F EEDING B ACK R ESULTS AND P RIORITIZING THE N EXT S TEPS

The second point of interest describes the results feedback process, as well as how the change team used the results of the RC Survey at Time 1 in their design and action-planning for the next intervention effort, Intervention II. As previously mentioned, the feedback process was considered to be a relational intervention, as defined in the Relational Model of Organizational Change.

7.2.1 Results Feedback Process

When the measurement of relational coordination was completed, a feedback process based on the results from the RC Survey at Time 1, as inspired by the principles of relational coordination as tools for change (Box 1, p 28), was on the agenda at a change team meeting. A dialogue-based exploration was facilitated, including relational assessment and relational mapping (Gittell, 2016). Afterward, the results of the measurement of relational coordination were presented to the change team, emphasizing that the results reflect a snapshot that could be helpful in the further improving work. Through a feedback dialogue, the change team reflected on the survey results, defining the strengths and weaknesses. The results of RC Survey at Time 1 are shown in Figure 25, illustrating how the seven RC dimensions were rated on a Likert scale ranging from one to five (values given in Table 17, p. 138).

Figure 25 Results of the RC Survey at Time 1 used to support Intervention I, design Intervention II, and as a baseline measurement in PHASE III. The bars indicate the mean of the ratings.

The within workgroup measures of relational coordination (RC) are based on the responses given by respondents about their own workgroup (e.g., OR nurses’ ratings of OR nurses). The between workgroup measures of RC are based on the responses

0 1 2 3 4 5

Problem solving Frequent Timely Accurate Mutual respect Shared Knowledge Shared Goal RC Index

RC Measures Before Implementation of Intervention

Between workgroups Within workgroups

given by respondents about workgroups they are not a part of themselves (e.g., all other work groups’ ratings of OR nurses).The results showed much stronger relational dynamics within the workgroups than between the workgroups. The results further showed that the frequency of communication (3.76) and mutual respect (3.50) between the health professionals collaborating in Surgery Unit II were rated the highest, indicating the strengths of collaboration in the surgical teams, even though they are still much lower than 4.0, which is considered a strong RC tie (RCA, 2015;

Gittell, 2016). Shared knowledge (3.34), problem-solving (3.23) and timeliness (3.07) in communication were the RC dimensions rated the lowest, indicating the greatest possibilities for improvement. The change team members expressed recognition of the picture of collaboration presented by the results. Further analyses of the RC Survey at Time 1 are presented in Chapter 8.

Given that the within relational dynamics were already strong, less attention was paid to them during the intervention. The change team initially focused on how the findings could be used to support and argue for Intervention I with reference to the Relational Model of Organizational Change (Figure 23, p. 136). They reflected on how the initiatives involved in Intervention I could be seen as initiatives intended to improve the relational coordination dimensions. Shared goals and timely and accurate communication were expected to be improved by structural and work process initiatives, such as board meetings, designation of a daily OR coordinator, and the adjustment of procedures for patients’ preparedness before surgery in Intervention I.

Shared knowledge, problem-solving communication, and mutual respect were expected to be improved by structural and relational initiatives, such as implementing ongoing debriefing in surgical teams and extending the collaboration with nurses in the orthopedic ward during Intervention I.

The change team compared the relational assessment of the current state of the collaboration that they had been drawn through relational mapping (Gittell, 2016, pp.

201-205) prior to presentation of the results of the RC Survey at Time 1 with the network map given by the results of the RC Survey (Figure 26, p. 141). Discrepancies were found within the change team, since several members of the change team imagined the collaboration ties to be stronger than the results showed. As shown in the network map (Figure 26), the RC scores of relational coordination dynamics between the surgeons and OR nurses indicated a moderate collaboration (blue line), when using the norms for weak, moderate, and strong ties given by RCA in 2015 (RCA, 2015; Gittell, 2016, p. 208).

The ties between the surgeons and all the other workgroups were rated as “moderate”

(blue line) or “weak” (orange line). The RC scores between the coordinating nurses and the AN nurses and OR nurses were rated as “moderate” collaboration ties. The tie between the OR nurses and AN nurses was rated as a “weak” collaboration tie.

The color of the bubbles indicated strong (green), moderate (blue) or weak (orange) collaboration ties within the workgroups. No further initiatives were planned to improve

the collaboration ties within workgroups in Surgery Unit II. Further description, explanation, and interpretation of the results of the RC Survey at Time 1 are presented in Chapter 8.

Within workgroups Between workgroups

Weak < 4.0 <3.5

Moderate 4.0 - 4.5 3.5 – 4.0

Strong > 4.5 > 4.0

Figure 26 Network map showing strong (green), moderate (blue), or weak (orange) relational coordination dynamics between the health professionals in the OR at Time 1. No collaboration ties were mapped to the workgroups of coordinating surgeons, surgeon assistants, and ward nurses, since these workgroups were not included as respondents. All the surgeons in Surgery Unit II were included in the RC Survey as members of the workgroup of surgeons because most of them worked as both surgeons, surgeon assistants, and coordinating surgeons. Below are norms for weak, moderate, and strong collaboration ties from the 2015 © Relational Coordination Analytics Inc., RC Survey 2.0 (RCA, 2018).

The time available for conducting the feedback process was short, and the participants were only slightly involved in the process. The shortness of time and the lack of involvement could be attributed to various reasons, which will be described and discussed in the discussion part of this chapter.

The change team determined to maintain the initiatives contained in Intervention I and to monitor the change process over the following six months. After six months, the initiatives should be evaluated, and further initiatives for Intervention II should be planned and implemented.

7.2.2 Prioritizing and Planning Intervention II

At a change team meeting in June 2015, Intervention I was evaluated, as shown in the timeline in Figure 22 (p. 131). Due to organizational changes, a new senior manager had assumed the role of chairman of the change team. The change team discussed the problems experienced and evaluated the implementation of Intervention I.

Establishing and maintaining the initiatives from Intervention I had proven to be difficult.

The initiatives that had the greatest priority, and mostly involved the change team, were initiatives intended to meet the need for patients to attend the OR on time in the morning. If the arrival of the first patient scheduled to undergo surgery was delayed, it had a major effect on the efficiency of the surgical unit, and it became challenging to ensure the appropriate use of both the health professionals and the available operating rooms. In the first few weeks after Intervention I was launched, there was a shared commitment to pursue the goal, although that commitment began to fade after a month or two.

The performance of Surgery Unit II had received; in the time just prior to the implementation of Intervention I, attention from the hospital management and from the political side. The attention was sharpened by press coverage regarding the surgical unit´s handling of a particularly busy weekend, when traumatized patients had been waiting for surgery for longer than usual.¹⁷ The top management launched an external analysis, including measurements of different indicators, with the purpose of monitoring whether the first patient arrived in the OR by 7:45 AM at the latest, and if not, why. The external analysis resulted in further structural interventions in Surgery Unit II, such as a change in the attendance time for OR nurses, the implementation of a “red protocol” in the OR to document present conditions resulting in delays, and the establishment of the functional role of coordinator, intended to be responsible for coordinating the distribution of acute patients in the orthopedic surgery clinic.

When reviewing the four initiatives included in Intervention I after six months, the change team summarized and concluded, that there was still much to do to implement and maintain the initiatives (Appendix 7). Based on the evaluation of Intervention I, the results of the RC Survey at Time 1, and the external analysis, the change team wanted to prioritize further initiatives to be implemented during Intervention II:

• A coordinating nurse visible at the board area all day.

• Meetings of the surgical teams in the OR between 7:30 and 8:00 AM.

• Qualification of the surgical prescription through new shared procedures.

• Qualification of the procedures for instruments and sterility.

The next steps in the organizational change process were planned. Intervention II was presented in September 2015 by the change team at a kick-off meeting to which all the

17 An article describing complaints made by patients and relatives in the regional newspaper Nordjyske, May 21, 2014.

health professionals in the surgical unit were invited, as shown in the timeline in Figure 22 (p. 131)

7. 2.3 Monitoring the Intervention Process after 12 Months

The initiatives were evaluated again one year after Intervention I. At this meeting, an optimistic dialogue between motivated change team members was witnesses. The change team discussed how the interventions were implemented, as well as how to support and maintain the changes. A short summary of how the initiatives were implemented is presented in the following, supplemented with quotations from the change team:

The Interdisciplinary meetings (board meetings) were successfully implemented, as described by one of the coordinating nurses:

“The atmosphere is significantly calmer in the OR hallway now and it is quieter in the operating rooms, which is often expressed positively by doctors as well as nurses. The board meeting is very useful for the anesthesiologists when they must conduct the anesthesia journal. At the meeting they get something to assume and to go after. The anesthesiologists also say it is more efficient that they should only address one person in the OR hallway [coordinating nurse]. Today, the coordinating surgeons have more knowledge about the acute patients, which is important when we plan the surgical schedule. So slowly, things are happening for the better!” [AN nurse 40]

The planning of the surgical schedule at the board meeting the day before was also found to have implications for other work processes. The surgical prescriptions and the anesthesia journal were increasingly conducted in the ambulatory, so more patients were prepared for surgery on time. A year after launching Intervention I, according to the change team, it was successfully executed that the first patient arrived in the OR at 7:45 AM at the latest, to the great satisfaction of all. The change team agreed to collect positive stories about how the unit managed to achieve better planning, get started on time, and be better prepared in order to create positive narratives within the surgical units.

The appointment of an OR coordinator to be responsible for the shared planning of the schedule in the surgical teams, including initiating a daily meeting in the OR between 7:30 and 8:00 AM, was less successful. The previous pattern manifested again. In the first few weeks after Intervention II was launched, there was a shared commitment to meet in the morning and plan the schedule of surgery for the day, although that commitment faded after a month. A template, including agenda items for the morning meeting, was prepared when the initiative was launched. After three months, there was a need to recall the agenda items and discuss why the morning meeting was important and how it should be maintained. Moreover, a reminder of why the implementation of a coordinator function in the operating room and a coordinating nurse in the OR hallway would be beneficial, was needed. The change team found that

the appointment of a OR coordinator and the establishment of morning meetings were really useful and effective, since the initiatives were carried out during the first month.

The following comments were expressed by an OR nurse and an AN nurse, who were members of the change team:

“We collaborated better in the OR. We identified the challenges and the opportunities when planning the surgical schedule and we discussed particular concerns for the individual patient." [OR nurse 4]

”At the morning meetings in the OR, the AN nurses informed the OR nurses about what they were particularly challenged by, and so did the OR nurses. It was much easier to collaborate when you knew what was at stake for the others.” [AN nurse 39]

The change team agreed to make a joint effort to get the coordinator function and morning meetings in the OR re-established, as well as to discuss why a daily interdisciplinary meeting being held in the morning was important and emphasize the benefits of these activities.

Extending the collaboration with the orthopedic ward was very successfully implemented. The orthopedic ward was doing great work in preparing patients for surgical procedures. According to the change team members, the collaboration was very positive. The change team agreed to acknowledge this great effort by informing their collaborators in the orthopedic wards that they had experienced a huge advance.

Today, according to the change team, patients are prepared on time, except for a few cases, which is of major importance for the completion of the surgery schedule and for collaboration within the surgical unit.

One year after the launch of Intervention I, no initiatives were provided to implement debriefing processes after surgical procedures with the purpose of reflecting on the task performance and the interdisciplinary collaboration at the end of the day’s teamwork. There were likewise no initiatives provided to qualify the surgical prescription and the procedures for instruments and sterility.