Organizational coordination has traditionally been viewed from an organizational-design perspective where rules, modalities, and structures are used to meet the information-processing demands of the environment. Fast-response organizations face unique coordination challenges as they operate under conditions of high uncertainty and fast decision making, where mistakes can be catastrophic. Based on an in-depth investigation of the coordination practices of a medical trauma center where fast-response and error-free activities are essential requirements, we develop a coordination-practice perspective that emphasizes expertise coordination and dialogic coordination. We argue that expertise coordination practices (reliance on protocols, community of practice structuring, plug-and-play teaming, and knowledge sharing) are essential to manage distributed expertise and ensure the timely application of necessary expertise. We suggest that dialogic coordination practices (epistemic contestation, joint sensemaking, cross-boundary intervention, and protocol breaking) are time-critical responses to novel events and ensure error-free operation. However, dialogic coordination practices are highly contested because of epistemic differences, reputation stakes, and possible blame apportionment.coordination, teams, high-reliability organization, practice, expertise coordination, communities of practice

This paper examines the leadership of extreme action teams-teams whose highly skilled members cooperate to perform urgent, unpredictable, interdependent, and highly consequential tasks while simultaneously coping with frequent changes in team composition and training their teams' novice members. Our qualitative investigation of the leadership of extreme action medical teams in an emergency trauma center revealed a hierarchical, deindividualized system of shared leadership. At the heart of this system is dynamic delegation: senior leaders' rapid and repeated delegation of the active leadership role to and withdrawal of the active leadership role from more junior leaders of the team. Our findings suggest that dynamic delegation enhances extreme action teams' ability to perform reliably while also building their novice team members' skills. We highlight the contingencies that guide senior leaders' delegation and withdrawal of the active leadership role, as well as the values and structures that motivate and enable the shared, ongoing practice of dynamic delegation. Further, we suggest that extreme action teams and other "improvisational" organizational units may achieve swift coordination and reliable performance by melding hierarchical and bureaucratic role-based structures with flexibility-enhancing processes. The insights emerging from our findings at once extend and challenge prior leadership theory and research, paving the way for further theory development and research on team leadership in dynamic settings.

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The authors review the scientific literature on operating room management operational decision making on the day of surgery. (1) Some decisions should rely on the expected (mean) duration of the scheduled case. Other decisions should use upper prediction bounds, lower prediction bounds, and other measures reflecting the uncertainty of case duration estimates. One single number cannot be used for good decision making, because durations are uncertain. (2) Operational decisions can be made on the day of surgery based on four ordered priorities. (3) Decisions to reduce overutilized operating room time rely on mean durations. Limited additional data are needed to make these decisions well, specifically, whether a patient is in each operating room and which cases are about to finish. (4) Decisions involving reducing patient (and surgeon) waiting times rely on quantifying uncertainties in case durations, which are affected highly by small sample sizes. Future studies should focus on using real-time display of data to reduce patient waiting.

Background: Consistent compliance with evidencebased guidelines is challenging yet critical to patient safety. We conducted a qualitative study to explore the underlying causes for non-compliance with evidencebased guidelines aimed at preventing four types of healthcare-associated infections in the surgical intensive care unit (SICU) setting. Methods: Twenty semistructured interviews were conducted with attending physicians (3), residents (2), nurses (6), quality improvement coordinators (3), infection control practitioners (2), respiratory therapists (2) and pharmacists (2) in two SICUs. Using a grounded theory approach, we performed thematic analyses of the interviews. Results: The concept of systems ambiguity to explain noncompliance with evidence-based guidelines emerged from the data. Ambiguities hindering consistent compliance were related to tasks, responsibilities, methods, expectations and exceptions. Strategies reported to reduce ambiguity included clarification of expectations from care providers with respect to guideline compliance through education, use of visual cues to indicate the status of patients with respect to a particular guideline, development of tools that provide an overview of information critical for guideline compliance, use of standardised orders, clarification of roles of care providers and use of decision-support tools. Conclusions: The concept of systems ambiguity is useful to understand causes of non-compliance with evidencebased guidelines aimed at reducing healthcare-associated infections. Multi-faceted interventions are needed to reduce different ambiguity types, hence to improve guideline compliance.Consistent compliance with evidence-based guidelines can significantly improve patient safety and quality of care.