Search

We examine how organizations select some routines to be changed, but not others, during organizational search. Selection is a critical step that links an exogenous trigger for change, change in individual routines, and larger processes of organizational adaptation. Drawing on participant observation of an initiative to improve perioperative efficiency in seven Ontario hospitals, we find that organizational roles shape selection by influencing both politics and frames in organizational search. Roles shape politics by defining the role-specific goals of the people who have authority to change a routine. Organizations will not select a routine for change unless at least some elites—people with role-based authority—frame the existing routine as negatively affecting their role-specific goals. Roles also shape individuals’ frames. Because people are only partially exposed to interdependencies between routines in their day-to-day work, they may not be fully aware of the diverse impact that an existing routine can have on their goals. Proponents for change can use strategic framing to focus attention on interdependencies between routines to get elites to better see how an existing routine negatively affects their goals. They can also change elites’ goals by using strategic framing to focus attention on new and broader goals that the change in routine would promote. [ABSTRACT FROM AUTHOR]

Study Objective: In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care., Methods: We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted., Results: In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (-14 minutes [95% confidence interval {CI} -47 to 20]) but decreased after wave 2 (-87 [95% CI -108 to -66]) and wave 3 (-33 [95% CI -50 to -17]); median ED length of stay decreased after wave 1 (-18 [95% CI -24 to -12]), wave 2 (-23 [95% CI -27 to -19]), and wave 3 (-15 [95% CI -18 to -12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI -0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone., Conclusion: Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation., (Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)