The ED as a social construction, and some personal notes

I’m interested in sense-making and cross-silo collaboration in complex environments. Despite these topics simmering inside of me for about a decade, it took time to articulate these interests into a short coherent sentence. The seeds were planted in 2006, whilst working on an oil platform as a medic, and it kept growing as I continued reading, experiencing and learning e.g. doing an MBA and a BTech Management. Eventually, it culminated into one study a PhD allowing me the opportunity to explore sense-making and operational decision-making in Emergency Centres (EC) as complex environments.

I chose a few public hospital ECs, all situated in Cape Town. The study was divided into two main parts, first a description of the ECs detailing and comparing policy, procedure and daily happenings.  After that, I explored how people make sense of their complex environment e.g. how and when they share of information, level of collaboration, trust, communication and beliefs regarding other disciplines and management.

The social constructionist stance

The research was approached from a social constructionist view; I argued that the EC staff create their own reality and that knowledge is generated and shared via social processes. Thus, social relationships shape how the team or workgroup experience their situation/reality. Management literature describes social networks to be a key determinant of resilience. In turn, resilience is a vital characteristic of high-reliability organisations (HROs).

Linking stories and culture

People interact by swapping stories and sharing their account of events.  Some of these accounts are repeated and in time it is accepted as truth, demonstrating how things happen ‘here’. In a way, it becomes a self-fulfilling prophecy – because people are more likely to see what they are scanning for whilst disregarding some other aspects in the environment. Newcomers are rapidly introduced into how things are done and what to notice and what not i.e. the culture of the workgroup. The culture is reinforced via daily rituals, communication, and anecdotes.

The underlying beliefs (and culture) determine vital interactions e.g. level of engagement, the ‘allowed’ social networks, level of transparency, trust and sharing between peers, other disciplines and those holding positional power (management).

For example, if the prevailing story is that management is ‘out to get people’ or that management cannot be trusted – the operational staff will protect themselves by withholding information and will not report minor mishaps, errors or events. For as long as the prevailing story sticks no progress will be made to introduce a safety culture, create transparency in relationships, etc. The grapevine and informal networks in the workplace are the gatekeepers of the culture.  And as mentioned earlier, these social relationships directly impact on the resilience and reliable functioning of the EC. Studies show that people are more likely to accept organisational stories by face value, favouring plausibility over accuracy.

As Nietzsche wrote:

Madness is rare in individuals – but in groups, parties, nations, and ages it is the rule.

The organisation is socially constructed

The EC is a social construction that is dynamically and collectively shaped by all working in the EC. Those holding positional or personal power have louder voices and are more influential than those with less voice. Those holding personal power may yield their influence to block change e.g. improvement projects that are driven from the top-down or hindering cross-silo communication.

Why it matters

Essentially sense-making is about how abnormality or fluctuation is noticed, whether this information is shared, and what happens next – the subsequent decisions and actions. Gaining insight into how sense-making occurs in the EC provides crucial knowledge about the more obscure factors that determine operational efficiency. It also provides information regarding team dynamics, communication methods, and cross-silo collaboration.

Exposing deeply held assumptions

Tapping into the underlying assumptions that inform sense-making is not straightforward; assumptions are accepted as regularly reinforced truths, and the dynamics are not obvious, not even to insiders.  These deep beliefs are a constraint to sense-making in the EC.  When it acts as an enabling constraint it ensures collective sense-making, effective decision-making, reliable operations, and social cohesion.  Alternatively, when deep beliefs act as limiting constraint, it results in failed collective sense-making, poor decision-making, operational failure, and strong silo mentalities.

Exploring sense-making

To recap: the people in the workplace hold deeply ingrained assumptions, that they are mostly unaware of.  These assumptions directly impact the level of collaboration, situation awareness and their ability to respond to variation in their environment.

So, how do we expose these assumptions? By exploiting the organisational stories told.

Language and stories are essential tools that shape how people understand the world (or workplace). The understanding created is reshared by sharing stories and knowledge, and by using specific words and phrases the storyteller can emphasize certain facts whilst ignoring others.

For part two of my research, we captured the stories that the people in the EC tell about their daily experience, hearing all voices equally. This was done by using the SenseMaker® tool – proprietary to Cognitive Edge to capture the stories.

Capturing stories

Using SenseMaker®, after telling us a story, the participants answered a series of questions based on the theoretical basis from the fields of collective and organisational sense-making, especially those that explored catastrophe, crises, ambiguity and time-critical decision-making.

This allowed for a comprehensive data set via a novel way of combining stories (qualitative data) with self-analysis (quantitative data). The data was then visually displayed allowing easy visualisation of patterns or clusters of responses.

What I liked most about using SenseMaker® is the self-analysis – participants provided information regarding the meaning of their story, distancing the researcher from the initial analysis.

Utilising the stories to effect change

Roughly, the stories can be divided into two extremes: those stories that promote sense-making and collaboration and those that don’t.  By shaping the daily stories in the direction of those that promote sense-making, the underlying beliefs and assumptions can shift, creating a new reality or situation. In time this may lead to a different experience of the workplace, (hopefully) improving relationships, decision-making, and cross-silo collaboration. This can be continuously tracked by using SenseMaker® as a monitoring and evaluation tool.

Personal impact

I plan on journeying more into sense-making, narrative methods, and complexity. I have a special interest in the gaps and overlaps between disciplines and cross-silo work as I deem it the space presenting the greatest potential to disproportionately improve systems and processes. By impacting the level of social cohesion between disciplines, the ability to continue functioning despite major flux or challenge is immediately improved, leading to resilience.

I intend on discussing my PhD learnings and its applications to the health industry, yet the unintended personal consequence is that I realise that I cannot limit myself to working only within Emergency Care or even healthcare. It’s time to spread my wings a bit wider, and in future blogs, the focus will shift a more towards complexity, culture, team, collective sense-making, communication, and management.

I’m in the process of revamping my blog site to be more aligned with these topics, and I hope that you (the reader) will continue supporting the new angle.  I thought it apt to end with the words of Winston Churchill. Even though WW2 only ended in three years later, the battle of Alamein in 1942 marked the turning point in the war and it was after this battle that Churchill spoke these wise words.

Now, this is not the end. It is not even the beginning of the end.  But it is, perhaps, the end of the beginning.

PhD reflection: getting it done

I (finally) submitted my PhD dissertation last week, after a rather arduous journey. Self-funding a PhD with no permanent income is hard enough. To complicate matters, 2 years in, I abandoned my initial topic choosing to focus on a topic that I felt was better aligned with who I am, my interests, previous experiences and future trajectory.

The decision to change the topic was tough, carrying financial, time and career costs. Not to mention self-doubt and questioning whether I had it in me to complete a PhD. Having already spent two years doing odd jobs to ensure flexibility and maximize PhD time, I knew that the change meant that time was not on my side and I had to make every minute count.

By setting the intention to work smart and not to waste time, resulted in submitting just shy of two years after sending the draft of the ‘new’ research idea/topic to my supervisors.

Below I outline seven tactics that helped me to get it done:

  • Eat the elephant one bite at a time. I dedicated one hour a day, every day to PhD work. I set an alarm and eliminated all distractions e.g. phone calls, messages or email notifications for that focused time.
  • Swapping outcomes-based plans for broad goals. Even as a compulsive planner, I experienced the traditional Gantt-like charts with outcome-based timelines as futile. The number of dependencies and constraints outside of my direct control was to significant to stick to outcome-based time-lines. I preferred broad goals e.g. one hour of reading every day for seven days, keeping a visual board that only showed the progress for that week. By chunking my progress into broad weekly goals, I experienced a consistent sense of accomplishment, where before I felt demotivated and despondent when detailed goals with external dependencies was unmet; whilst only reviewing progress occasionally reduced my ability to remain motivated.
  • Flexible strategies. Sometimes getting into the flow is easy, at other times there is no flow, no focus and no inspiration. I dedicated my good days to writing, cognitive tasks and conceptualizing. Bad days was used to ‘support’ the good days e.g. downloading articles, checking references, searching for specific articles, sorting out admin, etc. The commitment to only do one hour a day came in handy on days where I felt overwhelmed with other work and tempted to push the PhD hour aside.  Convincing myself to only do one hour always felt manageable and possible (even if I had to do it in four 15-minute slots).
  • Productive commuting. I saved reading time by listening to podcasts whilst driving. These podcasts included conference talks, lectures and interviews held with key thought-leaders. Listening to audio explanations and discussions provided me with a better grasp of the written materials and underlying theories.
  • Using queues and waiting times. Another trick was to never be caught without reading material. I stashed hard copy articles in my car and in every bag that I own. I was always prepared for some unscheduled reading time!
  • Fiercely protecting my time. Scheduling PhD time during my most productive hours was a non-negotiable. There will always be demands and conflicting interesting, and I learnt to (aggressively) protect my most productive time.
  • Breathe. Learn to breathe (properly) and do yoga. There are studies demonstrating the benefits, and I’m not going to cite those. Personally, yoga helped my concentration levels, sleeping and ability to deal with stress.

 

This is what worked for me. I would love to hear some other strategies – please feel free to comment!

 

 

Sense-making in Emergency Centres

Interruptions, incessant multi-tasking, mobile equipment thus continuous reconfiguration of the physical space, noise, people, flux….

How do people that work in emergency centres know what’s going on? 

How do they make sense of what’s happening, who do they talk to and then what happens? 

How does the formal processes e.g. policies and procedure enable (or disable) them from responding to expected and unexpected challenges? 

Exploring the above has consumed me for the past few years.  Using a multi-layered research design, I’ve studied five large busy government emergency centres in Cape Town.  First was an ethnographic study, and it was utterly fascinating to take an outsider stance, observing and ask naive questions about what’s happening and why things are done in specific ways.

To understand the formal systems doctor and nurse policies, procedures and rules was studied, and the managers was interviewed separately.  External managers e.g. human resources, finance, risk, bed flow was also interviewed.  This part of the project was largely influenced by Karl von Holdt’s work on South African government bureaucracies; Schein’s on culture, Weick and Sutcliffe’s high reliability organizations and Klein’s naturalistic decision-making and macrocognition.

This was followed with a SenseMaker® study.  EC doctors and nurses were invited to share a story; after telling it, they answered a set of specially designed questions.  The questions were based on a fusion of two sense-making theories; Karl Weick’s process of collective sense-making in organizations and Gary Klein’s data/frame model of sense-making.

The SenseMaker® tool provided me with a double set of data, the questions are quantified and visually displayed so that we can easily search for patterns and then a narrative analysis will add the final layer of insights.  For this part of the study I extensively relied on David Snowden’s methods, both the SenseMaker® tool and conceptual Cynefin framework was developed by him.

I’m planning a series of blogs discussing my work of the past few years, watch this space for more regular blogs from now on!

And on Thursday I’ll be presenting a teaser of the SenseMaker findings at the 4th African Conference on Emergency Medicine in Rwanda #AFCEM or http://www.afcem2018.com/

 

Emergency care…just like reality tv, not aviation

To any observer, the Emergency Centre (EC) appears chaotic. There is an endless in-flow of patients, all with different presentations, complaints and needs. Often the sicker ones that require admission are stuck in the EC due to (amongst other reasons) limited available beds in the rest of the hospital. Thus, the EC remains responsible for non-routine, acute cases whilst simultaneously functioning as a multi-disciplinary inpatient-ward accommodating routines for surgical, medical, psychiatric and gynaecological patients. Adding time-critical pressure to prioritize and manage life-threatening conditions makes for some complicated challenges in this part of the hospital.
Shifting gears
In January I found myself working on a reality television show called ‘I am a celebrity, get me out of here’. On this show a group of celebrities live for a few weeks in a constructed basic campsite in a jungle. They compete in challenges for food and other items for the camp. Each week one of the celebrities are evicted based on votes by the viewing public. The winner becomes the King or Queen of the jungle.
On set, it’s initially tricky to get your head around things e.g. all the radio channels and knowing when and how to communicate, the rapid changes and the variety of roles. Meanwhile, in the control room, there is an entire wall full of screens with the non-stop live stream of information and rows of people working with the raw information of what is happening in camp and during the challenges.
Yet, when watching the show, all the little bits somehow comes together in one coherent whole. Observing how things work behind the scenes, I more than once felt that there’s parallels between reality tv and the EC. I could see more similarities with reality tv than some of the other industries like manufacturing, aviation and formula 1 that healthcare has been learning from.

 

thumbnail_IMG_3808

The control room

Similarities
Too much information and it is constantly changing
Both have too many streams of information with various communication channels. This implies that everyone is not privy to or able to access the same information. With the oversupply of information people function by consistently blocking out ‘unnecessary’ information. Not receiving the same and the oversupply of information carries obvious risks for miscommunication or missing out on important information that was perceived as ‘white noise’.
Unpredictable behavior
In both industries there is limited control over the trajectory and the outcome. The participants (celebrities) and patients are unpredictable and have the power to change the storyline or treatment plan and can subsequently influence the desired outcome. Every situation is influenced by the interactions, dependencies and relationships between the people. Interactions and negotiations take time and can’t be rushed to fit the schedule.
Emergence
Due to the unpredictability, situations unfold as it is happening. This is called emergence and it requires the ability to constantly adapt to new circumstances. The expected trajectory cannot be set in stone and linear step-wise rules cannot be applied. It’s better to respond to emergence in a flexible way, basically real-time editing to the situation. The most efficient way to deal with the constant flux is permitting the people on the ground to respond and act on situations as they deem fit.
Fairly unscripted
In both each ‘scenario’ has a basic guideline. The reality tv hosts have a script, there is a plan and layout plans for camera’s, lighting, etc. In the EC we have typical presentations with algorhythms and triage policies. Despite the script and typical presentation, we can’t force all chest pain patients to describe their pain as an elephant sitting on their chest with pain radiating into the left arm. So, in both the tools (scripts, plans, algorithms) are guidelines and not rigid rules.
Time-critical
There is a time-critical element to both. And even though there is real-time editing, there is a time-critical limitation on the number of chances to get it right.
Different roles, tasks and goals but same end picture
In both, the different roles function independently with different reporting streams and hierarchies. At times the roles/functions are not aware of the reality that other roles/functions are facing. This can lead to conflict between disciplines on the best way forward. Even within the roles, there is a degree of independence e.g. two camera men on the same set have different views of what is happening.

 

thumbnail_IMG_3532
To wrap
Both industries are complex and the separate entities within them are also complex e.g. camera, sound, nursing, medical etc. These separate entities overlap and respond in various ways even within the same situation. They thus co-create the current state and what will happen next is unknown. Here, daily life is routine, yet non-routine, time-critical and constantly changing.

More about what we can learn from each other at another time. I’m in EM…get me out of here!

Valedictory speech Prof Di McIntyre

‘A Universal Health System for South Africa, some final words on the NHI’ – the title of Prof Di McIntyre’s valedictory lecture.

It is long; however, it is worth the listen if you are interested in the South African Healthcare system, the NHI and where we are now.
Prof McIntyre was part of the team that launched Africa’s first Health Economics Unit (HEU) and she has published, advised and collaborated widely. I have been reading and following her work as well as others at the HEU for the past few years
Valedictory lectures are often used as a reflection, Prof McIntyre used her valedictory to make an appeal to the Minister of Health regarding new committees and a potential change in direction of the proposed NHI. In her speech she states that
“I’m appealing to the minister because the minister is the person who can change this. He’s the one who put out the gazette with the different committees. They have put it on hold and they’ve now invited additional comment until the end of November. He can stop this. He can stop this insanity.”
She touches on other issues including how managers in public healthcare are incapacitated by the system to manage effectively. She also mentions that we require more community health programs to increase access to care. I am hopefully posting another blog on EFAR soon (a community first aid response system).
I also thought that her comment that over-servicing in the private health sector is rational economic behavior interesting and will be reading more on the topic.
Please have a listen

Stories matter, we should tell our stories

Everyone has a story, every story is different.  I am currently data collecting for my PhD and speaking to various role players in the EC.  This TED talk reminds me that there is never a single story about any place e.g. the EC in the hospital, the hospital, the health system.  We all have our own story…and every single person’s story matter…and that everyone’s voice should be heard….