Process Modelling and New Technology
We shadowed hospital managers documenting their everyday activities as they dealt with the creation and implementation of process models. Their intention was to standardise as many processes as possible to ensure an identity of service and practise across the distributed operations of the hospital. At the time of the fieldwork the production of process maps was being used to identify "bottlenecks" in the 'processing' of patients which, in the words of one manager, delayed "knife to skin" time.
As modern healthcare institutions have become increasingly information intensive technology increasingly plays an important role in healthcare delivery and management. When 'time is money' healthcare information systems are intended to supply cost effective improvements in managing patient care; in information gathering and dissemination; and in coordinating distributed organisational work. One organisationally popular approach to ensuring time, resources, staff and systems are allocated and used efficiently is process modelling.
Process modelling is fundamentally about time allocation and time awareness - it requires knowing appropriate sequences of activity and the likely or preferred time each activity will take. The development, design and deployment of electronic patient record systems.
One problem with process modelling was that despite the increasing investment in new technology managerial work often involved working with various kinds of 'legacy' system. A legacy system is one which, having been introduced with the best of intentions as an 'all singing, all dancing' solution has not been maintained, modified or developed to accommodate organisational or technological change. Particular systems were unable to 'talk' to any of the other databases or management information systems, necessitating time consuming 'workarounds' in the form of the printing of documents and multiple entry of data. The paradox of such legacy systems is that, despite their outdated and time-consuming character, they are often trusted. Such systems are adhered to long after their usefulness has become limited, precisely because of the way in which they are embedded in longstanding social and organisational processes.
One particularly important observation of the development of process models in the hospital is the ways in which process modelling becomes centrally implicated in activities of working towards achieving mutual relevances and co-ordination. Staff frequently drew upon ad hoc and wholly contingent interpretations and activities in order to arrive at an adequate representation of a particular flow of work. It is just these kinds of fine-grained, situated practices that are often 'missing' from the ultimate process model. This recognition of what a process model will inevitably miss is not intended as a suggestion that process modelling is somehow without any efficacy. On the contrary, despite the ironies and the quips and the griping exhibited while doing it, members clearly did find some kind of purpose in doing all of this. A paramount achievement was, however, arrival at some kind of shared local appreciation, 'knowledge' of what a particular division of labour or process amounted to, and the implicativeness of that.
Process modelling in the hospital was noteworthy for the way in which it promoted 'knowledge' through co-ordination and arrival at a sense of mutual relevances, and understanding of 'how a place like this works'. The actual achievement of any process map makes it clear that all versions of 'best practice' are negotiated products. The formulation of 'best practice' is a situated affair - and process maps are, at heart, locally sensible versions of best practice and problems may arise where such locally sensible versions are exported throughout an organisation to other settings where other relevances may apply. One significant finding here, then, is that process maps are not systematic, rational, scientific deductions of the most efficient process. Rather they are contingent objects of negotiation and experimentation amongst staff that primarily attend to local, situated concerns and understandings.
Hartswood, M., Procter, R. And Rouncefield, M. Information Technology and Managerial Work in a Hospital Trust. In Proceedings of the Conference on Sharing the Experience: Informatics and Research in Healthcare Practice. Foundation of Nursing Studies/British Computer Society Nursing SIG, London, 13th February, 2001.
Clarke, K.M., M. J. Hartswood, M., Procter, R.N., Rouncefield, M. (2001). 'The Electronic Medical Record and Everyday Medical Work'. Health Informatics Journal Vol 7. No 3/4 September/December 2001. Pp168-170.
Clarke, K., Harstwood, M., Procter, R., Rouncefield, M., Slack, R. And Williams, R.(2002) Improving 'Knife to Skin Time': Process Modelling and New Technology in Medical Work. Health Informatics Journal, 8(1). Sheffield Academic Press, p. 41-44, 2002.
Clarke, K.M., Hartswood, M., Procter, R.N., Rouncefield, M. (2001). 'NHS Managers Closely Observed: Some Features of New Technology and Everyday Managerial Work'. Proceedings of EDRA 32/2001. Published as: Old World, New Ideas: Environmental and Cultural Change in a Shrinking World., H.M. Edge (ed).
Clarke, K., Hartswood, M., Procter, R., Rouncefield, M. And Sharpe, M. The Electronic Medical Record and Healthcare Integration: Some Observations of Inter-organisational Working. In Bryant, J. (Ed.) Proceedings of the BCS Conference on Healthcare Computing, Harrogate, March 18th-20th, 2002. Pp 205-211.
Clarke, K., Hartswood, M., Procter, R., Rouncefield, M. And Slack, R. "Minus nine beds": Some Practical Problems of Integrating and Interpreting Information Technology in a Hospital Trust. In Bryant, J. (Ed.) Proceedings of the BCS Conference on Healthcare Computing, Harrogate, March 18th-20th, 2002. pp219-225
Karen Clarke, Mark Rouncefield, John Hughes (Lancaster University), Mark Hartswood, Rob Procter (Edinburgh). 'Normal, natural troubles': the practical organisation of bed management in a healthcare setting' - To be published in Francis, D. And Hester, S. (Eds.), Orders of Ordinary Action: Respecifying Sociological Knowledge. Ashgate Publishing.
Dave Martin, John Mariani, Mark Rouncefield (2004) Implementing an EPR Project: Everyday Features and Practicalities of NHS Project Work - in ISHIMR 2004.
Mark Rouncefield (Lancaster)
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