Why Hospitals Don't Learn from Failures: ORGANIZATIONAL AND PSYCHOLOGICAL DYNAMICS THAT INHIBIT SYSTEM CHANGE Anita L. Tucker Amy C. Edmondson T he importance of hospitals learning from their failures hardly needs to be stated. Not only are matters of life and death at stake on a daily basis, but also an increasing number of U.S. hospitals are operating in the red.' Organizational learning is thus an imperative. Recent research suggests there are plenty of problems, errors, and other learning opportunities facing these complex service organizations. In 2000, the Institute of Medicine issued a report estimating that 44,000 to 98,000 people die each year as a result of medical errors. Other studies suggest, in addition, that med- ical errors with less serious consequences are pervasive in hospitals.' Hospitals historically have relied on a dedicated and highly skilled profes- sional workforce to compensate for any operational failures that might occur during the patient care delivery process. Great doctors and nurses, not great organization or management, have been seen as the means for ensuring that patients receive quality care. Recently, however, the medical community has responded to increased public awareness of shortcomings in health care delivery by calling for systematic, organizational improvements to increase patient safety. Examples of such initiatives include creating shared databases of medical errors to facilitate widespread learning from mistakes and focusing renewed attention on hospital processes, culture, and reporting systems.* Front-line employees in service organizations are well positioned in these efforts to help their organizations learn, that is, to improve organizational We wish to thank the participating hospitals and nurses and Harvard Business School's Division of Research who supported this research. We are grateful to H. Kent Bowen and Steven J. Spear for engaging the participation of two of the study sites and for advice and guidance on using observa- tional methods to study the management of operations. Rogelio Oliva's comments were extremely helpful in clarifying our model of problem solving. Jennifer Chalfin's assistance with the model graphics is gratefully acknowledged. CALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003 55Page 2 of 19 Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures outcomes by suggesting changes in processes and activities based on their Hospital errors have received considerable nationwide attention recently; knowledge of what is and is not working.' Identifying and resolving causes of however, an emphasis on only those errors that lead to severe consequences problems that arise during the course of work is one method for achieving orga- such as the death of a patient has perhaps obscured the subtler phenomenon nizational learning. By catching, correcting, and removing underlying causes, of errors that take place within the care delivery process everyday-such as an front-line employees can contribute to changes that help avoid erosion of quality unnecessary pre-operative preparation. Thankfully, most errors are caught and and customer satisfaction in the future. In this way, through initiative taking and corrected before patients are harmed; however, a lack of attention to the process problem solving at the front lines, organizational systems and procedures can be errors that precede more visible, consequential failures may limit opportunities changed to avoid many of the most prevalent recurring problems (sometimes for organizational learning. referred to-perhaps overly optimistically-as "low hanging fruit"). The second type of failure is a problem, which we define as a disruption We conducted a detailed study of hospital nursing care processes to inves- in a worker's ability to execute a prescribed task because either: something the tigate conditions under which nurses might respond to failures they encounter worker needs is unavailable in the time, location, condition, or quantity desired in their hospital's operational processes by actively seeking to prevent future and, hence, the task cannot be executed as planned; or something is present that occurrences of similar failures. Our research suggests that, in spite of increased should not be, interfering with the designated task." Examples of problems emphasis on these issues, hospitals are not learning from the daily problems and include missing supplies, information, or medications. Unlike errors, work- errors encountered by their workers. We also find that process failures are not process problems have received little atten rare but rather are an integral part of working on the front lines of health care tion in the literature or press. Like errors, Whereas workers can take action delivery. problems are a valuable source of informa- to solve problems, prevention Although this study focused on hospital nurses, the lessons learned have tion about ways in which the system is not implications for managers in other service organizations as well. The tasks car- working. of errors necessarily requires ried out by nurses are knowledge-intensive, highly variable, and performed in Workers are well aware of the prob- lems they encounter. In contrast, by defini- management involvement the physical presence of customers, which heightens the worker's focus on the current customer's comfort and safety and can detract from awareness of the tion, people are unaware of their own errors to redesign work systems. need to improve the organizational system through which care is delivered. while making them. Not surprisingly, given These aspects are similar to work environments of other service providers who that we observed the work processes from the viewpoint of front-line workers, perform complex physical and mental tasks the majority (86%) of the failures we observed in the care delivery process were Amy C. Edmondson is an Associate Professor of Business Administration at Harvard Business in the presence of customers, such as com- problems rather than errors. Both kinds of failures require some kind of action School. puter help-desk operators, repair techni- for patient care to continue effectively. Whereas workers can take action to solve Anita L. Tucker is a doctoral candidate at Harvard cians, airline crews, fire fighters, police problems-due to their intense awareness of them-prevention of errors neces- Business School. officers, teachers, beauticians, and some sarily requires management involvement to redesign work systems in ways that customer service representatives. Further, make errors less likely to occur. hospitals have many features in common with other service organizations, notably time pressure, unpredictability in the workload, the relatively low status of nurses as front-line employees, and their reliance on others for supplies and Research Base information. These features contribute both to the emergence of failures and to In this article, we summarize findings from an in-depth study of work barriers to learning from them. system failures on the front lines of care delivery in hospitals. We analyzed qualitative data from 239 hours of observation of 26 nurses at nine hospitals Process Failures on the Front Lines of Hospital Care Delivery to develop understanding of and recommendations for organizational learning from process failures." After completing the observations, we conducted inter- Our research identified two types of process failures-problems and views with twelve nurses at seven of the hospitals studied. errors. We define an error as the execution of a task that is either unnecessary or Nursing units provide a rich context for studying problem solving. First, incorrectly carried out and that could have been avoided with appropriate distri- nurses are typically experienced and capable problem solvers because their pro- bution of pre-existing information. For example, we observed a patient who had fession requires a high level of cognitive reasoning and discretionary decision been unnecessarily prepared for colonoscopy at significant expense to the hospi- making." For example, nurses coordinate patients' care with support functions tal and discomfort to the patient before the specialist reviewed her case-reveal- such as diagnostic tests and physical and respiratory therapy, pulling together ing that the patient was not an appropriate candidate for the procedure- rpreting data to recognize ominous patterns that warrant contacting cancelled it. X 56 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003 ALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003 57Page 4 of 19 Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures TABLE I. An Overview of Hospitals where Observation of Workers Occurred physicians to intervene when a patient takes a turn for the worse. In addition, they provide direct patient care, including assessing patients' condition, adminis- Nursing Observation % of Total tering medications, bathing and moving patients to prevent bed sores, providing Type of Number Units Unionized Time Observation # of Nurses treatments (e.g., blood transfusions, dressing changes), and educating patients Hospital Hospital of Beds Observed Nurses (hours:min) Hours Interviewed (and their families) about their medical conditions. Nurses usually have multiple patients and meeting all of their physical and emotional needs is challenging, if Small 47 Intensive Non-Union 82:35 34% not impossible. Consequently, nurses continually evaluate what needs to be Community Care Unit done, reprioritizing their tasks to meet patients' changing needs. Second, the 2 Specialty 98 Surgical Non-Union 7:45 3% 0 Urban, unpredictable nature of health care and the high level of interdependence Teaching among service-providing employees" (e.g., nurses, doctors, pharmacy, central 3 Rural 134 Medical Union 27:19 1 1% 2 supply, and laboratory) make it likely that nurses will encounter failures in the Community Surgical course of their day-to-day work. Community, 243 Surgical Non-Union 34:30 14% With the exception of the first hospital, a community hospital actively Private and engaged in an organizational change effort, we purposely sought hospitals with Not-For-Profit Maternity Community, 297 reputations for nursing excellence by asking nursing governing boards for refer- Oncology Union 15:35 7% Government & Medical/ rals to such hospitals and by searching nursing magnet literature for hospitals Surgical nationally recognized for nursing excellence. Our goal was not gather a repre- Community, 250 Cardiac Union 1:30 1% sentative sample of hospitals, but instead to assess how excellent nursing hos- Government pitals handled service failures, while also ensuring that our findings were not Teaching 198 Oncology Non-Union 20:30 9% biased by results from only one organization. By including multiple excellent Urban organizations, we were able to discern that the basic pattern of problem-solving 8 Pediatric, 163 Oncology Union 9:1 4% behavior was similar across these nine across hospitals, with only modest varia- Teaching Urban tion from site to site. These hospitals are described in Table 1, using pseudonyms 9 Teaching 433 Intensive Non-Union 40.30 17% 2 to protect their confidentiality." Tertiary Care Care Unit Total 239:25 12 Failures on the Front Lines of Care Delivery We characterized the nature of the failures we observed on the front lines of patient care delivery, and subsequently we examined nurses' responses Second, we observed 28 errors, which fell into three categories: incorrect to them. We encountered 194 failures during our observations. Problems consti- actions made by the nurse (39%), errors made by other people (18%), and tuted the majority (166) of these data. Nurses experienced five broad types of unnecessary execution of tasks resulting from faulty process flows (43%). Exam- problems: missing or incorrect information; missing or broken equipment; wait- ples of these three categories respectively include a nurse who forgot to give a ing for a (human or equipment) resource; missing or incorrect supplies; and patient his medications for the entire shift, nurses having to correct mistakes simultaneous demands on their time. " Problems were most likely to surface made by the previous shift's nurse (i.e., a patient's diet entered incorrectly in while nurses were preparing for patient care (88% of the problems) and/or the computer system), and nurses beginning to transfer a patient to another unit as a result from a breakdown in information or material transfer to the nurse before receiving information from surgeons (and in two cases, family members) (91% of the problems), highlighting the boundary-crossing nature of this kind that reversed the transfer decision. of process failures. This finding is further reinforced in interviews. Five of the Distinguishing between problems and errors highlights the different twelve nurses interviewed noted that although nurses should take responsibility roles front-line employees can play in improvement. The relative visibility and for trying to improve how things work, many problems stem from other groups frequency of problems, compared to errors, makes them accessible to front-line and departments. An oncology nurse commented on her perception that down- workers who are well positioned to suggest important changes that managers stream, internal support departments were the source of many disruptions: would not be able to identify. Second, problems carry less stigma than errors, making discussion of them less interpersonally threatening." Understanding "The daily problems we face are from outside of our own unit-central supply and housekeeping, for example. It is not the people on the unit. It is not what how front-line employees respond to problems is thus important for efforts to we do or don't order for our supplies. It is a system problem." improve work systems and processes. 58 CALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures First-Order Problem Solving problem-solving behavior, ironically, can preclude improvement by obscuring the existence of problems and errors and preventing operational and structural Research on quality improvement has distinguished between two types changes that would prevent the same failures from happening again. of response to problems-short-term remedies that "patch" problems and more Our analysis identified two implicit strategies, or more colloquially, rules- thorough responses that seek to change underlying organizational routines to of-thumb that exemplify first-order problem solving. The first rule of thumb prevent recurrence." We make a similar distinction between first- and second- is as follows: when you encounter a problem, do what it takes to continue the order problem-solving behavior in service organizations." First-order problem- patient-care task-no more, no less. When nurses used this rule-which they solving behavior occurs when the worker compensates for a problem by getting the supplies or information needed to finish a task that was blocked or inter- did for 93% of the problems-their behavior involved securing the information rupted. The worker does not address underlying causes, thus not reducing the or material they needed to do their jobs without probing into what caused the likelihood of a similar problem in the future. In our research, we found that problem to occur. After the nurses were able to resume caring for the patient, they did not expend further effort on the incident; that is, they neither commu- nurses implemented a short-term fix for the overwhelming majority of the fail- nicated that it occurred to others nor sought to investigate or change causes. ures observed, enabling them to continue caring for their patients, without tak- This strategy served several purposes. It allowed a nurse to meet the require- ing any action to try to prevent recurrence of similar failures-that is, without ments of the current patient-a responsibility that the nurses we observed did prompting organizational learning. For example, an oncology floor nurse who not take lightly. It also reduced the amount of time the harried nurse spends worked on the night shift ran out of clean linen to change her patients' beds. away from patient care duties; engaging in extra activity beyond the immediate She walked to another unit that had linen in stock and took from their supply. fix would be a further drain on the care current patients received. At first glance, first-order problem solving seems successful: the nurse was able to obtain linen. The cost to the nurse and to the hospital was minimal; The second rule of thumb was-when necessary for continuity of patient care-to ask for help from people who were socially close rather than from those it only took a few minutes of her time and was inexpensive. Notably, this nurse who were best equipped to correct the problem. The second rule of thumb did not pay for a taxi to deliver the linen from an off-site linen cleaning service, helped to preserve the nurse's reputation regarding his or her competence at which nurses at other hospitals reported as how they often handled the problem handling the daily rigors of nursing. In addition, it allowed nurses to avoid of running out of certain supplies, including linen. Seven out of nine nurses unpleasant encounters with cantankerous physicians or managers as long as whom we interviewed reported feeling gratified when they figured out a way possible. At the same time, it all but precluded addressing underlying causes that to work around an obstacle enabling them to continue patient care. The nurse might improve the system. The nurses followed this rule for 42% of the prob- missing linens commented, lems and deviated from it for only 7% problems (e.g., they contacted a physician Working around problems is just part of my job. By being able to get IV bags or or other hospital personnel rather than attempting to solve the problem on their whatever else I need, it enables me to do my job and to have a positive impact on own)." The appeal and power of rules of thumb upon which one can tacitly rely a person's life-like being able to get them clean linen. And I am the kind of per- in a time-pressured situation may help explain the high level of consistency of son who does not just get one set of linen, I will bring back several for the other nurses' responses to problems. nurses." Upon further reflection, it appears that first-order problem solving can be Second-Order Problem Solving counterproductive. It keeps communication of problems isolated so that they do not surface as learning opportunities. Work- Second-order problem-solving behavior occurs when the worker, in First-order problem solving can ers rarely inform the person responsible for addition to patching the problem so that the immediate task at hand can be be counterproductive. It keeps the problem, which prevents those people completed, also takes action to address underlying causes. Second-order problem from learning that their processes could be solving includes: communicating to the person or department responsible for the communication of problems improved. Sometimes, first-order problem problem; bringing it to managers' attention; sharing ideas about what caused the isolated so that they do not solving creates new problems elsewhere, as situation and how to prevent recurrence with someone in a position to imple- when the above nurse took several sets of ment changes; implementing changes; and verifying that changes have the surface as learning opportunities. linens from another area. Moreover, consid desired effect. Given that nurses have so little spare time for extensive second- erable time (of highly paid professionals) is order problem-solving behavior such as tracking the problem to its source and wasted on tasks and rework that would not otherwise be necessary. We found making system changes to prevent recurrence, we categorized any behavior that that, on average, 33 minutes were lost per eight-hour shift due to coping with called attention to the situation-thereby starting a legitimate process of inquiry system failures that could have been addressed and removed. Thus, first-order into root cause which could then transpire over a period of time-as indicative 60 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO.2 WINTER 2003 61Page 8 of 19 Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures of second-order problem-solving behavior. Nonetheless, only 7% of nurse It is also not because nurses are uncommitted, lazy, or incompetent. The responses met even these lenient criteria. nurses studied were extremely dedicated and capable, often possessing advanced To illustrate second-order problem solving in this context, we observed degrees and all had worked more than three years on their unit. Nine out of ten an inexperienced intensive-care unit (ICU) nurse transfer a two-year old patient nurses whom we observed for an entire shift stayed an average of 45 minutes to the oncology floor by mistakenly leaving the sleeping child on his ICU bed after their shift had ended-without extra pay-to complete their patient care rather than moving him onto the standard hospital bed in his new room, despite duties. They ate their lunches in much less time than allotted and postponed the protests of the oncology nurse that the highly-specialized ICU beds had to be taking personal breaks in order to provide the care they felt their patients returned. Not unexpectedly, the ICU nurse manager called the oncology unit deserved. One nurse, who worked from secretary 30 minutes later, asking for the ICU bed. The oncology nurse-instead 7:00 A.M. until 7:00 P.M. called the unit at The lack of organizational learning of simply returning the bed-did something that was unusual, and certainly not 4:00 A.M. after waking up, suddenly remembering something she had forgotten from failures can be explained by necessary for the immediate care of her patient. She called the ICU nurse man- ager, explaining, "I don't want to get anyone in trouble, but I want you to know to tell the nurse who took over caring for an emphasis on individual what happened so you can talk to the nurse so that it does not happen again." her patients. The lack of organizational learning vigilance, unit efficiency concerns, In this example, the nurse took care of the immediate situation-getting the ICU bed back to the unit-and also took action to try to remove the underly- from failures can be explained instead by and empowerment. ing cause of the error-the new ICU nurse's mistaken belief that it was worse to three less obvious, even counterintuitive, move a sleeping child than to leave an ICU bed on another unit. The ICU nurse reasons: an emphasis on individual vigilance in health care, unit efficiency con- manager could then ensure that all ICU nurses were aware of this requirement. cerns, and empowerment (or a widely shared goal of developing units that can The oncology nurse's apologetic introduction, when calling the ICU to engage in function without direct managerial assistance). These three factors, while seem- system-correcting behavior, is perhaps indicative of how counter-normative such ingly beneficial for nurses and patients alike, can ironically leave nurses under- behavior can be in hospitals. Instead of being governed by tacit rules-of-thumb supported and overwhelmed in a system bound to have breakdowns because of that everyone seems to follow without explicit decision, second-order problem the need to provide individualized treatments for patients. solving seemed to take conscious effort. First, individual vigilance-an industry norm that encourages nurses and Second-order problem solving can have positive consequences for work- other health care professionals to take personal responsibility to solve problems ers and the organization. If the worker's action is successful and the problem as they arise-is explicitly developed and highly valued in health care organiza- does not recur, they will not have to face similar obstacles in the future. As a tions. Counterintuitively, this can create barriers to organizational improvement result, second-order problem solving is a way that real change is achieved. The because, in addition to encouraging individuals to be alert to things that can go organization can benefit from higher productivity, customer satisfaction (because wrong and to quickly take action, norms of individual vigilance encourage inde- service is not interrupted), and worker satisfaction (feelings of competence from pendence. Each caregiver thus tends to work on completing her or his own tasks improving their work systems and less frustration with completing their tasks). without altering common underlying processes. Nurses are allowed, and even encouraged, to resolve problems independently without having to consider the impact on the system. In this way, problems of missing supplies or equipment Three Positive Human Resource Attributes tend to be resolved by taking the necessary items from somewhere else, hence that Prevent Learning creating another problem downstream. We found that nurses' problem-solving action tended to be directed at meeting immediate needs of patients; its scope Why aren't hospitals-and we suspect many other service organizations rarely included assessing or remedying underlying causes-even when similar as well-learning all they can from daily problems encountered by their work- problems were confronted consecutively-making the chances of spurring orga- ers? Our research suggests that it is not because problems are highly complex nizational improvement and change through such efforts remote. or difficult to solve, nor is it because nurses are unmotivated-two plausible explanations. The problems we observed, while often requiring some sort of Second, nursing units were designed to maximize individual unit effi- system change for resolution, were neither ill defined nor technically challeng ciency. Nursing labor is expensive and in short supply. Understandably, hospitals ing. Instead, they were relatively straightforward and embedded in routine can ill afford to have nurses routinely working with slack resources. This staffing processes; typical examples included missing medications, regular-diet food trays model leads to an organizational design where workers do not have time to being delivered for diabetic patients, insufficient supplies, and a lack of necessary resolve underlying causes of problems that arise in daily activities. Instead, medical orders for patient care. nurses are barely able to keep up with the required responsibilities and are in essence forced to quickly patch problems so they can complete their immediate 62 CALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003 CALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003Page 10 of 19 Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures responsibilities. Thus, in this situation it is possible for an individual worker to FIGURE I. Model of First-Order and Second-Order Problem-Solving Behavior be working non-stop while the content of the work technically adds little value to the customer's experience because of the amount of rework and unnecessary - Norms of Individual Vigilance steps Efficiency Concerns Third, empowerment of workers has been cited as a solution for quality Empowerment and productivity problems." The flip side of empowerment, however, is the Barriers to Task Completion First-order Problem removal of managers and other non-direct labor support from daily work activi- B Solving Effort ties, leaving workers on their own to resolve problems that may stem from parts of the organization with which they have limited interaction. Reducing the degree to which managers are available to front-line staff can be a loss for Effectiveness of First- improvement efforts, especially when workers are already overburdened by Latent Failures order Problem Solving R existing duties. Managers tend to have a broader perspective than line workers, Burnout possess status necessary to resolve problems that cross organizational bound- R aries, and are capable of implementing solutions on a wider basis. This is not to Gratification say that nurses are not capable of engaging in such activities, but rather that the immediate nature of their duties precludes them from spending large amounts Effectiveness of Second-order of time away from patient care. Without a readily available nurse manager, they Problem Solving Second-order Problem Solving Effort are left without anyone to assist them in making these connections. Management Organization Support Responsiveness An Illusory Equilibrium Created by Psychological Safety Responses to Process Failures When a problem arises, a worker needs to engage in first-order problem solving merely to be able to continue his or her duties. First-order problem solv- engage in second-order problem-solving behavior. Because first-order problem ing, however, does not alter the underlying conditions that gave rise to barriers solving takes time, it can leave workers with less flexibility to investigate causes to task completion, and so the failure, or one just like it, is likely to recur. This and negotiate potential countermeasures. means that although the behavior appears to provide a solution, the solution, in A more subtle mechanism through which second-order problem-solving fact, is a temporary measure. As a model of this dynamic phenomenon, Figure 1 effort is reduced is the feelings of gratification that nurses report when effect depicts the causal relationships between these constructs. tively overcoming problems on their own. One nurse expressed her satisfaction The iterative relationship between problems (recognized by workers on when she was able to resolve issues that were preventing her from caring for the job as "barriers to task completion") and worker response (first-order prob- her patients, "I have a lot of job satisfaction when I go home and I feel like I lem-solving effort) is a dynamic structure of the type that researchers who study did everything that a patient needed and was entitled to. Even the little things." the dynamic properties of organizational systems have called a "balancing Ironically, this rewarding feeling of competence and self-sufficiency tends to loop."18 How it works is that the emergence of a problem (some disruption or further decrease the chances of expending effort to get others involved, as barrier that would otherwise preclude the continuity of patient care) increases needed for second-order problem solving-and so the rate of failure emergence the chances (indicated by a plus sign in the thick arrow at the top of Figure 1) is not reduced. This is also depicted in Figure 1, in the positive link between of a particular response-a first-order problem-solving effort. In turn, when this effective first-order problem solving and worker feelings of gratification. response successfully patches the problem, it reduces or removes the barrier In most hospitals, organizational culture and management behaviors (indicated by a minus sign next to the other thick arrow), allowing the caregiver tend to reinforce this already-robust system of individual vigilance. Seventy to continue the patient care task. percent of the nurses we interviewed commented that they believed their man- This is a system in apparent balance. A problem shows up, action is taken, ager expected them to work through the daily disruptions on their own. Speak- and the obstacle is gone-at least temporarily. As depicted in Figure 1, however, ing up about a problem or asking for help was likely to be seen as a sign of an increase in first-order problem solving actually reduces the likelihood that incompetence. As one nurse interviewed explained, "My manager is not inter- underlying causes will be addressed. First, the more effort expended in first- ested in hearing about things if they are small. If I went to her with a small order problem solving, the less likely he or she is to have and take time to problem, she would say, 'Solve it yourself.' To get any attention from managers, 64 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003 CALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003Page 12 of 19 Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures problems have to be something that is out of your hands-something you can't for change is management support, which can work deliberately to increase solve on your own." effort spent on second-order problem solving by front-line workers. This poten- Further, to those directly involved, things seem to be working reasonably tial influence is depicted on the right side of Figure 1. well. It is stressful, but basically in balance. The catch is-because first-order What do we mean by management support? To begin with, managers problem solving is time-consuming and tiring-over time, burnout begins to must make an effort to be regularly available for at least part of all shifts. We take its toll on the system. This time delay is represented in Figure 1 by two observed that the physical presence of managers increased the likelihood of slash marks between first-order problem-solving effort and burnout. This symbol managers being informed of problems occurring on the unit; this, in turn, indicates that first-order problem-solving behavior leads to burnout-but not allowed managers to investigate and support possible work system changes. immediately. Frustration and exhaustion accumulate over time. Not surprisingly, Next, managers can counteract time pressure by providing assistance for front- worker burnout then further decreases the chances of effortful engagement in line problem-solving efforts. In addition, by acting as role models of second- second-order problem solving (another order problem solving, managers can teach workers to think about what could Over time, therefore, the apparent causal arrow marked by a minus sign in be done to prevent similar problems from occurring in the future." balance of this system is revealed Figure 1). In addition, less effort on second- Second, to learn from failures, people need to be able to talk about them order problem solving means its effective- without fear of ridicule or punishment. Managers can help create an environ- as illusory. Workers experience an ness or ability to reduce latent failures also ment where workers feel safe taking the interpersonal risks that second-order increasing sense of frustration, goes down. To illustrate this, in our study, problem-solving entails, thereby making this one nurse said, "I am quite burned out as a behavior more psychologically feasible (see Figure To learn from failures, exhaustion and, in some cases, whole with nursing. I would quit tomorrow 1). Creating a psychologically safe work environ- people need to be able to leave the organization-worn out if I could find decent work with health ment does not require managers be excessively insurance-even for less pay." warm and friendly, but instead that they invite talk about them without fear by the task of swimming Over time, therefore, the apparent others to express their concerns and model fallibil- of ridicule or punishment. upstream against an incessant balance of this system is revealed as illusory. ity by admitting their own errors.2 Workers experience an increasing sense of Third, managers and others in the organization must respond to initiative tide of small, annoying problems. frustration, exhaustion and, in some cases, by following through on these suggestions and facilitating boundary-crossing leave the organization-worn out by the improvements that help reduce the rate of problem emergence. In short, if sec- task of swimming upstream against an incessant tide of small, annoying prob- ond-order problem-solving effort does not lead to any positive changes, workers lems. Across the health care delivery industry, this phenomenon is contributing will be discouraged about spending their time on this in the future. One nurse to unacceptable high levels of turnover in many organizations and to commented, "I know nurses on our floor used to come up with suggestions for widespread nursing shortages. 19 change. No one seems to listen and now no one bothers trying." Conversely, if the effort is effective (because the organization is responsive), workers' motiva- Levers for Change tion to engage in second-order problem solving in the future will be strength- ened. The left side of Figure 1 thus shows organizational responsiveness to The process of developing a causal feedback model suggests the location nurses' attempts at second-order problem solving as a positive influence on the of leverage points for change. The model shown in Figure 1 depicts first-order effectiveness of the effort. problem-solving behavior as a "fix that fails, "20 that is, it illustrates the all too Are these solutions feasible in the budget conscious world of health care? human response to take action expediently when things go wrong in such a way After all, most involve additional expenses, whether freeing up a manager to that the situation seems to improve, in the short term. Over time, however, as assist front-line workers with resolving failures, promoting more discussion of shown by the model, the situation gradually worsens. Thus, the power of a (and time devoted to) tracking down causes of problems, or implementing coun- causal feedback model such as this is that it calls attention to variables that are termeasures. Further analysis suggests that the extra expense would pay off. well positioned for creating more fundamental, long-term change. These lever- Although second-order problem solving requires an investment in developing age points constitute specific ways that managers can foster organizational learn- both human resources and organizational routines, over time the reduction in ing efforts by front-line workers in hospitals and other service organizations. failures could pay for themselves. At a bare minimum, we can estimate that As the model shows, the situation can only be improved in a real rather worker time wasted in work-arounds to cope with system failures was 8% of than illusory manner through second-order problem-solving behavior. To make a shift. Even with conservative estimates, this amounts to $256,000 per year in this happen, managerial intervention is likely to be essential. Thus, a first sing time for a 200-bed hospital."Further, many nurses are currently X 66 CALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003 ALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003 67Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures "subsidizing" the hospital by working through their breaks, lunch time, and TABLE 2. Comparison of Traditional and Learning Views of Desirable Employee Behaviors working unpaid overtime in order to make up the time they lost because of sys- tem failures and inefficiencies. This generosity backfires when nurses leave the When the "Ideal Employee" Employee Behaviors Conducive profession due to burnout. Employee Faces: Behaviors to Organizational Learning The savings due to reductions in patient complications could be even Missing materials or Adjust to shortcomings in materials Noisy Complainer: Remedies immediate greater. For example, we observed one patient who stayed in the intensive-care information and supplies without bothering situation but also lets the manager and supply unit for an additional night because a preparatory medication did not arrive on managers or others. department know when the system has failed. the floor in time and his procedure had to be delayed until the following day. Such discharge delays are extremely expensive for the hospital as they are reim- Others' errors Seamlessly corrects for errors of Nosy Troublemaker. Lets others know when bursed for a category of services provided, not by their actual costs of providing others - without confronting the they have made a mistake with the intent of person about their error. creating learning, not blame. each service. Moreover, many hospitals are capacity constrained, and so an extra day is a day that could have been provided to another patient. Own errors and Creates an impression of never Self-Aware Error-Maker: Lets manager and problems making mistakes. others know when they have made a mistake The burden of learning from failures does not lie solely with managers. so that others can learn from their error. Workers must take specific actions, suggesting a list of desirable behaviors by Communicates openness to hearing about front-line workers that differs in important ways from conventional wisdom their errors discovered by others. about the ideal employee. For example, most managers would identify an ideal Subtle opportunities for Committed to the current way of Disruptive Questioner who won't let well enough employee as one who can handle with ease any problem that comes along, improving the system doing business-understands the alone: Questions why do we do things this without bothering managers or others. From an organizational learning perspec- "way things work" around here. way? Is there a better way of providing the tive, this is questionable wisdom. The ideal employee is instead a noisy com- service to the patient? plainer, who speaks up to managers and others about the situation, thereby running the risk of being seen as someone who lacks self-sufficiency. Similarly, instead of quietly correcting others' errors without making a fuss, a front-line Therefore, not hearing anything about what kinds of failures workers are experi- worker should be a nosy troublemaker, actively pointing out colleagues' mis- encing is more likely to mean that managers are not present and receptive takes. Third, the ideal employee for organizational learning does not convey an enough for workers. The lack of communication does not mean there are no impression of flawless performance but rather openly acknowledges his or her problems. The clues managers can look for include worker frustration that input own errors. This self-aware error-maker not only facilitates correction but also is not heard and a resigned sense that "nothing ever changes around here." As speaks up about process failure and thus contributes to a climate of openness in one nurse mused, "I do not feel that my voice is heard. Often I am discouraged, which others can do likewise. Finally, the ideal employee is a disruptive ques- so I don't input my ideas. Where would my ideas go? We are not asked for tioner who won't leave well enough alone. This person is constantly question- input." Over time, this leads to a sense of futile resignation that the problems are ing, rather than accepting and remaining committed to, current practices. These going to always be there because nothing gets resolved. differences are summarized in Table 2. Even in the most successful service organizations, work system failures will occur. Both errors and problems can be detected and used as launching Conclusions points for organizational learning and improvement by motivating changes to By reframing workers' perceptions Our study shows that it is difficult for hospital workers to use problems as avoid recurrence. Front-line service opportunities for improvement. The dynamic pattern described in this article is providers are in the best position to discover of failures from sources of not unique to hospitals, although it may be exaggerated in health care by the and remove this type of work system fail- frustration to sources of learning, task variability, the extreme time pressure faced by workers, and the increasing ure. Managers have an essential role: assist- cost pressures faced by hospitals. Other service contexts present similar features. ing with problem-solving efforts, providing managers can engage employees For example, many service workers are motivated by the rewarding sense of support for workers who attempt to in system improvement efforts self-sufficiency that led some of the nurses we observed to avoid reporting or improve their work systems, and valuing getting help for fixing system failures. them as motivated employees. By reframing that would otherwise not occu Many service organizations are not learning all they can from their fail- workers' perceptions of failures from ures. Complex systems, like the ones used by most organizations to provide the sources of frustration to sources of learning, managers can engage employees in services their customers buy, are bound to suffer from failure and poor design. system improvement efforts that would otherwise not occur. 68 CALIFORNIA MANAGEMENT REVIEW VOL. 45, NO. 2 WINTER 2003 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003Why Hospitals Don't Learn from Failures Why Hospitals Don't Learn from Failures Notes nurse responses. In sum, our over-sampling of problems at this site does not pose a serious 1. For a report the poor financial state of hospitals in general, see for example, C. Kramer and threat to the generalizability of our findings. D. Dalmand, "Ernst & Young/HCIA-Sachs Study Finds Continued Financial Woes for Hospi- 12. To compute inter-rater reliability for the types of problems, a random sample of ten observa- tals on May Day," Ernst & Young/HCIA-Sachs [Electronic] (2001), accessed on October 8, tion days was evaluated independently by two non-nurse reviewers. The kappa statistic, 2002. which adjusts the rating downward to compensate for the probability that raters could 2. This often cited statistic comes from L.T. Kohn, J.M. Corrigan, M.S. Donaldson, "To Err Is assign items to the same category by chance, w s appropriate to use in this situation. The Human: Building a Safer Health System, " (Washington, D.C.: National Academy Press, kappa value was 0.88 for judgments about problem type, which is considered almost perfect Committee on Quality of Health Care in America, Institute of Medicine, 2000). by Landis and Koch. See J.R. Landis and G.G. Koch, "The Measurement of Observer Agree- 3. Many researchers have written about the pervasiveness of medical errors in hospitals. For ment for Categorical Data, " Biometrics, 33 (1977): 159-174. one of the most influential studies, see L.L. Leape, D.W. Bates, D.J. Cullen, et al. "Systems 13. Previous research has established a positive relationship between the degree to which work- Analysis of Adverse Drug Events," Journal of the American Medical Association, 274/1 (1995); ers feel safe taking interpersonal risks and the amount of errors that are reported. See A.C. 35-43. Edmondson, "Learning from Mistakes Is Easier Said than Done: Group and Organizational Both the popular press [J.P. Shapiro, "America's Best Hospitals," U.S. News and World Report Influences on the Detection and Correction of Human Error," Journal of Applied Behavioral (2000)] and the medical community [E.C. Nelson, P.B. Batalden, T.P. Huber, et al., Science, 32/1 (1996): 5-28, and A.C. Edmondson, "Psychological Safety and Learning Behav- "Microsystems in Health Care: Part I, Learning from High-Performing Front-Line Clinical ior in Work Teams," Admi Units," Joint Commission Journal of Quality Improvement, 28 (September 2002): 472-497] have 14. This pattern of simply fixing the problem rather than doing something to prevent its recur- turned their attention to flaws in the operational systems through which care is provided. rence is also reminiscent of reactive versus preventive control, as discussed in R.H. Hayes, Sim Sitkin has argued that small failures are excellent sources of learning because they S.C. Wheelwright, and K.B. Clark, Dynamic cturing: Creating the Learning Organization indicate that current processes can be improved upon, without causing organizations to (New York, NY: Free Press, 1988). Similarly, John Carroll and his colleagues explore this respond defensively as large failures are likely to do, which would inhibit effective learning. phenomenon with regards to accident reviews undertaken by nuclear power plant employ- S. B. Sitkin, "Learning through Failure: The Strategy of Small Losses," in L.L. Cummings ees, see J.S. Carroll, J.W. Rudolf, and S. Hatakenaka, "Learning from Experience in High- and B.M. Staw, eds., Research in Organizational Behavior, 14 (1992): 231-266. For articles that Hazard Organizations, " Research in Organizational Behavior (forthcoming). Nelson Repenning discuss the role of front-line workers in and John Sterman contrast two types of process improvement, first-order improvement and "The Road to 'Root Cause': Shop-Floor Problem-Solving at Three Auto Assembly Plants," second-order improvement, see N. Repenning and J.D. Sterman, "Capability Traps and Self- Management Science, 43/4 (1997): 479-502; A. Mukherjee, M. Lapre, and L.N. Van Wassen- Confirming Attribution Errors in the Dynamics of Process Improvement," Administrative hove, "Knowledge Driven Quality Improvement," Management Science, 44/11 (1998): $35- Science Quarterly, 47 (2002): 265-295. $49; S.J. Spear, "The Essence of Just-in-Time: Imbedding Diagnostic Tests in Work-Systems 15. Our concept of first and second-order problem solving is analogous to Argyris and Schon's to Achieve Operational Excellence," Production Planning & Control (forthcoming). notion of single and double loop learning. C. Argyris and D. Schon, Organizational Learning: 6. The phenomenon of workers lacking supplies at the point and time at which they need it A Theory of Action Perspective (Reading, MA: Addison-Wesley Publishing Company, 1978). It has been studied in depth by St His research into the Toyota Production System also draws from problem-solving literature in which a distinction is made between patching epitomized careful ethnographic observation of operating systems and the findings demon- problems and actually removing underlying causes. strated the insight that this method can produce. See S. J. Spear, "The Toyota Production 16. The reluctance to contact others about problems was common across all types and sizes of System: An Example of Managing Complex Social/Technical Systems: 5 Rules for Designing, hospitals, including teaching hospitals where one might expect nurses to feel more comfort- Operating, and Improving Activities, Activity-Connections, and Flow-Path," unpublished able exerting their expertise given the substantial population of inexperienced physicians-in- doctoral dissertation, Harvard Business School, 1999. training and students. In fact, for the twelve instances when nurses did contact the source, 7. For a more detailed explanation of the research methods used in this study, see A.L. Tucker, five (42%) were from Hospital 1-a non-teaching hospital and the smallest in our sample- A.C. Edmondson, and S.J. Spear, "When Problem Solving Prevents Organizational Learn- with another three (67% in total) from non-teaching hospitals 4 and 5. The remaining four ing," Journal of Organizational Change Management, 15/2 (2002): 122-137. occurred at teaching hospitals 2, 7, and 9. Furthermore, doctors were contacted immediately 8. Given the time that had elapsed, we were unable to gain additional access to two of the for only two problems, both times at community hospitals. Therefore, we conclude that hospitals. reluctance to confront physicians does not systematically vary by hospital size or teaching 9. The nursing literature has emphasized the importance of critical thinking, the cognitive status. component of nursing work. For examples, see R. Hansten and M. Washburn, "Individual 17. Linda Aiken and her colleagues found that empowerment of nurses is associated with high- and Organizational Accountability for Development of Critical Thinking," Journal of Nursing quality care and low nursing turnover. L.H. Aiken, and P.A. Patrician, "Measuring Organiza- Administration, 29/11 (1999): 39-45; J.L. Lee, B.L. Chang, M.L. Pearson, K.L. Kahn, and L. V. tional Traits of Hospitals: The Revised Nursing Work Index," Nursing Research, 49/3 (2000): Rubenstein, "Does What Nurses Do Affect Clinical Outcomes for Hospitalized Patients? A 146-153. Review of the Literature, " Health Services Research, 34/5 (1999): 1011-1032; C. Taylor, "Prob- 18. For a detailed explanation of system dynamic models, see P.M. Senge, The Fifth Discipline: The lem Solving in Clinical Nursing Practice," Journal of Advanced Nursing, 26 (1997): 329-336. Art and Practice of the Learning Organization (New York, NY: Doubleday Currency, 1990). Two 10. The complications caused by the interdependence of healthcare workers are discussed in S. excellent articles that utilize system dynamics models to explain how organizations become Glouberman and H. Mintzberg, "Managing the Care of Health and the Cure of Disease-Part trapped in self-reinforcing patterns of sub-optimal behaviors and, thus, poor performance I: Differentiation, " Health Care Management Review, 26/1 (2001): 56-69. are E.K. Keating, R. Oliva, N.P. Repenning, S. Rockart, and J.D. Sterman, "Overcoming the 11. The close proximity of Hospital 1 to our offices, combined with the willingness of its inten- Improvement Paradox," European Management Journal, 17/2 (1999): 120-134; Repenning and sive-care unit manager to allow o more hours of observation at Sterman, op. cit. Hospital 1 than was possible with the other institutions. In addition, Hospital I was the first 19. The connection between organizational factors-including the quality of hospital work site in which nurses were observed in this study. We thus spent considerable time at this site processes-and the nursing shortage is discussed in R.C. Coile, Jr., "Magnet Hospitals Use to develop a deep understanding of and ability to decipher hospital care processes before Culture, Not Wages, to Solve Nursing Shortage," Journal of Healthcare Management, 46/4 approaching other hospitals for access. Despite spending more time at this site than any (2001): 224-227. other, however, by the end of data analysis, we were able to conclude that the incidents 20. Senge, op. cit. and behaviors observed at Hospital I were typical of those observed at the other eight sites. 21. For more on the role of the manager or a dedicated problem-solving support person in a Further Hospital I was solidly in the "middle of the road" in terms of both problems and hospital, see S.J. Spear, "Deaconess-Glover Hospital Case (B)," case no. 9-601-023, Harvard Business School, 2001. 70 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003 CALIFORNIA MANAGEMENT REVIEW VOL 45, NO. 2 WINTER 2003