Entangled in complexity: An ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs.

AIM: The aim of this study was to visualize vulnerabilities and explore the dynamics of inter-professional collaboration and organizational adaptability in the context of care transitions for patients with complex care needs. DESIGN: An ethnographic design using multiple convergent data collection techniques. METHODS: Data collection involved document review, participant observations and interviews with healthcare and social care professionals (HSCPs). Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings. RESULTS: Inconsistencies in timing and precision during care transitions pose risks for patients with complex care needs as they force healthcare systems to prioritize structural constraints over individualized care, especially during unforeseen events outside regular hours. Such systemic inflexibility can compromise patient safety, increase the workload for HSCPs and strain resources. Organizational adaptability is crucial to managing the inherent variability of patient needs. Our proposed 'safe care transition pathway' addresses these issues, providing proactive strategies such as sharing knowledge and increasing patient participation, and strengthening the capacity of professionals to meet dynamic care needs, promoting safer care transitions. CONCLUSION: To promote patient safety in care transitions, strategies must go beyond inter-professional collaboration, incorporating adaptability and flexible resource planning. The implementation of standardized safe care transition pathways, coupled with the active participation of patients and families, is crucial. These measures aim to create a resilient, person-centred approach that may effectively manage the complexities in care transitions. IMPLICATIONS: The recommendations of this study span the spectrum from policy-level changes aimed at strategic resource allocation and fostering inter-professional collaboration to practical measures like effective communication, information technology integration, patient participation and family involvement. Together, the recommendations offer a holistic approach to enhance care transitions and, ultimately, patient outcomes. REPORTING METHOD: Findings are reported per the Consolidated Criteria for Reporting Qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method.

BACKGROUND: Hospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home. METHODS: Data were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations. RESULTS: Hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals' performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge. CONCLUSIONS: Mapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.

Exploring patient flow management through a lens of cognitive systems engineering.

Hospitals work to provide quality, safety, and availability to patients with a wide variety of care needs, which makes efficient prioritisation and resource utilisation essential. Anticipation of each patients' trajectory, while monitoring available resources across the hospital, are major challenges for patient flow management. This study focuses on how hospital patient flow management is realised in situ with the help of concepts from cognitive systems engineering. Five semi-structured interviews with high level managers and shadowing observations of seven full work-shifts with management teams were conducted, to explore how patient flow is coordinated and communicated across the hospital. The data has been analysed using qualitative content analysis. The results describe patient flow management using an adapted Extended Control Model (ECOM) and reveal how authority and information might be better placed closer to clinical work for increased efficiency of patient flow.Practitioner summary: This study describes how a large tertiary paediatric hospital's patient flow management functions. The results offer a new understanding of how patient flow management is communicated and coordinated across organisational levels of the hospital and how authority and information might be better placed closer to clinical work for increased efficiency.

Communicating intended routes in ECDIS: evaluating technological change.

Misunderstanding each other's intentions is one of the most common causes of shipping accidents. By sending out a number of waypoints ahead and displaying them on the Electronic Chart Display and Information System (ECDIS) a ship's intentions would be clearly visible for other ships. Displaying ships' intentions would be a major change compared to navigation today. It could be very beneficial but it could also have unintended consequences. This paper reports on findings from an evaluation looking for unintended consequences of change using system simulation. During the simulation an unanticipated behavior was observed. Bridge crews started to click and drag waypoints too negotiate crossing situations ahead of time. The behavior could be compared to agreeing over the VHF. However further research is needed to evaluate this new behavior and how it aligns to COLREGS.

Decision support for vessel traffic service (VTS): user needs for dynamic risk management in the VTS.

Vessel Traffic Service (VTS) is a shore-side service implemented by a "Competent Authority to improve the safety and efficiency of vessel traffic and to protect the environment". It is a service that operates through VTS centers, from which VTS operators monitor traffic, assist in navigational matters and provide information to all ships in a designated area. As VTS is provided by operators located on shore, they usually make use of several decision support systems to be able to monitor the traffic and to provide information to the vessels. Although several new tools and approaches have been introduced in the VTS domain, there is still room for improvements. This paper summarizes the results from three studies conducted within the EfficienSea project to approach user needs for dynamic risk management in the VTS domain. Data was collected by conducting study visits and observations at VTS centers, a focus group interview as well as several semi-structured interviews. The paper summarizes the results and presents technical and organizational user needs for dynamic risk management within the VTS domain.