using paper alongside electronic records ( Ellingsen et al., 2013)) or partly transfer it to another profession ( Reiz and Gewald, 2016). Such workarounds therefore have four main characteristics. inter-professional or inter-departmental boundaries, role ambiguity), practical inadequacies of new technologies ( Coiera, 2007), over-work ( Guédon et al., 2017), inflexible rules or communication blockages ( De Bono et al., 2013). Generally workarounds are responses to organisational problems ( Lalley and Malloch, 2010) (e.g. Often workarounds emerge as improvised repairs of ill-designed, incomplete, impracticable, over-restrictive or otherwise dysfunctional work processes ( Bar-Lev, 2015 Vogelsmeier et al., 2008) which make complex tasks still more difficult ( De Bono et al., 2013). Workarounds, however, adjust them further, beyond officially prescribed boundaries, to create informal, unauthorised improvisations that replace official rules and work processes with alternatives that the improviser thinks are more effective or practicable. Work processes are anyway typically discretionary: within limits, workers adjust them according to circumstances. Studies of clinical and healthcare IT workarounds have mostly focused on the informal modification, even subversion, of officially sanctioned work processes ( De Bono et al., 2010 Halbesleben et al., 2008), for example, in nursing ( De Bono et al., 2013), operating theatre safety ( Reason, 2005), or the use of electronic patient records ( Bar-Lev, 2015). Workarounds are the ways in which individual workers or work groups informally by-pass or alter the ways in which a formalised work process is executed, so that they can fulfil its task in another way ( Halbesleben et al., 2008). Background 1.1 The prototype: work-process workarounds We conclude that research into health system transformation, policy conflicts and implementation deficits can be made more nuanced and diagnostic by adding the concept of the ‘managerial workaround’ to the analytic and diagnostic repertoire. In light of our empirical findings, we refine and adjust our initial conceptualisation of managerial workarounds. The policy rationales and consequences of these three DRG systems are more widely reported than the managerial workarounds which help them operate, so we also add that analysis to the empirical literature. We then apply that conceptualisation empirically to analyse data about DRG payment systems for hospitals in England, Germany and Italy. Next we infer what the corresponding characteristics, antecedents and consequences would be, for managerial activity. First we abstract the generic characteristics, antecedents and consequences attributed to workarounds at work-process level. It exposes some implications for health policy, including the transformation of health systems by means of DRG payment systems. This paper's original contribution is to extend the concept of workaround for application to managerial activities. Unlike clinical and IT workarounds, managerial workarounds at organisational and inter-organisational level have seldom been analysed. In practice that has involved managerial workarounds at the payer–provider interface. Many attempts to increase healthcare providers' efficiency and contain the growth of costs have included a policy of paying healthcare providers through a Diagnostic Related Group (DRG) system. The full terms of this licence may be seen at. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial & non-commercial purposes), subject to full attribution to the original publication and authors. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Copyright © 2020, Rod Sheaff, Verdiana Morando, Naomi Chambers, Mark Exworthy, Ann Mahon, Richard Byng and Russell Mannion License
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