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The role of improvising in patient care

McKenna, Kalin; Leykum, Luci K.; McDaniel, Reuben R. Jr.

doi: 10.1097/HMR.0b013e31823ea9c7

Background: Uncertainty is inherent in health care systems. This uncertainty is related to the complexity of the system itself, as well as the potentially unpredictable trajectory of each patient’s disease. One implication of uncertainty is that patient outcomes may be dependent on providers’ ability to perform effectively in uncertain situations. Improvising is a critical activity that helps physicians act when the course of action is unclear or not routine.

Purposes: The objective of this study was to describe the phenomenon and role of improvising in health care settings.

Methodology/Approach: We observed 7 inpatient physician teams, analyzed a written case, and interviewed 7 physicians across specialties. We identified examples and themes related to improvising in each of these data sources.

Findings: We observed improvising in 2 of the 7 observed inpatient teams. We also identified improvising in the written case. Examples of improvising in health care were reported in 6 of the 7 physician interviews. In these examples, improvising was manifested in different ways, ranging from specific treatment regimens to interactions with patients and their families. However, the description of social interactions leading to a change from the usual course of action was a common theme.

Practice Implications: Improvising frequently occurs in health care, enabling physicians to adjust to the inherent uncertainty of patient care activities. Improvising is contingent on a foundation of medical knowledge from which providers can act in creative, novel ways. In addition, improvising is a social activity requiring a supportive relationship infrastructure. Enabling improvising may be an important approach for improving patient outcomes. Improving relationships will be an important component of these strategies.

Kalin McKenna, MBA. E-mail:

Luci K. Leykum, MD, MBA, MSc, is Associate Professor of Medicine, South Texas Veterans Health Care System/University of Texas Health Science Center at San Antonio. E-mail:

Reuben R. McDaniel Jr., EdD, is Charles and Elizabeth Prothro Regents Chair in Health Care Management, Department of Management Science and Information Systems, University of Texas at Austin. E-mail:

The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (TRX 01-091 and REA 05-129). Investigator salary support is provided through this funding and through the South Texas Veterans Health Care System. Dr. McDaniel receives support from the IC2 Institute of the University of Texas at Austin.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

© 2013 Lippincott Williams & Wilkins, Inc.