Top Management’s Focus of Attention and Organizational Learning from Errors

Ranga Ramanujam (Purdue University)Donna Keyser (RAND)

Carl Sirio (UPMC)Debra Thompson (Pittsburgh Regional Healthcare

Initiative)

Research objective

To explore whether and how the focus of attention of hospital top management influences organizational learning from errors

Study context

Pittsburgh Regional Healthcare Initiative (PRHI) Coalition of 39 hospitals implemented a common

system for data-sharing on medication errors (MedMarx®)

Initiated by top management in hospitals Expectation that increased incident reporting will

improve patient safety

Incident reporting-underlying premise

Patient Safety

Objectives

Set specific & challenging

aspiration level

Metrics

Link to process and outcomes

objectives; actionable

Data Collection/ Reporting

Efficient, timely, and user-friendly

information systems

Dissemination/ Information

Sharing Frequent review

by critical stakeholders

Analysis/ Problem Solving

Participants with requisite skills,

knowledge, authority, and responsibilities

Implementation/ Process

Improvement

Change management

capabilities; senior management

support

Structures & Processes for Learning

Reporting increased significantly

> 20,000 medication errors reported by 30 hospitals during 2002-03

Compared to 400 other hospitals that also used MedMarx Higher volume and rate of reporting Higher proportion of errors not reaching the patient

But, no conclusive or even suggestive evidence of learning from these data

Trend analysis confirmed increase in rate of reporting of errors but not of corrective actions (latent growth curve

analysis; Anderson, Ramanujam, et al 2007)

Key informants from 8 hospitals accounting for over 60%

of the reporting could not identify specific improvements directly linked to these data Verifiable improvements linked to other independent initiatives

e.g. implementation of Toyota Production System in an ICU

Role of top management

What could the top management of hospitals that initiated the process do to facilitate learning?

Inadequately studied question that calls for an exploratory and observation-based methodology Year-long case studies of 4 hospitals (Yin, 1984)

Sample – 4 hospitals

Pittsburgh Region Community Hospital System Hospital (member of a corporate system) Acute Care Hospital

Outside Pittsburgh University Hospital

Case study methods

58 interviews with CEOs, direct reports, committee chairpersons, and a sample of care providers

Analysis of archival records (e.g., mission statements, minutes, annual reports)

70 hours of participation in meetings where incident data were discussed

40 separate observations of medication administration process in 12 departments

Key Variables

Community Hospital System Hospital Acute Care Hospital University Hospital (non-PRHI)

Age 100 years > 100 years < 10 years > 100 years

Number of beds 265 700 155 683

Teaching? No Yes No Yes

Current CEO tenure

> 25 years < 5 years < 5 years >15 years

Increase in Medication Error Reporting (2002-04)

125% 100% 170% 200%

Meetings observed P & TPatient Safety Medication Error Task Force

P & TPatient Safety

P & TPatient Safety

Incident TrackingP & TPatient Safety

Initial conclusions (T1): Absence of organizational design for learning from incidents

Patient Safety Objectives

Absence of specific

objectives; low awareness

Metrics

Ambiguous and inconsistent

metrics

Data Collection/ Reporting

Inefficient, time-

consuming, and non-

user-friendly IT

Dissemination/ Information

Sharing

Minimal participati

on by critical

stakeholders (e.g.,

physicians)

Analysis/ Problem Solving

Insufficient skills and knowledge

Implementation/ Process

Improvement

Limited authority to implement corrective

actions

Observed Structures & Processes for Learning

Evidence of organizational learning from other data

Community hospital initiated programs in response to changes in patient transfer rates

Acute care hospital reduced staffing in response to changes in length of stay

What was top management attending to?

Community Hospital System Hospital Acute Care Hospital University Hospital (non-PRHI)

Key metrics monitored daily by CEOs

Patient transfer rates, average length of stay

Occupancy, case mix Reimbursements Multiple clinical/financial - reviewed monthly

Typical frequency of review of medication error data by senior leaders (CEO & direct reports)

Quarterly Monthly Weekly Monthly

Major CEO pre-occupation

Malpractice insurance Financial restructuring Prospective Payer System

Strategic Planning

Two hospitals initiated changes during case study period

Acute care hospital Introduced a balanced score card with patient safety

as a lead indicator Developed new metrics (e.g., # error-free days of stay

per patient) CEO started reviewing incident reports daily; moved

office to patient floor Increased involvement of physicians (e.g., one-on-one

meetings with CEO regarding illegible handwriting) Staff underwent training in problem solving techniques

Community hospital - Changes

Mission statement revised to include specific reference to improving patient safety

CEO carried out process observations; weekly review of data

Increased involvement of physicians

Revised conclusions

Starting premise Revised premise

Increasing reporting is a challenge Utilizing available data is the challenge

Learning about the causes of errors Learning about the persistence of errors

Shared understanding of the causes of errors Shared understanding of mutual vigilance

Dynamic capability i.e. routines for improving routines

Mechanism for stability

Conclusions

Increased top management attention facilitates the creation of formal and informal structures for learning from errors proactively Specific goals Increased awareness Streamlined reporting Widespread information sharing Enhanced problem solving capabilities Implementation of prevention strategies

In the absence of such attention, data used primarily for after-event review, management control, and regulatory compliance but not for deliberate learning

Implications

Questions the premise that increased incident-reporting will automatically promote learning

How can the reduction of operational errors be elevated to the level of a strategic priority?