Abstract
This research article presents a Full Thinking Process Analysis (FTPA), along with an in-depth comprehension of changes in healthcare, through a reframing of the Three-Cloud Approach. The reframed Three-Cloud Approach provides useful insights into the change implementation process, as it relates to the construction challenge of a new, 1000-bed hospital. Pertinent documents, formal evidence and interviews reveal multiple types of constraints, their dissolution and the implementation of shared answers to observed problems. Through the lens of the Thinking Process-Three-Cloud Approach, the case study shows how the process of identifying the Core Conflict Cloud is fundamental to implementing ongoing strategic and organizational change. The Three-Cloud Approach allows in-depth analyses of resistances to change and other intra-organisational processes, while it highlights the conditions necessary for underpinning and designing effective tactics for successful change implementation.
Introduction
On the wave of growing complexity in managing public and private domains, practices aimed at investigating, analysing and solving problems of organisational boundaries seem to be a sort of panacea for managers. Accordingly, the Theory of Constraints (TOC) has received great attention from academics and practitioners since the seminal work of Goldratt in the early 1980s. As a system-based management approach, TOC helps managers to find solutions to their problems through, simply, intuition and logic [1, 2]. In fact, TOC based its philosophy on Herbert Simon’s research endeavour [3] to comprehend the processes (e.g. perception, thinking, memory and imagery) that participate in human decision making. The Simon’s idea is that human beings do not maximize their choices, they satisfice choosing a good enough option, not the best option. The complexity of the environment and humans’ limited cognitive system make maximisation impossible in real-life decision-making situations.
The Thinking Process (TP) is one of the main streams concerning the TOC [4] and specifically it is a “methodology for addressing complex change issues” [5]. The change happens through the analysis of factors that act as a constraint in achieving the goals and objectives of organisations. The essential steps of the Thinking Process (TP) are: (a) the identification of these resistances (through the “What to change?” question), (b) the study of solutions to overcome them (focusing on “What to change to?”) and (c) planning a project of change to implement the solutions found (in answer to the question “How to make the change?”) [6–10].
As many authors describe, human systems (e.g. managers, change agents) manage this change path rationalising their ideas by means of tools (logic diagrams) with the aim to achieve the desired outcomes [5, 11]. Some authors [11] call “Full Thinking Process Analysis (FTPA)” the sum of these logic diagrams: the Current Reality Tree (CRT), Evaporating Cloud (EC), Future Reality Tree (FRT), Prerequisite Tree (PRT) and the Transition Tree (TT).
There are studies that focus their analysis on some of these tools, mainly the ones necessary to analyse the state of the art in an organisation [11]. Few investigations discuss the entire FTPA following the traditional sequence of tools mentioned above [9, 12–16]. Those researchers presenting a case study interpreted through an innovative order of tools, called the Three-Cloud Approach, introduce Negative Branch Reservations (NBRs) as the only change implementation tool [7, 17]. In fact, in both these studies the design of PRT and TT ismissing.
Worthy of attention, none of these studies develops the potentialities of the Three-Cloud Approach considering a simulated reality as the result of no action of change. Before deciding, managers ask to their-selves the natural consequences of some circumstances that require their attention. Thus, decisions derive from the awareness of future scenarios preserving the status quo. As Simon develops an effective and realistic model for decision makers to predict future outcomes [18], TP and, particularly, the Three-Cloud Approach could be the means to simulate the reality. Furthermore, the majority of the research focuses on manufacturing businesses and there is limited evidence in the service sector and healthcare in particular [9, 11].
These statements could appear challenging for an investigation of Western healthcare organisations that have recently shown an interest in improving the quality of care and performance while reducing accidents, waste and costs [19–21]. The TP (and the Three-Cloud Approach in particular) involves an in-depth analysis which makes the change process more workable. The TP underlines the human resistance to change and how to bring together different points of view for a better and shared result.
This article aims to introduce a FTPA and an in-depth comprehension of healthcare settings through the identification of internal change mechanisms. Specifically, the FTPA discussed shows some elements of innovation regarding the traditional sequence of tools used in previous literature. Exploration of the Three-Cloud Approach provides useful insights into the implementation process with EC, PRT and TT tools.
The focus on the implementation side of the process makes it possible to identify, analyse and manage human resistances to change starting from the initial stage. In this perspective, the centrality of EC analysis in the entire TP drives the top managers fulfilment of Core Conflict Cloud (CCC) that identifies the strategic change and the implementation priorities in the CRT. Previous studies on the Three-Cloud Approach have failed to highlight this strength and the crucial link (through the CCC) between the CRT, PRT and TT for decision-makers. This study points the gap out.
The construction of a new 1000-bed hospital seems to be a challenging area for studying the TP at work. In detail, researchers were involved for 3 years in thinking up an innovative way of organising the new building according to the intensity of care standards and patient focus. One of the projects of this huge programme of change concerns the design and implementation of new material flow logistics for the surgical block, which is the content of the article. Although the process analysed is only one section of the entire patient care process, the surgical area is one of the most critical areas with regard to speciality and emergency requests and the relevance of costs (also for materials).
Moreover, the hospital’s top managers have to take the re-organisation of the surgical block into consideration as the main problem. In fact, the move to the new hospital was postponed many times and this fact had many consequences. Firstly, the total costs of the construction increased and the new top managers were forced to solicit the regional government for more funds. Secondly, the internal staff were under stress to maintain a high quality of care while they were involved in the entire process of change. The new top managers established, during a process of change that is still under way, that the partial design of the organisational flows of the OTs and, above all, the implementation steps could not fail. An inefficient organisation of the new surgical block would had untenable consequences on the hospital’sperformance and image.
As managers of many organisations could be in the same situation as in the case described, where they must to take decisions based on an already started process of change, researchers based their analysis on this consideration. Methodologically, informal meetings, documents and notes from observations are used to analyse multiple types of conflict (i.e. physical, cultural, organisational, information, resource, political, etc.), their solution and the implementation of the shared answers to problems observed.
Initially, an overview of the TP path, previous FTPA studies and prior consideration about the importance of CCC will be presented (Section 2). After providing some background to the study and analysis motivation (Section 3), TP logic diagrams will be presented and interpreted (Section 4). Discussions (Section 5) and the conclusion (Section 6) are further presented.
Literature review
According to the TOC origins, this approach recognises the systemic nature of organisations in which the system is not just the sum of the components. Compared to traditional management philosophies, TOC is system focused in which managers has the aim to integrate the system components creating a whole that is larger than the sum of its parts [5].
The TP is one of the streams of the TOC, usually identified with five tools, “which enables the identification, analysis, and proposition of solutions for the organisational problems” toward a systemic view [22]. Goldratt describes it in his second best seller “It’s not luck” [23] with the aim being to generalise the use of the TOC’s constructs in various industries and at multiple levels.
The formal methodology [5] provides a way of identifying and analysing problems in the organisation discovering the weakest link(s) of the chain through the Current Reality Tree (CRT) and exploring the setting of this/these problem(s) (through Evaporating Cloud(s) (ECs)). The majority of cases studied refer to CRT and EC tools but not necessarily used together in the same research [11]. Only some of these show the CRT and EC together, although the joint use “provides potentially for more diagnostic and solution generation power than individual use of the EC or CRT” [11].
When the situation is clearer it is time to propose solutions to overcome the conflicts. The Future Reality Tree (FRT) shows cause and effect links able to solve the core conflict depicted in the current state of affairs. The FRT is normally associated with highlighting strategic injections (INJ) through a decisive path suitable for transforming undesirable effects (UDEs) into desirable effects (DEs) [23].
As decision-makers need an effective process, the implementation of the solutions is facilitated by the construction of the Prerequisite Tree (PRT) and the Transition Tree (TT). The PRT helps decision-makers to investigate problems associated with the solutions selected, identifying the prerequisites and the actions needed to overcome them. The TT supports the PRT and the implementation of change through a detailed plan “in moving from the present situation to the desired objective” [24].
Recently, some authors have summarised the assumptions of the implementation path with Negative Branch Reservation (NBR) exploring the possible new negative effects that could materialise in activating the solution. Since the introduction of NBR, some new reasoning regarding the use of tools has emerged from practice. Practitioners admit, for example, that the design of the CRT is too complicated and time consuming. This is the reason for the debate on the Three-Cloud Approach proposing a synthesized CCC responsible for the majority of the identified UDEs. The Three-Cloud Approach shows a different sequence of tools from the traditional (CRT-EC-FRT) one [7, 17]. Positive and even unexplored implications of this point are illustrated later.
As Kim et al. [11] recognise, there are few articles that analyse the full Thinking Process, probably due to difficulties of mapping the implementation process. Furthermore, the Three-Cloud Approach is only applied to these studies and requires some field work insights to increase the theoretical comprehension.
As regards FTPA research, Gupta et al. [14] focus their attention on how the TP tools help managers in an organisation to implement the strategy. Cause-and-effect relationships are interesting for comprehending management’s perceptions of managing business problems and solving resistance to change. The core problem identified concern cultural and organisational aspects. The solution path involves an effectuation process by which means are clear and available for developing creative solutions.
The emphasis on strategic planning and the full TP is shared by Boyd et al. [13] who set out to open the black box of strategy formulation through a systematic analysis with the tools under investigation. The authors base their empirical test on a teaching case that shows human resources, marketing, operations and leadership issues in a situation calling for immediate action.
As Gupta et al. [14] suggest, the FTPA can also be used in causation processes (i.e. when means are uncertain and the objectives are clear). Worley [16] describes the Motion Picture Production case study with the aim of highlighting uncertainties for each phase of the production process, mapping above all infrequent and unexpected uncertainties. This process is particularly effective in optimising the ways of conducting the project and for establishing routine decisions in each phase. The majority of uncertainties identified refer to physical and organisational constraints, although resource constraints play an important role in the unexpected events.
Klein and Debruine [10] suggest the TP as an approach to clawing back market shares for U.S. companies from Japanese and German firms. The manufacturing sector demonstrates how the management of constraints is necessary to reach good performance for the entire organisation. Mateen and More [25] depict the challenge in adopting supply chain finance in the Indian business environment. Through a detailed list of possible obstacles to the introduction of supply chain finance practices (UDEs), the authors develop FTPA with the aim of arranging a concrete plan for the organisations concerned to overcome the problems.
The focus on a positive ending of the implementation process is strengthened by the academics adding NBR to the PRT and TT. In this way, they map detailed negative impacts concerning the INJ developed with the EC after the design of the CRT. As the analysis is conducted considering a single case study, but the aim is to reach at least the businesses participating in the survey (collecting the initial UDEs), there are no precise references to people engaged with the change or their concrete resistances.
On the contrary, in reference to the healthcare sector, Ritson and Waterfield [15] conduct a study to align the delivery of mental health services with the population in a UK region. As a premise of the FTPA application, the authors identify change agents among the healthcare domains suggested by Glouberman and Mintzberg [26]: cure (physicians), care (nurses), control (administrators) and community (boards). Following on from this, they make use of the tools to promote a team approach that modifies the traditional role of managers; physicians and administrators are both enablers and managers of the change process.
Because of conflicting objectives, in the healthcare organisations the stakeholders quoted by Glouberman and Mintzberg [26] could enhance resistance to change. Physicians, nurse managers and administrative staff collaborate with difficulties [27] because of their conflicting aims and completely different background. As with manufacturing organisations, the most difficult constraints to be overcome are the cultural ones.
Mabin et al. [9] develop an interesting study using FTPA tools and the Three-Cloud Approach to overcome business resistance. According to TP assumptions, authors view resistance to change as positive instances: “Central to this methodology is an appreciation of resistance as a necessary and positive element in any change process” [9]. In fact, what decision makers and change agents label as “resistance”, could depict new ideas for the path of change. Thus, some academics depict resistance as a barrier to be overcome while others consider it as a novel idea for change. The TP is based on continuous loops of resistance identification and providing solutions.
Mabin et al. [9] in their analysis introduce a list of factors which could cause resistance to change, such as poor timing, force of habit, lack of confidence, fear of the unknown, loss of control and/or loss of face and/or competency, the need for security, lack of support and lingering resentment. Identifying these factors is an essential activity for the design and execution of the process of change through TP tool. Managers identify the core problem as the basis of the CRTand they propose a solution firstly through the EC and then the FRT.
After these steps, managers prefer to focus on the TT rather than the PRT. The PRT was not considered useful until managers wished to divulge the change program to other branches. Despite the authors’ intent to show the Three-Cloud Approach, the identification of the core problem does not appear to be rooted in ECs. As in the traditional sequence of TP tools, the aim of the EC is to find a solution for the problem.
Reid and Cormier [7] and Shoemaker and Reid [17] show the logical operation of the Three-Cloud Approach. The identification of the CCC following the design of ECs that gather the most UDEs is the essential step towards creating the CRT. As Davies et al. [2] argued, the CRT is not an empowerment tool, but it “usually paints a gloomy picture of the current situation and of the impact of inaction, and while it does motivate into action, it would not be seen as empowerment in the critical sense of the concept”. In these terms, CRT could also depict a situation in the near future for which no action are taken in the present.
Furthermore, the authors demonstrate how EC activity effectively guides actors from the current problem to the desired future in each phase of the implementation process. Other scholars [5, 14] focusing their analysis on strategic change, implicitly consider how strategy derives from the ECs. Gupta et al. [14] indicate that “a major part of building an EC is to bring hidden assumptions to the surface, which is also a key to formulating strategy”. The choice of strategy is a result of an on-going improvement which focuses on scanning threats and opportunities in the context in which an organisation is embedded [5]. Through the recognition of strategy, TOC offers to managers the opporunity to focus on local actions on achieving the whole strategic organisational goals and objectives [5]. In the previous studies related to Three-Cloud Approach the importance of CCC and CRT is just revealed by the development of FRT for evaluating the planned interventions as a solution to the core conflict [7]. None of these studies clearly considers that the discussion about the identification of the CCC strenghtens the positive effects of the change implementation through the the PRT and TT. Moreover, authors do not consider the positive implications of the design of ECs before the CRT. Thus, both CCC and CRT assume a focal role on driving the implementation of change.
The study setting and analysis motivation
The TP in action is observed in an Italian public hospital involved in the construction of a new building according to high intensity of care and patient focused principles. Top managers choose this organisational model for a series of strategic and governmental policies that could be summarised in two points. The first point concerns the growth in the number of patients treated involving more patients benefiting from low-intensity care and patients suffering from rare diseases coming from other Italian regions. The second point refers to a general call for increasing efficiency and cost rationalisation. In the new building, on a strategic and organisational level, high intensity activities are placed in a shared area with the creation of a new surgical block. The number of operating theatres (OTs) is higher than in the current hospital and the majority of surgery rooms are viewed as a shared resource among specialities. An increase in OTs and their level of use entails a higher number of operations per time unit and a concurrent promptness of demand satisfaction.
From this perspective, all things (i.e. materials, equipment, and instruments) and physicians in the surgical block are shared resources and necessitate accurate management over the entire process. This is the starting point of the on-going process ofchange.
Since in the present building, OTs were all dedicated to particular specialities and located far apart, the material supply chain was managed by each speciality. The nurse manager planned and controlled the reorder point of shared material stocks based on the historical trend of the amount consumed and schedules of speciality operations. This process is responsible for low efficiency (high batches and high costs) throughout the entire organisation because shared materials are stored in various areas.
Thanks to the new building, surgeons to increase the number of operations performed per day due to the huge shared area (i.e. surgical block). One of the main consequences is that all dedicated shared materials are stored in the same area despite the surgical block having few areas set aside as storerooms. In the new surgical block, the OTs are larger than other areas, such as the storerooms close to each OT. As a result, there is a general call for a redefinition of the material supply chain dedicated to operations.
In order to tackle this problem, the top management which recently took office, asked researchers for their opinion on the solutions they have identified to solve their current problem. Not only were newcomers checked on the progress of the construction, but they were also bombarded with questions coming from the regional and local governments, press agencies, contractors, internal staff and so on. The deadline about the moving was postponed several times, because previous top managers had encountered many feasibility problems. In fact, during the latest period, the first structural project was deeply changed. When the researchers were involved in the project, top managers were in this anxious situation and the construction of the new building was already drawing to a close.
In the same period, researchers were working on three areas in this hospital, firstly, with the management control area for the design of the cost centres which had to be implemented in the new building; secondly, with the cardiovascular department regarding the research of the efficiency concept nuances applied to cardiosurgery practices; thirdly, with the head of the nursing department concerning the study of the process of change of the nurse managers’ role. Thanks to frequent interactions with clinical and administrative staff whilst fulfilling these projects, the researchers were already aware of the strategic-organisational model chosen for the new building and also of some of the problems observed in the current building. The reorganization of the OTs was undoubtedly the main challenge.
During the first meeting with the top managers, the researchers were informed of the details of each specific choice regarding the new model, including the objectives of the new surgical block and the solutions to be adopted for implementing an efficient logistic flow of materials from/to each OT. Top managers firstly considered defining BoM and kits for each operation, assembling materials in areas close to the OTs. Secondly, they would create an office (named control room) close to the OTs for a shared scheduling of operations. As the complexity of the problem, an in-depth analysis was required in order to precisely detect the core problem at the basis of an entire reorganisation of the OTs. The real aim was not the validation of the top management proposals, rather the resolution of all the hidden dangers related to core conflict favoring an efficient implementation path. Thus, the design of ECs and CRT was useful.
For this reason, researchers adopted the TP as a “powerful system problem structuring and problem solving methodology which can be used to develop solutions with both intuitive power and analytical rigour” [6]. In particular, the application of the three cloud approach allows the anticipation of the analysis elicited by the ECs. As Davies et al. [2] argued, through the design of ECs academics and managers experience “spheres of problem-solving activity within different domains at different levels of ‘intervention”’. Thus, implicitly, in the process of building an EC, both the assumptions and the innovations emerge. As a result, the core problem identified through the Three-Cloud Approach contemplates both current and future situationalcontext.
The literature analysed shows the TP’s methodological steps on existing cases, whereas one of the distinct traits of the fieldwork debated is that the AS IS picture is based on a simulated no action strategy promoted by the top hospital management. For this reason, researchers try to mitigate the potentialities of the three-cloud approach with the TOC mainstreaming based on Cox et al. [28] dictionary.
Case study
The identification of UDEs
As a first step, the identification of problems and concerns related to the logistic flow of material was carried out. UDEs originate from asking to staff to simulate the circumstance in which the current organisation of the OTs is reproduced in the new building. Thinking about the mainstream’s definitions and the exact situation in which our empirical problem occurred we could define UDE, ECs, CCC and CRT as “simulated” UDEs, “simulated” ECs “simulated” CCC and “simulated” CRT. In our view, the concept of “simulated” highlights a possible future reality as the result of no action of change in the current circumstance.
The recognition of these symptoms [8] is important in helping to find a shared cause that symbolises the “what to change” [7, 23]. In fact, the focus on the core problem identification, as the first step in the analysis, favours the resistances to come to the surface. Not only were the change agents involved in the definition of UDEs, but the majority of staff members were involved in the identification of undesiderable situations provided by the simulated application of the current organisation in the newbuilding.
This activity required an analysis of different types of sources. First of all, with the aim of mapping the main critical topics related to the surgical block and material flows, researchers collected many documents. These sources refer to the new building’s implementation projects, other strategic internal documents, similar previous experiences in other hospitals and the regional and national policies. Furthermore, they had at their disposal notes from previous projects and informal meetings organised as soon as the top managers commissioned the researchers to do the study on materialflows.
The meetings involved the head of speciality departments, head of anesthesia and reanimation departments, head of the nursing department, head of the medical department, head of the management control office and head of the administrative department. After first identifying 24 issues related to the design of the new logistic flow, by analysing internal and external documents, participating in ad hoc projects and studying notes of informal meetings, the researchers were able to clarify, refine and reword the following nine “simulated” UDEs: Materials received in OTs are not consistent with materials required. Surgeons receive materials (in OTs) late
There is an incorrect determination of the cost of surgery
UDE 1 and UDE 2 are merged to form a more generic effect described as UDE 3 and UDE 8 is combined to the statement made in UDE 9. The UDEs selected are written in bold. Hereinafter a storyline has been developed for each UDE to provide a more comprehensive comprehending of the case.
UDE 1 Materials received in the OTs are not consistent with materials required. The coexistence of many requests deriving from different specialities and the expected increase in the number of operations per day, demands more sophisticated tools for formulating the requests and for processing, scheduling, transmitting and fulfilling them. Communication errors can lead to situations where the materials reaching the OTs are different to those requested.
UDE 2 Surgeons receive materials (in the OTs) late. The storage spaces are proportionally limited. Thus, a bad flow can mean delays in supplying the OT and waiting times that are detrimental to the efficient use of the OTs with negative repercussions on the quality of patient care.
UDE 8. There is an incorrect determination of the cost of surgery. The DRG (Diagnosis Related Groups) system used in Italy requires adequate account keeping. In particular, the present IT systems attribute the cost of individual surgery to a patient according to the speciality the patient belongs to. Moreover, the materials required are attributed to the speciality too. The strategic decision to share the OTs and resources undermines the attribution of the patient costs to the speciality, because specialities lose their resources. Thus, determining the cost of surgery through the speciality could lead to a totally incorrect amount.
The construction of ECs
When “simulated” UDEs are displayed, the design of “simulated” ECs helps find the common themes among UDEs. As previously described, the peculiarity of the Three-Cloud Approach is firstly the identification of three seemingly independent UDEs, secondly the creation of an EC for each independent UDE, and thirdly providing a synthesis of the three ECs in a single generic CCC.
By means of frequent discussions, the researchers identified three apparently independent UDEs, namely UDE 3, UDE 5 and UDE 9. UDE 3 describes an organisational conflict (related to EC 1) based on the inadequacy and delay of the materials required by each OT. UDE 5 describes a cultural issue (related to EC 2) that undermines the customisation, safety and cost sustainability of materials provided. Lastly, UDE 9 depicts an informative conflict (related to EC 3) that affects the correct determination of patient cost, surgery cost and costs for each speciality. The other UDEs describe important specific aspects of these three selected UDEs. Here below follows the detailed storyline of each EC.
The organisational conflict (EC 1) is based on the previous descriptions provided for UDE 3 (UDE 1 and UDE 2 are just examples of UDE 3) and UDE 4. To achieve the common purpose, namely to provide each OT as required with adequate and increasing amounts of materials on time, there are two necessary conditions. The firstis to manage the material requests for all the specialities and for an increasing number of operations and the second is to integrate the different requirements of shared materials guaranteeing an increasing stock rotation. The basic organisational conflict is whether each speciality must define its own requirements or not. In the latter case, there will be a coordination among the specialities to define the shared requirements (i.e. materials that could be shared by many/all specialities). The reorder point could, respectively, be defined by each speciality or by the coordinated action of all the specialities (Fig. 1).
The cultural conflict (EC 2) refers to the storyline provided for UDE 5. The problem mentioned in this case dealt with the probable increasing trend of stocking similar materials. The most probable consequences could be a general increase of the provisions and costs due to the materials purchased. To reach the common purpose, namely having the most customised and safe materials at a sustainable cost for each operation, there are two necessary conditions.
First to decide the materials needed for each operation autonomously and, second, when deciding on the materials needed, to consider the economic impact of the materials required for each operation. Consequently, the respective prerequisite for the first necessary condition is to have a wide variety of materials stored with the consequent need for more storage space. The second necessary condition mentions to have a modest variety of materials stored with the consequent need for less storage space (Fig. 2).
The informative conflict (EC 3) arises from UDEs 9 (UDE 8 is just an example of UDE 9), 6 and 7. All these UDEs are strictly related to the hospital’s need to produce an adequate and compulsory report for the regional government in order to receive the correct amount of funds (i.e. UDE 9). The stated objective of the report is to have a precise determination of patient cost, surgery cost and costs for speciality through two necessary conditions which are, respectively, having the traceability of materials per speciality and surgery and also having the traceability per patient. In order to satisfy the first prerequisite, managers do not have to implement changes in the present IT systems. On the contrary, in order to achieve patient traceability, managers have to implement changes and integrate new IT systems with the existing IT systems(Fig. 3).
The design of the Core Conflict Cloud (CCC)
A summary of the “simulated” ECs is provided by the design of a CCC for investigating the in-depth and shared problem linking underlying relationships among the UDEs [17]. The identification of the statements for the CCC took the majority of the identified UDEs into consideration. The CCC shown on Fig. 4 is the result of a two-step discussion. During the first one, each researcher individually proposed some possible CCC based on the same ECs. At the second discussion, the researchers presented their drafts of the CCCs for a mutual validation. The discussion ended with the selection of two possible clouds. The following CCC is the result of this second step of analysis which allowed a more in-depth consideration regarding the physical conflict of storerooms.
The researchers started by determining what the three D boxes (one for each ECs) have in common. A generic D emerged, namely there is the need for a large material storage space without implementing changes in routines and present IT systems. In contrast, the three D’ converged in the need for a modest material storage space with the implementation of changes in routines and IT systems. The dilemma emphasises organisational, cultural and informative dimensions of the conflict calling for a solution in physical terms (i.e. storage space).
Although the number of OTs had already been decided and there is less space for material storage close to the OTs than in the existing building, it appeared evident that there is a need to guarantee adequate material in time for operations, safeguarding an appropriate patient care flow. The two researchers discussed this problem in depth. The discussion highlighted the impossibility to reproduce the existing model in the new building, but at the same time there is a lack of clarity regarding the change required.
The present model implies a summation of spaces and materials that are currently located in the departments. The need for smaller spaces instead emanates from the aim to improve the rotation of supplies, from the existence of common materials that proportionally reduce the overall demand and from the prevention of an unnecessary duplication of materials. The idea was to measure physically the space occupied by the material stocked in the present storerooms close to the OTs in order to check the size of the problem. The analysis required multiple actions and the redefinition of the multiple hypothesis concerning where and how to prepare the material required for each operation. Progressively, other meetings were scheduled. The discussions always ended with the consideration of the storage space as the core dilemma.
Following the same steps for the objective and prerequisite entities, firstly the three objectives emphasise the need to have an efficient management of the material flow logistics in the block and in the OTs to guarantee a higher number of operations, quality of care and proportionally lower surgery costs. From the researchers’ point of view, this statement encompasses the aspects enclosed to A-entities of the three ECs. Secondly, the prerequisite B clarified that the system must guarantee material in the OTs in the quantities, of the quality and within the time requested and the prerequisite C specified that surgeons and nurse managers must manage shared materials and resources optimally.
B and C entities emerge from a precise analysis of the same entities captured by the three ECs. Thinking about UDEs and ECs, the researchers realised that one of the most difficult problems to be overcome in order to resolve the conflict was to encourage surgeons to change their habits. This is principally due to their backgrounds, their experiences, their status and also to the uncertainty as to whether the design of the new surgical block could guarantee the same quality of care to each patient. The identification of the core problem and UDEs, in this case, is responsible to a first step of the change: surgeons becoming conscious of their inherent resistance.
The following figure (Fig. 4) shows the “simulated” CCC and all the entities coming from previous ECs. The CCC is the basis for constructing the CRT [7] that aims to depict the causal links concerning UDEs. Moreover, CRT highlights core drivers which portray statements without any cause indicated (i.e. increase the reputation of the hospital for rare disease treatments in many specialities, increase the number of patients treated, financial budget constraints, pressure to rationalise material costs) and other stakeholders (community well-being)).
The design of the Current Reality Tree (CRT)
Constructing the “simulated” CRT allows the correctness of the “simulated” CCC outlined to be verified. Thus, the Three-Cloud Approach suggests rotating the CCC 90 degrees counter-clockwise for the base of the CRT. All the assumptions must be added to the CRT at the bottom of the page and the UDEs are placed at the top of the page. Lastly, appropriate entities could be added to link the base entities logically to the UDEs. Thus, the design of the CRT benefits from the previous reasoning about the construction of CCC. In fact the two researchers identified all the entities shown in the CRT.
Although the researchers were well-documented about the sufficiency-based logic of this tool, they did not take proper care of this aspect up to the revision process. During several meetings, they discussed every link, refining the words and sentences, only in the oral discussion. The free brainstorming activities partially tested some of the hypotheses that emerged in the previous meetings about the solutions that could be implemented in order to remove the core problem. Thus, the researchers focused the analysis on these probable solutions that differ partially from those the top managers had communicated at the beginning of the project. The solutions advanced will be described in the next section as INJ together with the process of transforming UDEs in DEs.
For this reason, the researchers decided to present the results of the analysis to the top management. The presentation concerned the entire process of analysis, including the UDEs identified, the resistances that emerged during the meetings from all the participants, the description of the core conflict and all the entities depicted in the CRT (i.e. entities from the CCC to UDEs). As the top managers did not know the TP methodology, the two researchers preferred to show other more familiar diagrams in order to focus the discussion on results and not on the method adopted.
They were impressed by the complete reasoning overcoming the logistic flow problem for the consideration of organisational, cultural and informative aspects. They understood the relationships between the decisions already taken about the design of the surgical block, the strategic objectives and the problems that had to be solved before moving to the new building. The clinical director expressed her doubts about the solutions previously put forward. She addressed the need to prepare the material required for each operation away from the surgical block in order to safeguard a fluid and safe patient flow. This decision could entail a reorganisation of the informative systems too. In the end, the researchers were encouraged to continue the analysis.
Considering Fig. 5, the entity no. 124 and 125 represent the core drivers that are clearly responsible for the resulting evidence that intensifies the core conflict. The resulting entity (no. 130) highlighted all the nuances of the core problem. It took a lot of time to refine this statement. As the construction of the new building was still not accomplished, many concerns arose during the researchers’ meetings.
The statement illustrated in entity no. 130 influenced both the branches of the tool. The left if-then branch shows the twofold impacts associated with the respect of the surgeon’s decisional autonomy, expressed above by UDE 5 and UDE 4. The right branch presents connections relating to a reduction in the quantity and variety of materials stored. In particular the pression in this direction produces the negative effects related to UDE 3 and UDE 9. Following the sufficiency-based path both the UDE 6 and UDE 7 are causes of the UDE 9.
At the top of the diagram, a new UDE emerges (entity no. 500) from both of the branches of the CRT, namely the hospital does not meet its objective of an efficient management of the material flow logistics in the block and in the OTs for guaranteeing a higher number of surgeries and quality of care and a proportionally lower surgery cost. This new UDE represents the contrary of the core objective (A-entity no. 100) at the bottom of the page and validates theidentification of UDE 3, 5 and 9 as the more representative and apparently independent UDEs.
The identification of strategic injections
Constructing the CRT helps to define the INJ that solve the CCC and transform the UDEs into DEs. Technically, the design of the FRT immediately followed the design of the CRT. During the meetings dedicated to the CRT, the members also discussed the useful INJ for evaporating the core conflict, but they did not present these proposals to the top managers. However, the researchers took the clinical director’s suggestions into consideration and in a subsequent meeting they presented the following INJ that are partially revised compared to those suggested by the top managers. More precisely, the revision concerns INJ 1. INJ 3 validates the second solution proposed by the top managers, whereas INJ 2 is a consequence of the new considerations regarding INJ 1. Lastly, INJ 4 came entirely from the researchers’ suggestions.
The fact that some materials are not included in the kit as they cannot really be standardised, allows the surgeon to define autonomously the best care for the patient. There are in fact trolleys in the OT area that contain certain non-standard materials that cannot be included in the kits. The implementation of this INJ requires the active participation and involvement of practitioners (i.e. surgeons, anaesthetists and nurse managers) right from the early stages of defining the BoMs for each specific operation.
Consequently, the reordering of materials is closely linked to the operation scheduling activity. The materials stored in the theatre lockers will be extremely limited and made up of ‘just-in-time’ materials, for example suturing thread, gloves etc., rather than re-usable surgical instruments and medical and surgical devices. This INJ originated from the fact that kits are not prepared in the surgical block as the top managers initially suggested. The provision of the kits takes place in this second level storeroom, in other words outside the surgical block and transfers the job of preparing the materials for operations from nursing staff to auxiliary staff, with operatives entrusted with the task of making up the kits.
When the operation is booked, a list of materials is generated for that operation on which the requests for supplies are based. The materials included in the list will follow different re-ordering procedures, which can be grouped into three processes, namely (i) the request for surgical instruments sent to the sterilisation centre, (ii) the request for procedural sets, prostheses and other medical devices sent to the storerooms, (iii) the request for drugs sent to the external pharmacy. This injection allows the entire management of materials (kits, lockers) to be reinforced.
Future reality tree
The FRT describes how the INJs transform the cause-effect relationships from the entity affected by the INJ to all subsequent entities. As shown on Fig. 6, INJ 1 Defining a BoMs and related kit allows, first of all, (entity 225) the formulation of the withdrawal/request list of materials that respect the surgeon’s decisional autonomy. This result is central for the launch of the INJ 2 and INJ 3. In fact, INJ 2 Creating a second level storeroom transforms (entity no. 350), namely the need for more and larger storerooms for each speciality into the running of high automation 1st level storerooms and lockers and 2nd level storerooms. The 2nd level storerooms have a strong impact on the distribution of space in thesurgical block to the benefit of the OTs. These storerooms contribute to a rationalisation of the areas because it shifts the majority of materials stocked outside the surgical block and, through the use of light transport, ensures the safety and promptness of supplies. Both the new entities no. 225 and 350 reduce the proliferation of materials with very similar characteristics (UDE 5).
INJ 3 Scheduling operations helps to synchronise the needs and means of the entire blockwith an important effect on the variety and quantity of material reorder and minimum stocks decision (entity no. 370). Thus, the efficient management of the material reorder point is guaranteed by both INJ 2 and INJ 3.
Considering the right branch of the diagram, INJ 1 also transforms entity no. 200 into the possibility of reducing the quantity and variety of material stored, subsequently enabling the sharing of some materials by multiple specialities (entity no. 250). Furthermore, INJ 1 changes entity no. 430 in the presence of coordinated requests coming from different specialities that addresses, together with entity no. 250, the transformation of UDE 3.
Lastly, INJ 4 Integration of information systems represents the connective tissue that binds the logistic path ensuring the monitoring according to the dimensions needed for internal management and external reporting to the regional government. This INJ contributes towards changing the status, respectively, of UDE 6, 7 and 9.
The FRT together with the INJs is illustrated on Fig. 6.
The implementation steps: PRT and TT
In answering the question “how to create the change”, the PRT and TT provide support [24]. Designing the PRT requires the identification of (i) obstacles that block the implementation of an INJ and (ii) intermediate objectives (IO) that, if accomplished, would overcome the obstacles (O) [24, 29]. Lastly, the TT is useful for determining the steps needed to achieve the intermediate objectives. Ritson and Waterfield [15] call TT the action plan “for setting out the actions in a logical step-by-step format for implementing improvements” (p. 455) in the fieldwork.
Constructing the ECs and the CCC has allowed a thorough examination of the links between the previously identified UDEs. In particular, it has become clear that the UDE that triggers all the others is no. 3 (i.e. surgeons suffer from temporary shortages of materials) arising from the limitation of storage areas. The policies and strategic-organisational change of directions imposed by the top management create a bottleneck in the supply chain for acquiring the materials necessary for operations and are the source of the conflict between large and modest storage space.
As outlined in the section 4.4 concerning the “simulated” CRT and then taken up again in the illustration of the INJs and in the FRT, the fact that the surgeons agree on the material needed for each operation means that the logistic flow of materials can be scheduled to make it fluid. INJ 1 (i.e. defining a BoM and surgical kit) is, therefore, the one that attracts most resistance to change. It implies a discussion among different professional roles (i.e. surgeons, anaesthetists and nurse managers) from multiple specialities, with backgrounds linked to different schools and whose habitual activities are based on total respect for decisional autonomy (especially that of the surgeons). For this reason the creation of the PRT was based on an analysis of the definition of BoMs and kits as the overall objective for the realisation of the planned change. The PRT of INJ 1 highlights the obstacles to change and identifies the objectives for overcoming them.
In detail, in order to achieve the definition of BoMs and kits, we must achieve (IO 10) the definition of standard materials for each operation with sustainable costs, in order to overcome (O 10) the fact that some standard materials may not be approved for the supply by the pharmacy due to the high costs. Furthermore, in order to achieve the IO 10, we must plan (IO 9) the simulation of the costs of materials for each operation, in order to overcome (O 9) the fact that surgeons do not know the financial impact of the materials. Subsequently, in order to achieve IO 9, we must achieve the definition of standard materials for each operation, in order to overcome (O 8) the fact that surgeons do not know the standard materials for each operation. In order to achieve the last IO (no. 8), we must achieve (IO 6) the identification of the materials that could be classified as standard andnon-standard for each operation and (IO 7) the definition of the average cost of materials classified as standard, in order to overcome (O 6) the fact that the point of view of renowned surgeons tends to prevail, increasing the materials classified as non-standard, and (O 7) the fact that the pharmacy and supply office could argue the choice of some materials asstandard.
The causal relationship between IO 7 and IO 6 is guaranteed by the overcoming of the (O 67) fact that surgeons and anaesthetists do not know the average cost of materials for each operation or category of operation. Moreover, in order to achieve (IO 5) the identification of materials required for a standard procedure and the materials required for the different scenarios of each operation, we must (IO 4) achieve the identification of all the useful materials for each operation, in order to overcome (O 4) the lack of a list of such materials.
To achieve IO 4, (IO 2) must be achieved, that is raising the surgeons’ awareness of a flexible adaptability of their own school of practices in order to share materials and (IO 3) related to the identification of all operations available in the hospital according to DRG, in order to overcome (O 2) the fact that each surgeon is used to asking for materials required for each operation basing the choice on his/her school background and routines and (O 3) the fact that there is not an approved list integrating operations and the level of care required by categories of patients. Lastly, at the bottom of the diagram, in order to achieve the IO 2, we must achieve (IO 1) a raising awareness of heads of departments about sharing materials to use the same financial resources for more operations, in order to overcome the (O 1) fact that surgeons follow their department principles and procedures.
As outlined in the PRT, the principal resistances to change are described in obstacles no. 1, 2 and 6 regarding the surgeons’ force of habit. Moreover, the lack of support from administrative staff needed to be solved by overcoming obstacles no. 67, 7 and 10. Secondary resistances emerged through the collection and analysis of data discussed by the researchers before the construction of CCC and CRT. The detailed actions provided by the TT also address these additional situations. The diagram below depicts the description of the PRT provided (Fig. 7).
Both the IOs and obstacles to change were presented to top managers for their validation. Before this meeting the researchers identified those actions that could overcome these obstacles through the design of TT. Following the sufficiency-based logic, the TT depicted on Fig. 8 is read as: We want to achieve the definition of the BoMs and kit (INJ).
Moreover, the following actions no. 3, 4, 5 and 6 could reach the same purposes clarifying, at the same time, the functioning of the new surgical block. Many surgeons and nurse managers, in fact, suffer as a result of not having a clear vision of the procedures and operating principles adopted in the new surgical area. Thus, in the end, the definition of standard materials (Action no. 8 and Action no. 10) requires great involvement of all these actors reassuring them of the benefits of choosing shared operating theatres.Lastly, Actions no. 7, 9 and partially 10 address the involvement of administrative staff and the pharmacy in order to support the clinical side in choosing adequate materials. Both physicians and administrative staff suffer from a lack of mutual support.
Discussion
As assumed by Simon, decision-makers face daily challenges in a complex environments. Thus, human beings choose a good enough option according to their purposes and the environmental constraints. This is the same for top-managers in a healthcare organisation. The inversion of the construction of ECs compared to the CRT (i.e. Three-Cloud Approach) allows to achieve and implement satisfying decisions.
Starting with the UDEs that are often quite numerous, the ECs help to identify similarities and links between UDEs, simplifying the considerations and helping to find the common cause. From a societal human systems perspective, these interrelationships are obvious. According to Kim et al. [11], with the construction of ECs and the CCC, the analysis of conflicts is developed but, above all, the links between the various problems are made clear, identifying the main conflict on which to focus without neglecting the connections with the others. This attention to conflicts of various types (logistic, cultural, organisational etc.) was relevant to the characteristics of the hospital and is more consistent with representing the complexity because it allows a more holistic and less “industrial” view of the healthcare product. In addition, through it, managers can understand where difficulties and resistances to change may be encountered.
The “simulated” CRT, therefore, becomes a reinterpretation/verification that confirms the validity of the common cause [17]. Moreover, as highlighted in the study system, bringing forward the analysis of possible INJ during the identification of the CCC makes researchers able to identify its deep roots and to give priority to the implementation procedures shown in the subsequent tools.
The CCC becomes essential when dealing with the implementation process as well, giving priority to the problems identified (through the PRT) and above all to the actions to be carried out (collected in the TT). Use of the Three-Cloud Approach in this sense provides a deep analysis of the top managers’ problem, comprehending the resistances at individual and social levels based on the routine and the existing power structures. Previous studies that have gathered evidence on the Three-Cloud Approach [7, 17] do not highlight this potential that emerges in the case study presented. This phase allows an intense discussion between the two researchers regarding the relationships between the problems that are evident and above all the implicit ones, as well as the infrequent or unexpected ones.
In this way the resistances to change also emerge more clearly which, according to Mabin et al. [9], can hinder the implementation of a possible solution or idea (negative view of the resistances), but can also help to identify a satisfying or more shared solution (positive view of the resistances), given that the people who resist are those involved in the change process. In the healthcare context, physicians are recognised as the people who resist to pressures that affect their identity and autonomy. Thus, physicians usually have conflicts with administrative staff due to their conflicting purposes [27]. The creation of stable working groups with heterogeneous roles and the presence of physicians was proposed for overcoming resistances in the case study.
The CCC has shown how the problem of sizing the storeroom and the consequent logistic flow is the basis of the UDEs but it also has organisational, cultural and IT implications. The activities of defining the BoM and the Kit address the issue maintaining the surgeons need for autonomy.
Considering Kanter’s classification outlined in Mabin et al. [9] and going back to the ECs, the most acute factors in the case studied are: Force of habit, Lack of confidence, Lack of Support and, partly, Poor timing. Indeed, the consolidated medical practices have their bearing on the way operations are performed as well as the materials used. In addition, in the current facility the availability of extra materials is made considerably easier by the presence of spacious and varied storerooms.
In the new building, the OTs are arranged very differently and the professional figures feel uncertainty due to a lack of clear vision of the surgical block set up following the change. The fear of not having adequate resources to effect the change also involves the administrative staff which has to give adequate support to the transition and to facilitating the process of taking stock of and allocating shared resources. Lastly, despite the changeover process being rather lengthy, the risk of feeling unprepared for the change, perceived as too quick and too radical, is especially important for top managers and all members considering the criticality of the area involved - patients’ health.
Use of the Three-Cloud Approach to highlight these potential obstacles to change has made it possible to place the engagement and the process of sharing of professional and administrative staff at the centre of the PRT and the TT. The establishment of frequent meetings and stable working groups (shown on TT) help top managers to stimulate a shared perspective on how choose materials and the related stuff. In this set up, the increasingly necessary bottom up type contribution derives from a positive and collaborative relationship with the practitioners. In the TP logic this contribution is traced back to and endorsed in keeping with the corporate identity and strategies, identified by means of the core drivers and the CRT and does not risk being broken up into solutions that are technically feasible but not strategically advantageous.
It also emerges that the TP approach needs to be interpreted in a dynamic sense rather than a static one. None of the previous studies enlighten this point. The TP encapsulates the dynamism in itself because it makes it possible to identify the need for change, the true cause of the problems, how to remove the problems, taking account of the obstacles and using which actions. This makes it possible to bring about a (planned) change but also to comprehend the emergent changes that would be lost with a static analysis model. In fact, any path of configuration and rationalisation of processes formulated cannot contradict managers’ past choices and, therefore, helps to interpret the logistic strategies in the light of the organisation’s general strategies.
The very strongly integrated, cross functional and systems view [1] of the TP fully embraces the potential and obstacles to change and the power relationships between the subjects involved and how they can influence the change. This seems especially interesting within the healthcare sector in which the relationship between physicians, nurse managers and administrative staff is particularly delicate and where the doctor’s professional approach is central to the care process.
The logistic path proposed, and fairly widespread in intensity of care situations, affects the balance of roles and failing to taking it into account could influence the change process itself. The TP allows these variables to be incorporated and the positive and negative aspects evaluated, in terms of resistances and new equilibriums.
Conclusions
The aim of this article was to show how the Three-Cloud Approach could be useful for addressing the TP as a fundamental process for implementing a strategic and organisational change. In particular, this study depicts a Full Thinking Process Analysis based on the Three-Cloud Approach and it investigates the healthcare setting, as an alternative to the production context, in order to realise the importance of implementing stages of change through the TP approach.
Furthermore, it points out the crucial link between CRT, PRT and TT through the intense analysis on the situation and resistances to change that generated the design of CCC. None of the previous studies clearly consider these points.
The Three-Cloud Approach allows an in-depth analysis of resistances to change and intra-organisational mechanisms of power. For these reasons it could strengthen the traditional FTPA based on manufaturing case studies. Furthermore, it sheds light on necessary conditions underpinning effective change and it addresses strategies for increasing the rate of success. For all these reasons, researchers adopt this approach in a peculiar healthcare organisation.
The Three-Cloud Approach stimulates additional research opportunities. Firstly, only a couple of studies have been published focusing on the innovative combination of TP tools. Other research calls for an analysis of the links between each TP tool in order to discover other strategic ways of directing the change implementation process. Secondly, other studies could benefit from the fact that the current situation of the field study is based on an on-going process of change in which some strategic decisions have already been taken but many other choices still have to be made in order to reorganise the entire surgical block. Thirdly, like other main streams concerning the TOC, the TP could benefit from in-depth enquiries taking a stance about some simplistic perceptions of its value as a strong methodology based on system-management philosophy.
Concerning the points of weaknesses of this study, researchers are aware that the improvements achieved thanks to the TP application have to be measured. Towing to the time when the research was conducted we have no evidence of the value of particular organisational and financial performance measures. However, researchers could offer some considerations related to this point.
Moving to another building makes it difficult to collect and compare measures related to the cycle time, lead time, due date performance, inventory size, revenue/throughput and profitability [30]. However, through TP reasoning and tools, the new surgical block was organised and the resources and patients were moved to the new building at the end of 2012. Nowadays, the hospital maintains the high standard of care and the daily number of operations has increased.
Furthermore, the researchers have observed by means of informal meetings and the press that the users’ perception of the quality of care has increased. Due to the high standards of care, the regional policies have been changed over the last few months. The hospital under investigation was recognised as one of the regional centres of excellence with good cost control.
In this case too, less tangible or measurable changes occurred, including an improvement in morale and an improved flexibility and responsiveness (related to nurses, nurse managers, top managers, anaesthetists and surgeons). By holding numerous meetings (well-documented in the TT), surgeons have increased their awareness of costs and their confidence in different kinds of materials.
Finally, by arranging informal meetings with the staff, the researchers have tried to discover their considerations regarding the resistance to change analysed during the implementation process. In fact, most of them are conscious of the importance of the actions adopted during the transition phase in the aim of diminishing the resistance that emerged.