Lyndon Garrett and Dr. Curtis LeBaron, Organizational Leadership and Strategy
Routines within organizations enable members to execute their work plans and achieve their strategic objectives. Because routines involve replication and repetition, some researchers have regarded them as rather mindless patterns of action, but recently scholars have begun to view routines as “mindful” accomplishments—especially routines that are changeable and open to variation1. Although there has been widespread attention to evolution and variation in routines, few studies have specified how routines actually stay the same, or how they are maintained2. Empirical studies increasingly conclude that routines are not objectively given, but are constantly in the process of being accomplished in a particular context.3
This calls our attention to the micro-level interactive moves that influence the performance of routines. We aim to fill a gap in research on organizational routines: that is the need to empirically scrutinize routine replication as mindless rule-following and to consider routines as co-authored accomplishments. Through the mindful enactment of routines, participants perform variety in each occurrence of the routine while preserving the shared sense of what the routine is.
This is a study of how an organizational routine may be interactively maintained through the manner and in the moment of its performance. Specifically, we examine a routine that is commonplace in healthcare organizations: the “handoff” is a transfer of patient care from one physician to another. Handoffs occur regularly at shift changes, as when a departing physician transfers information about and responsibility for a group of patients to an arriving physician. As an organizational routine, handoffs are mission critical because healthcare organizations cannot achieve their strategic objectives unless patients are transferred effectively and efficiently. In recent years, handoffs have become a focus of attention and concern as studies have shown that miscommunication during handoffs is widespread and can result in adverse events.4 Although patient-safety organizations have proposed guidelines and standards for handovers, some empirical research suggests that the practice of handoffs is a locally negotiated and constituted routine—something developed “from below” rather than institutionally imposed “from above.”5
Our research method is video ethnography. We selected as our research site the intensive care unit (ICU) of Kingston General Hospital in Ontario, Canada. Two attending physicians are assigned to the ICU for one-week periods, which start on Fridays. Attending physician handovers usually take place on Thursdays, typically in the form of oral communication, either in person or, less frequently, over the phone. We video recorded 21 handoff sessions involving attending physicians, for a total of 257 patient handoffs. During data collection, we were careful not to alter the behavior and setting that we were observing. All participants gave their informed consent to be videotaped, but none were aware of our research questions or the specific nature of the analyses we would be conducting. By watching the video recordings carefully and repeatedly, we were able to identify patterns of interaction that provided empirical grounding for our emerging research claims. Our analysis evolved from inductive to abductive as we began to intentionally search for specific kinds of phenomena.
In analyzing our data analysis, we employed the linguistic notion of markedness, which is that people sometimes change the way they speak so that hearers can notice the difference and make appropriate sense of that difference. When physicians conduct handoffs, they mark their behavior in ways that help each other to make sense of their unfolding interaction, in relation to the norms of the routine. In our data the physicians never discuss or describe the proper way to conduct a handoff, but they frequently show or mark their general awareness of how a handoff should and should not be conducted. First, we examined aspects of process, which is a hallmark of routine activity. Process emphasizes how something is done, including the physical arrangement (e.g., how people locate and orient their bodies), the social order (e.g., how people allocate the conversational floor), the form of activity (e.g., how the event is opened and closed), and so forth. One way for physicians to show that a handoff is happening is to structure their interaction so that it can be recognized as another occurrence of the established form. Second, we examine aspects of content, which emphasizes what is being accomplished (not just how). While handoffs display a recognizable structure or process, they must also deliver the sort of medical information that will satisfy the purposes of the routine. In our data, physicians consistently deliver two kinds of content:
They tell stories about their patients (past events, present conditions, and future possibilities); and they list main systems of their patients’ bodies (e.g., respiratory, vascular, neurological, etc.). Of course, narratives and lists involve structures of their own, which reminds us that process and content are fundamentally inseparable, and that our distinction between the two is largely an analytic emphasis and convenience. Our study of process and content focuses on two means of maintaining handoffs as an organizational routine: repair and reinforcement. Apologies and self-corrections are obvious patterns of repair. By saying “I’m sorry” or “I should have,” outgoing physicians acknowledge and begin to rectify deviations from their organizational routine. Although patterns of reinforcement are more subtle, incoming physicians can reinforce the handoff routine by asking questions or prompting topics that are appropriately next. For example, by asking “What about the family?” or by saying “Okay, who’s next?” incoming physicians anticipate and nudge toward the performance of next-relevant action. Thus, the physicians display their sense of what the handoff routine is through a host of indications of what it was not (repairing) and what it is not yet (reinforcing).
Handoffs are an ongoing negotiation of both process and content, with outgoing and incoming acting as co-authors of their performance. Patterns of repair and reinforcement are especially prominent at points of transition from one handoff to the next. To begin a transition is to assert that the current routine has been adequately accomplished, that it is somehow complete, or at least sufficient for the next one to begin.
When a transition to the next patient happens prematurely, before a routine is recognizably complete, participants usually mark the mistake while in the process of repairing it. Transitions may involve relatively intense interaction and negotiation as participants move quickly and boldly to maintain the integrity of the handoff routine by fixing flaws and filling gaps before the opportunity passes. In order for organizational routines to work, participants must be able to recognize when the routines have been accomplished so that everyone understands what they are (and are not) doing. Specifically, patients could suffer serious harm if the completions of handoffs were ambiguous and if handoffs were permitted to bleed into one another.
We find that the maintenance of routines is a result of their effortful accomplishment. Handoffs are not straightforward and unilateral transfers of information from one physician to another but instead are highly complex communication events, in which physicians interactively constitute and convey the salient past history and ongoing care related to the patient, as well as draw attention to issues that may become problematic in the future. In our study of handoffs, we find that both the process and content of the routine are mutually constituted and the way that handoffs take place depends on both participants. The handoff routine is interactively structured to be recognizable to both the incoming and outgoing physician, and deviations from that structure are marked and repaired.i
- Feldman, M. S., & Pentland, B. T. 2003. Re-theorizing organizational routines as a source of flexibility and change. Administrative Science Quarterly, 48: 94–118.
- Becker, M. C. 2004. Organizational routines: A review of the literature. Industrial and Corporate Change, 13(4): 643-677.
- Orlikowski, W. J. 2002. Knowing in practice: Enacting a collective capability in distributed organizing. Organization Science, 13: 249-273.
- Sutcliffe, K., Lewton, E., & Rosenthal, M. 2004. Communication failures: An insidious contributor to medical mishaps. Academic Medicine, 79(2):186-94.
- Ilan, R., LeBaron, C., Christianson, M. Heyland, D., Day, A., Cohen, M. (accepted). Handover patterns: An observational study of critical care physicians. BMC Health Services Research.