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Care Delivery Design Required for MU - Lessons from Order Wheels

August 27, 2010
by Joe Bormel
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Care Delivery Design Required for MU
Lessons from Order Wheels

Lots of CIOs are now contemplating pursuing very aggressive strategies to pursue Medicare-Hospital MU incentives in 2011. And with that, comes massive and probably hybrid care delivery design changes (e.g. some providers using existing order flow with written orders, while others are concurrently using CPOE). The nurses will be making sure that nothing slips between the cracks. The management of orders in the effected care units may be or will be re-designed to accommodate these flows. This was the garden variety work of bringing up CPOE before MU. Now, it's going to be happening wholesale, most hospitals and all impacted processes (CPOE is only one of them).

As I mentioned in my previous post, Adopting the Obvious, I've become interested in the science, practice and psychology of this sort of meta-design. I ran across a story involving Order Wheels that seemed relevant to share. It comes from this freely available Web page by author Richard Farson: Management By Design, :

Adam and Eve on a Raft

Ever since the forties, when sociologist William Foote Whyte conducted his famous study of the interpersonal tensions that arise at peak hours in restaurants, managers have been encouraged to think about human relations in systems terms. Noticing waitresses shouting orders to male cooks, Whyte surmised that such behavior violated role expectations of both gender and status, cooks being of higher status, and women expected to be subservient to men. (Remember, this was the forties). He designed a system in which the waitress would write down the order on a small pad of paper and stick the slip of paper on which she had written the order on a spindle [an Order Wheel]. The cook would then take it off when he saw fit, calling the waitress when it was ready. That system of realigning the roles remains in place, although the spindle has largely been replaced by a revolving drum, or by computers. It is considered one of the first uses of system design in the management of human relations in industry.

Okay, first, please calm down. The gender stereotyping and status issues were painful, probably even for the original author, Dr Farson.

The bigger picture is the approach to design taken, and its fulfillment with the Order Wheel. It respected the needs of those involved, without exacerbating the human dramas that probably exist at peak hours in hospitals as they do in restaurants.

What do you think?



I got a kick out of seeing your quote of my paragraph on William Foote Whyte's starting the system approach.

Just one problem, the spindle is not the circular drum, it is a sharp nail spike sticking straight up out of a metal base, and the waitresses would stick their paper notes with the customers' choices written on them so that they would pile up on the spindle (spike) and the chef would take them off when he pleased.

I realize now that nobody your age would know what a spindle is.

Thanks for your comment and the reference to my earlier opinion piece.

I wrote this blog post really thinking about the hospital's challenge in re-designing care delivery for providers and communication between providers.  There seemed to be something inspirational about knowing the back story of the Order Wheel. I was not thinking about vendor-provider relationships per se.

Candidly, I think that most if not all HCIT vendors do invest in communications (that's a blog post in itself). I know that all EMR HCIT vendors, like providers, are struggling with the time crunch, as laid out in the Final Rule, to deliver the products and services that will be sufficient.

The "be sufficient" is my segue to your last question, i.e. ease of customization as it relates to patient safety and quality care. I believe, more than ever, that making customization easier is a vital part of delivering more value.  To me, that includes making it possible to customize the basic artifacts, flowsheets, documentation, orders, (lets call them FDOs), and their sub-sets, as well as the logic to identify needed FDOs, without a call to the IT or IS department.

In my recent posts on checklist, I shared some observations that were validated by the research Atul Gawande shares in his book, The Checkist Manifesto. Checklists aren't static. They can be too long or too short.  And they need to be modified.  That's true of the checklists that are professionally developed and published by Boeing and Airbus in their Checklist Factories.  And it's true of Peter Provonost's ICU checklists and Gawande's Surgical checklists.  Dozens of iterations are typically required.  All of the industrial strength, commercial-quality enterprise platforms that I'm aware of make the burden of customization too great for adequately rapid PDCA cycles. 

To be fair, it's been hard enough from a technology perspective to maintain subsecond screen flips with relatively small collections of static screen definitions, while keeping up with inserting new data into databases and performing the transaction logic typical of order management with clinical decision support.  I'm not suggesting that the current successful vendors are lazy or stupid.  They, or rather we, just haven't built our platforms to both be transaction engines and to support dynamic learning.  ... Yet!

Based on the Stage 1 requirements that were, through the menu process, pushed into Stage 2, I don't see the degree of desirable customization enhancements coming any time soon.  Many pundits have articulated that the next innovation cycle will start in 2016. That's okay though, because, as I've alluded to in this post and said before, you've got to get the kitchen working functionally before the great chefs can do their best work.

Does that make sense to you?

Dr. Bormel,
This post spawns many questions. I'll try to keep mine to a reasonable number.

The Order Wheel has largely given way to newer "technology" in the food and beverage industry. But as I think about how orders are now placed, the interesting thing is that although faster and more detailed processes have been developed, they work much like the original. This makes transitioning much easier, faster, and with little push back from users.

That's really not the case with the majority of HCIT, and I see this as a critical factor that has had a negative effect on adoption, which leads to my first question. Do you think that the vendors are trying to improve communications with their customers to evolve their systems in such a manner that they will become more user friendly, therefore less intimidating? Or are the vendors, by and large, simply depending on MU to sell their product? I've seen little indication that HCIT vendors are making much effort.

However, if you disagree, then at what point in time will system usage become ubiquitous, thereby accounting, for instance, for virtually all orders issued electronically so the nurses no longer need to spend their time backstopping the process?

Additionally, do you think, in the foreseeable future, applications such as CPOE will become easier for clinicians to customized within the parameters of patient safety and quality care? I remember reading a paper you wrote five or six years ago about adapting CPOE with what you called Intelligent Care Sets. The concept you put forth at the time was both fascinating and logical. When do we get there?

Keep up the good work. I appreciate your posts to this site.

Doc Benjamin

Dr. Bormel,
One final comment. The spindle quickly proved to be totally impractical for waitresses to place food orders.

The reason is that the most recent order was always on top on the stack, while the oldest was at the bottom. Therefore, the cook or chef had to pull all of the orders off the spindle and reverse them so customers could be served promptly. This was a waste of time and spawned considerable frustration during peak dining periods. The spindle, in this instance, caused more problems than it solved! That's why it was quickly replaced by such "innovations" as the order wheel . . . an idea that actually worked!

In the end, the spindle proved practical for only one function in restaurants it was used by cashiers to "skewer" guest checks that had already been paid by customers.

Doc Benjamin

Thanks Doc Benjamin.

What I take away from this is
1) Design is extremely important
2) Design has to work on political/power levels (every act is a political act - RF)
3) Design has to meet the workflow / queuing needs, FIFO, FILO, LIFO, etc.
4) Real experience, ie an implementation will create the need for continuing design/redesign.

That's been the experience of creating medication reconciliation processes, checklist factories, and restaurant operations. Let's hope that Meaningful Use timelines are sufficiently long that requisite design evolution cycles don't preclude achieving measurement goals!

I understand and I'm sympathetic to your disappointment. You do have company.

Think about it. If you had $5M/hospital of incentive dollars available for pursuing a mature yet not innovative, lower risk path to ROI, would you defocus your development resources to explore new innovation? Not if you had an ounce of discipline.

The best work I've seen on in-depth communication is Suzette Haden Elgin. She has a blog, but you probably want to get her audio book on Gentle Art Syntonics.

Dr. Bormel,
Your reply makes perfect sense to me, although waiting until 2016 is somewhat disappointing, because I'll probably be retired by then. Such is life.

By the way, I would like to read a blog post dealing with an in-depth look at communication.

Doc Benjamin

Thanks Richard.

It's an even better story if the "Order Wheel" is even simpler, less complicated, and cheaper. Essentially "A Nail !"

I do remember diners in the 60s and 70s with something that looked more like a long, polished nail on a simple, round weighted base (image on right). To your point, over my life, those diners are completely replaced by fast food "restaurants" with nary a spindle to be found.

I don't think that the lesson is at all diminished: "[this simple design] is considered one of the first uses of system design in the management of human relations [design] in industry."
As we build out computer screens in what we think of as applications, it's critically important to bring participants familiar with human system design and knowledgable of the human context into the process.  It's unrealistic and unfair to expect an analyst or programmer to get this right without the help of a healthy team.

Thanks again Richard.

Interested readers can learn more from reading Dr Farson's book, The Power of Design.  I've read several of Richard's books for over a decade and I've given dozens of copies of his 1997 book, Management of the Absurd as gifts.  Richard writes about communications, power, politics, predicaments, child raising, successful mariages, and our societal structures (including the healthcare industry, education, and architecture.)  He's uniquely qualified and more effective at getting his points across than most authors you'll find.  Everyone I know who has read a Farson book has been deeply grateful.