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Published by: University of California, Berkeley
Published in: "California Management Review", 2003

Abstract

The importance of hospitals learning from their failures hardly needs to be stated. Not only are matters of life and death at stake on a daily basis, but also an increasing number of US hospitals are operating in the red. This article reports on in depth qualitative field research of nurses'' responses to process failures in nine hospitals. It identifies two types of process failures - errors and problems - and discusses the implications of each for process improvement. A dynamic model of the system in which frontline workers operate reveals an illusory equilibrium in which small process failures actually erode organizational effectiveness rather than drive learning and change in hospitals. Three managerial levers for change are identified, suggesting a new strategy for improving hospitals'' and other service organizations'' ability to learn from failure.

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Abstract

The importance of hospitals learning from their failures hardly needs to be stated. Not only are matters of life and death at stake on a daily basis, but also an increasing number of US hospitals are operating in the red. This article reports on in depth qualitative field research of nurses'' responses to process failures in nine hospitals. It identifies two types of process failures - errors and problems - and discusses the implications of each for process improvement. A dynamic model of the system in which frontline workers operate reveals an illusory equilibrium in which small process failures actually erode organizational effectiveness rather than drive learning and change in hospitals. Three managerial levers for change are identified, suggesting a new strategy for improving hospitals'' and other service organizations'' ability to learn from failure.

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