Knowledge Exchange

Ask a Researcher

Serge Gagnon, PhD, Ana Gavrancic, DPs (cand.) et Maxime Paquet, PhD, Research and Intervention Centre for Healthy Workplaces (CRISO), affiliated with the McGill University Health Centre

What is the source of «operational system failures » and how can they harm the quality of the psychosocial work environment ?

First, what is an operational system failure (OSF)? It is a disruption or error in the process of providing diagnostic, therapeutic, technical or administrative services or resources that are necessary for the good functioning of healthcare units, as much in terms of the quality of the psychosocial work environment as that of the provided care and services.

For instance: a pharmacy department is experiencing a shortage of technical personnel and asks the nursing department to help out for a while by having its personnel carry out the preparation of a medication, e.g. antibiotic dilution.

On average, 6.5 to 8.4 OSFs occur in an 8 hour work shift. Each occurrence consumes 5 minutes of the nurses’ time. Thus, a total of 32.5 to 42 minutes of every nurse’s shift goes towards compensating for OSFs. On the other hand, nurses who were monitored during entire shifts were observed to work about 42 to 45 additional unpaid minutes, which would equal the time needed to correct all the OSFs that developed during the shift (Tucker, 2004; Tucker & Spear, 2006). In other words, OSFs are a source of irritation on many levels. They not only stand in the way of the job getting done, but they can lead to conflicts between different work groups, units, departments, etc.

One of the bjectives of our CRISO/REISS 2008-2012 program (as presented in the April and May 2010 editions of «Ask a researcher»), is first to analyse the organisational dynamics underlying the development and recurrence of OSFs, then to determine the OSFs that need to be tackled with priority, and implement corrective measures.

The most common categories of OSF are medication problems, medication orders , various supply problems (e.g. missing or inadequate meals), problems related to personnel, and broken or missing equipment (Tucker & Spear, 2006). Among the factors that create OSFs, are human errors, equipment problems, deviations from known processes and poor communication between clients and suppliers (Tucker & Spear, 2006; Tucker, 2004; Tucker, Edmondson & Spear, 2002), or inadequate levels of resources in support services. Furthermore, the obligation of the nursing staff to compensate for the operational system failures while providing patient care is one of the principal reasons the support services departments responsible for the delivery of diagnostic, therapeutic, technical and administrative resources and services to the nursing staff do not self correct and why dysfunction cases linger (Tucker, 2004). We deduce therefore that these failures have an important impact on work climate and that appropriate problem solving strategies help maintain a healthy work climate.

Despite the high quality of data published in scientific literature, it was imperative to diagnose the failures specific to our partner organisation. For that purpose, 16 unit or staff managers participated in a semi-structured interview on OSFs and behavioral norms.

First, participants describe in detail the main operational failures in their sector (general description, frequency, impact on staff’s work, impact on the quality and safety of provided care , perceived causes, problem-solving strategies , behaviors and attitudes of those involved). Second, we improve the initial description by determining the dynamics underlying the development of failures , their recurrence, and the choice of adequate problem solving strategies.

While analyzing the collected data, we regard the hospital as a complex organisation, meaning that, first, it consists of a multitude of internal and external players (e.g. employees, managers, patients, regulatory bodies, etc.) who act and react to one another in a cooperative and competitive manner so as to respond to their respective needs. Second, this organisation is “adaptive” because it can change and learn from the results of its action s. Like a brain, the hospital consists of information processing , communication and decision making systems. However, in a hospital, the control function tends to be widely dispersed and decentralized. Consequently, the behavior of the entire system is the result of a very large number of decisions made simultaneously, every second, by many players. The consequence of this characteristic is that the global coherence of the system is a function of the players’ capacities for cooperation and competition, given the diversity of “points of view” and interests that must be reconciled (Holland, 1994 ). Moreover, the interests of the players involved in the organization are sometimes convergent and sometimes divergent making conflicts of interest unavoidable.

However , to this end, dialogue and confrontation are necessary. The best approach to explain this way of considering hospital dynamics is by realizing that there is a power relationship between “doctors having taken the Hippocratic Oath” and “administrators having pledged a policy of accessibility at the best price”!

We face two different logics that are at once complementary, antagonistic and competitive: for the common interest to prevail there has to be cooperation and competition as well as dialogue and confrontation. We contend that this dialectical understanding of hospital organizations is central to the diagnosis of “operational system failures” that are of a “recurring” nature . In the case of diagnosing the operational failures of the hospital participating in the research-intervention project, we attempt to determine to what degree the organization players use these two logics , and what impact these ways of doing things have on the current work climate. To take it even further, we use the operational failures to learn about the organizational culture.

Behavioral Norms

Viewed as a “culture”, the hospital appears as an “action system” with its history, traditions, and dominant behavioural norms. It is a community consisting of several practice groups, each characterized by a specific history and distinct cultural attributes. This community produces and reproduces in its daily interactions beliefs and understandings, fragmented or whole that are at the source of a large variety of operational norms and functional rituals, which exert a determining influence on the preferred and ordinary ways of seeing things. These norms and rituals become so powerful that many dead angles develop and cover up important areas of interest, producing certain recurring operational failures and eventually more or less adequate problem solving strategies.

But, generally, what are the behavioral norms in a hospital?

Formal communication spaces : interactions are heavily influenced by norms of achievement, affiliation, and convention BUT hardly influenced by norms of power, opposition and competition. This configuration does not help establish the optimal balance between dialogue and confrontation, resulting in slow handling or non-handling of many issues and, consequently, the creation of “parallel systems” for problem solving.

Informal communicationspaces: in “parallel systems”, interactions are probably also influenced by norms of achievement, affiliation, and convention BUT more so by norms of power, opposition and competition, because “parallel systems” are more likely to be regulated by the “law of the jungle”.

Consequences:

Our analysis tends to confirm the following interpretive hypothesis: the recurrence of OSFs are the result of imbalances, culturally preserved in formal spaces of communication, between the capacities for dialogue and those for confrontation and contradictory debate. In short, a low capacity for debate is observed in formal spaces of interaction (e.g. agency-organization committees, senior management, management teams, etc.) which frequently leads to:

a systematic avoidance of conflict

an increase in «parallel negotiation systems» (the “market” for temporary solutions!)

a large number of committees working on problems that should be solved elsewhere.

Do you recognize such a communication culture in your organization? Would you like to intervene, or simply learn more about it? Visit us at www.criso.ca !

References

Holland. J. H. (1994). Complexity: the emerging science at the edge of order and chaos. Harmondsworth: Penguin.

Tucker, A. L. (2004) The impact of operational failures on hospital nurses and their patients. Journal of Operations Management 22: 152-169.

Tucker, A.L., Edmondson, A.C., & Spear, S. (2002). When problem solving prevents organizational learning. Journal of Organizational Change, 15(2), 122-137.

Tucker, A.L., & Spear, S. (2006). Operational Failures and Interruptions in Hospital Nursing. Health Services Research, 41(3), 643-662.