Top Management

1
Top Managements Focus of Attention and
Organizational Learning from Errors

• Ranga Ramanujam (Purdue University)
• Donna Keyser (RAND)
• Carl Sirio (UPMC)
• Debra Thompson (Pittsburgh Regional Healthcare
  Initiative)

2
Research objective

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

3
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

4
Incident reporting-underlying premise
5
Reporting increased significantly

• gt 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

6
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

7
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)

8
Sample 4 hospitals

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

9
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

10
Key Variables Community Hospital System Hospital Acute Care Hospital University Hospital (non-PRHI)
Age 100 years gt 100 years lt 10 years gt 100 years
Number of beds 265 700 155 683
Teaching? No Yes No Yes
Current CEO tenure gt 25 years lt 5 years lt 5 years gt15 years
Increase in Medication Error Reporting (2002-04) 125 100 170 200
Meetings observed P T Patient Safety Medication Error Task Force P T Patient Safety P T Patient Safety Incident Tracking P T Patient Safety
11
Initial conclusions (T1) Absence of
organizational design for learning from incidents
12
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

13
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
14
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

15
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

16
Revised conclusions
17
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

18
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?