AOHN J O U R N A L SEPTEMBER 1987. VOL. 46, NO 3

Participatory Planning AN INTERACTIVE MANAGEMENT APPROACH

Eric W. Stein

o assist in adapting to changing conditions, OR managers might consider the appli- T cation of two organizational planning

frameworks to their units. The first, interactive planning, is a method that can help those who use and operate the surgical suite (eg, nurse managers, surgeons, or administrators) achieve a consensus on the desired attributes of the work environment and goals for the unit. The second, socio-technical analysis, is a mode of analysis appropriate for analyzing activity characterized by high levels of utilization. Both frameworks have been used extensively in public and private institutions and are based on developments in planning theory.

This article includes a socio-technical analysis of a hospital operating room suite. It describes the results obtained by nurses, physicians, and other staff members using this analysis and interactive planning to understand and improve the quality of working life in the operating room suite.

Data Collection and Situational Analysis

he data for the case was collected in a nonprofit hospital engaged in interactive T planning. This moderate-sized hospital

with a 13-room OR suite experienced a dramatic rise in the number of outpatient cases.

Twenty-five nurses, surgeons, anesthesiologists, and hospital administrators met twice a month for six months to correct the weaknesses and strains caused by the overload. As a result of ambiguous

roles and lines of authority, poor communication, and poor decision making, there was considerable tension at the outset among professional groups that used and managed the OR. Nurses’ morale was low, and relations among surgeons, nurses, anesthesiologists, and other staff members was strained.

Using Interactive Planning

nteractive planning is a participatory manage- ment planning process that grew out of work I in operations research, management theory,

Eric W. Stein, BA, is a systems research fellow, Department of Social Systems Sciences and the Busch Center, The Wharton School of the University of Pennsylvania, Philadelphia He has a bachelor of arts degree in physics from Amherst (Mass) College.

The author thanks Thomas Gilmore for his input and editorial assislance.

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Ends planning is the most creative phase, and can be enriched

with increased participation.

organizational and group behavior, and planning theory. In its earliest form, it was known as normative planning, as described by social systems planning theorist H. Ozbekhan.’ It was later restructured by R. L. Ackoff, another leading social systems theorist and practitioner.* Interactive planning represents the evolution and development of more familiar types of planning, such as strategic planning.

In interactive planning, the members of a work unit-ideally its users-meet under the direction of an outside facilitator to find ways to improve or change current operations. The five phases of interactive planning, all of which overlap, are:

“mess formulation,” ends planning, means planning, resources planning, and implementation and control.

Mess formulation is a detailed systems analysis of the work unit, including how it operates, who controls it, who it serves, and how it is related to the environment. In addition, obstructions, threats, and opportunities for change are identified.

In ends planning, the participants specify the goals that the work unit should pursue in the form of a mission statement and articulate the attributes of a new or improved system. The new system should be technologically feasible, operationally viable, and easily adapted to new environments. Ends planning is the most creative phase, and can be enriched with increased participation.

Means planning involves selecting or creating means for bringing about goals agreed to in the ends planning phase. The group must next determine the resources that are required for the restructuring; this phase is known as resources planning. And finally, participants must decide how to get the job done and control for unforeseen consequences; this phase is called implementation and control.

The scope of this article is limited to the

description of the mess formulation and ends planning phases that were carried out at the case hospital. Intervention at the hospital began with the establishment of goals for the OR suite. It is very important to begin with this phase; groups of people who work together in stressful environments tend to focus on current or individual problems, wasting energy that might be used to set goals for an improved version of the current system. Ends planning is a powerful technique for highlighting the gap that usually exists between what people would like and what actually exists, providing a target or goal. By focusing on what might be brought into being rather than what is, groups can take the necessary steps to change the system. Without such vision, planning efforts bog down, produce very little that is new-or worse-patch up what should be changed entirely. For these reasons, ends planning is an appropriate place to begin many planning efforts.

Ends Planning for the OR Suite

here are several work-related and social goals associated with the operation of an T OR suite. Work-related goals include such

things as meeting the demand for surgical use, providing quality care and service to patients, providing cost-effective care, and helping the hospital meet its bottom line financial obligations. Social goals include providing jobs for hospital staff and fee-for-service physicians, and serving the needs of the community of which the hospital is a part.

On a day-to-day basis, however, the most immediate goals for an operating room suite are that patients receive quality care in a timely fashion, that operating costs are kept under control, and that a desirable working environment is maintained. Although these statements may seem obvious, it was not until members of the group

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Table I Subgoals Contributing to an Improved OR Suite

1. All diagnostic work should be performed before admission. 2. All paperwork should be performed before admission. 3. All surgeons, nurses, anesthesiologists, and other staff members should be on time for

4. The type of procedure dictates the choice of OR room, and the room should be properly

5. Cases should be distinguished and scheduled according to a classification scheme:

upcoming procedures.

equipped.

(a) urgent (24 hrs) (b) emergency (6-8 hrs) (c) acute emergency (d) scheduled in-house (e) add-on elective (f) unexpected return to OR

6. The OR suite should be scheduled to maximize its use whenever possible. 7. Scheduling should take into account the needs of patients, physicians, nurses, and other

8. The patient should be prepared physically and emotionally for the upcoming procedure. 9. The patient should not be made to wait for surgery.

staff members.

10. The risk to the patient should be minimized.

engaged in interactive planning that these goals became publicly shared.

Each statement above requires the satisfaction of many subgoals, some of which are listed in Table 1. For surgical procedures to be performed in a timely fashion, for example, all paperwork and diagnostic work must be completed before admission. Although many nurses are familiar with the situation of putting a patient “on hold” until necessary paperwork arrives, surgeons may not be familiar with the situation, and they therefore do not understand why rooms are backed up. It was only by voicing these concerns publicly that the situation became understandable. The ends planning process thus helped highlight dependen- cies within the work unit and motivated participants to jointly seek ways to solve problems.

Anabsis of the OR System

nds planning alone does not reveal all aspects and problems of the work unit E being remodeled, and therefore, a systems

analysis is required to help “formulate the mess.” Socio-technical systems analysis, which was

developed and applied to industry by management scientists such as Eric Trist, was chosen for this task. The choice is appropriate because surgical suites, like many industries, are demand-driven, and technology has played a fundamental role in shaping organizational structures and functions.

OR units, like all socio-technical systems, use the following: tools (medical equipment such as x-ray machines, lasers, computed tomography scanners, and drills); techniques (specialized surgical techniques); procedures (surgery, methods of sterilization, scheduling, and setup and cleanup procedures); skills and knowledge (dexterity, quickness, steadiness, machine operation, medical and technical knowledge, and management capabilities); and devices (artificial limbs, implants, and life-support systems).

Like any complex flow system, OR units must have a coordinated mixture of personnel, equipment, supplies, paperwork, and patients through them. High volume and high utilization

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Table 2 List of Variables and Possible Deviations

Phase Variable Possible deviation

Preoperative 1. 2. 3. 4. 5. 6.

Case type* Procedure type* Patient condition* Time estimates* Rooms scheduled Laboratory work*

Complications extend time Underestimated Room changed

Admissions 7. 8. 9.

Patient registration* Patient called Patient transport Waiting for elevators

Setup

Anesthesia

10. 11.

Equipment Supplies Out of stock

12. 13. 14. 15.

Anesthesiologist* Nurses, staffr Patient* Anesthesia given

Arrives late Arrives late Consent form not signed

Preparation Surgeon* Effect of anesthesia* Tools and supplies Final preparation

Arrives late

Special tool not found

16. 17. 18. 19.

Surgery 20. 21.

Incision/procedure* Data collected

Less time needed than estimated

Recovery 22. Patient transport Staff not available

Cleanup 23. 24. 25. 26.

Cleanup staff Equipment Cleanup performed Next procedure

Other rooms cleaned Not available

*Key variable

have become primary performance criteria for systems under their control. The purpose of a health care organizations. Operating room suites, socio-technical analysis is to shed light on the as well as staff and management personnel, are complex sequences of events that are involved being stretched to their limits by technical and in running an OR. social demands. Now more than ever, OR F. Emery outlined nine steps to a socio-technical managers need to understand the nature of the systems analy~is.~ The three of these steps that

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Table 3 Interdependence of Variables That Affect Patient Flow Through the OR

Preoperative ( 1) Case type*

3 4 4 (4) Procedure time estimates* 5 5 5 (5) Rooms selected and scheduled

(6) Laboratory work* Admission 7 (7) Patient registration and paperwork*

8 8 (8) Patient called

(2) Type of procedure* (3) General condition of patient and probability of complications*

9 (9) Patient transport Setup (10) Equipment brought in

Anesthesia 12 12 ( 12) Anesthesiologist arrives* ( 1 1) Supplies brought in

13 13 (13) Nurses and staff arrive*

15 15 15 (15) Anesthesia induced 14 14 14 14 14 14 14 (14) Patient arrives in OR*

Preparation 16 16 16 (16) Surgeon arrives 17 17 (17) Effect of anesthesia*

18 18 18 18 18 18 (1 8)Tools and supplies 19 19 19 19 19 19 19 19 19 19 (19) Final prep

Surgery 20 20 20 20 20 20 20 20 20 20 20 20 20 (20) Incision

*Key variable

Variables are in chronological order following parentheses. Each variable can affect other variables. The other variables that can be affected can be located by reading from any variable down. For example, (2) Type of procedure, can affect variables 4, 5, 18, 19, and 20.

are described in this article are (1) identification of the main phases of the process; (2) identification of key process variables contributing to variance; and (3) controlling variance.

In the first step, the main phases in the production process are identified. These phases for the OR, in approximate order of occurrence, are preoperative, admissions, setup, anesthesia, preparation, surgery, recovery, and cleanup. Although this characterization of the OR is simplified, it is useful for grouping the process variables that affect the quality of service (step 2), and for identifying individuals and groups within the work unit who control variance (step

Variance within the system. When the variables deviate from what is expected, the system

3).

experiences variance. The main categories of variables that affect the delivery and quality of surgical care include: case types (urgent, in-house, ambulatory, elective); procedures (type and difficulty); patients (condition, procedure, complications, schedule, influx); rooms and equipment (quality, availability, failure rate); supplies (quality, availability); medical personnel (quality, schedules, availability, personalities); effects of drugs, supplies, and equipment on patient; and information (quality, accuracy).

A list of variables and deviations is shown in Table 2 for the operating room sequence. The variables are listed roughly in chronological order and are grouped around the main phases in the operating room sequence. In the next sections, the focus will be on key controllable variables

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that force operations to deviate from specified times or places and tend to increase stress.

Identijying key variables. The most impor- tant controllable variables are those that have the greatest potential for affecting the output of the system (ie, quality, quantity, operating costs, and social costs). These variables are identified as key variables.

One way to identify key variables is to display all variables in a matrix analogous to a correlation matrix (Table 3). All variables shown along the diagonal are factors that affect the surgical care process. The chronology of phases is shown in the left column.

It is easy to see that variables occurring early in the process may affect others that follow. For example, late or improperly prepared paperwork (key variable 7) can affect all of the following: the time at which the patient is called (variable 8), the time the patient arrives in the OR (key variable 14), the time the surgeon arrives (key variable 16), the start of preparation (variable 19), and the time the incision is made (key variable 20).

In general, the earlier in the sequence a variable occurs, the greater its affect on the system. On the other hand, late-occurring variables such as the arrival of the surgeon are obviously key as measured in terms of costs, quality, and quantity of service.

Controlling variance. Many variables within a process may be controlled by members of the social system to decrease overall system variance. Physicians, for example, exercise control of the schedule through the procedure time estimates they provide the OR schedulers. Procedure time estimates (key variable 4) determine when the room is scheduled (variable 5) and when key staff arrive (key variables 12, 13, 14, and 16). Poor estimates can throw off the schedules of other physicians, nurses, and staff. An analysis of records kept by nurses and physicians in this case hospital revealed that estimates deviated 15 minutes or more 55% of the time and 30 minutes or more 30% of the time. The symmetrical, bell-shaped frequency distributions of the deviations indicated that surgeons underestimated as often as they overestimated (mean = -0.06 minutes).

Although these figures explain nothing about the estimation efficiency at the case hospital compared to other hospitals, the participants involved in this analysis viewed procedure time estimates as a key variable that could be controlled and therefore improved.

Making Changes

nce members of a work unit have identified the problems and set goals, 0 changes must be made. Although a full

description of means planning is outside the scope of this article, a few proposed changes are worth mentioning. For example, to improve the scheduling system, members of the interactive planning group suggested providing the surgeons with the monthly distribution of scheduling deviations. The surgeons could then modify their estimates to decrease schedule variance. The group also considered offering 'incentives such as preferential start times to responsible estimators.

Another idea for the purpose of improving decision making and reducing tension among professional groups using the OR was to revise the management structure. This involved estab- lishing a new position of Administrative Director of Surgical Services, an OR advisory board consisting of surgeons, nurses, and anesthesiolo- gists, and a modified reporting structure. The goals for the new structure were to facilitate safe, cost- effective, and efficient patient care, promote a comfortable working environment, assure com- pliance with all local, state, federal, and Joint Commission on Accreditation of Hospitals regulations, and develop an improved scheduling system, among others.

Summary and Conclusion

lanning meetings are usually viewed as a means for accomplishing tasks, creating P plans, exchanging information, or analyzing

material. Although a large part of this article includes a description of work that resulted from planning meetings, the value of the meetings should not be overlooked. Working together on common problems at the hospital regenerated

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esprit de corps and served to remind individuals of their shared goals. The process fostered an appreciation of the constraints, objectives, and external demands of each professional group using the OR and helped explain seemingly arbitrary or irrational behavior. The meetings also forced tensions out into the open and helped defuse “hot” issues that might have been played out in the OR suite.

Although most work units engage in some form of planning, there is a tendency to “get it over with” as quickly as possible until another crisis occurs. Another approach is to schedule group planning and design on a regular basis as a form of group catharsis. Given the high levels of stress that members of the OR are subjected to, this idea may make more than just good planning sense. 0

Notes 1. H Ozbekhan, “Towards a general theory of

planning,” in Perspectives of Planning, ed. E Jantch (Paris: OECD, 1969) 1 - 152.

2. R L Ackoff, Creating the Corporate Furure: Plan or Be Planned For (New York: John Wiley & Sons,

3. F Emery, The Emergence of a New Paradigm of Work (Canberra, Australia: Centre for Continuing Education, Australian National University. 1978) 1 - 154.

I98 I ) 74-250.

Suggested reading Pasmore, W, et al. “Socio-technical systems: A North

American reflection on empirical studies of the seventies.” Human Relations 35 (December 1982)

Trist, E. “The evolution of socio-technical systems.” Occasional Paper no. 2, Ontario Ministry of Labour and Ontario Quality of Working Life Centre, Toronto (June 1981) 5-67.

1 179- 1204.

Blood Order Schedule Reduces Cross Matching By adopting a maximum surgical blood order schedule, the University Hospital of Jacksonville, Fla, reduced unnecessary cross matching of blood and saved more than $6,000 in labor and reagents, according to an article published in the April issue of The American Surgeon.

The blood order schedule specified the amount of blood to be cross matched for elective surgery. It was implemented because a retrospective study of the number of units cross matched to the actual number transfused showed that much of the cross matched blood was not used. The sche- dule was implemented in 1984, and within 10 months a 33% reduction of units cross matched was noted, according to the article.

The surgical staff and blood bank personnel determined that the following procedures could be performed with only a type-and-screen test: ventricular shunts, thyroidectomy, abdominal or vaginal hysterectomy, cesarean section. and amputation above the knee. They also specified the number of units of blood to be cross matched for other procedures: thoracotomy, one unit; abdominal aortic aneurysm, two units; radical

mastectomy, two units; radical hysterectomy, three units; coronary artery bypass graft, six units; and open hip procedures, four units.

Only patients who were free of irregular or unexpected antibodies could participate in the study. Patients the surgeons deemed likely to require more blood during surgery than allowed by the schedule were excluded.

According to the article, there have not been any significant medical problems associated with the maximum surgical blood order schedule or any negative impact on patient care. Few hospi- tals have adopted the schedule, and the researchers feel that surgeons may be reluctant to restrict blood ordering because some of the surgeries have a high probability of blood use. The researchers contend that the schedule deserves careful consideration because it offers savings in labor, reagents, and supplies, as well as the blood products themselves.

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