Table 5 Managerial response to... | Emerald Publishing

Table 5

Managerial response to challenges in implementing and sustaining standardised flow practices (formal and informal)

	Managerial response
	Formal		Informal
Operational Dependencies	Improvement initiatives: (Inter) departmental meetings focussed on flow: “Stroke doctors have regular meetings with radiologists, discuss good/bad cases, pathway evaluation reports and get good communication. We get invited to meetings and the opportunity to meet regularly with stroke team” (R3) Visibility (KPIs): “ED has competing priorities… To meet the 4h target they transfer out of the ED to the ward. So, that will come ahead of the stroke. They talk about not meeting their 4h, but no-one cares about the stroke care pathway” (SNP2)	Coaching: “The stroke pathway is working very well because the SNP will be involved rather than just being only the ED nurses. You actually have somebody who is specialised on stroke being there to assess with the process” (EDN1) EDC1 added: “The ED nurses are very good but some of them lack confidence. The first few times they need to assess or treat the patient there is a bit of “are we sure we can do this?” and that is where the SNPs have been invaluable, supportive with the staff to do it”	Social capital: Shared stroke care knowledge/interest improved co-ordination. e.g. one Mon. Am SNP1 transferred patient [37] back to ED. She sought a specific ED doctor interested on stroke care to assist her. Although busy with the care of another patient, ED doctor received the handover for the patient and advised SNP1 how to proceed	Authority: Shaped boundaries and information exchange: “I have a very different relationship with the bed managers … Because of what I do, they respond very differently to me.” (EDC1) Engagement: Influenced professionals' knowledge sharing and efforts for improvement: “I think part of the problem is that it is very difficult to get the ED staff to all sit together and discuss issues. They have some many patient groups to care of. Stroke is not their priority or what they are mainly interested about.” During the study period, no ED staff members were present in any interdepartmental meetings. Although ED staff members were invited to the meetings, these were mainly happening between radiology and ASU
Professional dependencies	Improvement initiatives: In addition to stroke professionals, an ED doctor and ED coordinator participated in the design of three pathway artefacts SD3 added: “… nursing wise it matters who is there, I think Y who is involved in a lot of projects related to stroke and she is aware of what the priorities are. The level of awareness of importance and priorities of stroke down there is patchier for the nurses in the ED.” Visibility and clarity: developed and used by experts in each professional group but people with varying levels of expertise use them	Co-location: SNPs had high levels of interaction (e.g. tasked to inform all ED staff members of arrival of stroke patients) and consequently, were more familiar with the working approach of other professionals Improvise: “Hunt the doctor” would involve walking around ED, finding doctors who were available to assist: “Sequence might involve 2–3 different ED doctors, for different medical tests, for the same patient. I often run down here to talk to them because the phones are not being answered (SNP1)” Authority: “I feel that since we started, some ED staff seem to have taken a back seat when it comes to stroke. While I think the patient should be our centre of attention. I should not need to tell them what they should do.” (SNP2)	Authority: One Sunday morning ED nurse asked SNP2 to check patient [47] admitted with “slight confusion”. SNP2 was reluctant to assess immediately. “I do not want to get involved with patients … with limited symptoms of stroke … whenever I go down [to] ED, I do everything for the patient and still in the end, the patient is diagnosed without a stroke.” In case [47] ED doctor did not diagnose stroke and the patient was discharged. [47] was readmitted the following day, diagnosed by ED doctor as stroke and followed pathway Judgement: To avoid delays or inaccurate decision-making, SNPs would contact ED/ASU stroke doctor whom they judged to be knowledgeable and experienced in the pathway: “It is the ED doctor who should assess the patient, but we can also alert our stroke consultant, because our stroke doctors have more experience about thrombolysis and patient outcome than ED doctors” (SNP3)	Authority: “At the weekend we have problems getting a scan booked because sometimes the radiologist can be rude and cranky. So, things like that do not help.” (SNP2) SNP1 added: “I really do not like this radiographer, she is always very rude to me. But, I cannot do anything about it; I really do not have any choice” Co-location: When the SNPs faced issues with ED senior doctors; they voiced their concerns and showed their annoyance to stroke team colleagues, but not to the ED doctors directly. We also observed several discussions between ASU practitioners and RD staff during their interdepartmental meetings, about lack of collaboration from ED staff members
		SNP specific

	Managerial response
	Formal		Informal
Operational Dependencies	Improvement initiatives: (Inter) departmental meetings focussed on flow: “Stroke doctors have regular meetings with radiologists, discuss good/bad cases, pathway evaluation reports and get good communication. We get invited to meetings and the opportunity to meet regularly with stroke team” (R3) Visibility (KPIs): “ED has competing priorities… To meet the 4h target they transfer out of the ED to the ward. So, that will come ahead of the stroke. They talk about not meeting their 4h, but no-one cares about the stroke care pathway” (SNP2)	Coaching: “The stroke pathway is working very well because the SNP will be involved rather than just being only the ED nurses. You actually have somebody who is specialised on stroke being there to assess with the process” (EDN1) EDC1 added: “The ED nurses are very good but some of them lack confidence. The first few times they need to assess or treat the patient there is a bit of “are we sure we can do this?” and that is where the SNPs have been invaluable, supportive with the staff to do it”	Social capital: Shared stroke care knowledge/interest improved co-ordination. e.g. one Mon. Am SNP1 transferred patient [37] back to ED. She sought a specific ED doctor interested on stroke care to assist her. Although busy with the care of another patient, ED doctor received the handover for the patient and advised SNP1 how to proceed	Authority: Shaped boundaries and information exchange: “I have a very different relationship with the bed managers … Because of what I do, they respond very differently to me.” (EDC1) Engagement: Influenced professionals' knowledge sharing and efforts for improvement: “I think part of the problem is that it is very difficult to get the ED staff to all sit together and discuss issues. They have some many patient groups to care of. Stroke is not their priority or what they are mainly interested about.” During the study period, no ED staff members were present in any interdepartmental meetings. Although ED staff members were invited to the meetings, these were mainly happening between radiology and ASU
Professional dependencies	Improvement initiatives: In addition to stroke professionals, an ED doctor and ED coordinator participated in the design of three pathway artefactsSD3 added: “… nursing wise it matters who is there, I think Y who is involved in a lot of projects related to stroke and she is aware of what the priorities are. The level of awareness of importance and priorities of stroke down there is patchier for the nurses in the ED.”Visibility and clarity: developed and used by experts in each professional group but people with varying levels of expertise use them	Co-location: SNPs had high levels of interaction (e.g. tasked to inform all ED staff members of arrival of stroke patients) and consequently, were more familiar with the working approach of other professionalsImprovise: “Hunt the doctor” would involve walking around ED, finding doctors who were available to assist: “Sequence might involve 2–3 different ED doctors, for different medical tests, for the same patient. I often run down here to talk to them because the phones are not being answered (SNP1)”Authority: “I feel that since we started, some ED staff seem to have taken a back seat when it comes to stroke. While I think the patient should be our centre of attention. I should not need to tell them what they should do.” (SNP2)	Authority: One Sunday morning ED nurse asked SNP2 to check patient [47] admitted with “slight confusion”. SNP2 was reluctant to assess immediately. “I do not want to get involved with patients … with limited symptoms of stroke … whenever I go down [to] ED, I do everything for the patient and still in the end, the patient is diagnosed without a stroke.” In case [47] ED doctor did not diagnose stroke and the patient was discharged. [47] was readmitted the following day, diagnosed by ED doctor as stroke and followed pathwayJudgement: To avoid delays or inaccurate decision-making, SNPs would contact ED/ASU stroke doctor whom they judged to be knowledgeable and experienced in the pathway: “It is the ED doctor who should assess the patient, but we can also alert our stroke consultant, because our stroke doctors have more experience about thrombolysis and patient outcome than ED doctors” (SNP3)	Authority: “At the weekend we have problems getting a scan booked because sometimes the radiologist can be rude and cranky. So, things like that do not help.” (SNP2)SNP1 added: “I really do not like this radiographer, she is always very rude to me. But, I cannot do anything about it; I really do not have any choice”Co-location: When the SNPs faced issues with ED senior doctors; they voiced their concerns and showed their annoyance to stroke team colleagues, but not to the ED doctors directly. We also observed several discussions between ASU practitioners and RD staff during their interdepartmental meetings, about lack of collaboration from ED staff members
		SNP specific