Meta-coordination activities: Exploring articulation work in hospitals

Coordination of distributed activities is central to organizational work. The effective functioning of organizations hinges on their ability to manage interdependencies both within (intra-) and between (inter-) various departments. However, more than just the management of these individual dependencies is required for smooth coordination in organizations. Organizations must also manage the interactions between intra- and inter-departmental coordination activities. In this thesis, I investigate a certain set of interactions which I refer to as negative cross-level interactions. These interactions often result in poor performance, increased errors and higher coordination costs. Consequently, in order to achieve organizational goals, workers must perform a certain type of articulation work---meta-coordination activities---to manage and mitigate the effects of these negative cross-level interactions.To examine negative cross-level interactions and how they are dealt with in an organizational setting, I conducted a year-long qualitative research study of the patient transfer process at a large academic hospital in the Northeastern United States. Patient transfers are particularly appropriate to study because they require both intra- and inter-departmental coordination activities to be successful. I focused on the patient transfer activities between two clinical departments (emergency department and neurosciences department) and the role of a non-clinical department (inpatient access department) in facilitating the patient transfer process. I utilized standard qualitative methods including observations, shadowing and interviews. Through this study, I provide a detailed understanding of patient transfer process, with a particular emphasis on (a) the challenges that lead to negative cross-level interactions and its effect on both inter-departmental coordination and on overall hospital workflow, and (b) the meta-coordination activities that are performed to mitigate the effects of these negative cross-level interactions, and (c) the relationship between meta-coordination activities and articulation work.The findings from this study will make contributions to research in the fields of Computer Supported Cooperative Work (CSCW) and Medical Informatics (MI). The main contributions to the CSCW field include (a) examining a unique set of coordination challenges---negative cross-level interactions that occur at the intersection of intra- and inter-departmental coordination activities (b) uncovering a particular type of work activities---meta-coordination activities---that are performed to mitigate the effects of negative cross-level interactions (c) developing a conceptual and empirical understanding of meta-coordination activities (d) identifying meta-coordination activities as a type of articulation work focused on fixing breakdowns that occur when intra- and inter-departmental coordination activities affect each other (e) providing deeper insights on organizational articulation work across multiple levels (f) developing a framework of inter-departmental coordination work that highlights the relationship between the concepts of negative cross-level interactions and meta-coordination activities.The main contributions to the MI field include (a) drawing attention to the role of non-clinical staff during patient transfers (b) providing detailed understanding about an inter-departmental workflow (e.g. patient transfer) that depends on the coordination between clinical and non-clinical departments and (c) informing the design of systems that can support inter-departmental workflows.