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This study explored internal supply chain issues within 2 hospitals with the aim of understanding organisational factors that contribute to operational failures.

They note that frontline clinicians spend at least 10% of their time working around operational failures resulting from insufficient information, supplies or equipment.

It’s noted:

·        Constant exposure to missing resources, which precipitate workarounds, leads to inefficiency, staff burnout and impaired patient safety

·        “Despite the seriousness of their impact, the most common response to operational failures is to work around them without expending additional effort to prevent recurrence” (p33) – called first-order problem solving rather than second-order problem solving

·        The time devoted to workarounds is said to be significant: nurses account for ¼ of a hospital’s budget yet spend at least 10% of their time performing workarounds to failures and insufficient resources

·        For this study an internal supply chain is a set of interdependent departments providing patient-facing employees with a stream of resources/materials

·        They provide an example of the supply chain of medication administration – starting with a physician ordering the medication, the computerised system relaying the order to the pharmacy, the pharmacist verifying and dispensing the order, delivery of the med and the medication dispensing device (if needed), nurses who administer the med, engineers/technicians/IT who maintain the systems, others who maintain adequate stocks, others who clean etc.

·        Prior work has highlighted the value of mapping the flow of materials in organisations, identifying opportunities to improve work design

 Results

Based on 54.2 hours of work observation – 120 operational failures were observed that interfered with nursing work. Therefore, “on average, a nurse experienced one operational failure every 37 minutes” (p35, emphasis added); or 14% of their work time.

10 nurses were asked what resources they needed for when a new patient arrived. They mentioned 12 items and all but 3 were within their own scope/budget. However, the responsibility for supplying, cleaning and maintaining the items fell entirely to other departments (supply chain).

An audit of supplies in a hospital unit found insufficient numbers of resources/items compared to the minimum needed as felt by nurses. The authors suspect that “the high frequency of failures stemming from the nursing unit resulted from the ambiguity about whether supplies of necessary equipment were sufficient, and if not, which department was responsible for addressing the shortfall” (p36).

Nurses responded to the lack of available resources by workarounds. Common workarounds included to “go shopping” to beg/borrow/commandeer equipment from elsewhere or working against company policies by personally claiming shared equipment by putting their name on it and use of social pressure or making the equipment appear to be broken to keep it available.

They note that “These compensatory behaviors exacerbated the shortage of functional equipment” (p36).

Moreover, when staff reflected on operational failures they tended to attribute “poor performance to shortcomings of other departments rather than to a suboptimal system design. They also failed to recognize that their own department’s routines could be contributing to poor internal supply chain performance” (p36).

Further on the above, everybody expressed satisfaction with their own department’s work (in the context of the supply chain performance) and didn’t express a belief that their department’s routines could be changed in a way to improve the overall supply chain. For them, the issues lay elsewhere.

The authors argue that the high frequency of operational failures “stemmed from a lack of interconnectedness between the supply departments and the nursing units”, where interconnectedness was defined as “the degree to which departments’ routines and performance metrics have been designed to efficiently meet the needs of patients by enabling entities (eg, patients), resources (eg, supplies and equipment), and knowledge (eg, relevant critical patient information) to flow smoothly and swiftly across interdependent departments” (p36).

They propose four dimensions of interconnectedness to improve the internal supply chain:

1)     hospital-level performance measures over department-level

a.      Most existing metrics measured departmental performance and not hospital-level (e.g. number of medications delivered by the pharmacy but not the time elapsed from the full medication supply chain lifecycle from ordering, dispensing, delivery etc.)

b.      They found “few shared rewards for good internal supply chain performance”

2)     Internal supply chain routines that respond to specific patient needs over predetermined routines

a.      Processes were designed to optimise departmental performance and not internal supply chain performance, with an operating assumption that optimising the components would result in a well-functioning hospital

b.      In contrast, evidence suggested that while individual supply departments could operate efficiently this didn’t mean the supply chain operated efficiently unless it was directly linked to current patient needs

c.      Nurses in one example bypassed the national IT helpline for technical help because of long waiting times and instead found workarounds

3)     Knowledge of efficient handoffs of materials across departmental boundaries

a.      Work routines in one department weren’t always known by the downstream department, “making resource handoffs between departments less efficient than they could have been” (p37)

b.      They note “how communities of practice unknowingly fail to translate pertinent knowledge because they do not know what others do not know” (p38)

c.      Moreover, “it does not even occur to [people in one department] that the problem could have been caused by someone not knowing a fact that they consider common knowledge” (p38)

4)     Cross-departmental collaboration mechanisms enabling improvement in the supply chain flow

a.      Mechanisms to foster cross-departmental monitoring and improvement of internal supply chains is needed. This is important because “the inconvenience caused by the breakdown is not experienced by the department with the largest ability to remove underlying causes” (p38)

 A summary of the interconnectedness dimensions are below:

Next they cover the lack of interconnectedness in hospital internal supply chains (image below). Trigger opportunities highlight opportunities to disrupt breakdowns in supply chains, where one resource requirement may not necessarily trigger the necessary resources to support it.

In short, improving performance can come about via more thoughtful and careful system design and structures and informed via the areas of interconnectedness.

Nevertheless, a barrier is that “Employees are unlikely to recognize systemic causes of workarounds because they often blame poor performance on the shortcomings of others rather than on poor work-system design” (p40).

This is exacerbated by a myopic focus on departmental performance, which may be functioning efficiently but signalling “false feedback mechanisms … [that masks] poor hospital-level performance” (p40).

[** My thoughts: while these findings were undertaken in healthcare I think they’re directly applicable elsewhere: people locally optimise for their own goals and this can impact overall system performance. Value stream and work stream mapping of the supply chain, work routines, a focus on WAD etc. are all valuable perspectives to undertake. The way nurses respond to missing resources reminds me of how construction site supervisors adapt to keep things operating.]

Authors: Tucker, A. L., Heisler, W. S., & Janisse, L. D. (2014). The Permanente Journal, 18(3), 33.

Study link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116263/

Link to the LinkedIn article: https://www.linkedin.com/pulse/designed-workarounds-qualitative-study-causes-ben-hutchinson