Anita L. Tucker

When problem solving prevents organizational learning

We propose that research on problem‐solving behavior can provide critical insight into mechanisms through which organizations resist learning and change. In this paper, we describe typical front‐line responses to obstacles that hinder workers’ effectiveness and argue that this pattern of behavior creates an important and overlooked barrier to organizational change. Past research on quality improvement and problem solving has found that the type of approach used affects the results of problem‐solving efforts but has not considered constraints that may limit the ability of front‐line workers to use preferred approaches. To investigate actual problem‐solving behavior of front‐line workers, we conducted 197 hours of observation of hospital nurses, whose jobs present many problem‐solving opportunities. We identify implicit heuristics that govern the problem‐solving behaviors of these front‐line workers, and suggest cognitive, social, and organizational factors that may reinforce these heuristics and thereby prevent organizational change and improvement.

The Impact of Combining Conformance and Experiential Quality on Hospitals’ Readmissions and Cost Performance

To investigate the opportunity for hospitals to achieve better care at lower cost, we examine two key process quality measures, conformance quality and experiential quality, and two measures of performance, readmission rate and cost per discharge. Conformance quality represents a hospital’s level of adherence to evidence-based standards of care, whereas experiential quality represents the level of interaction between hospital’s caregivers and patients. Analyzing six years of data from 3,474 U.S. acute care hospitals, we find that combining conformance and experiential quality results in lower readmission rates. However, conformance quality and experiential quality each independently increase cost per discharge, which suggests that a readmissions–costs trade-off is unavoidable. To investigate this further, we conduct post hoc analyses by distinguishing between the granular elements of experiential quality (EQ) based on task type: response-focused EQ and communication-focused EQ. Response-focused EQ measure...

Past the Point of Speeding Up: The Negative Effects of Workload Saturation on Efficiency and Patient Severity

Service organizations face a trade-off between high utilization and responsiveness. High utilization can improve financial performance, but causes congestion, which increases throughput time. Employees may manage this trade-off by reducing processing times during periods of high workload, resulting in an inverted U-shaped relationship between utilization and throughput time. Using two years of inpatient data from 203 California hospitals, we find evidence that patient length of stay (LOS) increases as occupancy increases, until a tipping point, after which patients are discharged early to alleviate congestion. More interestingly, we find a second tipping point—at 93% occupancy—beyond which additional occupancy leads to a longer LOS. These results are indicative of a workload-related “saturation effect” where employees can no longer overcome high workload by speeding up. Our data suggest that the saturation effect is due to an increase in the workload requirements of the remaining patients. Collectively, w...

The evolving literature on safety WalkRounds: emerging themes and practical messages

The evidence is clear: a strong culture of safety is necessary to deliver reliably safe care.1 Safety culture encompasses a groups shared values, assumptions, attitudes and patterns of behaviour regarding safety.2 ,3 In healthcare organisations with weak safety culture, employees perceive the low priority assigned to safety, and patient safety suffers as a result.4 Researchers measure safety culture using surveys that include items eliciting perceptions of policies, procedures and practices that reflect the extent to which the organisation prioritises safety relative to competing goals.4 Numerous studies find that higher safety climate correlates with better performance on a variety of outcomes.1 ,5–17 Research also shows that senior managers play a critical role in creating, changing and sustaining safety culture.2 ,4 Senior managers’ words and deeds receive outsize attention and greatly influence how frontline workers and middle managers perceive what their organisation values and rewards. We know less, though, about specific actions senior managers can take to effectively demonstrate their commitment to safety.18 Senior managers seeking to create a stronger culture of safety need to know what steps can overcome consistent differences between frontline workers’ and managers’ perceptions of safety climate. Frontline workers typically have more negative views of safety climate compared with senior managers.19–21 One approach for strengthening safety culture is for managers to spend time on the frontlines of care, talking with staff and observing work. The Lean literature refers to these types of programmes as Gemba walks.22 These walks aim to have senior managers observe concrete problems confronted by frontline staff in real time and foster stronger relationships with frontline staff.23 ,24 Gemba walks thus resemble ‘Management by Walking Around,’ popularised by Peters and Watermans description of Hewlett–Packards use of the programme in the 1980s. …

The Impact of Workaround Difficulty on Frontline Employees’ Response to Operational Failures: A Laboratory Experiment on Medication Administration

Operational failures persist, in part because employees work around them without engaging in actions to prevent recurrence. To break this cycle, we investigate the impact of work design factors on responses to operational failures. We use hospital nurses as subjects in a laboratory experiment, where, unknown to them, two medication administration supplies are missing. We observe their real-time responses to the two failures and whether they contribute an improvement idea. We randomly assign half of the participants to an experiment location far away from a satellite pharmacy where the missing supplies can be obtained (“difficult condition”), and the other half are located near the satellite pharmacy (“easy condition”). Both conditions contain risky, against-policy supplies that can be used to complete the work tasks, giving participants a choice between policy-compliant workarounds and risky, against-policy workarounds. In the first study, we find that participants in the difficult condition are more likely to contribute improvement ideas but are less likely to use policy-compliant workarounds. A second experiment with a 2 × 2 design shows that participants in the difficult condition who have high access to the process owner are more likely to use policy-compliant workarounds than when they have low access. Our results suggest that hospitals can increase communication about operational failures by deliberately making it difficult to work around them while simultaneously providing a high level of access to process owners. Otherwise, nurses encountering operational failures are likely to resort to against-policy workarounds, a behavior observed in practice. This paper was accepted by Serguei Netessine, operations management .

Applying Organizational Learning Research to Accountable Care Organizations.

To accomplish the goal of improving quality of care while simultaneously reducing cost, Accountable Care Organizations (ACOs) need to find new and better ways of providing health care to populations of patients. This requires implementing best practices and improving collaboration across the multiple entities involved in care delivery, including patients. In this article, we discuss seven lessons from the organizational learning literature that can help ACOs overcome the inherent challenges of learning how to work together in radically new ways. The lessons involve setting expectations, creating a supportive culture, and structuring the improvement efforts. For example, with regard to setting expectations, framing the changes as learning experiences rather than as implementation projects encourages the teams to utilize helpful activities, such as dry runs and pilot tests. It is also important to create an organizational culture where employees feel safe pointing out improvement opportunities and experimenting with new ways of working. With regard to structure, stable, cross-functional teams provide a powerful building block for effective improvement efforts. The article concludes by outlining opportunities for future research on organizational learning in ACOs.

Closing the Productivity Gap: Improving Worker Productivity Through Public Relative Performance Feedback and Validation of Best Practices

Public relative performance feedback (RPF) on an individual worker’s productivity metrics is used in various organizations with the hopes of improving worker productivity, but its effects are not well understood. We examine whether public RPF could be leveraged to facilitate adoption of best practices in an organization by enabling the validation of best practices shared by identifiable top performers. We use data from two emergency departments, both of which shared best practices for improving productivity and one of which changed from privately to publicly disclosing RPF to physicians. The public disclosure of RPF allowed workers to identify their top-performing coworkers, which in turn enabled the identification and validation of best practices within the work group. We find that the intervention is associated with a 10.9% improvement in physician productivity. We also find evidence for a significant reduction in variation in productivity across providers, which stems from bottom-ranked workers exhibit...

Determinants of Successful Frontline Process Improvement: Action versus Analysis

Senior manager participation is a key success driver for process improvement programs. To increase their participation, we designed an intervention in which senior managers worked with frontline staff to identify and solve safety-related problems over an 18-month period. On average, the 20 randomly selected treatment hospitals identified 17.3 problems per work area and solved 9.1 of these. However, their readmission rates and percentage increase in nurses’ perceptions of safety improvement were no better than 48 control hospitals’. Thus, we investigated drivers of successful program implementation within the set of treatment hospitals. We found that managers from hospitals with low and high perceived improvement identified similar numbers of problems. However, high perceived improvement hospitals took action on more problems. We found no benefit from selecting problems with the highest benefit-to-cost ratios because there was a flat landscape for problems’ benefit-to-cost ratios. Thus, for safety improvement in hospitals, allocating resources to search for and select high benefit/cost problems appears to be of limited benefit versus allocating resources to take action on known problems. This approach also aligns with how managers actually selected problems for resolution efforts: problems that were easy to solve were more likely to be selected.

Performance Improvement in Health Care Organizations

Performance improvement is an important organizational capability that is essential for health care organizations to achieve excellence on the three components of the Triple Aim: patient experience, health, and cost. In this monograph, we present a framework for performance improvement in health care organizations: the Model of Transformational Performance Improvement. This model takes a system-level approach to performance improvement and comprises six key components: (1) determining and communicating a system-level goal; (2) developing and using system-level performance measures; (3) understanding and managing interdependencies; (4) selecting a portfolio of projects aligned with system-level goals; (5) creating an organizational engine for improvement; and (6) implementing, spreading, and sustaining improvements. In addition to presenting this model, we review the operations management literature on performance improvement with a special focus on operations management tools and principles that may help with successful implementation of these six components. Though work has already been done in these areas, much remains unknown and many opportunities for future research exist. This monograph seeks to inform the research of operations management scholars and to equip clinicians and health care leaders with techniques that may be leveraged to improve performance in health care organizations.

Nudging Healthier Choices in a Hospital Cafeteria: Results From a Field Study:

More than two thirds of adults and one third of children are overweight or obese in the United States. These trends have led to initiatives to provide information that supports informed choices. Traffic light labeling has been shown to increase consumer awareness and encourage healthy selections. This article contributes to the literature on healthy choices by comparing the additional contribution of a number of interventions used in combination with traffic light labeling. We conducted a 21-month field study in a workplace cafeteria. We analyzed cash register receipts, focusing on sales of beverages and chips. We found that the traffic light system was effective. The addition of caloric information to traffic light labeling had a positive effect on the purchase of healthy chips. However, other interventions appeared to produce more harm than good, essentially wiping out the benefits from traffic light labeling. These findings suggest that although it is possible to improve on traffic light labeling with selective interventions, caution is in order as some interventions may trigger compensatory behavior that results in the purchase of unhealthy items.