Creating a common understanding of organizational problems across disciplines in hospitals – a case study of stroke care delivery

doi:10.21203/rs.3.rs-3604790/v1

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Creating a common understanding of organizational problems across disciplines in hospitals – a case study of stroke care delivery

https://doi.org/10.21203/rs.3.rs-3604790/v1

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published 06 Aug, 2024

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Background: Research has revealed that a lack of coordination between specialist units reduces the quality of care and leads to a waste of resources. Improved cooperation is necessary to ensure better care delivery, but not easy to achieve. To obtain sustainable improvement, medical practitioners need to have deep insights into the relevance of interdisciplinary coordination at their particular unit. In a case study we explore the development of knowledge and the effect of interdisciplinary coordination.

Methods: We present and reflect on a project to improve stroke treatment in a Norwegian hospital led by the first author. Data was obtained via documents, observations, and interviews with participants in a cross-functional improvement group.

Results: The participants developed a common understanding of why it took a long time to provide effective treatment for patients suffering from thrombotic stroke. These insights were used to implement practical changes, which led to immediate improvements in care for stroke patients. Their successful implementation set into motion a permanent improvement structure. The participants considered that mapping and then assessing the entire patient and work flow across disciplines were relevant methods for improving the quality of patient care.

Conclusion: This study provides a practical example of how improvement work can be organized in a hands-on way. The practical approach makes medical professionals discover and understand the importance of cross-disciplinary coordination for the quality of patient care.

Cross functional

disciplinary improvement

enhanced coordination in hospitals

quality improvement

stroke care

This study aims to develop new knowledge to promote continuous improvement of work processes in hospitals. To enablesuch development, we believe there is a need to organize learning arenas that make it possible for practitioners to discover the importance of coordination across professional units. Such learning arenas need to inform practitioners of how tasks are distributed across entire treatment pathways. Then, the practitioners’ assessments of whether the overall workflow is appropriate will constitute arenas for reflection and learning about the importance of coordination.

A general principle of the organizational structure of hospitals is to gather practitioners into communities according to their medical competence. The communities’ surgery, neurology, internal medicine, radiology, etc. usually have their own manager, their own budget, and separate arenas for follow-up of results. This organizational principle has led organizational researchers to classify hospitals as institutions with their own inherited ideological appeal and complex power relations constituted around various categories of expert knowledge [1]. Another typical feature of hospitals is that most outcomes are created through work processes that include contributions from many of the autonomous professional units, i.e. diagnosis and treatment of emergency medical conditions such as myocardial infarction, femoral neck fracture, stroke, and sepsis. In daily work, practitioners in the ambulance service, emergency departments, intensive care unit, radiology, medical laboratories, groups of doctors (MD), and wards will be involved in solving defined subtasks that are part of one continuous treatment path.

Research has revealed that the discipline-based organization of healthcare creates dysfunctions [2-6]. Studies report that lack of interaction and communication between the functional units leads to lower efficiency [7], discontinuity in the flow to the patients that decreases both productivity and satisfaction [8], duplication of work [6], and a lack of trust between employees working in different parts of the organization [5, 6].

A frequently cited study conducted at eight US hospitals highlights why it is difficult to find solutions to achieve better coordination across units [9]. It was found that practitioners experienced repeated problems due to a lack of coordination between professional units. However, these problems did not form a starting point for involving other units in the search for better solutions. Instead, practitioners solved problems as they arose by detouring or doing rework inside their own unit, without involving others. Results indicate that cultural norms in the hospital could explain the practitioners’ way of dealing with coordination problems. Firstly, efficiency concerns prompt staff to resolve issues quickly in order to prioritize patient care. Secondly, individual vigilance norms encouraged practitioners to solve problems without bothering other professional units. Finally, a widespread empowerment norm leads practitioners to solve problems themselves without involving managers. If practitioners’ knowledge of problems is to be used as a starting point for system learning, the researchers suggest focusing on management's presence and making assumptions for a safe psychological work environment [9].

These previous research findings have an impact on the conclusions in a summary review of organizational science in healthcare [10]. Their systematic literature review of organizational science in the health sector describes research findings and trends by means of an analysis of the 730 most cited articles in the field over the past decade. They reported a lack of research on how different dependencies between subsystems create challenges and require solutions. These researchers argue that increasing specialization requires the development of new knowledge that can inform how different parts of the organization contribute to the overall care system [10].

The present study aims to answer the call from Mayo and colleagues. We argue that sustainable solutions need to create insights among practitioners, so that they understand why coordination between professional units is relevant to the quality of services to patients. Such knowledge creation will also need to develop an understanding of why accurate interaction between professional units is crucial for avoiding duplication of effort and waste of valuable medical expertise. Based on this premise, we pose the following research question:

How can we organize cross functional improvement work in hospitals that allows practitioners to discover the importance of coordination?

We regard the initial period of an improvement intervention to be of specific interest to answer this question. Therefore, this study describes and analyzes the development of organizational problem understandings across professional hierarchies in the first period of a multi-year interdisciplinary effort to improve stroke treatment in a Norwegian hospital. Several researchers describe such startup periods as a problem clarification phase [11-14], because the participants develop understanding of the purpose and objectives of the work.

We describe and explore the startup period of cross-functional improvement work in a typical small Norwegian hospital. The improvement work was part of a larger effort to introduce lean thinking in the hospital. The lean approach aimed to develop the hospital’s ability to continually improve cross functional work processes through designing these with coherent flows with the least amount of waste [15, 16]

The hospital had chosen value stream analysis as the preferred methodology, and specialist units with practical tasks in value streams should be a part of improvement work. A case emerged based on the collected data. A case study is useful for understanding both complex social occurrences and organizations [17]

We present data from two different time periods. The first dataset is a systematization of documents, observations, and field notes from the period May– November 2013. This information was originally gathered to document work conducted in a cross-functional group to improve stroke treatment. The second data source is interviews with five employees who participated in a cross-functional working group. The interviews were conducted between November 2022 and February 2023.

Participants

The participants in this study are nine employees who took part in an interdisciplinary improvement group. They comprised a neurologist, a specialist nurse from the intensive care unit, a biomedical laboratory scientist, a radiologist, a radiographer, a nurse from the emergency department, a MD employed by the medical department, a local head of the ambulance service, and a quality advisor in the director's leader group. Two of the participants in the interdisciplinary group were employed in cross-cutting divisions in the health trust. The representative from the ambulance service was affiliated with the Prehospital Services Division, and the biomedical laboratory scientist belonged to the Medical Services Division. All employees had many years of experience working in the hospital and were experienced clinicians.

Data collection

Data was collected between August 2022 and February 2023. It consists of documents and observations from the period June – October 2013 in connection with the startup phase of improving stroke treatment. This includes meeting minutes, action lists, flow charts, electronic mail exchanges, and some field notes. The field notes are important as observational data collected by the first author when working as an internal change agent in the cross-functional working group. These data are supplemented by five in-depth interviews with employees who participated in an interdisciplinary group. These comprise two MDs, an ambulance driver, a nurse, and an employee of the ambulance service. Interviews were conducted in the period November 2022 - February 2023 and transcribed verbatim.

Analysis

Field notes and documents were chronologically organized in order to gain an overview of activities in the startup phase of the work conducted in the cross functional improvement group during the period May to October 2013. The first author transcribed all interviews. A thematic analysis [18] was conducted to identify the main themes and concepts in accordance with the research question. All data was assessed as a complete set and read as a whole several times in the search for patterns and themes. The back-and-forth process between codes and possible themes involved reviewing relevant research and theoretical perspectives to help us understand the data. Development of the main and sub-themes was guided by the research question.

Ethical and methodological reflections

Conducting research as an insider is challenging [19].The first author of this study had a defined responsibility for organizing the interdisciplinary working group and his participation has potentially affected the outcomes of this study (data collection, analyses, and results). The co- authors participated in discussions about this matter, as it is important to obtain an adequate perspective on the author's own preconceptions. As a result, the first author has been forced to reflect on questions such as; why was it so important to involve practitioners? Or - why was it important that practitioners understood the necessity of changing the distribution of tasks between units?

Employees who participated in the cross-functional working group voluntarily consented to participate in this study and completed informed written consent form.

The case –cross functional improvement work to enhance stroke treatment.

In May 2013, a concerned senior neurologist met up at the office to the hospital`s quality advisor. The MD had recently participated in a national stroke forum, which made her realize that patients suffering from stroke received poor-quality care at our hospital. According to the neurologist, poor organizing resulted in a delay in providing intravenous drug treatment to dissolve a blood clot in the brain. She called for immediate action, as patients with blood clots suffer extensive brain cell damage for every minute the condition remains untreated. The quality advisor agreed and suggested establishing an improvement group consisting of representatives from all specialized units involved in the treatment process. The neurologist objected, as she thought such a strategy would delay improvements. What she needed was the quality advisor’s help to reformulate procedures in the quality system – and then ensure formal approval among hospital leaders. This should then be sent to all involved units with instructions to follow the new standard. After a discussion, the neurologist agreed to carry out the work using a group, on condition that the quality advisor took responsibility for gathering representatives from all the involved units

At the next leader meeting, the quality advisor asked managers to support this work by selecting suitable representatives to form an interdisciplinary group. The selection should be based on two criteria. Firstly, the participants must possess good practical knowledge of the stroke treatment practice in the unit. Secondly, they must have a high professional reputation among employees in their own unit.

The cross-functional stroke improvement group had its first meeting four weeks later. The participants consisted of eight skilled professionals without any formal leadership position. In total, the group represented about 300 employees working in ambulances, emergency departments, radiology, intensive care, medical biochemistry, neurology, and as MDs. Prior to the meeting, the quality advisor arranged the meeting room. Eight chairs were set up in a semicircle in the middle of the room. Yellow and red post-it sticky notes and a pen were placed in front of each chair. After all participants had introduced themselves, the quality advisor put two notes on the wall. These represented the first (ambulance picks up patient) and last task (patient receives treatment to dissolve blood clot in brain) of the entire stroke work process at the hospital. Participants were told to write every work task their unit performed when treating stroke patients and place these notes on the wall. A couple of the professionals were alert, and the quality advisor sensed that unrest was spreading in the group. One participant approached the quality advisor and said: "Is the problem that you don't you know how we work as professionals?" One MD shook his head and said, "We don't have time for such nonsense, I believe we need to work more efficiently. Let's start changing the stroke procedure, that's why we're here." The quality advisor ignored these inputs. He had noticed that the ambulance driver and nurse from the emergency department were in the process of writing down tasks and asked them to put their notes on the wall and explain the tasks to the rest of the group. One of the notes from the ambulance driver read; "driving the patient to the municipal emergency room". One of the MDs now raised his voice and exclaimed: 'No, you can't do that, it delays the treatment'. The representative from the ambulance service explained that they had been told by the municipal MDs to stop by the municipal emergency room as this would ensure that the patient was "properly medically clarified". The quality advisor said this was important information and explained that the red notes placed in front of the chairs could be used to register what the participants perceived as bottlenecks in the care process. He told the MD who had provided input to write; "delay" on a red note and place it on the wall in connection with the ambulance driver's description of the action. The next person to place task notes on the wall was the nurse from the emergency room. One of the notes read "conducts patient examination – takes vital parameters". Both the ambulance driver and the MD then told the nurse that this action was unnecessary and delayed treatment because these data had already been gathered. The emergency department nurse responded that this was a standard routine for all patients, and nurses were instructed to do it by their manager. Again, the quality advisor requested that this should be written on a red post it note and placed on the wall. Several of the clinical staff now began to write notes describing tasks performed in their unit and placed them on the wall. The neurologist hung up a note that read "order emergency X-ray examination", and at the same time a red bottleneck-note, which read; "unnecessary waiting". The participant from the X-ray department now reacted, raising his voice in an annoyed manner. He approached the neurologist and said: 'We`re doing the best we can, but equipment is always in use by another patient. Surely, we can't just evict another patient who has nearly completed an extensive examination? ». The quality advisor interrupted this somewhat heated discussion, stating that the issue could not be resolved at today’s meeting. At this stage of the meeting, activity in the group increased, participants brought up more yellow notes outlining tasks and several red notes describing bottlenecks. Over/During the next two hours, more than 60 task notes were placed on the wall and over 20 bottlenecks identified. Figure 1 presents a simplified version of the survey conducted in the group at this meeting.

At the end of this session several participants commented that they had doubts about whether all tasks and bottlenecks had been included in the map. To gain better knowledge, the group decided to collect more data by observing the stroke practice before the next meeting.

Two weeks later the cross-functional stroke improvement group met again. The participants had new information. A MD, involved in the treatment of a stroke patient had noticed that treatment had been postponed due to the patient`s high blood pressure. The MD applied a red bottleneck tag on the wall that read "high blood pressure". The ambulance driver replied, «perhaps ambulance personnel could prescribe drugs to patients to lower blood pressure before arrival at the hospital?” The intensive care nurse had also experienced a new bottleneck, as treatment had been delayed because of the time required to insert a peripheral venous catheter. The ambulance driver replied; they had time to insert venous catheters during transport to the hospital, but he had another issue. Several of his colleagues thought it was difficult to assess stroke diagnosis because similar symptoms could occur in other medical conditions. The neurologist replied that the MD at the hospital could help in such cases. She said paramedics could get a direct number for the neurological doctor on duty at the hospital, and in case of doubt, they could call for professional support 24/7.

At the end of the second meeting the participants agreed that the wall-map now represented a credible picture of how tasks were distributed in the entire workflow. As the group assessed the entire care path the quality advisor asked: Is this design well suited for the purpose of providing the patient with the fastest possible treatment? The clinicians smiled exasperatedly and shook their head, - all participants agreed that the design was weak. They summarized that delay in treatment was due to: Patients being diagnosed several times by different actors, and four separate transport stages with delays between each stage. Finally, the process was slow because all units were unprepared when the patient arrived. Employees lacked knowledge of the arrival of a stroke patient and conflicts arose because everyone was busy solving other tasks. The quality advisor then posed the following question to the participants: 'Who decided that the hospital should organize stroke treatment in this way? Several of the employees laughed, and one said: "It is obvious that whoever designed it was not a genius!". At the end of the meeting the group agreed to meet again two weeks later in order to work out a redesigned standard for stroke treatment.

In this study, a thematic qualitative analysis of improvement work in a hospital was conducted to answer the question; “How can we organize cross functional improvement work in hospitals that allows practitioners to discover the importance of coordination?”

The analysis revealed three main themes. Theme one; Practitioners acknowledged the relevance of the process to improve/enhance patient care. This theme includes following subthemes; Use of an inter-disciplinary group, mapping the entire workflow, and assessing the entire workflow. Theme two; “Practical changes with intermediate results”. Theme three; "Development of awareness of the importance of cross disciplinary cooperation”.

Practitioners acknowledged the relevance of the process to improve patient care.

Development of strategy – use of an inter-disciplinary group

The first meeting between the quality advisor and the experienced neurologist involved a dialogue that over time resulted in a common understanding of the change strategy. Firstly, they agreed that tardiness in stroke treatment was related to the weak coordination in task distribution among sub-units. Their understandings differed in terms of strategy. The neurologist wanted help from the quality advisor to edit the stroke protocol in the quality system to be sent to all departments with instructions to follow. The quality advisor’s understanding was that in order to make change happen the employees needed to develop their own understanding. Thanks to the dialogue, the neurologist accepted that the quality advisor had expertise in how to organize work to achieve behavioral change among 300 hospital employees. Because the quality adviser was in a position to receive assistance from the hospital's senior management team, the group was composed of practitioners which had relevant practical experience in the field to be improved, and high professional standing among employees in their own unit. Many years later, the neurologist expressed her «new» understanding as follows: "I had the answer, but not the recipe.... I've learned a lot from the work that we've done. It's made me understand that there's no point in getting someone to change if they don't understand why" (MD Nov. 2022).

The interdisciplinary group became an arena for neurologist to explain the significance of changes for the future health of patients with thrombotic stroke. A participant expressed; 'I was surprised at the damage to patients if treatment was delayed by a few minutes.' 'In this case, the benefits for the patient's health were so obvious that it made it easier to make an effort in the work' (Radiographer, December 2022).

Mapping the entire workflow clarified the fact that weak coordination between tasks was the main problem.

At the start of the work the participants brought different goals, motives, and understanding of problems to the improvement work. In this start-up phase, the participants' understanding was colored by their own experiences from practice. A common denominator for the focus on problems can be summed up by the statement "At the beginning, everyone thought of themselves" (radiographer, Dec.2022). One of the nurses recounted; “The instruction from my unit was to not play an active part in this work. The reason was that stoke treatment could be a time waster in terms of us having to leave our own unit, thus affecting the care of the other patients in the intensive care unit.». How can this focus be understood? At this stage of the improvement work, the stroke workflow was organized so that units solved their tasks in separate stages. This indicates that each unit only had experience of a limited part of the complete care delivery process.

Together the practitioners used their experience form clinical practice to create a wall image revealing the entire stroke workflow. Later on they specified this description by collecting information from practice. Over time it led member of the group to develop a confidence that the image represented a truthful description of how work actually was carried out. The graphic wall picture made it possible for all participants to assess the entire work process at the same time. When they assessed the entire workflow, they found that units' problems described as workflow bottlenecks (in figure 1) was part of another problem, namely a lack of logic and coordination in the distribution of tasks between units. Participants realized that different units solved the same tasks at different times in the process (e.g., diagnosis and repeated documentation in medical records). Lack of communication, (e.g., no notification to the next unit of the arrival of a stroke patient) created simultaneous conflicts and delays because equipment and personnel were busy. The map made it obvious to everyone that the delay to treatment of patients was a consequence of the way the process was designed. A member of the improvement group remarked: "To consider all stages of a workflow was new to us, and we discovered connections we hadn't been aware of before." (Ambulance driver, December, 2022). Several participants who were interviewed found it difficult to point out a particular time or event that changed their understanding of the problem. "I learned a lot from this with mapping the bottlenecks, but we spent quite a lot of time formulating a description of reality that we all agreed was truthful. I think this (authors remark: knowledge development) takes time, and it's important in itself." (Nurse, Feb., 2023)

Understanding dependencies

The new understanding of the problem was also evident in how the participants observed the field of practice. One of the MDs had observed that high blood pressure had delayed the treatment of a patient (if blood pressure is too high, the patient may suffer serious injury if blood-thinning treatment is administered). When this information was brought into the next meeting of the improvement group, the ambulance service was immediately willing to help measure blood pressure, and in cases where blood pressure was too high, provide drug therapy to lower blood pressure before the patient arrived at the hospital. At the same meeting, the specialist nurse brought information that a delay had occurred because it took time to insert a venous line (which makes it possible to administer intravenous blood-thinning medicine). Paramedics replied that they could insert a venous line during transport to the hospital. "For us, it was very useful to gain an understanding of the entire work process, and not just our own tasks. It created a better understanding of how we could work to contribute to better patient care." (Ambulance driver Nov., 2022)

Ownership of new knowledge led to an obligation to contribute.

During the mapping process, the practitioners discovered that no one was responsible for the entire stroke process. They also understood that the poor design was not knowingly created by anyone. They realized that the task distribution was something that had evolved over time, probably due to an accumulation of changes within each professional unit. At this point these insights were not familiar to other professionals in the hospital. Together, these factors contributed to an understanding that if someone was to take responsibility for improving treatment for stroke patients, the group had to play an active role. A specialist nurse stated; "I had a different feeling about whether we should be involved after the group had completed the workflow mapping. I went directly to my manager after this meeting and said that here we need to play an active part in the change work if stroke patients were to receive better treatment» (Nurse – February, 2023)

Practical changes with intermediate results.

Practitioners’ new insights made them implement some practical changes in the task distribution that resulted in patients with stroke receiving much faster treatment to dissolve blood clots in the brain (figure 2). Important changes were that ambulance personnel received assistance from a neurologist at the hospital to make a preliminary diagnosis. Subsequently, all units were notified, and patients were brought directly to the radiology department. There professionals from various units gathered as a team to finalize diagnosis and provide treatment.

Statistics from the National Stroke Registry (Norwegian Stroke Registry | National Service Environment for Medical Quality Registries) for the period 2016-2022 confirms that the results are permanent and place the hospital among the best at national level in the years 2021 and 2022.

Awareness of the importance of cross disciplinary cooperation.

The hospital has a large number of work processes that cross professional hierarchies. It is not unreasonable to assume that weak coordination also creates problems in other cross-cutting work processes. The question is whether employees have developed a generalized understanding of the importance of coordination. If so, this would mean that they understand that weak coordination can be the cause of a number of quality problems at the hospital.

Several of the participants in the interdisciplinary improvement group suspected that other quality problems in the hospital could be understood in light of weak coordination in cross-cutting work processes. For example, one MD explained that 'a lack of quality in referrals from municipal MDs leads to the hospital staff spending a lot of time assessing low quality referrals, and this weakens the quality of patient services' (MD, Nov., 2022). Similarly, an employee from the ambulance service believed that patients with a type of acute heart disease would receive better improved health services if the entire patient pathway was better coordinated. Furthermore, they considered that the organizing principles used to improve stroke treatment would also be efficient for improving other cross-cutting work processes. However, the analysis of the data in this study does not provide sufficient support for claiming that the participants have developed a basic understanding that many quality problems in the hospital are due to poor coordination between units.

Figure 3 sums up the main results in this study. The most important result is that the practitioners discovered that a poorly coordinated workflow resulted in a great delay in the provision of effective treatment to stroke patients.

In organizational theory this indicates that provisioning “theory in use” [11, 12] made a major contribution to professionals’ new understanding.

Could practitioners have achieved their new understanding without been directly involved in the improvement group? An alternative may having process consultants map the entire workflow by walking the stroke pathway (following the patient’s footsteps). This could possibly provide a workflow quite similar to the one produced in the interdisciplinary group (illustrated in Figure 1), which could save time, and allow representatives from the various units to reflect on the fully mapped workflow. However, the results in this study indicate that this strategy is not a workable shortcut. Feedback from the participants in the improvement group reveals that the interaction with other professionals was crucial for the development of their problem understanding. Several participants reported that their understanding changed over time because of the learning process. This can be understood by considering how their increased comprehension was obtained. Understanding was acquired when assessing the logical consistency in a complex graphic workflow consisting of more than sixty work tasks and more than twenty bottlenecks (see figure 1). It is difficult to recreate this opportunity for reflection for employees who have not been part of the learning process. This finding may find support in a study reporting that healthcare professionals benefit most from learning styles that focus on the discovery of connections through their own participation [20]. The workflow mapping also led participants to observe practice with new glasses. Over time they discovered new bottlenecks or problems in the work process as a result of their new perspective.

Interviews indicate that the employees’ new insights made them suspect that poorly coordinated cross-cutting processes resulted in other quality problems in the hospital. Such generalized organizational knowledge will be very valuable to hospitals that have a countless number of hidden cross-cutting processes and where the appropriateness of the distribution of tasks between units had not been assessed. However, the data analysis does not support the assumption that participants have developed a basic understanding that many other quality problems in the hospital are due to poorly coordinated cross-cutting processes. The findings in this study shows that the participants gained little experience from similar improvement work describing the entire interdisciplinary work processes. Therefore, they have not had the opportunity to assess how appropriate the overall distribution of tasks is in other interdisciplinary work processes. One nurse put it as follows: "We have another process where we possibly could use this methodology to improve a cross cutting process. However, it is difficult for us to gain legitimacy to assemble such groups across sub-units in the hospital". The clinical staff also state that a lack of allocated time prevents them from taking the initiative to form interdisciplinary groups. One MD stated: «Those of us who work with patient care are very busy. There is a need for someone who can organize improvement work across the board»

Methodological limitations

The case described is not especially complex or unusual in a hospital context, as many daily work processes require contributions from several professional specialties. It can be argued that the stroke improvement work made a special case because it was easy to establish a common understanding of firstly the need for change, and secondly the feasibility of improvements (a need to offer faster effective treatment to dissolve a blood clot in the brain). Other cross functional processes may need to invest more effort into establishing a common understanding of the necessity of change. In such cases, it will be more important to work on clarifying objectives before choosing a learning methodology like value stream mapping.

This study provides a practical example of how improvement work can be organized in a hands-on way in hospitals so that practitioners can discover the importance of cross-disciplinary coordination for the quality of care. Such knowledge is in demand in summary research [10] and research that questions how hospitals can achieve organizational learning [9]. The participants in this study developed an understanding that other quality problems at the hospital may also be due to poorly coordinated cross-cutting work processes. To develop a deeper understanding of the importance of coordination, practitioners need to regularly participate in practical work that provides opportunities to assess whether the overall coordination of work tasks in other cross-disciplinary work processes is appropriate.

MD: Medical doctor

Authors’ contributions

AF: change agent, data collection, gather feedback, research design, interpretation, main author. JB: conceptualization, frequent discussions during writing process, co-author. GVB: Contributed in designing and planning the study, responsible project leader on behalf of the Hospital, participating in the analytical process and discussions during writing process, co-author. HH: conceptualization, frequent discussions during writing process, co-author. All authors read an approved the final manuscript

Funding

This project is funded by Innlandet Hospital Trust, Norway. The funding body had no role in the study design, data collection, analyses and interpretation of data or writing the manuscript.

Availability of data and materials

The datasets generated in the present study are not publicly available, but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The Norwegian Centre for Research data (NSD) was notified about this study. The data protection officer of Innlandet Hospital Trust`s Institutional Review Board, where the study was conducted also approved the study. In addition, the hospital director has given approval for the researcher to obtain information to shed light on research questions in this study.

All authors declare that the methods were carried out in accordance with relevant guidelines and regulations. Participation in this research depended on informed and voluntary consent. All participants received verbal and written information about the study. All participants who consented to participate signed informed consent forms. They were free to withdraw from the study at any time.

Consent for publication

Not applicable.

Competing interest

The authors declare no competing interests.

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No competing interests reported.

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Creating a common understanding of organizational problems across disciplines in hospitals – a case study of stroke care delivery

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Abstract

Figures

Background

Design and methods

Participants

Data collection

Analysis

Ethical and methodological reflections

Results

Development of strategy – use of an inter-disciplinary group

Mapping the entire workflow clarified the fact that weak coordination between tasks was the main problem.

Understanding dependencies

Ownership of new knowledge led to an obligation to contribute.

Practical changes with intermediate results.

Awareness of the importance of cross disciplinary cooperation.

Discussion

Conclusion

Abbreviation

Declarations

References

Additional Declarations

Status:

Journal Publication

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