Richard M.J. Bohmer

Disrupted Routines: Team Learning and New Technology Implementation in Hospitals

This paper reports on a qualitative field study of 16 hospitals implementing an innovative technology for cardiac surgery. We examine how new routines are developed in organizations in which existing routines are reinforced by the technological and organizational context All hospitals studied had top-tier cardiac surgery departments with excellent reputations and patient outcomes yet exhibited striking differences in the extent to which they were able to implement a new technology that required substantial changes in the operating-room-team work routine. Successful implementers underwent a qualitatively different team learning process than those who were unsuccessful. Analysis of qualitative data suggests that implementation involved four process steps: enrollment, preparation, trials, and reflection. Successful implementers used enrollment to motivate the team, designed preparatory practice sessions and early trials to create psychological safety and encourage new behaviors, and promoted shared meaning and process improvement through reflective practices. By illuminating the collective learning process among those directly responsible for technology implementation, we contribute to organizational research on routines and technology adoption.

Learning How and Learning What: Effects of Tacit and Codified Knowledge on Performance Improvement Following Technology Adoption

This paper examines effects of tacit and codified knowledge on performance improvement as organizations gain experience with a new technology. We draw from knowledge management and learning curve research to predict improvement rate heterogeneity across organizations. We first note that the same technology can present opportunities for improvement along more than one dimension, such as efficiency and breadth of use. We compare improvement for two dimensions: one in which the acquisition of codified knowledge leads to improvement and another in which improvement requires tacit knowledge. We hypothesize that improvement rates across organizations will be more heterogeneous for dimensions of performance that rely on tacit knowledge than for those that rely on codified knowledge (H1), and that group membership stability predicts improvement rates for dimensions relying on tacit knowledge (H2). We further hypothesize that when performance relies on codified knowledge, later adopters should improve more quickly than earlier adopters (H3). All three hypotheses are supported in a study of 15 hospitals learning to use a new surgical technology. Implications for theory and practice are discussed.

Managing The New Primary Care: The New Skills That Will Be Needed

Developing new models of primary care will demand a level of managerial expertise that few of todays primary care physicians possess. Yet medical schools continue to focus on the basic sciences, to the exclusion of such managerial topics as running effective teams. The approach to executing reform appears to assume that practice managers and entrepreneurs can undertake the managerial work of transforming primary care, while physicians stick with practicing medicine. This essay argues that physicians currently in practice could be equipped over time with the management skills necessary to develop and implement new models of primary care.

National Assessment of Business‐of‐Medicine Training and Its Implications for the Development of a Business‐of‐Medicine Curriculum

Objectives/Hypothesis: The objectives were, first, to determine the current state of business training in otolaryngology residency programs in the United States and, second, to lay the groundwork for development of a business‐of‐medicine (BOM) curriculum.

A Classification and Meta-analysis of Community-based Directly Observed Therapy Programs for Tuberculosis Treatment in Developing Countries

In many developing countries, Directly Observed Therapy (DOT) for tuberculosis has been undertaken mainly in the clinic setting. However, clinic-based DOT may create a high patient load in already overburdened health facilities and increase barriers to care by requiring patients to travel to clinic frequently for therapy. Community-based DOT (CBDOT) may overcome some of these problems. This aims of this review are (a) to describe the main features of CBDOT programs, and (b) to compare features and outcomes of CBDOT programs that do and do not offer financial reward for CBDOT providers. Ten major features define CBDOT program structure and function. Programs that paid their CBDOT providers tended to differ from unpaid programs based on all of these features. CBDOT programs in which providers received financial reward had success rates of 85.7 versus 77.6% in programs without financial reward for providers. This difference was not statistically significant. CBDOT programs fall into two major archetypes, which differ in their structure and possibly in their outcomes.

Learning new technical and interpersonal routines in operating room teams The case of minimally invasive cardiac surgery

This study investigated operating room teams confronted with learning a radically new technology for performing cardiac surgery. Implementing new technology in hospitals is challenging because of the perceived risk to human life of trying something new when current approaches meet widely accepted standards of care. Understanding the learning and adoption process is therefore critical, both for innovators introducing new technologies and for hospitals seeking to adopt them. Past research in medicine has found that cumulative experience using new techniques leads to improvement but has not investigated organizational and group characteristics that may facilitate obtaining the right kinds of experience and ultimately facilitate successful adoption of new approaches. This paper begins to address this gap by examining organizational and group characteristics that vary across operating room teams learning a new technology. A specific barrier to learning that these teams faced was the highly precise routines characterizing the conventional surgical procedure; the new technology disrupted these routines, requiring the operating room teams to relearn how to work together. We report on data collected in 165 interviews with members of the operating room and others associated with the cardiac surgery process at 16 hospitals.

Lessons from England's health care workforce redesign: no quick fixes.

In 2000 the English National Health Service (NHS) began a series of workforce redesign initiatives that increased the number of doctors and nurses serving patients, expanded existing staff roles and developed new ones, redistributed health care work, and invested in teamwork. The English workforce redesign experience offers important lessons for US policy makers. Redesigning the health care workforce is not a quick fix to control costs or improve the quality of care. A poorly planned redesign can even result in increased costs and decreased quality. Changes in skill mix and role definitions should be preceded by a detailed analysis and redesign of the work performed by health care professionals. New roles and responsibilities must be clearly defined in advance, and teamwork models that include factors common in successful redesigns such as leadership, shared objectives, and training should be promoted. The focus should be on retraining current staff instead of hiring new workers. Finally, any workforce redesign must overcome opposition from professional bodies, individual practitioners, and regulators. Englands experience suggests that progress is possible if workforce redesigns are planned carefully and implemented with skill.

Learning in a new cardiac surgical center: An analysis of precursor events

BACKGROUND Few studies of learning in the health care sector have analyzed measures of process, as opposed to outcomes. We assessed the learning curve for a new cardiac surgical center using precursor events (incidents or circumstances required for the occurrence of adverse outcomes). METHODS Intraoperative precursor events were recorded prospectively during major adult cardiac operations, categorized by blinded adjudicators, and counted for each case (overall and according to these categories). Trends in the number of precursor events were analyzed by hospital and by defining 10 equal-sized groups across time, as were trends in outcomes obtained from institutional databases. Results from the first 101 cases performed at a new cardiac surgical site (hospital A) were compared with 2 established centers. RESULTS A steep reduction in the total number of precursor events over time was observed in the early experience of hospital A (9.2 +/- 4.9 to 2.0 +/- 1.2 events per case, from first to last decile of time, P(trend) < .0001) compared with qualitatively stable levels in the other hospitals; this reduction was driven largely by decreases in the minor severity (P(trend) < .0001), compensated (P(trend) < .0001), and environment (P(trend) < .0001) categories of precursor events. No detectable changes over time were observed in postoperative mortality and complications. No significant improvement was observed in patient comorbid conditions or medical status over time to explain the trend in hospital A. CONCLUSION Analyzing and targeting specific kinds of process-related failures (precursor events) may provide a novel and sensitive means of tracking, deconstructing, and optimizing organizational learning in medicine.

DIFFERENT PATTERNS OF PERFORMANCE IMPROVEMENT FOR TACIT AND EXPLICIT KNOWLEDGE: AN EMPIRICAL TEST.

This paper explores the roles of explicit and tacit knowledge in performance improvement as experience is gained with a new technology. We propose that the same technology can present simultaneous ...