From Teams to Transactions: Stepping Back From Feed-Forward Practices : Journal of Healthcare Management

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From Teams to Transactions: Stepping Back From Feed-Forward Practices

Ford, Eric W. PhD; Editor

doi: 10.1097/JHM-D-22-00214
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Ensuring effective and safe patient care coordination is among the hardest challenges that healthcare managers deal with on a day-in, day-out basis. The gold standard for care coordination holds effective teamwork as the central tenet for success. To that end, the Agency for Healthcare Research and Quality (AHRQ) freely distributes its TeamSTEPPS strategy ( to promote effective communication in health systems.

Many hospitals and health systems struggle to create consistent staffing schedules, which complicates their intention to form teams and leverage those dynamics to improve care. As a result, patient experiences are a series of care processes that rely on providers exchanging information in a one-off, one-way transactional format. Those care transactions often occur through the electronic health record (EHR), further removing human affect and discourse that are crucial for teamwork.

The transactional care coordination model is unlikely to go away any time soon. Recognizing this fact and acknowledging the challenges it creates are the first steps to improving care coordination and, ultimately, safety. From a system's perspective, the main challenge with a transactional model is that it relies on a feed-forward design with very limited feedback mechanisms, particularly when they run through an EHR system. Pure feed-forward designs are sometimes called “ballistic” because once a signal is sent, it can be altered only by another signal from the original source. Feed-forward designs are best used when the outcome anticipated is highly predictable and stable. Such is rarely the case for the average patient on a medical–surgical unit.

Feed-forward is commonly found in the EHR, specifically in medication order routines. If only the initiating physician can terminate or alter a medication order, it is a pure feed-forward design. If another physician, pharmacist, or nurse must reach out to the prescriber to alter or cease a medication, the feedback mechanism can become ad hoc, onerous, and potentially dangerous. Some healthcare leaders go as far as to castigate nurses who fail to deliver an ordered medication even when there are strong reasons not to do so, such as with drug interaction alerts or clear duplications. Recognizing such issues, progressive health systems are providing more effective feedback mechanisms within the EHR and delegating authority to other professionals to alter medication orders as needed.

The EHR is a communication medium that relies heavily on feed-forward algorithms. However, there are ongoing innovations in the EHR to create feedback mechanisms. The development of nursing notes and instant messaging functionality are clear improvements along these lines. The organizational innovations that mitigate the feed-forward issue include policy changes that give pharmacists the authority to remove clearly contraindicated orders and refer the matter back to the physician on the floor. Such policy improvements offer the opportunity to reconcile contradictory information with a well-reasoned and flexible solution.

In short, the transaction care coordination model is an organizational constraint because it creates bottlenecks in patient throughput and allows the weakest link in the system to adversely affect an outcome—potentially compromising patient safety.


My interview in this issue is with John B. Chessare, MD, FACHE, president and CEO of GBMC HealthCare. Dr. Chessare has led a distinguished career inspired by titans of the patient safety movement, including Avedis Donabedian and Donald Berwick. Our conversation inspired this editorial and prompted me to reread my copy of The Goal: A Process of Ongoing Improvement by Eliyahu M. Goldratt and Jeff Cox, a management novel that introduces the Theory of Constraints. I hope you'll find our interview inspiring as well.

Our yearlong series of feature columns exploring the future workforce comes to a close with the personal perspective of Chris Van Gorder, FACHE, president and CEO of Scripps Health. He discusses workplace violence and its impact on healthcare providers. One of the main challenges of working in healthcare is that we often encounter people at their very worst moments. The inability to effectively cope with fear, uncertainty, and a lack of control often gives rise to violent reactions. It is an unfortunate state of affairs, but one that Scripps Health is addressing.

The first peer-reviewed article in this issue is by Danielle DeCicco, MD, PhD; Troy M. Krupica, MD; Ronald Pellegrino, MD; and Ziad O. Dimachkie, MD, of West Virginia University School of Medicine and J. W. Ruby Memorial Hospital in Morgantown, West Virginia. The authors analyze the costly practice of downcoding, in which a health system fails to capture all the charges that it is entitled to receive, and share their successful intervention.

Battling physician burnout with the use of scribes is no longer an innovation, but using virtual scribes extends the idea. In their study of a virtual scribe program, Jennifer Stephens, DO, FACP; Autumn M. Kieber-Emmons, MD; Melanie Johnson; and Grant M. Greenberg MD, FAAFP, of Lehigh Valley Health Network report that quality, time savings, burnout, and productivity moved in positive directions with virtual scribes.

Striving for equity in healthcare leadership ranks is one of my personal areas of interest. Colleagues from across several institutions—Julie Robbins, PhD, of Ohio State University; Brooke Z. Graham of James Madison University; Andrew N. Garman, PsyD, of Rush University; Randa Smith Hall of the University of Alabama at Birmingham; and Jeffrey Simms of the University of North Carolina at Chapel Hill—look at how fellowships help fill the leadership pipeline. Unfortunately, gender disparity remains an issue.

Bookending the editorial and the interview is a new look at the effectiveness of Lean daily management systems (DMSs) during the early stages of the COVID-19 pandemic. Dorothy Y. Hung, PhD; Thomas G. Rundall, PhD; Justin Lee; Negeen Khandel; and Stephen M. Shortell, PhD, of the University of California at Berkeley conducted a series of interviews with health leaders and learned how DMS for crisis management can carry forward into COVID-19 recovery efforts.

We close with three abstracts from the 2022 Forum on Advances in Healthcare Management Research. Featured contributors are Dan Fisher, PhD, of the University of North Carolina Wilmington; Katherine A. Meese, PhD, of the University of Alabama at Birmingham; and Heather Block and Carole South-Winter, EdD, ND, of the University of South Dakota.

On behalf of my colleagues at the American College of Healthcare Executives, I wish you the happiest of holiday seasons. We hope to see you March 20–23 at the 2023 ACHE Congress on Healthcare Leadership in Chicago.

Eric W. Ford, PhD

© 2022 Foundation of the American College of Healthcare Executives