The case and your client

Your client is large, urban hospital located in Melbourne. The hospital has an Emergency Department, which is having trouble meeting government-established targets for the timely provision of emergency care. That is, patients who attend the ED are waiting too long for assessment, treatment, and discharge or admission. These delays are risky and stressful for patients, and stressful for patients' families and carers. Overcrowding and poor patient flow through the ED also creates an environment where treatment errors are more likely, and is highly stressful for hospital staff (triage nurses, doctors, nurses, management and administrative staff, porters, and the range of professional staff who run tests and x-rays). This situation is also damaging to the hospital's reputation and the morale of staff, because the hospital's performance against their targets is made public, in the interests of transparency. Staff in the ED feel stretched, under pressure, and concerned about the timeliness and quality of care for their patients.

To rectify the situation, hospital management has hired a consultancy firm that specialises in the Toyota Production System and all of its process improvement derivatives (business process reengineering, Lean thinking, Total Quality Management, Six Sigma, and so on). The consultant has worked with the hospital's Improvement Advisor, whose role is to coach medical staff in the development and implementation of process improvement techniques to solve process problems (for example, the flow of patients through the Emergency Department; waiting lists for outpatient services; discharge processes). The consultant and the improvement advisor have attempted to consult with the ED staff (doctors, nurses, administrative staff, porters, managers, etc.) but had low levels of engagement with the improvement project, which led them develop a new process effectively on their own to aid the flow of patients from entering the ED, through to being seen, assessed, treated, and either discharged or admitted.

The new process involved giving the nurses more power and control over the flow of low-risk patients, and conducting and ordering standard preliminary tests (blood tests, x-rays, and so on) - i.e. the nurses conducted a preliminary "workup". The nurses would then advise the doctors on which low-risk patients to see, when, and in what order. The nurses would control the flow of patients so that patients were seen by doctors only when all required tests (e.g. blood and urine tests) had been completed and results received. The aim was to remove "waste" in the system in the form of doctors' time, who could be devoting their attention in the meantime to more critical cases, and step in when and as needed to swiftly finalise and administer treatment, with all relevant information at hand. As part of this process, a physical whiteboard was made up with a grid with the steps in the process, and magnets indicating how many patients were being processed at a given time, and at what stage of their journey they were at (e.g. "waiting for urine test results"; "waiting for availability of ultrasound"; "waiting for blood test results". The time the patients entered the ED, and the time that their "target" expired (e.g. the government target was for all patients to be seen and treated within four hours of arrival) was recorded on the white board, so that the nurses in control of the system were visibly confronted with the "clock" ticking down and the processes yet to be navigated. This system of visual management is called "Kanban".

When the consultant and the Improvement Advisor attempted to implement the system, disappointed ensued. No one understood the new process, and everyone felt it was overly complex, despite the fact that the process was meant to streamline patient flow. The new process was followed half-heartedly. Doctors behaved autonomously, refusing to take process advice from the nurses, and complaining to the Head of the ED about the Improvement Advisor, the consultant, and the management change sponsor intruding into their professional jurisdiction. Nurses were uncomfortable providing an advisory role to doctors. Doctors also protested that "patients are not cars" and that the application of the Toyota Production System was inappropriate for medical contexts. Doctors and nurses protested against their performance being timed and measured at every step within the new process, claiming the measurements did not account for the nuances of the decisions they needed to make, and the complexity of the pathways that patients can take through the ED. When the Improvement Advisor would start work in the ED each morning, to support the implementation of the process, she would find that staff members during the nightshift had been playing "snakes and ladders" and "naughts and crosses" on the Kanban board. The Improvement Advisor was not able to measure performance against the new process, because staff refused to consistently adopt it. The Head of the ED (a doctor), mindful of needing the support of the doctors, produced statistical reports to undermine the legitimation of the new process, which had not had a chance to be properly established.

In frustration, senior management decided to start again, and hire a new consultancy firm that claimed to be expert not only in solving functional problems through process improvement, but in staff consultation and engagement.

YOU are the new consultant who is expert in both elements of problem-solving. Expressed differently, YOU are the new consultant who is expert in looking at organisational problems through a functionalist AND interpretivist/social relativist lens.

Assessment requirements

To complete this assessment you must do the following:

• Analyse and critique the strengths and limitations of the functionalist approach taken by your predecessor (the consultant specialising in the Toyota Production System). This critique must be theoretically informed. That is, you must explicitly draw on the theory of functionalism that we have covered in lectures and tutorials, and the scholarly texts in the Reading List. It is noted that the strengths of the functionalist approach are unrealised in this particular case, but nevertheless you will be able to articulate them and demonstrate your understanding as to why hospital management and the Improvement Advisor is attracted to process improvement. It is crucial that you address the limitations of the functionalist approach. This part of your report might be titled, Lessons learned from the process improvement pilot: a critical functionalist perspective (approximately 500 words).
• Draw on the theory of interpretivism / social relativism to consider why stakeholders (including the consultant and the Improvement Advisor) had different concerns and views about the pilot, why consultation with staff is so important, and why the pilot was not seen by staff as legitimate. You must explicitly draw on the theory of interpretivism / social relativism that we have covered in lectures and tutorials, and the scholarly texts in the Reading List. (If you have studied stakeholder theory in a different course, do NOT draw overtly on this theory; the aim of this part of the assignment is to test your knowledge about interpretivism / social relativism). Consider different methods of consultation that might help develop and legitimate a new process improvement project. This part of your report might be titled, The value of incorporating interpretivism / social relativism into the design of a new process improvement project (approximately 500 words).
• Drawing on your reflections, above, develop a set of consultation recommendations for your client. (approximately 200 words).
• Reflect on some of the challenges that your client might expect to encounter as they facilitate this consultation; identify some of the practical limitations of interpretivism / social relativism. This part of your report might be titled, Proposed consultation process: challenges and limitations (approximately 300 words).
• Consider the "order/regulation - conflict/radical change" axis of Burrell and Morgan's typology of paradigms. Reflect on your role as consultant for this project. Why might your work and role be classified as belonging to the "order/regulation" end of this axis? How does the work you do as a consultant embody assumptions about organisations and society that exemplify an interest in, and valuing of, order and regulation? What are the strengths and limitations of seeing the world through perspectives based on order/regulation assumptions? This part of your report might be titled, Reflections on consultancy assumptions and their strengths and limitations (approximately 500 words).