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When responsibility for an individual patient is transferred within or between groups of medical professionals, a “handoff” occurs so that patient-specific medical information can be provided to the medical professional(s) assuming responsibility for that patient. Providing an appropriate summary supports safe, high-quality, effective medical care; inadequate or incorrect information may create risk for the patient. A handoff approach was developed to facilitate this process, using the mnemonic “S*T*A*R*T” (S: situation; T: therapies; A: anticipated course; R: reconciliation; T: transfer). Surveys of handoffs occurring before and after introduction of the S*T*A*R*T system document areas with potential for process improvement.

Patient handoffs involve the exchange of information between health professionals accompanying a transfer of responsibility for, or control of, a patient. Concerns over the safety risks of poor handoffs have resulted in regulatory pressure to standardize practice and considerable growth in research. But handoffs involve more than information transfer, and their consequences for health care organizations extend beyond the safety of patients. Using an organization theory lens, we review the literature on handoffs and propose a framework that characterizes handoffs as multifunctional, situated organizational routines. We also identify implications for researchers and hospital policymakers. Standardization and improvement efforts run the risk of causing unintended problems if they overlook the complexity of handoff and the larger organizational functions it serves. Deepening our understanding of the multifunctional, situated nature of handoff can lead to improvement efforts that not only safeguard individual patients, but also enhance the capabilities of the larger health care organization.

The high-risk/high-stress nature of hospital emergency departments has made handoffs (i.e. patient transfers across organizational units) an area of significant safety consequence, as evidenced by numerous studies and 2006 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). Joint Commission Resources, Inc.: Author; 2005. This same high-risk/high-stress environment is known for generating resistance to traditional deficit-based, external expert driven approaches to improvement. The authors describe how one hospital overcame this resistance by using an Appreciative Inquiry approach to the redesign of the information flow and organizational roles within a mission-critical area of the hospital. Rather than designing to ameliorate the root causes of ineffective handoffs, this positive lens approach (Appreciative Inquiry) was used to engage staff in identifying and expanding upon their most effective handoff experiences. Implications for shifting from problem-based design to a positive lens approach in the creation of micro-information systems and new organizational processes are discussed.

In today's internationalized world, value creation consists of knowledge and work integration involving workers from around the world. Members of these globally distributed work teams (GDWT) encounter organizational behavior issues (identity, cultural differences, and leadership) and organization design issues (dependencies, information processing, media use, and teamwork structures). While most research on GDWT focuses on the first set of issues, this chapter is among the few to systematically explore the second set. We propose and elaborate on strategies for either reducing the intensity of collaboration, or enabling teams to collaborate intensely on a global scale. Implications for research and practice are explored.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

John D. Blair examines, in systematic detail, the challenges and opportunities that arise from the significantly different perspectives of context-specific versus context-free researchers and the literatures to which they contribute. He argues that reviews of one type or the other or both types of literatures may provide different understandings of the state of the art in a particular area of health care management. He also provides some detailed suggestions for writing quality reviews along with suggested topics for future reviews.

Adopting an intra-organizational viewpoint is essential to grasp legal intermediation. To deepen our understanding of such phenomena, this chapter proposes a qualitative and “multi-level” approach drawing on insights from the neo-institutional literature, policy ethnography analysis and the research on legal intermediaries. Such a perspective is particularly suited to capture the complexity and the depth of institutional change. Using the 12-hour work legal mechanism of derogation in the context of French public hospitals as an example, this chapter highlights how both macro-level actors (actors of a “reform network”), and micro-level ones (hospital directors) contribute to the shaping and framing of legality in French public hospitals. Results show that variation in how those actors use law depends on the local configuration. Second, results demonstrate that the legal games they play are not merely based on symbolic and superficial compliance with the law, but also on outright manipulations and conscious rule-breaking.

The most basic solution for monitoring position and attitude of an UA is through direct line-of-sight. Because they are usually standing outside, a pilot that maintains direct line-of-sight with the aircraft is usually referred to as the EP, as opposed to an internal pilot (IP) who obtains position and attitude information electronically while inside of a ground control station (GCS). Flight using an EP represents the most basic solution to the problem of separating the pilot from the aircraft while still enabling the pilot to monitor the location and attitude of the aircraft. Pilot perspective is changed from an egocentric to an exocentric point of view. Maintaining visual contact with the UA, the EP can control the aircraft using a hand-held radio control box. Many of these control boxes are similar to those used by radio-controlled aircraft hobbyists and provide direct control of the flight surfaces of the aircraft through the use of joysticks on the box. Very little automation is involved in the use of such boxes, which control the flight surfaces of the aircraft.

A common observation is that both single- and multi-payer health care systems will achieve lower overall costs if they use primary care gatekeeping. Questioning this common wisdom, we focus on the health care access system, that is, the way in which patients gain access to health care. Gatekeeping, the use of primary care providers to control access to more specialized physician and hospital services, has come under intense scrutiny in the United States and in Europe. The few international comparative studies that have focused on the issues of quality of care, cost containment, and patient satisfaction find weak or no support for common assumptions about gatekeeping. Hence, we examine the institutional environments in seven countries in order to: (a) define and categorize health care access systems; (b) identify the components of a health care access system; (c) explore the notion of a strategic fit between health care financing systems and access system configurations; and (d) propose that the health care access system is a key determinant of process-level cost efficiency. Drawing upon institutional and governance theories, we posit that the structure and organization of an access system is determined by how it addresses six essential questions: Who is covered? Which services are included? What are the points of access? How much time elapses before access? What are the ways of selecting among points of access? and Are services and their quality the same for everyone? This analytical framework reveals that national health care access systems vary the most in their points of access, access times, and selection mechanisms. These findings and our explanations imply that access systems are one of the only tools for demand management, that any lasting change to an access system typically is implemented over an extended time period, and that managers of health care organizations often have limited freedom to define governance structures and shape health care service production systems.

The needs for health system change and improved patient safety have been pointed out by policymakers, researchers, and managers for several decades. Patient safety is now widely accepted as being fundamental to all aspects of health care. The question motivating this special volume on patient safety is: How can the increased emphasis on patient safety among health care managers be more effectively translated into better policy and reduced clinical risk? The 12 contributions in this volume are divided into four sections: (1) theoretical perspectives on managing patient safety; (2) top management perspectives on patient safety; (3) health information technology (HIT) perspectives on patient safety; and (4) organizational behavior and change perspectives on patient safety. Patient safety is a topic that provides a fertile niche for management researchers to test existing theories and develop new ones. For example, the patient safety goals of reducing medical errors while maximizing health outcomes draws upon the tenets of evidence-based medicine (EBM), as well as the managerial theories of human relations, organizational culture, organizational development, organizational learning, organizational structure, quality improvement, and systems thinking. Indeed, these and other managerial theories are drawn upon and applied in different ways by the various contributors. Overall, the authors of this volume demonstrate that the future of patient safety for health care management requires health care professionals and managers who can successfully engage in multi-faceted projects that are socially and technically complex.