Presented at CHI 2005. We report on an ethnographic study of workarounds—informal temporary practices for handling exceptions to normal workflow—in a hospital environment. Workarounds are a common technique for dealing with the inherent uncertainty of dynamic work environments. Workarounds can help coordinate work, especially under conditions of high time pressure, but they may result in information or work protocols that are unstable, unavailable, or unreliable. We investigated workarounds and their effects through observation and interviews in a major teaching medical center. Our results suggest 4 key features of workarounds that technologies might help address: (a) workarounds differ as a function of people’s role; (b) workarounds draw on tacit knowledge of others’ abilities and willingness to help; (c) workarounds can have a cascading effect, causing other workarounds down the line; (d) workarounds often rely on principles of fairness and who owes whom a favor. We provide recommendations for designing systems to better support workarounds in dynamic environments.

1. Work Coordination, Workflow, &
Workarounds in a Medical Context
Marina Kobayashi, Susan R. Fussell
Human Computer Interaction Institute
Carnegie Mellon University
Yan Xiao, F. Jacob Seagull
School of Medicine - Human Factors Research Program
University of Maryland, Baltimore
April 6, 2005

2. Motivation
Time
People
Task
Resources

3. Workarounds: medical context
Context: Urban Hospital
Trauma Operating Room (OR)
– High-reliability: required to be
dependable with minimal
errors
– Fast-response: limitations to
amount of time to attend to
tasks
– Critical task environment: high
urgency and emergent

4. Workarounds: current study
Data Collection: Field study
– 120 hours of observations,
interviews, focus groups
– Personnel in targeted roles:
charge nurse, charge
anesthesia, surgeon
– Critical incident reports

5. Workarounds: current study
Workarounds—informal
temporary practices for handling
exceptions to normal workflow.
How do workarounds influence
work coordination and workflow
in the medical context?

6. Workarounds
Blood not sent
for testing
Lab
Use universally
accepted type
Patient blood
type unknown
Nurse Charge Nurse

7. Workflow

8. Findings: Workaround patterns
 Differ as a function of actor’s role
– “As the charge nurse I think about things in one way and there’s things
that I’m concerned about, but [she] is a clerk, so even though she’s helping
me with the same task she’s thinking about other things…”
 Draw on tacit knowledge of other’s abilities and willingness to
help
– "[You] just kind of know from experience who your stronger people are,
who your weaker people are, who's flexible…"
 Have a cascading effect
 Often rely on principles of fairness and who owes whom favors
– “[In any OR management situation] what you really want when you’re
running the OR is you want everybody to owe you a favor at all…It helps if
they can remember last week when you helped them….”

9. Workaround support tools
 Training
– Provide a library of previously used workarounds and
outcomes
 Memory
– Remind workaround initiators of who they should call on for
a favor, or where to find a person with specific skills/
experience
 Decision-making
– Simulate and predict the short and long-term effects of
different workarounds, and suggest strategies to best
handle repercussions
 Awareness
– Provide knowledge of availability or current status of
resources and personnel

10. Future research
 Implement and evaluate workaround support tools
 Further study of workarounds in ORs
– Triggers
– Execution
– Outcome (short & long)
 Workarounds in other critical contexts

11. Thanks!
Sara Kiesler, Yuqing Ren, Peter Scupelli,
Scott Davidoff, Lui Min Oh, and other members
of our research group on Large-Scale Collaboration
Our collaborators at the
University of Maryland Medical Center
This project is supported by
National Science Foundation grant #0325087

12. Questions? Contact us…
Marina marinak@andrew.cmu.edu
Susan sfussell@andrew.cmu.edu
Yan yxiao@umaryland.edu
Jake jseag001@umaryland.edu