies a workaround, but if this is not known by those able to offer solutions, it cannot be solved. In the case study, actions were presented that, if implemented, would mean immediate improvement of the work system. The workaround snapshots thus indeed enable the identification of gaps between work processes and information systems (Petrides et al., 2004), draw attention to things that need fixing (Lalley & Malloch, 2010) and encode knowledge about the needs of users and the customisations of the system that are necessary (Safadi & Faraj, 2010).
The proposed components of the snapshot have proven to be very encompassing. In terms of modelling the workaround, the usage of separate lanes for the modelling of the prescribed process and workaround activities, as proposed by Röder et al. (2015), works well and is understood quickly by participants. The workaround activities all fit one of the three types of workarounds defined by Koppel et al. (2008): omitting a step, performing them out of sequence, or executing unauthorised steps. The devil’s quadrangle of the workaround’s impact adds valuable knowledge that needs to be taken into account. As expected, there is a trade-off involved in the impact of a workaround. Very few workarounds have a negative impact on all factors. On the contrary, some workarounds have great benefits on time, cost, quality and/or flexibility, which corresponds to the idea that workarounds can in some ways be beneficial (Cabitza & Simone, 2013; Cresswell et al., 2016; Nadrah & Michell, 2013; Röder et al., 2014a; Safadi & Faraj, 2010). The Possible Actions component has proven to be especially useful, as this often provides new information in terms of solutions other process participants are unaware of. All solutions fit nicely into one of the four actions. Lastly, the Monitoring component may serve as a basis for further analysis in terms of keeping track of the workarounds over the months and years.
One necessity for identifying workarounds and developing snapshots, is for the participants to be willing to share this information. Lalley & Malloch (2010) proposed the development of a new culture of user involvement and sharing. Process participants in such a culture need to be encouraged to share their workarounds so that awareness can be achieved. Organisations need to be proactive in identifying workarounds and addressing them (Koppel et al., 2008), creating standard procedures for identifying, monitoring and evaluating workarounds. They hereby become more responsive so that they can react to changing needs (Lenz & Kuhn, 2004). By developing such procedures, they are on track to grow, instead of build, their work system (Atkinson & Peel, 1998).
6.2. Identifying and Examining Workarounds on the Ward
The workaround snapshot presents valuable new information. In almost all cases, the decision was made to prevent the workaround or redesign the work system. Tolerating the workaround was never seen as the correct option, even though many workarounds have been tolerated for some time, considering the existence of many workarounds was already known. According to Röder et al. (2014b), managers are more willing to tolerate workarounds when they are expected to result in efficiency gains. Many of the identified workarounds are expected to be more efficient in terms of time and cost than the prescribed process, but toleration is still not chosen. When being presented with a workaround that has negative effect on factors such as quality, it is perhaps also a question of impression management to not choose to tolerate (Elsbach, 1994). Impression management includes individuals using verbal accounts to avoid blame for events that affect the organisation. For example, using paper instead of a COW for inputting patient checks, was of no concern to the team lead. It also did not make him take action, as quality was considered more
important than a small stroke of efficiency. Therefore, the next question, which action to take, did not need to be answered. However, prevention was chosen as the type of action. When asked why, the motivation was that it was best if everyone would use the COWs. Reading between the lines, the action chosen is really to tolerate. In the snapshot, toleration is presented as an action that may affect the organisation negatively. Therefore, the team lead may feel he needs to justify his decision, and consequently chose differently.
Similar to creating a culture of user involvement for participants to share information on issues and workarounds, decision-makers should also be allowed to admit that some workarounds will be tolerated. Not all issues can be solved at once, choices have to be made regarding investing in solutions. There is another trade-off here in terms of choosing the workarounds that are most in need of a solution. If using paper instead of COWs is preferred by workers, the impacts are not considered problematic, and an alternative is costly, it is acceptable to tolerate the workaround.
The impacts trade-off is especially evident in terms of quality and flexibility. Not only was literally mentioned that quality and flexibility were the most important impact factors, it also came forward in cross-referencing the devil’s quadrangle and the chosen actions (Appendix 7). As mentioned before, most workarounds had devil’s quadrangles where either flexibility or quality or both were negatively impacted. For those workarounds, action would be taken. For the remaining two workarounds, using paper instead of the COW and the checking of occupancy at other departments, quality and flexibility were either positively or neutrally impacted. Therefore, one might assume that workarounds that have a positive or neutral impact on quality and flexibility, may be the first ones to be tolerated in terms of selecting those workarounds most in need of investing in a solution. This prominent perspective on quality is in line with the finding of Röder et al. (2014b), namely that managers are less willing to tolerate workarounds that expose the organisation to compliance risk. Compliance risk effects quality negatively, which makes managers less willing to tolerate workarounds that have a negative effect on quality and the other way around.
One pattern found in the causes of workarounds is communication. At least one-third of the workarounds have something to do with information not being communicated correctly. This corresponds to one of the two types of unintended consequences Ash et al. (2004) have defined in the use of health information technology: issues related to the communication and coordination the system is supposed to support. Another pattern concerns the use of standard content. The vendor of the HIS aims to equip hospitals with standard content, as opposed to customising the HIS for each and every hospital. This allows them to support hospitals more easily, but it brings side-effects with it. Although this has not been studied in depth as this was not the focus of the research, some workarounds may actually be the result of this standard content. For example, by deploying a standard patient dismissal checklist that is not tuned to a specific hospital ward, users are overwhelmed by the amount of tasks and sometimes choose to dismiss the checklist altogether. By introducing standard content that does not suit the work process, this may in fact pave the way for workarounds. This “self-defeating propagation of additional computer workarounds”, should be avoided at all times (Azad & King, 2008).
6.3. Practical Implications and Limitations
The findings in this study have several implications for practice. The Workaround Snapshot Approach not only enables an organisation to build awareness of how and why people work around, but also to utilise this knowledge. Creating workaround snapshots allows for the
gathering of knowledge from different domain experts, empowering the organisation to make a well-informed decision. The research proposes the usage of the devil’s quadrangle to illustrate the impact of a workaround on the work system, and proposes to take action by preventing workarounds, formalising workarounds, tolerating workarounds or redesigning the work system. It also provides a basis for quantitative analysis in the sense of automatic workaround detection and monitoring.
There are limitations to this study as well. First of all, the case study has been done on a single ward in a single hospital. A second team lead was consulted to verify the findings, who recognised many workarounds, although in slightly different form. The interest in monitoring, re-inventory of workarounds and the belief that awareness of workarounds can lead to an improvement of the work system, is shared, but application outside these wards and this hospital still needs to be verified. Second, this research has not reached saturation in terms of the workarounds identified on the ward. Twelve workarounds were selected, but more may exist. The limited period of study allowed little time on site, during day shifts, and not all ward employees could be spoken to. Moreover, the research was undertaken by one researcher, resulting in only one perspective on the workarounds, although the approach to the development of snapshots through discussing the information with many different participants allows for multiple perspectives. The inventory of workarounds and their frequencies is not intended to be exhaustive, but intends to explore the application of the approach in an actual hospital ward.
The study presents a first step towards realising continuous improvement of work systems using the WSA. Further research might validate the application of the approach on a larger scale and over the course of years. As this research has been done during a time-frame of three months, continuous improvement could not be proven. Longitudinal research would allow for the tracking of changes over time, analysing the effect of actions taken on the work system. Future research may also focus on automatic detection and monitoring of workarounds through analysing the logs from the information system.
7. Conclusion
This research has aimed to discover how awareness of workarounds in healthcare processes can enable the continuous improvement of work systems, by exploring whether a level of workaround awareness can be achieved that enables an organisation to make a well-informed decision on an action to be taken, and thereby improving the healthcare work system. In order to achieve such a level of workaround awareness, the Workaround Snapshot Approach has been proposed. This approach has proven to be a valuable tool in addressing the misfit between healthcare work processes and the HIS. The research contributes to existing research in moving from how and why people work around, to how this knowledge can be utilised. The creation of workaround snapshots, by capturing knowledge from different types of participants, contributes to raising awareness about workarounds in terms of impact, motivation, possible actions that can be taken, and ways of monitoring the workaround. The case study shows that the approach allows an organisation to make well-informed decisions, as several proposed actions bring about immediate improvement to the work system. The approach puts the workaround central, not the process, and provides a basis for quantitative analysis and automatic monitoring. Future research may focus on applying the approach to more healthcare settings and may even test the application on settings other than healthcare. It may also take a more quantitative stance, by examining the possibility of monitoring workarounds over the years.
Acknowledgements
This research would never have been as interesting without including the concept of workarounds. Because of this, I would like to express my gratitude to my supervisor Inge van de Weerd, not in the least for the meaningful and comfortable sparring sessions. I would also like to thank everyone, but especially my mom, for willing to listen to my occasional speech waterfalls about workarounds, snapshots, information systems and everything I came across about healthcare along the way. Last but definitely not least, I would like to thank everyone at ICTZ for providing the knowledge and facilities necessary for executing this research, and for allowing me to explore the possibilities for doing a PhD about this subject at the company.
References
Alter, S. (2013). Work system theory: overview of core concepts, extensions, and challenges for the future. Journal
of the Association for Information Systems, 14(2), 72.
Alter, S. (2014). Theory of Workarounds. Communications of the Association for Information Systems, 34. Alter, S. (2015). A workaround design system for anticipating, designing, and/or preventing workarounds.
In International Conference on Enterprise, Business-Process and Information Systems Modeling (pp. 489-498). Springer International Publishing.
Andrade, E., van der Aa, H., Leopold, H., Alter, S., & Reijers, H. (2016). Factors Leading to Business Process Noncompliance and its Positive and Negative Effects: Empirical Insights from a Case Study. Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health
care: the nature of patient care information system-related errors. Journal of the American Medical
Informatics Association, 11(2), 104-112.
Atkinson, C. J., & Peel, V. J. (1998). Transforming a hospital through growing, not building, an electronic patient record system. Methods of information in medicine, 37(3), 285-293.
Azad, B., & King, N. (2008). Enacting computer workaround practices within a medication dispensing system. European Journal of Information Systems, 17(3), 264-278.
Azad, B., & King, N. (2011). Institutionalized computer workaround practices in a Mediterranean country: an examination of two organizations. European Journal of Information Systems, 21(4), 358-372. Berg, M. (1999). Patient care information systems and health care work: a sociotechnical approach. International
journal of medical informatics, 55(2), 87-101.
Bryman, A. (2015). Social research methods. Oxford university press.
Cabitza, F., & Simone, C. (2013). “Drops Hollowing the Stone”: Workarounds as Resources for Better Task-Artifact Fit. In ECSCW 2013: Proceedings of the 13th European Conference on Computer Supported
Cooperative Work, 21-25 September 2013, Paphos, Cyprus (pp. 103-122). Springer London.
Cresswell, K. M., Mozaffar, H., Lee, L., Williams, R., & Sheikh, A. (2016). Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals. BMJ quality & safety, bmjqs-2015. Dumas, M., La Rosa, M., Mendling, J., & Reijers, H. A. (2013). Fundamentals of business process
management (Vol. 1, p. 2). Heidelberg: Springer.
Elsbach, K. D. (1994). Managing organizational legitimacy in the California cattle industry: The construction and effectiveness of verbal accounts. Administrative science quarterly, 57-88.
Ferneley, E. H., & Sobreperez, P. (2006). Resist, comply or workaround? An examination of different facets of user engagement with information systems. European Journal of Information Systems, 15(4), 345-356. Halbesleben, J. R., Wakefield, D. S., & Wakefield, B. J. (2008). Work-arounds in health care settings: Literature
review and research agenda. Health care management review, 33(1), 2-12.
Helfert, M. (2009). Challenges of business processes management in healthcare: Experience in the Irish healthcare sector. Business Process Management Journal, 15(6), 937-952.
Ignatiadis, I., & Nandhakumar, J. (2009). The effect of ERP system workarounds on organizational control: An interpretivist case study. Scandinavian Journal of Information Systems, 21(2), 3.
Kobayashi, M., Fussell, S. R., Xiao, Y., & Seagull, F. J. (2005). Work coordination, workflow, and workarounds in a medical context. In CHI'05 Extended Abstracts on Human Factors in Computing Systems (pp. 1561-1564). ACM.
Koppel, R., Smith, S. W., Blythe, J., & Kothari, V. (2015). Workarounds to computer access in healthcare organizations: you want my password or a dead patient?. In ITCH (pp. 215-220).
Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. T. (2008). Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Journal of the American
Medical Informatics Association, 15(4), 408-423.
Lalley, C., & Malloch, K. (2010). Workarounds: the hidden pathway to excellence. Nurse Leader, 8(4), 29-32.
Lenz, R., & Kuhn, K. A. (2004). Towards a continuous evolution and adaptation of information systems in healthcare. International journal of medical informatics, 73(1), 75-89.
Mans, R. S., Schonenberg, M. H., Song, M., Aalst, W., & Bakker, P. J. (2009). Application of process mining in healthcare–a case study in a dutch hospital. Biomedical engineering systems and technologies, 425-438.
Nadrah, N., & Michell, V. (2013). A normative method to analyse workarounds in a healthcare environment: their motivations, consequences, and constraints. In The 14th International Conference on Informatics and
Semiotics in Organisations, ICISO (pp. 195-204).
Niazkhani, Z., Pirnejad, H., van der Sijs, H., & Aarts, J. (2011). Evaluating the medication process in the context of CPOE use: the significance of working around the system. International journal of medical
informatics, 80(7), 490-506.
Outmazgin, N., & Soffer, P. (2013). Business process workarounds: what can and cannot be detected by process mining. In Enterprise, Business-Process and Information Systems Modeling (pp. 48-62). Springer Berlin Heidelberg.
Peffers, K., Tuunanen, T., Rothenberger, M. A., & Chatterjee, S. (2007). A design science research methodology for information systems research. Journal of management information systems, 24(3), 45-77.
Petrides, L. A., McClelland, S. I., & Nodine, T. R. (2004). Costs and benefits of the workaround: Inventive solution or costly alternative. International Journal of Educational Management, 18(2), 100-108.
Rebuge, Á., & Ferreira, D. R. (2012). Business process analysis in healthcare environments: A methodology based on process mining. Information systems, 37(2), 99-116.
Röder, N., Wiesche, M., & Schermann, M. (2014a). A situational perspective on workarounds in IT-enabled business processes: A multiple case study.
Röder, N., Wiesche, M., Schermann, M., & Krcmar, H. (2014b). Why managers tolerate workarounds–the role of information systems.
Röder, N., Wiesche, M., Schermann, M., & Krcmar, H. (2015). Workaround Aware Business Process Modeling. In Wirtschaftsinformatik (pp. 482-496).
Safadi, H., & Faraj, S. (2010). The Role of workarounds during an Open Source Electronic Medical Record System Implementation. In ICIS (p. 47).
Southon, F. C. G., Sauer, C., & Dampney, C. N. G. K. (1997). Information technology in complex health services. Journal of the American Medical Informatics Association, 4(2), 112-124.
Vogelsmeier, A. A., Halbesleben, J. R., & Scott-Cawiezell, J. R. (2008). Technology implementation and workarounds in the nursing home. Journal of the American Medical Informatics Association, 15(1), 114-119.
Yang, Z., Ng, B. Y., Kankanhalli, A., & Yip, J. W. L. (2012). Workarounds in the use of IS in healthcare: A case study of an electronic medication administration system. International Journal of Human-Computer
Studies, 70(1), 43-65.
Appendices
Appendix 1 – Individual Workaround Evaluation Questions
The evaluation questions were the same for each of the twelve workarounds, and were asked in Dutch. The English translation of the questions are the following:
Q1: Is the snapshot clear and understandable? Q2: Were you aware of this workaround? Q3: Does the snapshot provide new information? Q4: Does it cause concern?
Q5: Does it make you take action? Q6: Which action?
Q7: Why this action? Is this related to the type of impact?
Q8: Are you interested in the automatic monitoring of this workaround? Q9: Does the snapshot lack certain information about the workaround?
Appendix 2 – General Evaluation Questions
After discussing the twelve workarounds in detail and filling in the evaluation forms, the following general evaluation questions were asked:
Q1 general: Do you think this information enables you to improve the work system? Q2 general: Do you see value in a re-inventory of the present workarounds after, say, a year?
Appendix 3 – Workaround Modelling: Addition and Omission
The modelling of workarounds was done using Business Process Model and Notation (BPMN) and the extra lane as proposed by Röder et al. (2015). The first figure is an example of the modelling of a workaround that includes an added activity. From the model can be read off that the task is not executed in the prescribed process, but it is in the workaround.
Modelling the addition of activities.
The second shows the model of a workaround that includes an omitted activity. The task is executed in the prescribed process, but it is skipped in the workaround version.
Appendix 4 – Workaround Snapshots
The following pages show the detailed snapshots that were created for this research. They are in Dutch.
Work
around
Snaps
Datum snapshot Betrokkenen Mate van distributie
1 mei 2017 Verpleegkundige, arts-assistent. Teamhoofd, 3 verpleegkundigen, arts.
Beschrijving workaround
Een patiënt ligt op het OK-complex. De arts-assistent is verantwoordelijk voor het invullen van de nodige medicatie in HiX, maar doet dit soms niet volledig. Ook moet de thuismedicatie door de arts worden omgezet naar opnamemedicatie, maar dit gebeurt ook vaak niet goed. Als vervolgens de patiënt op de afdeling wordt opgevangen door de verpleegkundige, is de medicatie-informatie niet aanwezig en moet de arts-assistent gebeld worden. De verpleegkundige moet wachten tot de arts hier tijd voor heeft en de medicatie vervolgens ad-hoc invoeren, alvorens het toe te kunnen dienen.
Factor Effect Omschrijving
Kosten Negatief
Op de korte termijn positief, want de verpleegkundige neemt taken over van de arts door medicatie ad-hoc toe te voegen. Op de lange termijn zijn de kosten echter negatief, omdat het uiteindelijk meer tijd kost, en daarom ook geld. Zie daarvoor ook ‘Tijd’.
Tijd Negatief
Het kost de arts in eerste instantie minder tijd, maar de verpleegkundige juist meer. Ad-hoc invoeren is voor een keer en moet alsnog geverifieerd worden door de arts. Daarnaast wordt de arts ook gebeld door de verpleegkundige en kost ook dat tijd.
Kwaliteit Negatief Door belangrijke informatie niet in te voeren, krijgt de patiënt mogelijk niet de juiste medicatie of niet op het juiste moment.
Flexibiliteit Negatief De verpleegkundige kan de medicatie niet direct toedienen maar moet eerst de arts bellen. De arts wordt gestoord door telefoontjes op momenten dat het niet uitkomt.
Motivatie
De arts heeft het vaak druk en heeft meerdere OK’s per dag. Artsen zijn zich er ook niet altijd van bewust dat het verpleegproces stagneert met deze workaround. Vervolgens kan de verpleegkundige niet toedienen dus belt die de arts. De arts heeft niet altijd direct tijd, dus moet de verpleegkundige wachten. In sommige gevallen heeft de arts de medicatie wel ingevoerd, maar is vergeten op de knop met het klokje te klikken. In andere gevallen is het niet goed gelukt om de thuismedicatie om te zetten in opnamemedicatie.
Mogelijke acties
Actie Beschrijving Advies
Flexibiliteit
Kwaliteit Tijd
aanzetten arts, zodat die ernaar kan kijken op een geschikt moment. mogelijk niet op.
Voorkomen:
organiseren training artsen
Het organiseren van een training voor artsen waarin aandacht wordt besteed aan medicatie in HiX, met name bewustwording van artsen om het zorgvuldig in te voeren, extra aandacht voor het klokje dat aangeklikt moet worden en het omzetten van thuismedicatie in opnamemedicatie.
Ons advies, mogelijk in combinatie met het invoeren van de extra check artsen.
Formaliseren Artsen vertellen in te voeren wat zij nodig achten en verpleegkundigen vragen de arts te bellen wanneer nodig.
Niet aan te bevelen. De effecten op kosten, tijd, kwaliteit en flexibiliteit zijn alle negatief.
Tolereren Het proces laten zoals het is.
Niet aan te bevelen. De effecten op kosten, tijd, kwaliteit en flexibiliteit zijn alle negatief.
Monitoring
Mutatielogging: wie heeft wat ingevoerd? Is het geaccordeerd door de arts? Is het geaccordeerd door de apotheek? Wanneer is het geaccordeerd? Is het als ad-hoc ingevoerd? Is het als SEH-medicatie ingevoerd?
Work
around
Snaps
Datum snapshot Betrokkenen Mate van distributie
2 mei 2017 Verpleegkundige, arts-assistent. Teamhoofd, 3 verpleegkundigen, arts.
Beschrijving workaround
Op de afdeling zijn 5 Computers on Wheels (COWs) aanwezig. Daarmee kunnen verpleegkundigen controles doen bij de patiënt en de metingen direct invoeren in HiX. Veel verpleegkundigen schrijven echter de metingen op een papiertje in plaats van de COW te gebruiken. Na de controles bij alle patiënten te hebben gedaan, gaan ze achter een computer zitten en voeren ze alles in.
Factor Effect Omschrijving
Kosten Neutraal Er zijn geen kosten gemoeid met het op papier schrijven van controles, i.p.v. het gebruiken van de COWs. De COWs zijn namelijk al aangeschaft.
Tijd Negatief De controles moeten eerst op papier geschreven worden en vervolgens alsnog ingevoerd worden in het systeem.
Kwaliteit Neutraal
De controles worden eerst op papier geschreven en vervolgens in het systeem ingevoerd, wat het foutgevoelig maakt. Aan de andere kant wordt de verpleegkundige mogelijk minder afgeleid met invoeren dan wanneer hij/zij bij de patiënt zou staan.
Flexibiliteit Positief Verpleegkundigen hoeven niet een COW overal mee naartoe te nemen.
Motivatie
Verpleegkundigen geven aan het fijner te vinden om op een rustige plek de controles in te voeren, omdat ze dan minder vragen krijgen. Daarnaast kan de verpleegkundige zo gemakkelijk de arts bellen bij een hoge EWS-score, zonder dat de patiënt meeluistert. Enkele verpleegkundigen laten het afhangen van de drukte of ze een COW gebruiken. Als het rustiger is, pakken ze de COW, anders vullen ze het eerst op papier in. Verpleegkundigen beschouwen het eerst opschrijven op papier soms als een snellere manier, ondanks dat de metingen twee keer ingevoerd moeten worden.
Mogelijke acties
Actie Beschrijving Advies
Kwaliteit Tijd
Voorkomen:
aantrekkelijker maken invoeren via COW
Het inloggen op de COWs kan worden versneld met behulp van inloggen met medewerkerspas via een scanner. Het invoeren van controles binnen HiX kan mogelijk ook overzichtelijker en gemakkelijker gemaakt worden, zodat het aantrekkelijker wordt om de controles via de COW in te voeren.
Zou uitkomst kunnen bieden, maar het is mogelijk dat er dan nog steeds geen gebruik wordt gemaakt van de COWs.
Herontwerpen:
overwegen aanschaf andere apparaten
Invoeren controles niet via COWs, maar met behulp van bijvoorbeeld tablets. Op tablets kun je inloggen met
vingerafdruk en kunnen gemakkelijk meegenomen worden. Er zou een tijd-kostenvergelijking gemaakt kunnen worden van het verschil.
Heeft de voorkeur. Een onderzoek naar de geschiktheid van andere apparaten en navolging daarvan kan ertoe leiden dat er geen papier meer wordt gebruikt voor controles.
Tolereren Het proces laten zoals het is.
Niet aan te bevelen. De workaround heeft een negatief effect op zowel tijd als kwaliteit.
Monitoring
Verschil invoertijd en mutatietijd (mutatie in database). Op het moment dat deze tijden afwijken, dan is het achteraf ingevoerd.
Work
around
Snaps
Datum snapshot Betrokkenen Mate van distributie
1 mei 2017 Verpleegkundige, arts-assistent. Teamhoofd, 3 verpleegkundigen, arts.
Beschrijving workaround
Een semi-arts is een coassistent in de laatste fase van zijn/haar coschappen. Tijdens het laatste coschap mag hij/zij al wel dingen doen die een arts-assistent ook doet. De semi-arts krijgt echter een coassistenten-inlog in HiX met alleen de bevoegdheden van een coassistent. De semi-arts logt vervolgens in met een account van een arts-assistent, om toch zijn/haar werkzaamheden te kunnen verrichten.
