T. vogus saturday the case for org

The Case for Organizational Professionalism

Tim Vogus

October 20, 2012

Agenda

Creating a professional culture

Infusing professionalism Mindful organizing

EnactingFrontline actions that• Surface latent and

manifest threats to professionalism

• Mobilize resources to reduce threats

Professional Culture

EnablingLeader actions that • Direct attention to

professionalism• Create contexts safe to

speak up and act in ways that improve it

Outcomes

ElaboratingLearning practices that • Develop comprehensive

representations of outcomes

• Provide feedback that modifies enabling and enacting

EnactingFrontline actions that improve patient safety

- Interpersonal processes (e.g., teamwork)

- Reporting and voicing concerns

- Coordinating at care transitions (handovers) and across interdependent functions (checklists)

Culture

EnablingActions that motivate the

pursuit of safetyExternal actions: - Accrediting and

advocacy organizations- Survey tools- Work hours rulesInternal actions:- Leader behaviors and

practices- HR practices- Technology (EMR)

Improved ReliabilityFewer hospital errors

ElaboratingLearning practices that extend safe practices

- Learning-oriented interventions

- Education (simulation)- Frontline system

improvement- Case-based analysis

(M&M)- System monitoring

(prospective, retrospective, concurrent)

Culture

Cu

lture C

ultu

re

Cu

lture

Safety Climate

Frontline interpretations of

safety-related leader actions and

organizational practices

Emulate “Reliability Professionals”

High reliability organizations (HROs)

Roberts, 1990; Weick & Roberts, 1993

Schulman, 1993

LaPorte & Consolini, 1991

Reliability Professionals

Couple “the need for anticipation and careful causal analysis with the need for flexibility and improvisation” (Roe and Schulman 2008, p. 64)

Actions foster nearly error-free operations in contexts that are extremely Complex Dynamic Interdependent

Why Reliability Professionals?

Reliability a persistent and costly problem 98,000 deaths annually (IOM, 2000) May be significantly higher

(Classen, et al. 2011)

Improvement efforts have yielded little (Wachter, 2010) Despite significant effort (Landrigan,

et al., 2010)

Why Reliability Professionals? (cont.)

Complex Cognitively demanding (Aiken, et al.,

2002) Dynamic

Highly uncertain (Argote, 1982) Numerous exceptions (Tucker, 2004)

Interdependent Across shifts Distributed expertise (Benner, et al.,

1996)

How do reliability professionals do their work in a

nearly error-free manner?

Mindful Organizing

A social practice enacted collectively Not an intra-psychic process (cf. Langer, 1989)

Consists of Preoccupation with failure Reluctance to simplify interpretations Commitment to resilience Sensitivity to operations Deference to expertise

Mindful organizing allows for the rapid detection and correction of errors and unexpected events

Mindful Organizing Occurs When

People are Spending time identifying what could go wrong Discussing alternatives as to how to go about

everyday activities Developing an understanding of who knows what Talking about mistakes and ways to learn from

them Taking advantage of the unique skills of one’s

colleagues (even if the person is of lower status in the organization)

Concept Survey Item(s)

Preoccupation with failure• Chronic wariness of the unexpected

When giving report to an oncoming nurse, we usually discuss what to look out for.

We spend time identifying activities we do not want to go wrong.

Reluctance to simplify interpretations• Questioning assumptions and received wisdom

We discuss alternatives as to how to go about our normal work activities.

Sensitivity to operations• Up-to-date knowledge of where expertise

resides

We have a good “map” of each other’s talents and skills.

We discuss our unique skills with each other so we know who on the unit has relevant specialized skills and knowledge.

Commitment to resilience• Deliberate learning from experience

We talk about mistakes and ways to learn from them.When errors happen, we discuss how we could have

prevented them.

Deference to expertise• Migrating decision-making to person with most

expertise, not most authority

When attempting to resolve a problem, we take advantage of the unique skills of our colleagues.

When a patient crisis occurs, we rapidly pool our collective expertise to attempt to resolve it.

Measuring Mindful Organizing

Research Questions

Is mindful organizing associated with reliability? Do complementary practices enhance its effects?

What factors enable mindful organizing?

What interventions enhance mindful organizing?

Is Mindful Organizing Associated with Reliability?

95 nursing units A one unit increase in mindful organizing associated with 35%

fewer medication errors 7 fewer errors per year per unit

A one unit increase in mindful organizing associated with 69% fewer patient falls

13 fewer falls per year per unit

125 nursing units Mindful organizing positively related to manager ratings of safety

and quality

184 software firms Increases innovation and stock price over time

Do Complementary Practices Enhance These Effects?

Mindful organizing doesn’t occur in a vacuum Potentially enhanced by complementary practices

Care pathways Standardization of care according to best practice

Structure interactions Build connections (Feldman and Rafaeli, 2002)Facilitate coordination (Gittell, 2002)

“The majority of our patients are on care pathways” (Gittell, 2002)

Joint Effects – Mindful Organizing and Care Pathways

0

2

4

6

8

10

12

Low Mean High

Re

po

rte

d M

edi

cati

on

Err

ors

Level of Mindful Organizing

Minimal use of Pathways

Extensive use of Pathways

What Enables Mindful Organizing?

Mindful organizing is a function of the skilled efforts of “reliability professionals” (Roe & Schulman, 2008) Experience (Klein, 1998) Communication (Weick & Sutcliffe, 2007) Commitment (Levinthal & Rerup, 2006; Schulman, 1993)

What Enables Mindful Organizing?

Mindful OrganizingMindful OrganizingWorkgroup

Professional Experience

Workgroup Professional Experience

Workgroup Quality Performance

Workgroup Safety Performance

Workgroup Quality Performance

Workgroup Safety Performance

H1a + H4 +

H3 +

H2 -

H1b -

Professional ExperienceVariability

Professional ExperienceVariability

Workgroup Professional Commitment

Workgroup Professional Commitment

Methods

Survey of frontline registered nurses in a large Catholic health system

Mailed to 3,298 nurses using multi-contact strategy (Dillman, 2000)

51.1% response rate (1,685 responses); No evident non-respondent bias

125 units; average of 12 responses per unit, 13 hospitals 95% female Age 40.99 years (s.d. = 9.75) Tenure 15.29 years (s.d. = 10.18)

Results

Mindful OrganizingMindful OrganizingWorkgroup

Professional Experience

Workgroup Professional Experience

Workgroup Quality Performance

Workgroup Safety Performance

Workgroup Quality Performance

Workgroup Safety Performance

.015* .95***

.04*

-.05**

-.003**

Professional ExperienceVariability

Professional ExperienceVariability

Workgroup Professional Commitment

Workgroup Professional Commitment

.79**

Mindful Organizing and Professional Experience

Mindful Organizing, Experience, and Experience Variability

LOW PROF EXPERIENCE VARIABILITY (-1SD)

HIGH PROF EXPERIENCE VARIABILITY (-1SD)

Mindful Organizing, Experience, and Commitment

What Enables Mindful Organizing?

HR practices Selective staffing

Hiring for interpersonal as well as technical skills Extensive training

Preceptor programs, training in interpersonal skills, ongoing informal training

Developmental performance appraisalOngoing, 360-degree, and focused on learning

Employee involvementDiscretion over work practice

Reward suggestions Job Security

How Do HR Practices Help?

Through signaling Signaling the behaviors expected, supported, and

rewarded Signaling about what?

How work is to be carried outDevelopmental performance appraisal and coaching signal

the importance of learning and feedback seeking They foster a psychological contract

Employees are valued and treated fairly, so they reciprocate and generalize

What Enables Mindful Organizing?

HR Practices

Respectful Interaction

Mindful Organizing

+

+

+

Patient Safety  

+

• HR Practices include

• Selective staffing

• Developmental performance appraisal

Dyadic interactions – trust, honesty, and self-respect

Capabilities for detecting and correcting the unexpected

+

Employee Commitment

OCB+

+

Findings

HR Practices

MindfulOrganizing

Respectful Interaction Med. Errors

OCB

.09*

.78*

.30*

-.36*

.48*Commit

.08* Pat. Falls

.28*

-.51*

-.27*

-.16*

χ 2 = 91.05, df = 12, CFI = .93, SRMR = .053

What interventions enhance mindful organizing?

Interventions

Change the conversation Leader rounding

Managers on their unitsTop management on all units

HuddlesPost-event cross-profession debriefs; what, why, and

lessons to learn

Create mechanisms for change Safety action teams

Emerging Evidence

Increased leader engagement More regular rounding More consistent follow up actions

Institutionalization of huddles Increased reporting of errors and threats to safety

“The list” Safety action teams a mechanism for frontline

change and dissemination of reliability information

Highly variable and contingent

What Does This Mean for Clinical Practice?

A potential guide for making M&M conferences more impactful

A road map for debriefing close calls, errors, and uncomfortable situations

A framework for planned change (e.g., QI projects)

Preoccupation with Failure

A wariness about what could go wrong

Questions to ask What are we most worried about? Where are we most vulnerable? What is the “worst case scenario”?

Reluctance to Simplify Interpretations

Questioning assumptions to develop better ways of working

Questions to ask What assumptions are we making? Are there data that disconfirm our assumptions? What other assumptions could we make? What are alternative ways to carry out our work?

Sensitivity to Operations

A shared understanding of current status and where necessary expertise resides

Questions to Ask Who will be most impacted by our work? Where does the necessary expertise reside? Who needs to be at the table?

Commitment to Resilience

Regularly reflecting on and learning from outcomes to build group capabilities

How do we know we need to stop and huddle or debrief?

What went well? How can we replicate it? What went wrong? How can we avoid the same

mistakes?

Deference to Expertise

Decision-making based on problem-specific expertise, not formal authority

Questions to ask Who has the most experience with this situation? Who has knowledge we need to consider? How will we get their perspective? What barriers will prevent us from drawing upon the

appropriate expertise?

Conclusions

Mindful organizing is associated with reliability Quality, safety, and innovation Effects are enhanced by complementary practices

Mindful organizing is enabled by Workgroup professional characteristics HR practices

Mindful organizing responsive to interventions Rounding, huddles/debriefing, and questions

A well-designed organization is not a stable solution to achieve, but a developmental process to

keep active.

(Starbuck & Nystrom, 1981, p. 14)

That means:You NEVER get

High Reliability Organizing behind you!

Reliability and Mindful Organizing Resources

Roberts, K. H. and R. G. Bea (2001). "When Systems Fail." Organizational Dynamics 29(3): 179-191.

Rosenthal, M. M., and K. M. Sutcliffe (2002). Medical Error: What Do We Know? What Do We Do? San Francisco, CA, Jossey-Bass.

Sutcliffe, K. M., E. Lewton, et al. (2004). "Communication Failures: An Insidious Contributor to Medical Mishaps." Academic Medicine 79(2): 186-194.

Weick, K. E. (1987). "Organizational Culture as a Source of High-Reliability." California Management Review 29: 112-127.

Weick, K. E. and K. M. Sutcliffe (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, Jossey-Bass.

Weick, K. E. and K. M. Sutcliffe (2003). "Hospitals as Cultures of Entrapment: A Reanalysis of the Bristol Royal Infirmary." California Management Review 45(2): 73-84.

Weick, K. E. and K. M. Sutcliffe (2007). Managing the Unexpected: Resilient Performance in and Age of Uncertainty, Second Edition. San Francisco, CA, Jossey-Bass.

Shameless Self-Promotion Singer, S.J., & Vogus, T.J. (Forthcoming). “Safety Climate Research: Reflections and New

Directions.” BMJ Quality and Safety. Vogus, T.J., Sutcliffe, K.M., & Weick, K.E. (Forthcoming). “Searching for Safety Culture: An

Integration and Research Agenda.” Academy of Management Annals. Singer, S.J., & Vogus, T.J. (Forthcoming). “Reducing Hospital Errors: Interventions that Build

Safety Culture.” Annual Review of Public Health. Vogus, T.J., & Sutcliffe, K.M. (Forthcoming). “Organizational Mindfulness and Mindful

Organizing: A Reconciliation and Path Forward.” Academy of Management Learning & Education.

Vogus, T.J., Sutcliffe, K.M., & Weick, K.E. (2010). “Doing No Harm: Enabling, Enacting, and Embedding a Culture of Safety in Health Care Delivery.” Academy of Management Perspectives, 24(4): 60-77.

Vogus, T.J., & Sutcliffe, K.M. (2007b). “The Impact of Safety Organizing, Trusted Leadership, and Care Pathways on Reported Medication Errors in Hospital Nursing Units.” Medical Care, 45: 997-1002.

Vogus, T. J. and K. M. Sutcliffe (2007a). "The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units." Medical Care 45(1): 46-54.

Back Up Slides

Workgroup Professional Experience

Greater experience Frees up attention (Levinthal & Rerup, 2006) Enables sensing anomalies (Benner, et al. 1996; Weick &

Sutcliffe, 2007) Increases recognition of importance of collaboration

(Sonnentag, 2001) and collective learning (Barton & Sutcliffe, 2009)

Diminishing returns to experience result from Fewer novel experiences (Reason, 2008) Infrequent updating (Finkelstein & Hambrick, 1990)

Professional Experience Variability

Variability (disparity) in experience inhibits drawing upon collective experience

Reduce cohesion and increase conflict (Williams & O’Reilly, 1998) Less informal communication (Smith, et al., 1994)

Makes experience inaccessible

Status differences Less likely to seek out expertise (Barton & Sutcliffe, 2009; Weick &

Sutcliffe, 2007) Over-deference to experience (Blatt, et al., 2006; Morrison & Rothman,

2009) Experts have difficulty understanding and helping novices

Different language (Hinds, et al., 2001)

Professional commitment

Mindful organizing is effortful (Levinthal & Rerup, 2006) Requires extra-role behaviors (Schulman, 1993)

Professional commitment motivates and directs extra-role behavior (Meyer, et al., 2004)

Directs it behaviors consistent with professional values (Johnson, et al., 2009)

More likely to share experiences to prevent errors (Hofmann, et al., 2009)

Professional commitment coalesces because Common frame of reference (Abbott, 1988; Pfeffer & O’Reilly, 1989) ASA processes (Schneider, 1987) Social information processing (Salancik & Pfeffer, 1978)

So what?

What does a 0.4 to 0.6 change in mindful organizing mean? A 0.4 unit increase in mindful organizing leads to

14% fewer medication errors on a nursing unit3 fewer errors per year per unit

A 0.4 unit increase in mindful organizing leads to 28% fewer patient falls on a nursing unit5 fewer falls per year per unit

30% or more result in moderate to severe injuries $15,000 - $30,000 for each severe fall

Respectful Interaction

The basis for socially shared cognition (Campbell, 1990; Asch, 1952) Honestly reporting what we perceive to each other. Demonstrating a great deal of mutual respect for each

other. When discussing patient information, attempting to

integrate our interpretations without belittling our own opinions or another nurse’s.

Exhibiting trustworthiness. Respectful interaction enables people to

Come to a shared and nuanced understanding Surface information that conflicts with the majority view

Unexpected Finding

Why is OCB associated with higher levels of errors and falls? Interruptions and tough cognitive shifts (Tucker &

Edmondson, 2003; Leroy, 2010) Culture of heroes

Acting outside of competence Inadequate systems

Normalizing deviance (Vaughan, 1996) If these are plausible, a mindful system should

mitigate the negative impacts

What About Edmondson (1996)?

Didn’t measure reporting, used chart review Someone else makes the determination if there was an error

or not Differences in culture of reporting now and in mid 1990s

Cross-sectional study, I’m modeling over time Why should effective practice be associated with reporting

more errors/falls over time? I control for ratings of whether or not a unit was a “good” unit

If better units report more, should see a positive relationship Observe a negative relationship

What Edmondson captured consistent with my OCB effect