Organisational and work-place routines and healthcare.
Organisational routines as a concept were introduced in 1940 by Stene and have come to be regarded as the major measure organisations apply to accomplish what they do (Feldman and Pentland, 2003).
This essay examines the study of work-place routines and how this can be used to help ensure the adoption and sustaining of best practice in healthcare organisations. It begins by examining what routines are, their defining characteristics as well as the different types that exist. It then goes on to explore what role routines play in the acceptance and sustaining of innovative work practices as exemplified by the provision of interpreted consultations in General Practices in the NHS.
Routines are important in organisations as most outputs are achieved through the use of specific routines.
Routines were defined by Sidney Winter in 1964 as ‘patterns of behaviour that are followed repeatedly; but are subject to change if conditions change’ (Becker, 2004). The Santa Fe Institute defined routine as ‘an executable capability for repeated performance in some context that has been learned in an organisation in response to selective pressures’ (Feldman, 2000). Feldman described routines first as ‘repeated patterns of behaviour that are bound by rules and customs and that do not change very much from one iteration to another’ (Feldman, 2000) and then as ‘repetitive, recognisable patterns of interdependent actions, involving multiple actors’ (Feldman and Pentland, 2003).
An examination of all these definitions reveals that there are a few defining characteristics of routines including: being recurrent, collective behaviour patterns; being specific; serving to co-ordinate activities as well as to conserve scarce cognitive resources; storing tacit knowledge; reducing uncertainty; conferring stability while containing seeds of change; changing in a path-dependent manner and being triggered by actor-related factors and external cues (Becker, 2004; Greenhalgh, Voisey and Robb, 2007).
Recognising that routines are recurrent, collective phenomena is central to an understanding of the concept. Feldman and Pentland (2003) refer to routines as involving multiple actors. As a result they can be distributed across space or across the organisation but are linked by interactions between the individuals carrying them out. Re-occurrence is also important as it is the regular occurrence of specific behaviours and activities that lead us to refer to them as routines (Becker, 2004).
Routines are context specific and embedded in each organisation and its structures. Being developed to complement their specific background means that there are marked differences in the ability of each routine to be transferred across organisations. They are said to demonstrate specificity. They have histories, local contexts and environmental conditions and, as such, one cannot say that there is a ‘universal best practice’ (Becker, 2004; Greenhalgh, Voisey and Robb, 2007).
Organisations have limited cognitive resources and thus cannot attend to all their goals simultaneously. The processing of repetitive events requires less cognitive resources leaving an increased cognitive potential available for non-routine events (Becker, 2004).
When essential, recurring organisational functions have become a part of the organisational routine, this effectively helps to co-ordinate the activities within the organisation. It does this by regularizing and unifying the practices of the group, supporting a high level of simultaneity as well as providing actors with knowledge of each other’s behaviour on which they can base their decisions (Becker, 2004). Nelson and Winter (1982) express the belief that the routinisation of organisational activities serves to store specific operational knowledge and differs from other repositories of knowledge in that it can store tacit knowledge (Becker, 2004).
The definition of routines as ‘recurrent patterns’ and ‘not changing much’ implies stability. Routines provide stability which serves as a baseline against which to detect novelty or change as well as to compare and to learn. It can therefore be concluded that organisational routines contribute to both stability and change and are very important to organisational flexibility (Feldman, 2000; Feldman and Pentland, 2003; Becker, 2004). The changes in routines take place in a path-dependent manner. Any adaptation of a routine made in response to feedback about its outcomes will be based on the previous state of the routine (Becker, 2004). Finally, routines are triggered by different factors. These include external cues, such as actions from other departments within an organisation, and actor-related triggers, such as an individual’s aspirations, which could dictate performance levels (Becker, 2004).
Types of Routines
Traditionally, routines were seen as an essential aspect of organised work, providing stability while serving as a source of accountability, especially in bureaucracies. They were focused on structures and order and were thus understood as rules or guidelines. This was especially so in the business world where varieties of rules exist and are sometimes written down in forms such as Standard Operating Procedures as described by Cyert and March in 1963 (Feldman, 2000; Becker, 2004).
In contrast to the traditional views, recent theories of organisational routines view them as consisting of two related parts. Ostensive routines embody the abstract generalised ideas or perceptions of the routine and what it entails. They could exist as a taken-for-granted norm or could be codified as Standard Operating Procedures. However, it is important to bear in mind that ostensive routines can never be seen as a single generalisable object because they incorporate the subjective understandings of diverse participants (Feldman and Pentland, 2003; Becker, 2004).
Performative routines are the specific actions taken by specific people at specific times when they are engaged in an organisational routine. This brings the agency into the picture. Routines are carried out by individuals whose reactions occur within personal, institutional and organisational contexts and are motivated by will and intention (Greenhalgh, Voisey and Robb, 2007). Both of these aspects are necessary to constitute what we understand as routine with the performances creating and recreating the ostensive aspect which itself constrains and enables the performances (Feldman and Pentland, 2003).
Interpreted Consultations in General Practices in the NHS
General Practices in the NHS have most of their activities coordinated and patterned into organisational routines to allow for their smooth functioning. These routines tend to be relatively stable and persistent. Recent large-scale immigration to the UK has led to the increasing occurrence of language barriers between healthcare professionals and their patients. As a result, there have been a rising proportion of medical errors, undermining of physician-patient trust and failure of vulnerable groups to access necessary medical care. In 2004, as part of its bid to provide an equitable service based on need, the NHS made a commitment to providing a professional interpreter to any patient that needed it (Greenhalgh, Voisey and Robb, 2007).
The provision of professional interpreting services for clinical consultations can be described as a complex service innovation, and defined as a ‘novel set of behaviours, routines, and ways of working that are directed at improving healthcare outcomes, administrative efficiency, cost effectiveness, or users’ experience and that are implemented by planned and coordinated actions’ (Greenhalgh et al., 2004). It is also worth bearing in mind the fact that the adoption of a complex innovation in any organisation progresses slowly and encounters impediments that have to be dealt with before it can be said to have been effectively assimilated (Greenhalgh, Voisey and Robb, 2007).
This leads us to the question of how an innovation such as interpreted consultations is to be ‘routinised’. As mentioned earlier, current theories of organisational routines emphasise that routines consist of an ostensive as well as a performative aspect (Feldman, 2000; Feldman and Pentland, 2003; Becker, 2004). Recent work emphasises the role of the agency and choice of individual actors especially in response to failure and external environment. In periods of sustained change, effort is required on the part of the individual actors to effectively implement the routines (Greenhalgh, Voisey and Robb, 2007). It therefore stands to reason that failure of an innovation to become routinised could also be a result of the individual actors.
In the General Practices studied by Greenhalgh, Voisey and Robb, (2007), routines were established for providing interpreters for clinical consultations when needed. These included steps such as: ascertaining the language the patient spoke; the booking of the interpreter for future consultations; linking the interpreter to the correct doctor and patient on the day of the appointment and completion of paperwork to allow the interpreter to get paid following the consultation. There was considerable variation between the practices on how well-developed the routines were (Greenhalgh, Voisey and Robb, 2007). This is in line with the concept of routines being specific and embedded in the organisation in which it is taking place (Becker, 2004).
A routine may fail to be adopted for a variety of reasons. For the practices studied, the most commonly perceived problems were: poor collaboration and communication between the GPs and the interpreters, poor coordination on the part of the GPs, the inadequacy of the interpreter service to deal with the patient load as well as the difficulty of working within the inflexibility of the rules of the interpretation service which made little or no allowance for the unpredictable nature of illness (Greenhalgh, Voisey and Robb, 2007).
Most of the problems encountered by the GPs in their attempts to provide interpreted consultations had to do with having to work within the constraints imposed by NHS regulations and policies as well as the wider environmental factors, such as the level of immigration and population requiring the services. Working within these constraints would limit the extent to which the staff and practices could modify the process to suit their specific contexts, which also helps to speed up the adoption of an innovation (Greenhalgh et al., 2004; Greenhalgh, Voisey and Robb, 2007). It is also worth mentioning that the routines were complex, requiring multiple steps, a fact that might reduce the possibility of the adoption of an innovation, as routines perceived as simple are more likely to be adopted (Greenhalgh et al., 2004). A solution to that problem might be the breaking down of the routine into smaller steps with more individual actors taking responsibility for more of the steps.
Routines are a measure used by healthcare organisations to achieve most of their work processes and are an essential component in organisational change and flexibility. While routines could be made up either of taken-for-granted norms or clearly outlined Standard Operating Procedures, they are carried out by individual actors motivated by will and the intention of working in a variety of contexts. As a result, they are uniquely capable of being modified or changed and are useful as a means of introducing innovative changes within an healthcare organisation as exemplified by interpreted consultations within GPs in the NHS. However, greater flexibility to allow for contextual differences between different GPs might allow for wider assimilation of the practice.
Becker, M. C. (2004) ‘Organisational Routines: A Review of the Literature’ Industrial and Corporate Change 13(4): pp. 643–677
Feldman, M. S. (2000) Organisational Routines as a Source of Continuous Change’ Organisational Science
Feldman, M. S. and Pentland, B. T. (2003) ‘Reconceptualizing Organisational Routines as a Source of Flexibility and Change’ Administrative Science Quarterly 48(March): pp. 94–118
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P. and Kyriakidou, O. (2004) ‘Diffusion of Innovation in Service Organisations: Systemic Review and Recommendations’ The Milbank Quarterly 82(4): pp. 581–629
Greenhalgh, T., Voisey, C. and Robb, N. (2007) ‘Interpreted consultations as `business as usual’? An analysis of organisational routines in general practices’ Sociology of Health and Illness 29(6): pp. 931–954