By Lukasz Mazur, University of North Carolina:
Along with my colleagues, we have recently published an article focused on improvement behaviors: Mazur, L.M., McCreery, J., and Chen, S-J. Quality Improvement in Hospitals: What Triggers Behavioral Change? Journal of Healthcare Engineering, vol. 4, no. 4; pp. 621-648, 2012.
We learned that improving operations in hospitals is complicated, because it requires changing complex behaviors. Thus, using single-loop and double-loop learning theory as a foundation, we uncover key improvement behaviors and the factors that may be associated with such behavior changing process in hospitals. The five key behaviors we identified were Quick Fixing, Initiating, Conforming, Expediting, and Enhancing. These behaviors can be summarized as follows:
• Quick Fixing: This behavior consists of detection and correction of defects most often accompanied by a discussion or description – most often in the form of a complaint – of the problem to coworkers and the immediate manager, but without formal reporting of defects.
• Initiating: This behavior involves formal reporting of defects and the initiation of an improvement effort. It also involves formal acknowledgment and action by the organization to correct the documented defects.
• Conforming: This behavior is characterized by compliance with standard procedures and processes under the conditions of a system free of defects (being aware of an issue, but not willing to initiate improvement efforts).
• Expediting: This behavior describes non-compliant procedures performed to complete the work under the conditions of a system free of defects.
• Enhancing: This behavior is seen in efforts to make long-lasting system improvements with regard to work efficiency, effectiveness, or patient safety, although the system is not overtly defective.
As one can predict, the consequences to the hospitals of the five different behaviors are quite different. As we write in our article, when defects occur, Quick Fixing behavior is effective at resolving immediate crises, but such efforts are not captured, validated, or and disseminated by the organization to prevent recurrences in this or other units of the hospital. Thus, the grand challenge is to transform Quick Fixing behavior into Initiating behavior by calling attention to defects and providing the organization with the opportunity to take preventive action. Furthermore, in the absence of defects, healthcare professionals can Conform, Expedite, or Enhance. The most desirable behavior is Enhancing, as this type of individual focuses on growing the organization’s capabilities for efficient, high quality healthcare delivery. Such behaviors should be modeled and strongly supported by leadership and management. In contrast, Expediting behaviors involve shortcuts and deviations from standard operating procedures in order to make individuals’ jobs easier or more productive, but the shortcuts cause problems of their own. Because of this non-compliance, Expediting behaviors may introduce variability and uncertainty into the system, which can cascade and cause downstream quality and safety problems. Thus, Expediting behaviors should be eliminated. The third type of non-defect behavior we observed is Conforming behavior. This type of individual is seemingly not motivated to make improvements to current ways of operating, since there are no overt defects to be dealt with. For the individual engaged in Conforming behavior, the logic of “leaving well enough alone” applies.
We hope that our research insights can help practitioners focus on helping healthcare employees make the transition to double-loop learners and root-cause problem solvers. Our findings may help achieve breakthrough results in quality, safety, cost reduction, patient satisfaction, and counterbalance the negative effects of employee frustrations and burnout regarding improvement leading to higher retention rates of healthcare professionals.