Steven J. Spear

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.

Ambiguity and Workarounds as Contributors to Medical Error

The Quality Grand Rounds series in Annals illustrates how work-system conditions can produce errors and adverse events (1). The human cost of medical error provided incentive for such studies (2-5). In one case, a nurse mistakenly used insulin rather than heparin to flush the arterial line of a patient, Mrs. Grant, causing severe hypoglycemia, seizures, coma, and, ultimately, death (6). In another, unreliable processes for identifying patients, assuring consent, and exchanging information led to a Mrs. Morris being mistaken for a Mrs. Morrison; as a result the patient was subjected to an unnecessary, potentially dangerous electrophysiologic examination (7). We ask: Do medical errors such as these have common root causes? Can lessons to improve reliability be drawn from nonhealth care organizations that overcome the potential for catastrophe brought on by work complexity, knowledge intensiveness, and variety and volatility of circumstance (8)? The answer to both questions is yes. Error-prone organizations tolerate ambiguity, a lack of clarity about what is expected to happen when work proceeds. Therefore, defining what constitutes a problem is difficult for several aspects of work. It is not perfectly clear 1) what the workgroup is trying to achieve; 2) who is responsible for what tasks; 3) how to exchange information, materials, or services; or 4) exactly how to perform tasks. Moreover, even when recognized, problems are worked around; people improvise to get the job done, even when indicators suggest something amiss. They fail to contain problems or improve processes, leaving factors that confounded one persons work to confound again. In contrast, superlative organizations design work as series of ongoing experiments by consistently specifying how to do work. Specification makes clear what is expectedwho is to be where, who should be doing what, and what results should occur. When specifications deviate from actual experience, these organizations promptly investigate the deviations to prevent them from causing harm or recurring (Table). Table. Contrasting Error-Prone and High-Performing Organizations Contributions of Ambiguity and Workarounds to Medical Errors Mrs. Grant stabilized after cardiac surgery, allowing reasonable clarity about what additional care she needed (aspect 1); who was responsible for one element of that care, flushing the arterial line (aspect 2); and the fact that her nurse knew he needed to perform that task (aspect 3)evidenced by his responding to an alarm indicating an occlusion. While there was clarity concerning how to flush the line (aspect 4), heparin and insulin were difficult to differentiate. Both were stored in vials of similar size, shape, weight, and location; and once in a syringe, the drugs are indistinguishable because they are both colorless. Lack of clarity meant that the nurse could not tell whether he had done his job correctly. As for the contribution of workarounds to the tragedy, nurses probably had previously chosen insulin rather than heparin but had corrected the error before administration. (Bates [9] estimates that incorrect drug administrations outnumber patient harm by a ratio of 100 to 1.) Switching the right drug for the wrong one, without reducing the chance of confusing the two again, preserved the potential for recurrence. Seventeen errors were identified in the Morris/Morrison case. Among these was miscommunication (aspect 3) between the nurse who was looking for Mrs. Morrison and someone who thought this nurse was seeking Mrs. Morris. Errors in task performance (aspect 4) included a nurses incorrect report that Mrs. Morrison had been transferred and the laboratorys failure to verify Mrs. Morriss identity. The danger of workarounds is evident in the decision of Mrs. Morriss care team to continue her transport despite the absence of an order or a signed consent form in her chart, and even over the patients objections. A resident caring for Mrs. Morris did not intervene when he found the laboratory doing the unexpected procedure; rather, he assumed that the attending physician had not informed him of a study, a failure in communication that had occurred before. High-Performing Systems: Specification and Immediate Problem Solving In pursuing quality, safety, productivity, and flexibility, leaders in other industries specify exactly what is expected in the 4 aspects of work described above. In so doing, they create the opportunity to be surprised, allowing workers to recognize deviations from the expectations implied by the original specification. Then, once surprised, these leaders treat discrepancies as something that is not normal and should be investigated immediately. This approach contains problems, generates knowledge, and leads to improvements. For example, aircraft carriers are dangerous workplaces because of severe weather, limited visibility, rapid changes in mission, and continuous arrivals and departures of aircraft, all needing the same limited deck space, equipment, and crew. Despite these dangers, flight operations are typically safe. Work is highly specified, even for circumstances in which a change in situation requires a change in roles. Crews color-code uniforms, demarcate spaces on the deck, and define what is to be done during launches and recoveries. Aberrations, such as someone being out of position, quickly make it obvious that operations cannot continue as if all were normal (10). Southwest Airlines is faster and more accurate than its competitors at the critical process of flight departuresdespite having to coordinate specialized employees amid the vagaries of weather, airport congestion, mechanical failures, and load fluctuations. It specifies what must be done to ensure a smooth departure and also to make it evident even when the situation has changed (and thereby requiring a different but also specified plan) (11). Toyotaa leader in the complex work of product design (12, 13), new-model introduction (14), and production (15, 16)specifies how work is to be done so that even small deviations from expectations (whether in routine work or in highly complex unique efforts such as new-model launches and disaster recovery [17]) are evident. Once detected, problems are promptly investigated (15, 18, 19) and contained, and information relevant to understanding them is fresh and easier to accurately reconstruct than it would be if problem solving were delayed (20-22). Examples in Health Care Some health care organizations have successfully tested highly specifying processes. The Shock, Trauma, and Respiratory intensive care unit at LDS Hospital in Salt Lake City, Utah, developed protocols to better control glucose levels, decrease nosocomial infection rates, and reduce costs. These protocols are noteworthy because once developed, they were often changed as users encountered problems applying them (23). Thompson and colleagues (24) reported on how hospitals reduced ambiguity and workarounds. In one hospital, on each shift nurses averaged 23 searches for keys to the narcotics cabinet; this wasted 49 minutes per shift and delayed analgesia to patients. Rather than tolerate continued searches, administrators tested assigning numbered keys at the start of each shift, with safeguards to prevent loss or misuse. This procedure nearly eliminated searches for keys and saved 2895 nurse-hours yearly in a 350-bed hospital. Another hospitals pharmacy used deviations from design to trigger process improvement, not workarounds. Without any technology investments, searches for missing medication decreased by 60% and stockouts fell by 85%. Avoiding Ambiguity and Workarounds in the Annals Cases What difference might similar procedures have made in Mrs. Grants case? The first time a nurse saw that the patient had taken a wrong drug, an investigation would have been initiated to discover why selecting the wrong item was so easy. Insulin and heparin might then have been stocked in distinctive vials or location before someone else could err again. In Mrs. Morrisons case, hospital staff would have specified a particular time for Mrs. Morrisons electrophysiologic examination (aspect 1). This would have resulted in well-specified assignments for who was responsible for transport (aspect 2), the manner in which the electrophysiology laboratory was to request the next patient (aspect 3), and how staff would identify patients and obtain consent (aspect 4). With such clarity about what was supposed to happen, staff would have seen that Mrs. Morrisons situation (being left unprepared for a test and not being transported as expected) was contrary to expectations and would have treated it as a problem. In turn, then, they would have immediately stopped work and triggered investigation, problem-solving, and process improvement. Conclusions By meticulous specification of who should supply what goods, information, or services, to whom, in what fashion, and when, problems can be identified, often before they produce adverse events. With this sort of system, the consequences of problems do not propagate, and investigations result in design changes that reduce the likelihood of recurrence. But how does one start, given that health care seems to be unique in its extraordinary complexity? Every patient presents unique features, diagnostic and therapeutic methods change quickly, the consequences of error can be profound, and the needs of several patients often must be met concurrently. Start small. There is no need to specify an entire system at once. As with the examples from Thompson and colleagues and LDS Hospital, small pieces of larger systems can be specified. As problems reveal themselves, other items that need to be specified become more evident. At the same time, the process teaches important lessons in applying and internalizing these principles. Start simple. Much of what patients require, and the fact that meeting these needs sometimes results in error,

Driving improvement in patient care: lessons from Toyota.

Nurses today are attempting to do more with less while grappling with faulty error-prone systems that do not focus on patients at the point of care. This struggle occurs against a backdrop of rising national concern over the incidence of medical errors in healthcare. In an effort to create greater value with scarce resources and fix broken systems that compromise quality care, UPMC Health System is beginning to master and implement the Toyota Production System (TPS)—a method of managing people engaged in work that emphasizes frequent rapid problem solving and work redesign that has become the global archetype for productivity and performance. The authors discuss the rationale for applying TPS to healthcare and implementation of the system through the development of “learning unit” model lines and initial outcomes, such as dramatic reductions in the number of missing medications and thousands of hours and dollars saved as a result of TPS-driven changes. Tracking data further suggest that TPS, with sufficient staff preparation and involvement, has the potential for continuous, lasting, and accelerated improvement in patient care.

Medical education as a process management problem.

With complaints that new doctors are less prepared for residency and practice than expected, are burdened with debt, and then take even longer to complete their specialty training, the authors ask whether medical education can be designed more effectively. Curriculum redesign and pedagogical reform efforts to date address fragments of medical education—the content of particular courses or clerkships or the way in which the courses or clerkships are conducted. However, these reforms do not typically address the relationships among the various elements, that is, in what order skill sets should be sequenced, how communication should occur between disciplines, and by what mechanisms skills or knowledge should be mastered and assessed by the end of one phase so students are prepared adequately for the next. In failing to address these systems issues, current reform efforts may forgo some opportunities to convey and properly insure greater mastery of knowledge and skills in less time, at less cost. A case study of a typical students third- and fourth-year clerkships illustrates how focusing only on educational elements leads to the exclusion of opportunities to systemically facilitate the relationships among them. This situation is contrasted with how other demanding, high-tech, knowledge-intensive industries with outstanding operations have learned to achieve superlative performance by managing and designing both the elements and the interactions among them within complex work and learning systems. The authors’ exploratory research offers suggestions for medical education reform and frames additional opportunities for further discussion.

Using Real-Time Problem Solving to Eliminate Central Line Infections

BACKGROUND An estimated 200,000 Americans suffer central line-associated bloodstream infections (CLABs) each year, with 15%-20% mortality. Two intensive care units (ICUs) redefined the processes of care through system redesign to deliver reliable outcomes free of the variations that created the breeding ground for infection. METHODS The ICUs, comprising 28 beds at Allegheny General Hospital, employed the principles of the Toyota Production System adapted to health care--Perfecting Patient Care--and applied them to central line placement and maintenance. Intensive observations, which revealed multiple variances from established practices, and root cause analyses of all CLABs empowered the workers to implement countermeasures designed to eliminate the defects in the processes of central line placement and maintenance. RESULTS New processes were implemented within 90 days. Within a year CLABs decreased from 49 to 6 (10.5 to 1.2 infections/1,000 line-days), and mortalities from 19 to 1 (51% to 16%), despite an increase in the use of central lines and number of line-days. These results were sustained during a 34-month period. DISCUSSION CLABs are not an inevitable product of complex ICU care but the result of highly variable and therefore unreliable care delivery that predisposes to infection.

Fixing healthcare from the inside: teaching residents to heal broken delivery processes as they heal sick patients.

There is a marked gap between the potential of medical science to treat illness and injury and the performance of the health care system in which hard-working, intelligent, well-trained people put that science to work. Care is available to too few, and costs and risks of injury are too high. This is avoidable. Experience in Boston, Pittsburgh, Salt Lake City, Seattle, and elsewhere indicates that quality can be raised—while risks and costs are dramatically reduced—by applying lessons from the highest-performing industrial organizations to designing, operating, and improving health care processes. What are these lessons? Improve sick processes with the same approaches used to treat patients. Specify “normal.” When problems in quality, safety, efficiency, responsiveness, and the like occur, quickly determine exactly what is abnormal and determine what might be causing them. Develop a “treatment plan”—process changes that will eliminate or counteract the causal factors. Run the process (or a facsimile) with a modified, watching for gaps between actual and expected outcomes. When gaps occur, do a new work-up, diagnosis, treatment plan, and test. Lessons in designing, operating, and improving processes can be taught just as medical expertise is developed. Teach basic frameworks didactically; then, provide hands-on experience in applying those principles to real problems. Start with simple well-bounded situations that can be practiced frequently, with rapid feedback and close mentoring before advancing to more complex, less well bounded situations that occur less frequently and provide less immediate feedback between action and outcome. Incorporate development of process improvement skills into residency training so that deepening expertise within specialties is complemented by greater skill at integrating functional knowledge into well-integrated care processes.

The essence of just-in-time: Embedding diagnostic tests in work-systems to achieve operational excellence

This paper asserts that problem identification and problem-solving processes can be integrated into work processes by embedding tests in work that evaluate performance with every exchange of products, services, and information. These tests make it unambiguous when, where, and by whom problem solving is necessary. This hastens improvement and deepens process knowledge frequently and at low-cost. These assertions are based on an ethnographic study of how some firms sustain outstanding performance through iterative problem solving, a concern of organizational and operations management theory. This field research revealed attributes of just-in-time (JIT) as it is practiced by Toyota and its affiliates - companies that have been associated with JIT and that have been recognized for outstanding performance - that have not been fully explored previously. Whereas JIT&s role in controlling material flows through sequential processes has been much discussed, Toyota and its affiliates also use JIT to evaluate work-system performance with high frequency and resolution. When work is not proceeding as designed, problem solving begins close in time, place, process and person to each problem. These results suggest using JIT to advance process knowledge from lower stages to higher.

Commentary: "Who was caring for Mary?" revisited: a call for all academic physicians caring for patients to focus on systems and quality improvement.

Over 15 years have passed since Marys near death (Annals of Internal Medicine. 1993;118:146-148). Disappointment in the care by fellow academic physicians persists; however, a reanalysis of her case through the lens of complex systems design and performance yields a more accurate and actionable perspective. Marys suffering was not due to human failure alone. Human failure was provoked and exacerbated by broken processes including ambiguous assignments of responsibility; inadequate transfers of information and authority; unreliable or unavailable protocols for providing safe, effective treatment; and a failure to integrate the deep but narrow perspectives of individual specialists into a complete picture of Marys condition. Her case exemplifies, in personal terms, many of the system challenges academic medical centers face: Faculty have other missions that can conflict with patient care; disease complexity is high, requiring input from multiple subspecialists; clinical departments serve as roadblocks to communication; and novice physicians, requiring close supervision, have primary responsibility for the day-to-day care of acutely ill patients. The academic physicians who first cared for Mary unwittingly accepted flawed systems, and they failed to work around them. At great monetary and emotional expense, last-minute heroics saved Mary. In a dysfunctional system, even the most conscientious physician may be viewed as uncaring. As Marys case so clearly illustrates, patients and their families see the system and the physician as one. Only by working to improve the systems of delivery will academic physicians again be consistently viewed as caring.