Anita L. Tucker

The 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. This article reports on in-depth qualitative field research of nurses' responses to process failures in nine hospitals. It identifies two types of process failures—errors and problems—and discusses implications of each for process improvement. A dynamic model of the system in which front-line workers operate reveals an illusory equilibrium in which small process failures actually erode organizational effectiveness rather than driving learning and change in hospitals. Three managerial levers for change are identified, suggesting a new strategy for improving hospitals' and other service organizations' ability to learn from failure.

This paper contributes to research on organizational learning by investigating specific learning activities undertaken by improvement project teams in hospital intensive care units and proposing an integrative model to explain implementation success. Organizational learning is important in this context because medical knowledge changes constantly and hospital care units must learn new practices if they are to provide high-quality care. To develop a model of factors affecting improvement project teams driving essential organizational learning in health care, we draw from three streams of related research—best-practice transfer (BPT), team learning (TL), and process change (PC). To test the model’s hypotheses, we collected data from 23 neonatal intensive care units seeking to implement new or improved practices. We first analyzed the frequency of specific learning activities reported by improvement project participants and discovered two distinct factors: learn-what (activities that identify current best practices) and learn-how (activities that operationalize practices in a given setting). Next, ordinary least squares (OLS) regression analyses supported three of our four hypotheses. Specifically, a high level of supporting evidence for a unit’s portfolio of improvement projects was associated with implementation success. Learn-how was positively associated with implementation success, but learn-what was not. Psychological safety was associated with learn-how, which was found to mediate between psychological safety and implementation success.

OBJECTIVE: To describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care. DATA SOURCES: Primary observation, semistructured interviews, and surveys of hospital nurses. STUDY DESIGN: We sampled a cross-sectional group of six U.S. hospitals to examine the frequency of work system failures and their impact on nurse productivity. DATA COLLECTION: We collected minute-by-minute data on the activities of 11 nurses. In addition, we conducted interviews with six of these nurses using questions related to obstacles to care. Finally, we created and administered two surveys in 48 nursing units, one for nurses and one for managers, asking about the frequency of specific work system failures. PRINCIPAL FINDINGS: Nurses we observed experienced an average of 8.4 work system failures per 8-hour shift. The five most frequent types of failures, accounting for 6.4 of these obstacles, involved medications, orders, supplies, staffing, and equipment. Survey questions asking nurses how frequently they experienced these five categories of obstacles yielded similar frequencies. For an average 8-hour shift, the average task time was only 3.1 minutes, and in spite of this, nurses were interrupted mid-task an average of eight times per shift. CONCLUSIONS: Our findings suggest that nurse effectiveness can be increased by creating improvement processes triggered by the occurrence of work system failures, with the goal of reducing future occurrences. Second, given that nursing work is fragmented and unpredictable, designing processes that are robust to interruption can help prevent errors.

Abstract Operational failures in healthcare can hinder employees, potentially decreasing both productivity and quality of care. At the same time, regulatory agencies, industry experts, and consumers increasingly demand that health care organizations learn from prior failures to prevent recurrence. Building on the notion that learning from operational failures requires an accurate understanding of their nature, this paper reports on an in‐depth study of operational failures encountered by hospital nurses. Data analysis suggests that in this context (1) most operational failures stem from breakdowns in the supply of materials and information across organizational boundaries and (2) employees quickly compensate for most failures. We propose that these two conditions—lack of control of processes that create failures and the ease with which employees restore functioning—make it difficult for organizations to recognize these incidents as learning opportunities, and if they do, to capitalize on the opportunity. This has an important implication for efforts to generate organizational learning and improvement from employees’ experiences with failures. Highly interdependent front‐line workers do not control organizational processes responsible for the majority of failures they encounter and have a difficult task convincing powerful associates that these obstacles warrant solution efforts, making it likely operational failures will persist.

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.