**4.1 Learning and knowledge creation culture**

Middle managers would like to have data about the performance in real time, in order to be able to take appropriate actions if the situation starts to be worse, instead of saying the following day that: "oh well, now this was damn crazy yesterday". It should be possible to follow up and document lead times at the triage work, if it is going up and down. This is now just recognized based on experience of the staff. Thus, there is a prevalent culture where the staff adapts to changes in the admission of patients. Moreover, knowledge of how to match the schedule to the needs is important and it makes the planning much smoother. Knowledge and experience of where there are shortcomings and what needs to be changed in the planning saves a lot of resources. However, professionals need a lot of education to acquire such knowledge. The departments also have whiteboards for planning and following up on the daily management. The resource utilization can also be reassessed if anyone anticipates changes in the workload. Moreover, oral analyses are made at the departments on a daily basis. These analyses focus on what worked and what did not work, deviations and so on, and aim at learning and creating knowledge for the future operations and capacity planning at the department. These oral analyses are however not documented and deeper analyses are sometimes needed. Moreover, the results from the previous day are sometimes more or less obvious. There is a desire at the hospital to work with, and follow up, based on real-time data, instead of using data from the day before, in order to learn and create more appropriate knowledge, and be able to put in efforts a little earlier. A suggestion is to have a visual and real-time based monitor that shows the inflow, the operations, and outflow of the hospital as support for the daily planning.

Since the operations at the emergency department cannot be planned in advance, resources are allocated based on historical numbers of patients. It is somewhat unclear how many patients the emergency department can handle, as there is no defined assignment. The professionals work toward a goal of shortening the waiting times at the emergency department based on requirements from the regional level. Forecasts are dependent on whether someone discovers changed patterns in an ad hoc basis. It is difficult to compare outcomes since there have been so many changes at the hospital during the last years.

A certain number of operating rooms with staff and other resources must be available at the hospital. The planning of resources is not directly related to which operating activities will be conducted in these operating rooms. Instead, the operating rooms with staff and other resources are prepared for immediate use. The number of prepared operating rooms is measured in retrospect, based on how much the operating rooms were actually used at a specific time, or a specific day. The

managers have discussed whether they could do as much in 10 rooms as they do in 12 rooms, so it is not only a matter of the number of rooms. The dimensioning of capacity is thus not only based on knowledge about needs: traditions are also crucial. Different doctors or departments are, for example, used to be in one specific operating room, and may not want another doctor or department to use it. There are huge discussions about how the scheduling of the operating rooms should be arranged, and how the availability and the use of the operating rooms can become more effective. There are some ideas about how to solve this situation. As doctors often have other things planned at the same time, and the time is not clearly set aside for the operation, the schedules for doctors could be more strict. Learning how to manage the required resources has to improve.

The production of health care at the hospital depends on how the professionals are scheduled to work, as patients have planned visits to a specific department or visit the emergency department. This is a way of production, capacity planning, and dimensioning that is based on old traditions. Different amount of time is devoted to scheduling the staff, depending on how experienced the planning staff is in identifying shortcomings. The staff should have knowledge to schedule their own work, but sometimes a manager has to decide. Based on experience, the number of patients, and how their medical needs have to be followed up, the situation is monitored based on what is working and what is not working at each department. Managers want to follow up the daily work in order to analyze the performance, but this is only done occasionally based on knowledge about a normal situation. Since there are no routines for documenting the work performance, analyses and follow-

Forecasts are reviewed once per year. The health-care agreement specifies a number of admissions; a number which is independent of the number of average admission days. The number of admissions is monitored and communicated to the decision makers. The use of resources cannot be estimates based on the specified number of admissions, since admissions can last from 1 day to a few months. This situation puts pressure on physicians to discharge patients before they are fully investigated. Activities related to patients with planned visits to specific departments need to be considered and planned to ensure a smooth workflow with

Readmissions do not take into account on what medical basis the patient was previously admitted, and there are no regulations of how readmissions are defined at or between hospitals. The health-care professionals have to use their own knowledge and experience in order to share knowledge about the medical status of the patient, and if the patient seems to be readmitted, or admitted for the first time. There are also daily meetings about the current situation among all the departments. Each discharge of a patient needs to be planned right from the time of the admission. Since many patients are frail elderly who need interventions from the municipality health care and the primary health care at home, other health-care

The departments within each area have one daily meeting where the managers and coordinators meet for their common planning. It is important to exchange information about the discharge of patients, in order to reach the goals for the outflow. Both the common inflow and the common outflow are important to monitor within each area. Especially, the flow of patients at a medical elderly health-care department is important. At the same time, as a patient is admitted, the staff has to plan the discharge of the patient, and therefore it is important to quickly estimate the number of admission days for the patient. The coordinators also have contact with the physicians in order to allocate the patients between the different departments depending on their medical needs. Whether the patient is still admitted at a department related to the medical needs is also followed up after 1 day. Knowledge about the patients, their medical status, and number of admission days, is continuously shared. Knowledge about the status of the patients is also shared with nurses and other professionals in the municipalities where the patients live in order to plan

Improvement work, for example, regarding more effective working methods, is primarily initiated by department managers. Ideas often come from the staff. The ideas that come directly from the professionals are often the best ideas. A lot of brainstorming takes place at department meetings, and there are well-established routines and professional skills for how to transform the organization and achieve

ups are not documented.

*Operations Knowledge Management in Health Care DOI: http://dx.doi.org/10.5772/intechopen.93793*

appropriate capacity each day.

providers need to be involved in planning the discharge.

for supporting them in their homes after discharge.

knowledge diffusion.

**259**

Even though collaboration and knowledge sharing with other health-care organizations is highly prioritized, as it contributes to decreasing the emergent inflow of patients, the extent of collaboration and knowledge sharing within and between departments largely depends on staff availability. A coordinator at each department is responsible for having daily meetings with other coordinators, in order to gather knowledge from the doctors and distribute knowledge to the departments about what is going on at the moment, and what inflow and outflow of patients to expect during the day.

There is a test package for each group of disease, such as X-ray, blood tests and other screening activities. These tests need to be taken from each patient and analyzed. However, there is no follow-up if those standardized test packages are needed every time. Thus, the knowledge about the effectiveness of such test packages is not acquired at the hospital. This is one example of an area for improvements in the learning and knowledge creation culture, where the health-care OM could be more appropriate.

The learning and knowledge creation culture does not seem so formally structured in the organizational culture at the hospital. Planned activities that support learning and knowledge creation, especially activities that could contribute to improving the performance of the organization, do not seem to exist. KM practices do not seem to be an implicit assumption that guides how the professionals act. The interviewees did not discuss any specific or formalized KM-specific roles or operations which suggest that any formal KM initiatives exist. Yet, there are different informal learning and knowledge creation activities going on. Therefore, the learning and knowledge creation culture is not at all missing at this hospital.

#### **4.2 Organizational architecture for adaptive and exaptive capacity**

Three different IT systems are used for forecasting, planning, and follow-ups, however, they are used in different ways at different departments. The emergency department uses one more IT system that makes it possible to compare numbers in all the regional emergency departments, also at other hospitals. One IT system together with Excel sheets are used for scheduling the staff. Since the IT system alone does not give a clear picture of the schedule in order to plan, Excel sheets are also used. Information about activities conducted in relation to the patients is registered in another IT system. Some information is also registered in the patients' medical record system. These IT systems are not integrated and do not have all the functions that are actually needed. Since the staff must always be reminded of manual routines, the statistics cannot always be trusted. The data quality thus partly depends on how well the professionals remind each other to register information. For example, doctors have to manually register when meeting a patient in a planned visit and for how long time. This system also makes it difficult to detect deviations in the reported information and what has happened in reality.

#### *Operations Knowledge Management in Health Care DOI: http://dx.doi.org/10.5772/intechopen.93793*

managers have discussed whether they could do as much in 10 rooms as they do in 12 rooms, so it is not only a matter of the number of rooms. The dimensioning of capacity is thus not only based on knowledge about needs: traditions are also crucial. Different doctors or departments are, for example, used to be in one specific operating room, and may not want another doctor or department to use it. There are huge discussions about how the scheduling of the operating rooms should be arranged, and how the availability and the use of the operating rooms can become more effective. There are some ideas about how to solve this situation. As doctors often have other things planned at the same time, and the time is not clearly set aside for the operation, the schedules for doctors could be more strict. Learning how

Even though collaboration and knowledge sharing with other health-care organizations is highly prioritized, as it contributes to decreasing the emergent inflow of patients, the extent of collaboration and knowledge sharing within and between departments largely depends on staff availability. A coordinator at each department is responsible for having daily meetings with other coordinators, in order to gather knowledge from the doctors and distribute knowledge to the departments about what is going on at the moment, and what inflow and outflow of patients to expect

There is a test package for each group of disease, such as X-ray, blood tests and

The learning and knowledge creation culture does not seem so formally structured in the organizational culture at the hospital. Planned activities that support learning and knowledge creation, especially activities that could contribute to improving the performance of the organization, do not seem to exist. KM practices do not seem to be an implicit assumption that guides how the professionals act. The interviewees did not discuss any specific or formalized KM-specific roles or operations which suggest that any formal KM initiatives exist. Yet, there are different informal learning and knowledge creation activities going on. Therefore, the learn-

Three different IT systems are used for forecasting, planning, and follow-ups, however, they are used in different ways at different departments. The emergency department uses one more IT system that makes it possible to compare numbers in all the regional emergency departments, also at other hospitals. One IT system together with Excel sheets are used for scheduling the staff. Since the IT system alone does not give a clear picture of the schedule in order to plan, Excel sheets are also used. Information about activities conducted in relation to the patients is registered in another IT system. Some information is also registered in the patients' medical record system. These IT systems are not integrated and do not have all the functions that are actually needed. Since the staff must always be reminded of manual routines, the statistics cannot always be trusted. The data quality thus partly depends on how well the professionals remind each other to register information. For example, doctors have to manually register when meeting a patient in a planned visit and for how long time. This system also makes it difficult to detect deviations

other screening activities. These tests need to be taken from each patient and analyzed. However, there is no follow-up if those standardized test packages are needed every time. Thus, the knowledge about the effectiveness of such test packages is not acquired at the hospital. This is one example of an area for improvements in the learning and knowledge creation culture, where the health-care OM could be

ing and knowledge creation culture is not at all missing at this hospital.

**4.2 Organizational architecture for adaptive and exaptive capacity**

in the reported information and what has happened in reality.

to manage the required resources has to improve.

*Operations Management - Emerging Trend in the Digital Era*

during the day.

more appropriate.

**258**

The production of health care at the hospital depends on how the professionals are scheduled to work, as patients have planned visits to a specific department or visit the emergency department. This is a way of production, capacity planning, and dimensioning that is based on old traditions. Different amount of time is devoted to scheduling the staff, depending on how experienced the planning staff is in identifying shortcomings. The staff should have knowledge to schedule their own work, but sometimes a manager has to decide. Based on experience, the number of patients, and how their medical needs have to be followed up, the situation is monitored based on what is working and what is not working at each department. Managers want to follow up the daily work in order to analyze the performance, but this is only done occasionally based on knowledge about a normal situation. Since there are no routines for documenting the work performance, analyses and followups are not documented.

Forecasts are reviewed once per year. The health-care agreement specifies a number of admissions; a number which is independent of the number of average admission days. The number of admissions is monitored and communicated to the decision makers. The use of resources cannot be estimates based on the specified number of admissions, since admissions can last from 1 day to a few months. This situation puts pressure on physicians to discharge patients before they are fully investigated. Activities related to patients with planned visits to specific departments need to be considered and planned to ensure a smooth workflow with appropriate capacity each day.

Readmissions do not take into account on what medical basis the patient was previously admitted, and there are no regulations of how readmissions are defined at or between hospitals. The health-care professionals have to use their own knowledge and experience in order to share knowledge about the medical status of the patient, and if the patient seems to be readmitted, or admitted for the first time. There are also daily meetings about the current situation among all the departments. Each discharge of a patient needs to be planned right from the time of the admission. Since many patients are frail elderly who need interventions from the municipality health care and the primary health care at home, other health-care providers need to be involved in planning the discharge.

The departments within each area have one daily meeting where the managers and coordinators meet for their common planning. It is important to exchange information about the discharge of patients, in order to reach the goals for the outflow. Both the common inflow and the common outflow are important to monitor within each area. Especially, the flow of patients at a medical elderly health-care department is important. At the same time, as a patient is admitted, the staff has to plan the discharge of the patient, and therefore it is important to quickly estimate the number of admission days for the patient. The coordinators also have contact with the physicians in order to allocate the patients between the different departments depending on their medical needs. Whether the patient is still admitted at a department related to the medical needs is also followed up after 1 day. Knowledge about the patients, their medical status, and number of admission days, is continuously shared. Knowledge about the status of the patients is also shared with nurses and other professionals in the municipalities where the patients live in order to plan for supporting them in their homes after discharge.

Improvement work, for example, regarding more effective working methods, is primarily initiated by department managers. Ideas often come from the staff. The ideas that come directly from the professionals are often the best ideas. A lot of brainstorming takes place at department meetings, and there are well-established routines and professional skills for how to transform the organization and achieve knowledge diffusion.
