Rangaraj Ramanujam

The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance

BackgroundThe effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs.MethodsSurveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models.ResultsFor all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used.ConclusionProvider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.

Medical Trainees’ Formal and Informal Incident Reporting Across a Five-Hospital Academic Medical Center

BACKGROUND Despite the importance of incident reporting for promoting patient safety, the extent to which residents and fellows (trainees) in graduate medical education (GME) programs report incidents is not well understood. A study was conducted to determine the prevalence of and variations in incident reporting across hospitals in an academic medical center. METHODS Trainees enrolled in GME programs sponsored by the Indiana University School of Medicine (IUSM) completed (1) the Behavior Index Survey (BIS), which asked respondents if they knew how to locate incident forms and if they ever submitted an incident form, and (2) the Safety Culture Survey (SCS), which asked about the frequencies of their formal and informal incident reporting behaviors. RESULTS Some 443 of 992 invited trainees (45% response rate) participated in the study. Of the 305 BIS respondents who rotated through all five hospitals, varying proportions knew how to locate an incident form (22.3%-31.5%) and had completed an incident form (6.2%-20%) in each hospital. Incident report completion rates were higher (20.1%-81.3%) among trainees who knew how to locate an incident form. Higher proportions of the 443 SCS respondents had informally discussed an incident with other trainees (90%), faculty physicians (70%), and at resident meetings and conferences (73%). DISCUSSION The study confirms that GME trainees formally report incidents rarely. The flow of communication to and from trainees about patient safety and incidents is low, despite an organizational focus on safety and quality. Discussion of safety issues among trainees occurs more informally among colleagues and peers than with faculty or through formal reporting mechanisms. The data suggest a number of strategies to increase the culture of safety among GME trainees.

The Dynamics of the Performance--Risk Relationship Within a Performance Period: The Moderating Role of Deadline Proximity

Risky organizational decisions are frequently made within the confines of performance periods with predefined durations and deadlines for achieving desired levels of performance. The relationship between performance and risk taking has been studied mostly across such periods but rarely within them. Building on the shifting-focus-of-attention model of organizational risk taking, we argue that the temporal proximity of deadlines regulates the focus of organizational attention within a performance period. Decision makers will focus their attention on attaining and maintaining aspirations early in a period; however, as deadlines approach, decision makers in underperforming firms will increasingly be likely to focus on ensuring survival, whereas decision makers in outperforming firms will increasingly be likely to focus on experimenting with slack resources. We propose that the relationship between performance and risk taking should thus be moderated by deadline proximity within a performance period. We tested and found support for our hypotheses in the context of 22,603 fourth-down decisions made by the 32 National Football League teams during the 2000--2005 regular season games. Our findings suggest that the notion of temporally bound performance periods and deadline proximity should play a more central role in attention-based frameworks of organizational risk taking.

The Relationship Between Change Across Multiple Organizational Domains and the Incidence of Latent Errors

The authors examined the relationship between types of organizational change (i.e., changes across multiple domains, e.g., employees, structure, and technology) and the incidence of latent errors (i.e., potentially consequential deviations from rules and procedures), using data from internal audit reports and interviews with managers in 80 business units in a large financial institution. Consistent with their premise that latent errors result from the increased demands on organizational attention associated with organizational change, the authors found that changes in multiple organizational domains was positively related to the frequency of latent errors. Moreover, this relationship was only observed for changes that had an adverse impact on managerial time, expertise, and/or work coordination. Implications for research on organizational change and latent errors, as well as for managers, are discussed.

Tua Culpa: When an Organization Blames its Partner for a Shared Failure

We examine the growing but understudied phenomenon of organizational blame shifting in the aftermath of a failure in inter-organizational collaboration. By “blame shifting,” we mean an organization’s public attempt to assign to its partner organization the responsibility for a failure–i.e., an adverse event such as an accident or a scandal that could potentially undermine the legitimacy and trustworthiness of the organization involved. Our core premise is that blame shifting represents an organization’s strategic effort to intervene in and shape stakeholders’ sensemaking process and thereby divert or diffuse its own responsibility for the failure. However, blame shifting can also expose the organization to the costly risks of dissolution of the relationship with the partner organization and to public backlash. Building on this premise we identify two features of the failure, magnitude and causal ambiguity, and two features of the inter-organizational relationship, power imbalance and status differential, ...