An exploration of standardised processes in a knowledge-intensive healthcare operation: Implementing the acute stroke care ‘pathway

  • Marianna Frangeskou

Student thesis: Doctoral ThesisPhD


A widely used mechanism for improving the efficiency and effectiveness of healthcare is the introduction of the clinical care pathway (i.e. an OM-type process initiative summarising the optimal sequencing and timing of care for different types of patient). Research to date suggests variable levels of success for these improvement initiatives and, consequently, the research reported in this thesis sought to answer two framing research questions: (1) What, if any, are the distinctive characteristics of standard professional/judgement (healthcare) work, and (2) What are the challenges associated with implementation of standard work in a professional (healthcare) operations setting? The work draws on, and develops, concepts and insights from (healthcare) operations management and organisational routines. The research design takes the form of a single in-depth case study of the adoption of a stroke care pathway in a UK hospital, but various methods were used to triangulate the source material (e.g. multiple interviews, extensive non-participant observation, analysis of archival documents, performance data, etc.). The research suggests three areas where there is novel (OM) insight and specific implications for both healthcare practitioners/policy makers.Firstly, the stroke care pathway was a UK national (i.e. top-down) initiative requiring local implementation. This setting highlighted a specific gap in the traditional process logic. The pathway took flow dependency as its design logic but failed to recognise that a single treatment pathway would also be subject to other forms of dependency that would, in turn, undermine the adoption process. Specifically, informal competition between pathways for particular resources such as scanning created resource-sharing dependencies. Similarly, integration with other extant formal and informal care pathways, manifest in hospital KPIs, flow charts (and other artefacts) diagnostic disputes and the basic geography of the Hospital created fit/portfolio alignment dependencies. For theory, stressing the need for a multi-faceted/level notion of process is a key insight and for practice, these dimensions represent a useful extension for future pathway design.Secondly, building on key insights from the routines literature, pathway artefacts (diagrams, instruction manuals, software, etc.) can offer a critical insight into a key challenge for ‘standard’ (and the standardising of) professional work: individual autonomy. Autonomy with respect to specific (care) judgements is arguably the characteristic of such knowledge work but it inevitably leads to differential interpretation (diagnoses, models of care), negotiations and consequential “turf wars”. Artefacts can be a significant visual/physical manifestation of these ‘zones of autonomy’. It is equally important to note that the accuracy and representation of artefacts may have an effect on how practitioners perceive and process information, which subsequently is used to perform the work. For theory, OM scholars need to move beyond a normative (this is the flow, etc.) view on process artefacts (e.g. process maps simplistically labelled ‘as is’ and ‘to be’) and for practice, developing a more interactive and collaborative approach to the creation of these artefacts may add significant value to the design/implementation process.Thirdly, the notion of continuous improvement needs to be revisited in professional/knowledge-intensive work settings. Specifically, mechanisms for knowledge sharing between (professional) individuals need to be more fully considered. Some of this relates to the above conclusions, fuller characterising of the pathway, active consideration of professional autonomy (and use of artefacts to help understand and improve the inevitable ‘design as negotiation’ process) but the research also highlights the significance of investing in support of relational resources between healthcare practitioners. Some of this builds on ‘typical’ OM logic, co-locating spaces, time to communicate, support (S&OP type) infrastructure, etc. which, can, ironically be overlooked because of the very autonomy described above.
Date of Award30 May 2018
Original languageEnglish
Awarding Institution
  • University of Bath
SupervisorChristos Vasilakis (Supervisor) & Michael Lewis (Supervisor)



Cite this