The bit of paper
During ethnographic observation on the ward, something small kept catching my attention: the doctors' notebooks. Not the electronic patient record, not the digital dashboard on the screen at the nursing station, but the small bits of paper - sometimes a folded A4 sheet, sometimes a pocket notebook - that each doctor carried through the board round.
As the team moved through the patient list, doctors would jot things down: which discharge coordinator to follow up with, which family member needed a conversation, which test result to chase. The digital system displayed patient status and discharge readiness; the paper captured what actually needed doing next.
This gap fascinated me. The Timely Care Hub presents a view of the ward - beds, patients, statuses, metrics - that aligns with how "the centre" thinks about hospital operations. But the work of care happens in a different register entirely. The notebook represents the handoff from the digital system's representation of the world to the embodied, relational work of actually making things happen.
It's a small observation, but it opens onto a larger question: what metaphors are we using to understand hospital work, and whose purposes do they serve?
The dominance of flow
The language of "patient flow" is ubiquitous in NHS operational management. Hospitals are framed as systems whose performance can be optimised by smoothing the passage of patients through discrete, sequential steps: admission, treatment, discharge. The metaphor borrows directly from industrial and systems engineering traditions - the same conceptual toolkit that gave us lean manufacturing, throughput optimisation, and bottleneck analysis.
Jackson (2024) traces this lineage explicitly: the success of the Toyota Production System ensured the popularity of flow-based thinking across sectors, including healthcare. The appeal is obvious. Flow metaphors make complex systems legible; they allow performance to be measured (length of stay, bed turnover, discharge rates) and bottlenecks to be identified and addressed. Valente et al. (2023) describe interventions using daily multidisciplinary board rounds to enhance patient flow by focusing on safe, early discharges - precisely the operational context I was observing.
The digital tools built for this worldview reflect it faithfully. Dashboards display beds as slots to be filled and emptied, patients as items moving through a pipeline, discharge as the endpoint that matters. The abstraction is powerful: it renders the hospital visible as a system that can be managed, optimised, improved.
But as Örtenblad, Putnam and Trehan (2016) observe, the metaphors we use to understand organisations do more than describe - they shape what we see and what we overlook. "The whole point of viewing organizations through metaphor is to make practitioners refine their ordinary practices of understanding". The flow metaphor refines understanding in particular directions: toward throughput, toward efficiency, toward measurable outcomes. What does it obscure?
The limits of flow
The flow metaphor tends to reduce the complexity of care to a series of measurable, linear stages. It foregrounds what can be quantified - length of stay, discharge times, cancellation rates - and backgrounds what cannot: clinical judgement, patient experience, interdepartmental communication, the relational work of coordinating care across professional boundaries.
Rasche and Pfannstiel (2018) argue that conceptualising hospitals purely as flow systems risks overlooking adaptive feedback loops and the relational dynamics inherent in complex, knowledge-intensive environments. The flow metaphor assumes patients move through a predetermined sequence; actual care involves constant reassessment, branching paths, and decisions that emerge from the specifics of each situation.
There's also a question of perspective. Flow is a view from above - the perspective of operational management, or at a national scale, from "the centre". From this vantage point, patients are units to be processed, beds are resources to be allocated, staff are capacities to be deployed. It's not wrong, exactly, but it's partial. It doesn't capture what care looks like from the bedside, or what coordination feels like to the nurse trying to get a dozen things done before the end of a shift.
Shorrock (2017) distinguishes between "work-as-imagined" (how managers and designers think work happens), "work-as-prescribed" (how procedures say it should happen), and "work-as-done" (how it actually happens in practice). The flow metaphor operates primarily in the first two registers. The doctor's notebook - capturing the gap between what the system displays and what needs doing - lives in the third.
The notebook as boundary object
The notebooks aren't a failure of the digital system, or predate it; they're an adaptation to its limitations. They capture information the system doesn't represent well: the relational context of each patient (who needs to be spoken to, what conversations are pending), the temporal texture of the work (what needs to happen first, what can wait), the situated judgement about priorities that emerges from the discussion rather than from the data.
In the language of design research, the notebook functions as a boundary object - an artefact that facilitates work across different contexts and communities of practice. But it's a peculiar kind of boundary object: one that bridges the digital representation of the ward and the embodied practice of care delivery.
Dourish (2006) describes the "socio-technical gap" - the distance between our technological reach in design and our grasp of social and organisational complexity. The notebook sits precisely in this gap. It's a workaround, in Goodman and Kuniavsky's (2012) sense: "situations in which informal, ad hoc responses to a problem have become the status quo". The informal practice persists because it serves needs the formal system doesn't address.
What would it mean to take the notebook seriously as a design prompt? Not to digitise it - that would likely just create another system that misses the point - but to understand what it reveals about the shape of the work?
Alternative metaphors
If flow is limited, what other metaphors might better capture the complexity of hospital care? The literature suggests several alternatives, each foregrounding different aspects of the work:
The journey metaphor frames care not as linear passage but as a series of meaningful transitions with decision points and potential detours. Jones et al. (2017) use clinical roadmaps and pathway diagrams to visualise patient journeys with their various stages and branch points. This metaphor preserves the temporal dimension of flow but adds agency and contingency - the patient isn't just moving through a pipeline but navigating a landscape.
The ecosystem metaphor treats the hospital as a dynamic environment where patients, staff, technology, and processes interact and co-evolve. This view emphasises adaptability and resilience, recognising that local disturbances can have cascading effects. It captures something the flow metaphor misses: the interdependence of different parts of the system, the way changes in one area ripple through others.
The network metaphor highlights relational and communicative aspects, viewing care as emerging from interconnections among diverse agents and departments. Rather than unidirectional throughput, it emphasises multidirectional exchanges and decentralised decision-making. This maps more closely to what I observed in the board round: information flowing in multiple directions, decisions emerging from dialogue rather than procedure.
The orchestration metaphor likens care coordination to conducting an orchestra - multiple "instruments" (clinicians, systems, processes) that must be harmoniously synchronised. The conductor doesn't play the music; they enable others to play together. This captures something about the nurse coordinator's role that the flow metaphor misses: not just tracking status but actively coordinating the timing and sequencing of multiple activities.
The navigation metaphor like the journey, draws on information foraging theory (Pérez-Montoro & Codina, 2016) to frame care as wayfinding through uncertain terrain. Clinicians continuously interpret data, adjust plans, and coordinate transitions based on emerging information. This emphasises the improvisational quality of care work - the constant reassessment and realignment that the flow metaphor's linearity obscures.
What metaphors afford
Different metaphors don't just describe differently; they enable different kinds of action. A flow-based digital tool naturally supports tracking throughput and identifying bottlenecks. A journey-based tool might instead illuminate stage transitions and help staff anticipate changes in patient needs. A network-based tool might prioritise interdepartmental communication and real-time collaboration.
The Timely Care Hub, like most operational dashboards, is built on flow assumptions. Its primary views - bed occupancy, discharge readiness, length of stay - render the hospital legible in flow terms. This isn't wrong; these metrics matter, and the visibility they provide is genuinely useful for operational management.
But the tool doesn't capture the relational work that the notebooks record. It doesn't represent the conversations that need to happen, the coordination across professional boundaries, the situated judgements about priorities that emerge from discussion. It shows where patients are in the pipeline; there is more it can do to support the work of moving them through it.
Designing for different perspectives
This isn't an argument against flow-based tools or operational metrics. Hospital management genuinely needs to understand throughput and identify bottlenecks; the flow metaphor serves real purposes. But it is an argument for metaphorical plurality - for recognising that different perspectives require different conceptual frames, and that tools designed for one perspective may not serve others.
The view from the centre, be that the centre of the trust (operational management) or trust executives, or in terms of centralised NHS provider reporting legitimately needs to consider flow. The view from the ward - nurses, doctors, discharge coordinators - might need something more like orchestration or navigation. The question isn't which metaphor is correct but which metaphor is useful for which purpose.
Jones and Van Ael (2022) advocate for "framing" as a discovery process that creates common understanding of issues, scope, and systems. Part of that work is surfacing the metaphors already in play and considering what alternatives might reveal. The journey mapping work I've been doing on this project operates in this space: trying to represent the ward from multiple perspectives simultaneously, acknowledging that no single view captures the whole.
The doctor's notebook, or the slips of paper medical professionals use to track actions will persist, I suspect, regardless of what digital tools are deployed. It serves a function that formal systems struggle to address: capturing the gap between how work is represented and how it's actually done, or how that work is allocated or distributed across the system. But perhaps that gap itself is the interesting thing - the place where design could usefully intervene, not by eliminating the informal practice but by understanding what it reveals about the shape of care work and the gaps or seams between the different supporting systems.
References
- Dourish, P. (2006). Implications for design. In Proceedings of CHI '06. ACM.
- Goodman, E. & Kuniavsky, M. (2012). Observing the User Experience: A Practitioner's Guide to User Research (2nd ed.). Morgan Kaufmann.
- Jackson, M. (2024). Critical Systems Thinking. Wiley.
- Jones, P. & Van Ael, K. (2022). Design Journeys Through Complex Systems. BIS Publishers.
- Jones, P., Shakdher, S. & Possingham, H. P. (2017). Synthesis maps: Visual knowledge translation for the CanIMPACT clinical system and patient cancer journeys. Current Oncology, 24(2), 129-134.
- Örtenblad, A., Putnam, L. L. & Trehan, K. (2016). Exploring Morgan's Metaphors: Theory, Research, and Practice in Organizational Studies. SAGE.
- Pérez-Montoro, M. & Codina, L. (2016). Navigation Design and SEO for Content-Intensive Websites. Chandos Publishing.
- Rasche, C. & Pfannstiel, M. A. (2018). Service design and service thinking in healthcare and hospital management. In M. A. Pfannstiel & C. Rasche (Eds.), Service Design and Service Thinking in Healthcare and Hospital Management. Springer.
- Shorrock, S. (2017). The varieties of human work. Humanistic Systems. Retrieved from https://humanisticsystems.com/2016/12/05/the-varieties-of-human-work/
- Valente, R., Santori, G., et al. (2023). Introducing a structured daily multidisciplinary board round improves discharge planning and patient flow. BMC Health Services Research, 23, 456.