4
Transformational Leadership and Evidence-Based Management

Creating work environments for nurses that are most conducive to patient safety will require fundamental changes throughout many health care organizations (HCOs)—in the ways work is designed and personnel are deployed, and how the very culture of the organization understands and acts on the science of safety. These changes require leadership capable of transforming not just a physical environment, but also the beliefs and practices of nurses and other health care workers providing care in that environment and those in the HCO who establish the policies and practices that shape the environment—the individuals who constitute the management of the organization.

Behavioral and organizational research on work and workforce effectiveness, health services research, studies of organizational disasters and their evolution, and studies of high-reliability organizations (see Chapter 1) have identified management practices that are consistently associated with successful implementation of change initiatives and achievement of safety in spite of high risk for error. These practices include (1) balancing the tension between production efficiency and reliability (safety), (2) creating and sustaining trust throughout the organization, (3) actively managing the process of change, (4) involving workers in decision making pertaining to work design and work flow, and (5) using knowledge management practices to establish the organization as a “learning organization.” These five management practices, which are essential to keeping patients safe, are not applied consistently in the work environments of nurses.

The committee concludes that transformational leadership and action by each organization’s board of directors and senior and midlevel manage-



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Keeping Patients Safe: Transforming the Work Environment of Nurses 4 Transformational Leadership and Evidence-Based Management Creating work environments for nurses that are most conducive to patient safety will require fundamental changes throughout many health care organizations (HCOs)—in the ways work is designed and personnel are deployed, and how the very culture of the organization understands and acts on the science of safety. These changes require leadership capable of transforming not just a physical environment, but also the beliefs and practices of nurses and other health care workers providing care in that environment and those in the HCO who establish the policies and practices that shape the environment—the individuals who constitute the management of the organization. Behavioral and organizational research on work and workforce effectiveness, health services research, studies of organizational disasters and their evolution, and studies of high-reliability organizations (see Chapter 1) have identified management practices that are consistently associated with successful implementation of change initiatives and achievement of safety in spite of high risk for error. These practices include (1) balancing the tension between production efficiency and reliability (safety), (2) creating and sustaining trust throughout the organization, (3) actively managing the process of change, (4) involving workers in decision making pertaining to work design and work flow, and (5) using knowledge management practices to establish the organization as a “learning organization.” These five management practices, which are essential to keeping patients safe, are not applied consistently in the work environments of nurses. The committee concludes that transformational leadership and action by each organization’s board of directors and senior and midlevel manage-

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Keeping Patients Safe: Transforming the Work Environment of Nurses ment are needed to fully secure the advantages of these five management practices. Because HCOs vary in the extent to which they currently employ these practices, as well as in their available resources, collaborations with other HCOs can facilitate more widespread adoption of these practices. This chapter takes a detailed look at the crucial role of transformational leadership and evidence-based management in accomplishing the changes required in nurses’ work environments to improve patient safety. We first discuss transformational leadership as the essential precursor to any change initiative. We then review in turn the five management practices enumerated above and describe their uneven application in nurses’ work environments. Next, we present several models for evidence-based management in nurses’ work environments. Finally, we examine how evidence-based management collaboratives can be used to stimulate the uptake of health care quality improvement practices. During the course of the discussion, we offer four recommendations (highlighted in bold print) for addressing the deficiencies in nurses’ work environments through enhanced leadership and management practices. TRANSFORMATIONAL LEADERSHIP: THE ESSENTIAL PRECURSOR The central function of leadership is to achieve a collective purpose (Burns, 1978). Not surprisingly, leadership has been observed to be the essential precursor to achieving safety in a variety of industries (Carnino, undated), a critical factor in the success of major change initiatives (Baldridge National Quality Program, 2003; Davenport et al., 1998; Heifetz and Laurie, 2001), and key to an organization’s competitive cost position after a change initiative. In a study of hospital reengineering initiatives in U.S. acute care hospitals from 1996 to 1997, only the chief executive officer’s (CEO) involvement in core clinical changes had a statistically significant positive effect on the cost outcomes of reengineering (Walston et al., 2000). The exercise of leadership has also been associated with increased job satisfaction, productivity, and organizational commitment among nurses and other workers in HCOs (Fox et al., 1999; McNeese-Smith, 1995). In his Pulitzer Prize–winning, seminal study on leadership, James Burns identifies the essential characteristics of leadership (as distinct from the wielding of power) and distinguishes “transactional” leadership from the more potent “transformational” leadership (Burns, 1978). He stresses that leadership, like the exercise of power, is based foremost on a relationship between the leader and follower(s). In contrast to power, however, leadership identifies and responds to—in fact, is inseparable from—the needs and goals of followers as well as those of the leader. Leadership is exercised by engaging and inducing followers to act to further certain goals and pur-

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Keeping Patients Safe: Transforming the Work Environment of Nurses poses “that represent the values and motivations, the wants and needs, the aspirations and expectations of both leaders and followers” (Burns, 1978:19). The genius of leadership lies in the manner in which leaders see, act on, and satisfy followers’ values and motivations as well as their own. Leadership therefore can be either transaction-based or transformational. Transactional leadership typifies most leader–follower relationships. It involves a “you scratch my back; I’ll scratch yours” exchange of economic, political, or psychological items of value. Each party to the bargain is conscious of the power and attitudes of the other. Their purposes are related and advanced only as long as both parties perceive their individual interests to be furthered by the relationship. The bargainers have no enduring relationship that holds them together; as soon as an item of value is perceived to be at risk, the relationship may break apart (Burns, 1978). This point is illustrated by labor strikes resulting from a change in the terms of work. The compliance of labor with management is based on an acceptable set of transactions; when the transactions are changed, the relationship may not have much to hold it together. Burns notes that in such cases, a leadership act takes place, but it is not one that “binds leader and follower together in a mutual and continuing pursuit of a higher purpose” (Burns, 1978:20). Transactional leadership is not a joint effort of persons with common aims acting for a collective purpose, but “a bargain to aid the individual interests of persons or groups going their separate ways” (Burns, 1978:425). In contrast, transformational leadership occurs when leaders engage with their followers in pursuit of jointly held goals. Their purposes, which may have started out as separate but related (as in the case of transactional leadership), become fused. Such leadership is sometimes described as “el-evating” or “inspiring.” Those who are led feel “elevated by it and often become more active themselves, thereby creating new cadres of leaders” (Burns, 1978:20). Transformational leadership is in essence a relationship of mutual stimulation and elevation that raises the level of human conduct as well as the aspirations of both the leader and those led, and thereby has a transforming effect on both (Burns, 1978). Transformational leadership is achieved by the specific actions of leaders. First, leaders take the initiative in establishing and making a commitment to relationships with followers. This effort includes the creation of formal, ongoing mechanisms that promote two-way communication and the exchange of information and ideas. On an ongoing basis, leaders play the major role in maintaining and nurturing the relationship with their followers. Burns notes that, most important, leaders seek to gratify followers’ wants, needs, and other motivations as well as their own. Understanding of followers’ wants, needs, and motivations can be secured only through ongoing communication and exchange of information and ideas. Leaders

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Keeping Patients Safe: Transforming the Work Environment of Nurses change and elevate the motives, values, and goals of followers by addressing their followers’ needs and teaching them about their commonly held goals. Doing so may require that leaders modify their own leadership in recognition of followers’ preferences; in anticipation of followers’ responses; or in pursuit of their common motives, values, and goals. Although a transforming leader plays the major role in achieving the combined purpose of leader and followers, transformational leadership recognizes that leaders and followers are engaged in a common enterprise and thus are dependent on each other. The premise of transformational leadership is that, regardless of the separate interests people may hold, they are presently or potentially united in the pursuit of higher goals. This point is evidenced by the achievement of significant change through the collective or pooled interests of leaders and followers. The effectiveness of leaders and leadership is measured by the extent to which intended change is actually accomplished and human needs and expectations are satisfied (Burns, 1978). Burns offers reassurance that transformational leadership is far more common than might be thought, given the above discussion. He notes that acts of transformational leadership are not restricted to (and often are not found in) governmental organizations, but are widespread in day-to-day events, such as whenever parents, teachers, politicians, or managers tap into the motivations of children, students, the electorate, or employees in the achievement of a needed change. In acute care hospitals, individuals in potential transformational leadership roles range from board-level chairmen and directors; to chief executive, operating, nursing, and medical officers; through the hierarchy to unit managers. In nursing homes, such leadership can come from a facility’s owners, administrator, director of nursing, and unit managers. Leadership by these senior organization managers and oversight boards is essential to accomplishing the breadth of organizational change needed to achieve higher levels of patient safety—changes in management practices, workforce deployment, work design and flow, and the safety culture of the organization (see Chapter 1). However, if these individuals rely solely on a traditional, transactional approach to leadership, such substantive changes are likely to be difficult to achieve and sustain, as leaders will need to conduct frequent, ongoing, possibly contradictory renegotiations with workers in response to rapidly changing external forces. In contrast, transformational leadership seeks to engage individuals in the recognition and pursuit of a commonly held goal—in this case, patient safety. For example, individual nurses may desire wide variation in the number of hours they would like to work on a 24-hour or weekly basis. Attempting to secure their commitment to the organization by accommodating all such requests (transactional leadership) despite evidence that extended work hours may be detrimental to patient safety would

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Keeping Patients Safe: Transforming the Work Environment of Nurses likely be both time-intensive and unsuccessful. Instead, transformational leadership would engage nursing staff in a discussion of patient safety and worker fatigue and seek to develop work hour policies and scheduling that would put patient safety first and respond to individual scheduling needs within that construct. Such a discussion could have a transforming effect on both staff and management as knowledge was shared. A leadership approach that aims to achieve a collective goal rather than a multitude of individual goals and aims to transform all workers—both managers and staff—in pursuit of the higher collective purpose can be the most efficient and effective means of achieving widespread and fundamental organizational change. In practicing transformational leadership, leaders need to engage managers and staff in an ongoing relationship based on the commonly held goal of patient safety, and communicate with and teach managers and staff about this higher collective purpose. When teaching managers about the actions they can take to minimize threats to patient safety, HCO leaders should underscore the five management practices enumerated earlier that have been found to be consistently associated with successful implementation of change initiatives and with the achievement of safety in organizations with high risk for errors. These management practices also underlie all of the worker deployment, work design, and safety culture practices that are addressed in the remaining chapters of this report. FIVE ESSENTIAL MANAGEMENT PRACTICES “The more removed individuals are from … front-line activities…, the greater is their potential danger to the system” (Reason, 1990:174). As discussed in Chapters 1 and 2, latent work conditions have been documented as posing the greatest risk of errors. Therefore, it should not be surprising that errors often have their primary origins in decisions made by fallible system designers and high-level managerial decision makers (Reason, 1990). The corollary to this statement is that these high-level managerial decision makers have a substantial role to play in error prevention—a role that deserves more attention and support. The concept of evidence-based practice first emerged in clinical medicine and now suffuses the language, decision making, and standards of care of health care clinicians, managers, policy makers, and researchers throughout the world. Evidence-based clinical practice is defined as the conscientious, explicit, and judicious integration of current best evidence—obtained from systematic research—in making decisions about the care of individual patients (Sackett et al., 1996). The use of systematic research findings for evidence-based practice is also supported and applied in the fields of educa-

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Keeping Patients Safe: Transforming the Work Environment of Nurses tion, criminal justice, and social welfare through the efforts of the international Campbell Collaboration—a sibling of the Cochrane Collaboration that prepares and maintains evidence-based systemic reviews of the effects of health care interventions (The Campbell Collaboration, undated). Evidence-based management, however, is a newer concept—not yet as widely embraced, but just as important (Axelsson, 1998; Hewison, 1997; Kovner et al., 2000; Walshe and Rundall, 2001). Evidence-based management means that managers, like their clinical practitioner counterparts, should search for, appraise, and apply empirical evidence from management research in their practice. Managers also must be prepared to have their own decisions and actions systematically recorded and evaluated in a way that will further add to the evidence base for effective management practices (Axelsson, 1998). While health care practitioners have been encouraged and supported in the adoption of evidence-based practice, the same support and encouragement has not been widely available to health care managers for multiple reasons: Organizational research is sometimes esoteric and does not consistently address practical management questions (Axelsson, 1998). Further, research conducted on health care management is limited compared with management research in other industries. The main funders of research in health care (government agencies and private foundations) have historically not funded management research. When large health systems have funded such research, its findings have often been considered proprietary and the results not widely published. As a result, little empirical evidence has been generated about best health care management practices (Kovner et al., 2000). The empirical evidence on effective management practices that does exist is difficult to locate. Management literature is poorly indexed for practical applications and is not easily reviewed and synthesized (Walshe and Rundall, 2001). Many managers are not trained or experienced in the use of such evidence in making management decisions (Kovner et al., 2000). While physicians are trained in a strongly professional model with fairly uniform educational preparation, managers come from a variety of very different professional backgrounds and training. Some management training comes more from long-term practical experience in the workplace, as opposed to formal professional education (Axelsson, 1998; Walshe and Rundall, 2001). Although many health systems spend millions of dollars on consultants for strategic recommendations based on data, they typically underfund their own data systems designed to support decision making and internal management research (Kovner et al., 2000). A study of 14 U.S. hospitals

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Keeping Patients Safe: Transforming the Work Environment of Nurses implementing reengineering initiatives in the 1990s found that existing operating budgets often were used to measure progress in meeting reengineering goals, but did not contain baseline statistics managers could use for comparative purposes or identification of causes and effects (Walston and Kimberly, 1997). Some HCOs lack sufficient size and resources to conduct and evaluate applied research (Kovner et al., 2000). Managers’ decision-making practices are often quite different from those of health care practitioners. While practitioners’ decisions are many in number and made independently, management decisions are often few, large, and made by groups, involving negotiation or compromise and many organizational constraints (Walshe and Rundall, 2001). For the above reasons, in health care, often “the weapons are ahead of the tactics”—a description used by historian Shelby Foote to characterize military leadership during the U.S. Civil War (Ward et al., 1990). In the case of American health care, the sophisticated medical technology (the weaponry) outclasses the tactics (management) used to organize work and implement change. Despite the limitations discussed above in the supply of and access to empirical information to guide managerial decision making, there is strong evidence that the management practices enumerated at the beginning of this chapter play a critical role in achieving organizational goals and successfully implementing change within an organization. These five practices are discussed in turn below. Balancing the Tension Between Efficiency and Reliability The health care cost-containment pressures of the last two decades (see Chapter 1) have forced HCOs to examine their work processes and undertake work redesign initiatives to deliver care more efficiently. Efficiency frequently calls for conducting production activities in as cost-effective and time-efficient a manner as possible. Organizations in many industries often try to accomplish efficiency by downsizing, outsourcing, and cutting costs. Such efficiency measures can be at odds with safety (Carnino, undated; Cooper, 2000; Spath, 2000). For example, when system failures associated with four large-scale disasters (Three-Mile Island, Chernobyl, the Challenger space shuttle, and the Bhopal chemical plant) were compared, subordination of safety to other performance goals was one of 11 common attributes found (Petersen, 1996). HCOs are not immune to these pressures. Concerns have been raised that HCOs, in responding to production and efficiency pressures, may adopt practices that threaten patient safety (Schiff, 2000; SEIU Nurse Alliance, 2001; Thomas et al., 2000).

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Keeping Patients Safe: Transforming the Work Environment of Nurses For example, one of the practices used by high-reliability organizations to increase safety is to consciously incorporate personnel and equipment redundancy into some aspects of work design. This redundancy creates some slack in the system such that if one component in the work production process fails, a replacement will be available to perform the function. Air traffic controllers, for example, are assigned to radar screening in groups of two. While their job functions are somewhat different, each controller acts as a check on the other (Roberts, 1990). This redundancy and other practices characteristic of high-reliability organizations—such as promoting inter- and intragroup communication, cross-training personnel, and attending to the interdependencies of work production processes—might be viewed by other organizations as “frills” (Roberts and Bea, 2001b) and a hindrance to efficient production. In high-reliability organizations, however, performance reliability (safety) rivals productivity as a dominant organizational goal, and such work components are viewed as essentials rather than frills (Roberts, 1990). Organizations can achieve balance between production efficiency and reliability by balancing and aligning their organizational goals; accountability mechanisms; and reward, incentive, and compensation mechanisms (Roberts and Bea, 2001a). Creating and Sustaining Trust Creating and sustaining trust is the second of the five management practices essential to patient safety. Trust has been defined as the willingness to be vulnerable to the intentions of another (Mayer et al., 1995; Rousseau et al., 1998) and is strongest when parties believe each other to be competent and to have one another’s interests at heart. When trust links people and groups to organizations, it generally makes workers willing to contribute their efforts without expecting an immediate payoff, and increases the extent to which leaders can rely on workers to have the organization’s interests at heart (and vice versa). Workers’ trust in organizational leaders has been found to be directly related to positive business outcomes, such as increased sales and profitability, and inversely related to employee turnover (Mayer et al., 1995). Trust has the added advantage of increasing workers’ capacity for change by reducing the uncertainty and discomfort with change that otherwise impair individual and group adaptability (Coff and Rousseau, 2000; Rousseau, 1995) and increasing workers’ willingness to take risks associated with change (Mayer et al., 1995). Honest and open communication, necessary for successful organizational change, depends on the development of trust throughout the organization (Carnino, undated; DeLong and Fahey, 2000), in part because the level of trust that exists between the organization and its employees greatly influences the amount of knowledge that

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Keeping Patients Safe: Transforming the Work Environment of Nurses flows among individuals and from individuals into organization databases, archives, and other records (DeLong and Fahey, 2000). Further, when trust is lacking, participants are less likely to believe what leaders say and to contribute the extra effort, engagement, and knowledge needed to make change successful. It is easier to share information, downplay differences, and cooperate when those involved in a change trust each other. Trust flows two ways—up and down the hierarchies of organizations. Top-down trust is based largely on competence (Rousseau et al., 1998). Leaders are more willing to entrust subordinates with complete information and with the authority to make decisions when they believe those subordinates to be competent and capable of making and carrying out appropriate decisions. It is well established that leaders manage subordinates differently depending on the employees’ perceived competence (Graen et al., 1982; Lowin and Craig, 1968). This is because when hiring, employers put themselves at risk, depending on those they hire to act in ways that help rather than hinder the organization. Employees are hired to act for their employers by making decisions and carrying out responsibilities on the employers’ behalf (Pearce, 2000). Employers cope with this vulnerability by attempting to hire employees they can trust and by managing those they hire in ways that sustain that trust. Top-down trust is reinforced whenever leaders have positive exchanges with their employees. Such exchanges are more likely to occur in long-standing relationships in which both parties have made investments in each other, for example, when leaders have developed subordinates who in turn have worked to understand the leader’s goals and preferred ways of managing and adjusted their behavior accordingly (Huselid, 1995; Miles and Snow, 1984). Bottom-up trust, on the other hand, is based in part on workers’ perceptions of a manager’s or organization’s ability, benevolence, and integrity (Mayer et al., 1995). An organization’s ability comprises its collective skills, competencies, and expertise. Trust can be fostered by an organization’s strong reputation for competence and capabilities, as well as by members’ ability to directly access the expertise of others within the organization, the collective capabilities of members, their shared knowledge of each other’s expertise, and recognition of “who knows what” based on a history of shared experience (Coff and Rousseau, 2000). Conversely, trust can be damaged by disclosure of failures in competence or by workers’ direct observation of instances in which competence falls short of prior expectations. Bottom-up trust is also based on benevolence, that is, the extent to which managers and organizations are understood by workers to want to do good (aside from a self-concerned or profit motive) for the person who trusts the entity (the trustor). Benevolence gives rise to an attachment between the entity being trusted (the trustee) and the trustor. An example of such a benevolent relationship is that between a mentor and a protégé. The

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Keeping Patients Safe: Transforming the Work Environment of Nurses mentor wants to be helpful to the protégé, even though there is no extrinsic reward to the mentor for doing so. Benevolence also has been associated with a trustee’s motivation to speak truthfully (Mayer et al., 1995). The relationship between integrity and trust involves the trustor’s perception that the trustee adheres to a set of principles that the trustor finds acceptable (Mayer et al., 1995). In health care organizations, where many workers have strong professional identifications, trust of leadership by subordinates often reflects the extent to which leadership is committed to the values inherent in the professions of medicine and nursing (Bunderson, 2001; Thompson and Bunderson, in press). Conversely, evidence indicates that change initiatives targeting quality improvement are far less likely to generate support when clinical caregivers believe those changes are motivated by either economic or political considerations (Rousseau and Tijoriwala, 1999). Integrity is assessed by the consistency of a party’s past actions, credible communication about the trustee from other parties, the belief that the party has a strong sense of justice, and the extent to which the party’s actions are consistent with his or her word. Trust between workers and the organizations in which they work therefore results from the workers’ perceptions of the interplay among the organization’s ability, benevolence, and integrity. Each of these factors exists to a varying degree along a continuum. Although in the best case, high degrees of trust result from high levels of all three factors, meaningful trust can exist with lesser levels of a combination of the three. The degree of trust between parties also is dynamic and evolves over time as the parties interact. The outcomes that result when a trustor takes a risk and places his or her trust in the trustee affect the degree of trust that exists for subsequent potential interactions (Mayer et al., 1995). Mutual trust is enhanced by positive exchanges that have occurred in the past and are expected to continue in the future (Zucker, 1986). Therefore, trust in organizations also depends to a certain extent on the extent of stability in the relationships that make up the organization (e.g., worker to manager, manager to senior executive). In organizations with high turnover, mutual trust is difficult to achieve (Bryman et al., 1987). In firms in which promotions tend to be internal and the employee development system builds organization-specific capabilities, both workers and managers are more likely to possess common knowledge and similar points of view, and managers are more likely to trust workers (Miles and Snow, 1984). Such bases for trust are less common in many contemporary firms, where external mobility and reduced opportunities for within-firm development mean that organization members, leaders, and workers have fewer shared experiences and frames of reference (Leana and Rousseau, 2000). It is widely evident that over the course of the twentieth century, senior managers in many industries have come to place greater trust in workers

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Keeping Patients Safe: Transforming the Work Environment of Nurses (Miles and Creed, 1995). Employees increasingly have experienced greater discretion and reduced standardization in the way they accomplish their work, coordinated more of their interactions with coworkers and other departments, and reduced their dependence on supervisors for problem solving. At the same time that modern organizational practices presume a higher degree of trustworthiness among workers, however, workers’ trust in management remains highly variable (Freeman and Rogers, 1999). In a large-scale survey of the American workforce, Freeman and Rogers found that workers generally reported levels of loyalty to their employer greater than the degree of trust they placed in their employer to keep its promises to them or other workers. This low level of trust is connected to a widespread sense on the part of American workers that they have little influence over workplace decisions. Where workers exercise greater influence over workplace decisions, they are more likely to trust their managers and act in ways that ease implementation of those decisions. With respect to nursing, higher levels of nurse autonomy and control over nursing practice have been associated with greater trust in management among nurses and greater commitment to their employing HCO (Laschinger et al., 2000, 2001b). Actively Managing the Process of Change Actively managing the process of change is essential to patient safety because all organizations have difficulty in navigating major organizational change (Kimberly and Quinn, 1984). HCOs are no exception. Despite their vast experience with introducing new medical technologies, HCOs have a history of ineffective attempts at organizational change and remain prone to poor change implementation (Mintzberg, 1997). A large body of research and other published work offers frameworks, models, and guidance for undertaking change (Baer and Frese, 2003; Goodman, 2001; Parker, 1998; Rousseau and Tijoriwala, 1999; Walston et al., 2000). This work consistently calls attention to five predominantly human resource management practices1 as particularly important for successful change implementation: ongoing communication; training; use of mechanisms for measurement, feedback, and redesign; sustained attention; and worker involvement. Ongoing Communication Frequent, ongoing communication through multiple media is a key ingredient of successful organizational change initiatives (Ingersoll et al., 1   The human resource side of change tends to be undermanaged as compared with management of the implementation of technological changes (Kimberly and Quinn, 1984).

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Keeping Patients Safe: Transforming the Work Environment of Nurses Pittsburgh Regional Healthcare Initiative The Pittsburgh Regional Healthcare Initiative (PRHI) is a coalition, begun in 2000, of 35 hospitals; four major insurers; more than 30 major and small-business health care purchasers; numerous corporate and civic leaders; organized labor; state and federal governments; and academic and research institutions, including Carnegie Mellon University, RAND Corporation, the University of Pittsburgh Center for Health Services Research, and Purdue University (Feinstein, 2002). PRHI adapted the principles of the Toyota Production System and implemented practices to manage change, involve workers in decision making about work design and work flow, and become a learning organization to achieve the goal of “perfecting patient care” (Feinstein et al., 2002). PRHI participants have as their goal “delivering patient care on demand, defect free, one by one, immediately, without waste or error, in an environment that is physically, emotionally, and professionally safe” (The Jewish Healthcare Foundation of Pittsburgh, 2002:12). PRHI is spearheaded by a “leadership obligation group” comprising hospital and other corporate CEOs charged with keeping the initiative moving forward (Robinet, 2002). It focused initially on two patient safety goals: eliminating medication errors and hospital-acquired infections (Feinstein et al., 2002). Multidisciplinary advisory committees at each PRHI partner facility adopted and use the same incident-reporting system for hospital-acquired infections and medication errors. In a partnership with the U.S. Centers for Disease Control and Prevention (CDC), PRHI hospitals developed a common reporting tool based on CDC’s national Nosocomial Infection Surveillance System—the oldest and most widely used surveillance system for hospital-acquired infections—and a similar standardized web-based error-reporting tool for medication errors. PRHI hospitals share their data with each other, as well as nationally. The data are translated into knowledge that front-line health care workers can use to protect patients (Feinstein, 2002). PRHI collects data from all participating hospitals, maps them to patient outcomes, and correlates them with processes of care. Based on those findings, its members institute experimental changes in work design to improve patient safety. In this way, PRHI carries out the practice of becoming a learning organization. Groups of people actually performing the work determine the root cause of a problem, experiment with ways to solve the problem using scientific methods, and then measure the results and share what has been learned (Feinstein et al., 2002). PRHI partners empower health care workers to address problems. When a problem is detected, a team of workers designs a solution immediately, employing a set of predesigned principles and scientific methods. Every worker is expected to be-

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Keeping Patients Safe: Transforming the Work Environment of Nurses come a scientist and to contribute to rapid, frequent improvements. PRHI also includes a Center for Shared Learning that coordinates all PRHI improvement efforts. The Wellspring Alliance Wellspring Innovative Solutions, Inc. (Wellspring) is a federation of 11 freestanding not-for-profit nursing homes in eastern Wisconsin. Fully operational since 1998, its two-fold purpose is to improve the clinical care provided to residents and to create a better work environment for employees. A 15-month evaluation of the Wellspring model found: Better patient surveillance by staff. Improved performance as measured by federal oversight surveyors. Better quality of life for patients and improved quality of staff–resident interactions. Lower staff turnover relative to comparable nursing homes in Wisconsin for the same time period. In achieving these benefits, Wellspring has attended to the leadership of these organizations, trusted workers to make decisions about improvements to patient care, created structures and processes to sustain these changes, and instituted practices aimed at supporting members as learning organizations. Leadership and management support is provided by a formal organizing superstructure (The Wellspring Alliance) that, in addition to carrying out several practical functions, such as joint purchasing, provides a forum for collaborative information sharing, education and training, and knowledge dissemination across the facilities. The Alliance functions on many levels, including CEOs; administrators; line staff; and a designated Wellspring coordinator in each facility, whom evaluators identified as arguably the single most important contributor to the successful implementation and sustained operation of the Wellspring model. Coordinators serve as both a formal link between the facility and the Alliance and an informal conduit of information across facilities. These individuals meet and interact at quarterly meetings and training events and help codify lessons learned. Employee education and training are facilitated by a geriatric nurse practitioner who serves as a primary resource on clinical care, develops staff training modules, provides centralized clinical education and training to staff, and travels to member facilities on a quarterly basis to provide feedback to the facility and reinforce and sustain the adoption of the clinical practices taught in the various modules. Training is cross-disciplinary and targeted to employees as team members. Team members learn collabo-

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Keeping Patients Safe: Transforming the Work Environment of Nurses rative problem solving and share responsibility for resident outcomes. Wellspring uses this team training as a way of decreasing the hierarchical relationships that are typical in nursing home staff relationships. Care resource teams are described as the “main engine” of the patient care improvement activities undertaken by the facilities. These teams are interdisciplinary, nonhierarchical (e.g., nursing assistants may lead a team), voluntary, and self-directing. Teams are expected to identify and develop new work strategies, monitor implementation success, and intervene when problems in implementation arise. The Wellspring Alliance fosters the evolution of all its member facilities into learning organizations through several practices. One is the sharing of the geriatric nurse practitioner and the facility coordinators to disseminate and nurture the adoption of evidence-based best practices in the care of residents. Another strategy being pursued is having each member facility enter data (e.g., number of incontinent episodes, falls, and weight loss) into a common data set on a quarterly basis (although evaluators found this aspect of the Wellspring model to be most problematic and least well implemented). A data analyst aggregates the data, prepares analytic reports, and presents these reports at quarterly meetings. This practice facilitates the systematic transfer of knowledge across facilities and nursing units, through the clinical resource teams, to staff, and the application of that knowledge is sustained through regularly scheduled care resource team meetings in the facility (Stone et al., 2002). USE OF EVIDENCE-BASED MANAGEMENT COLLABORATIVES TO STIMULATE FURTHER UPTAKE The PRHI and Wellspring models described above are examples of learning collaboratives in which resources, knowledge, and experiential learning are shared to improve clinical practice. Collaborative approaches have also been used as mechanisms to facilitate the uptake of health care quality improvement practices (Institute for Healthcare Improvement, undated), technology assessment and dissemination (The Health Technology Center [HealthTech], 2003), and strategic marketplace assistance for HCOs (VHA, 2003). Evidence-based management collaboratives (EBMCs) have been proposed as a means of bringing together managers, consultants, and researchers to improve health care management and thereby organizational performance (Kovner et al., 2000). These collaboratives would consist of a team of managers, researchers, and consultants from a variety of organizations whose aim would be to better understand problems in effective health care management and to develop more effective approaches to managing health systems. EBMCs would provide access to data and partners within an

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Keeping Patients Safe: Transforming the Work Environment of Nurses organization’s network to permit pooling of data and resources for the conduct of research, demonstrations, and evaluations that no single organization could undertake. Estimates are that just 10 percent of the annual consulting budget for a large health system redirected to such a collaborative would be sufficient to finance this capacity. EBMCs could be implemented across several different health systems, in one health system, or both. Organizing across systems that are in competition in specific markets has been identified as difficult; thus, organizing noncompeting organizations and their existing alliances has been proposed as an initial approach. EBMCs would require (1) a strong commitment to improving health care management through the application of evidence, (2) a willingness to use and share management data from compatible management information systems to track and monitor strategic interventions and organizational performance, (3) an interest in participating in applied research, and (4) an interest in being involved in demonstration projects to improve health system performance. In return, collaborative partners would receive comparative information on current ways of organizing services; access to the collective experiences of other cooperative members; results from applied research projects; and an array of technical assistance on statistical, management, and marketing issues (Kovner et al., 2000). A critical partner in these endeavors would be a research center, typically university-based, with an interest and capacity in applied research on health systems and performance, strategic initiatives, and related management and financial issues. The academic partner could provide expertise in data analysis, survey design, program evaluation, and professional education. In addition to serving its collaborative members, the EBMC could assist in disseminating its findings to a broader community of HCOs through peer-reviewed journals, and in training new evidence-based managers and health services researchers (Kovner et al., 2000). The prototype EBMC is the Center for Health Management Research (CHMR), led by the University of Washington and codirected by the University of California at Berkeley. CHMR was founded in 1992 by a consortium of HCOs and academic centers to provide a forum for managers, clinicians, and researchers to: Develop a health care management research agenda in collaboration with corporate members. Undertake research, development, and evaluation projects in pursuit of that agenda. Disseminate research findings and successful management practices of other HCOs and other industries to its members.

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Keeping Patients Safe: Transforming the Work Environment of Nurses Now involving 17 academic centers with graduate programs in health services administration (personal communication, T. Rundall, University of California, Berkeley, May 2003), CHMR is sponsored by the National Science Foundation (NSF) under its Industry/University Collaborative Research Centers program. It is the only one of the 50 NSF Collaborative Research Centers to receive this designation for the field of health services administration (Center for Health Management Research, 2003). CHMR is also supported by its 10 member health systems, which provide financial resources, collaborate on setting research priorities, and allow researchers to collect data at their various facilities. These members are thereby able to develop and implement a research agenda focused on their defined interests and needs. By serving as the primary sites for CHMR research, member institutions also are able to develop, test, and evaluate management practices, as well as other innovations and new technologies. CHMR practices are disseminated to entities not part of the collaboration through published reports and journal papers. Studies are designed with the transferability of research findings in mind. Other activities include commissioning papers to review and synthesize research findings on selected topics, conducting roundtable discussions on management topics, and holding dissemination conferences where members receive oral and written presentations from researchers (Walshe and Rundall, 2001). CHMR has undertaken a wide range of research projects to enable evidence-based managerial decision making in its member health systems. By design, its corporate members are integrated delivery systems, and the overarching theme of its research projects has been the strategies, structures, processes, and performance of such systems. One recent research project addressed mechanisms for building more effective relationships between the HCO members and physicians (Walshe and Rundall, 2001). Similar initiatives could address the work environments of nurses and patient safety. The committee concludes that broader use of such collaboratives could hasten the uptake of the evidence-based management practices described in this chapter, and therefore makes the following recommendation: Recommendation 4-4. Professional associations, philanthropic organizations, and other organizational leaders within the health care industry should sponsor collaboratives that incorporate multiple academic and other research-based organizations to support HCOs in the identification and adoption of evidence-based management practices.

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Keeping Patients Safe: Transforming the Work Environment of Nurses REFERENCES Aiken L. 2002. Superior outcomes for magnet hospitals: The evidence base. In: McClure M, Hinshaw A, eds. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing. Pp. 61–81. Aiken L, Smith H, Lake E. 1994. Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care 32(8):771–787. Aiken L, Sochalski J, Lake E. 1997. Studying outcomes of organizational change in health services. Medical Care 35(11 Supplement):NS6–18. Aiken L, Sloane D, Lake E, Sochalski J, Weber A. 1999. Organization and outcomes of inpatient AIDS care. Medical Care 37(8):760–772. Aiken L, Clarke S, Sloane D. 2000. Hospital restructuring: Does it adversely affect care and outcomes? Journal of Nursing Administration 30(10):457–465. Aiken L, Clarke S, Sloane D, Sochalski J, Busse R, Clarke H, Giovannetti P, Hunt J, Rafferty A, Shamian J. 2001. Nurses’ reports on hospital care in five countries. Health Affairs 20(3):43–53. Appleby C. 2002. Industrial strength. Trustee 55(1):10–14. Axelsson R. 1998. Towards an evidence based health care management. International Journal of Health Planning and Management 13:307–317. Baer M, Frese M. 2003. Innovation is not enough: Climates for initiative and psychological safety, process innovations, and firm performance. Journal of Organizational Behavior 24:45–68. Baldridge National Quality Program. 2003. Criteria for Performance Excellence. [Online]. Available: http://www.quality.nist.gov/PDF_files/2003_Business_Criteria.pdf [accessed April 24, 2003]. Barry-Walker J. 2000. The impact of system redesign on staff, patient, and financial outcomes. Journal of Nursing Administration 30(2):77–89. Bazzoli G, LoSasso A, Arnould R, Shalowitz M. 2002. Hospital reorganization and restructuring achieved through merger. Health Care Management Review 27(1):7–20. Beaulieu R, Shamian J, Donner G, Pringle D. 1997. Empowerment and commitment of nurses in long-term care. Nursing Economics 15(1):32–41. Bigley G, Roberts K. 2001. Structuring temporary systems for high reliability. Academy of Management Journal 44:1281–1300. Blackler F. 1995. Knowledge, knowledge work and organizations: An overview and interpretation. Organization Studies 16(6):1021–1046. Bryman A, Brensen M, Beadswoth A, Ford J, Keil E. 1987. The concept of the temporary system: The case of the construction project. Research in the Sociology of Organizations 5:253–283. Bunderson J. 2001. How work ideologies shape the psychological contracts of professional employees: Doctors responses to perceived breach. Journal of Organizational Behavior 22:717–741. Burns J. 1978. Leadership. New York, NY: Harper and Row. Carnino A, Director, Division of Nuclear Installation Safety, International Atomic Energy Agency. Undated. Management of Safety, Safety Culture and Self Assessment: International Atomic Energy Agency. [Online]. Available: http://www.iaea.org/ns/nusafe/publish/papers/mng_safe.htm [accessed January 15, 2003]. Center for Health Management Research. 2003. About CHMR: Who We Are. [Online]. Available: http://dept.washington.edu/chmr/about [accessed May 6, 2003]. Ciborra, C. 1996. The platform organization: Recombining strategies, structures, and surprises. Organizational Science 7:103–118.

OCR for page 108
Keeping Patients Safe: Transforming the Work Environment of Nurses Clifford J. 1998. Restructuring: The Impact of Hospital Organization on Nursing Leadership. Chicago, IL: AHA Press-American Hospital Publishing, Inc. and the American Organization of Nurse Executives. Coff R, Rousseau D. 2000. Sustainable competitive advantage from relational wealth. In: Leana CR, Rousseau DM, eds. Relational Wealth: The Advantages of Stability in a Changing Economy. New York, NY: Oxford University Press. Pp. 27–48. Conger J, Kanungo R. 1988. The empowerment process: Integrating theory and practice. Academy of Management Review 13(3):471–482. Cooper M. 2000. Towards a model of safety culture. Safety Science 36:111–136. Davenport T, DeLong D, Beers M. 1998. Successful knowledge management projects. Sloan Management Review Winter:43–57. Decker D, Wheeler G, Johnson J, Parsons R. 2001. Effect of organizational change on the individual employee. The Health Care Manager 19(4):1–12. DeLong D, Fahey L. 2000. Diagnosing cultural barriers to knowledge management. Academy of Management Executive 14(4):113–127. Donaldson N, Rutledge D. 1998. Expediting the harvest and transfer of knowledge for practice in nursing: Catalyst for a journal. The Online Journal of Cinical Innovations 1(2):1–25. Edmondson A. 1999. Psychological safety and learning behavior in work teams. Administrative Sciences Quarterly 44:350–383. Feinstein K, Chair, Pittsburgh Regional Healthcare Initiative and President, Jewish Healthcare Foundation of Pittsburgh. 2002. Invited testimony on March 7, 2002 on the subject of medical errors before the House of Representatives Committee on Ways and Means Subcommittee on Health. Feinstein K, Grunden N, Harrison E. 2002. A region addresses patient safety. AJIC: American Journal of Infection Control 30(4):248–251. Fox R, Fox D, Wells P. 1999. Performance of first-line management functions on productivity of hospital unit personnel. Journal of Nursing Administration 29(9):12–18. Freeman R, Rogers J. 1999. What Workers Want. Ithaca, NY: ILR Press. Frese N, Teng E, Wijnene C. 1999. Helping to improve suggestion systems: Predictors of giving suggestions in companies. Journal of Organizational Behavior 20:1139–1155. Garvin D. 1993. Building a learning organization. Harvard Business Review July–August:78–91. Gelinas L, Manthey M. 1995. Improving patient outcomes through system change: A focus on the changing roles of healthcare organization executives. Journal of Nursing Administration 25(5):55–63. Gelinas L, Manthey M. 1997. The impact of organizational redesign on nurse executive leadership. Journal of Nursing Administration 27(10):35–42. Gifford B, Zammuto R, Goodman E. 2002. The relationship between hospital unit culture and nurses’ quality of work life. Journal of Healthcare Management 47(1):13–25. Goodman P. 2001. Missing Organizational Linkages: Tools for Cross-Level Organizational Research. Thousand Oaks, CA: Sage Publications. Goodman P, Garber S. 1988. The effects of absenteeism on accidents in a dangerous environment. Journal of Applied Psychology 73:81–86. Goodman P, Leyden D. 1991. Familiarity and group performance. Journal of Applied Psychology 76:578–586. Goodman P, Darr E. 1996. Exchanging best practices through computer-aided systems. Academy of Management Executive 10:7–19. Graen G, Novak MA, Sommerkamp P. 1982. The effect of leader-member exchange and job design on productivity and satisfaction: Testing a dual attachment model. Organizational Behavior and Human Performance 30:109–131.

OCR for page 108
Keeping Patients Safe: Transforming the Work Environment of Nurses Hansen M, Nohria N, Tierney T. 1999. What’s your strategy for managing knowledge? Harvard Business Review March–April:106–117. Havens D. 2001. Comparing nursing infrastructure and outcomes: AANC magnet and nonmagnet CNEs report. Nursing Economics 19(6):258–266. Heifetz R, Laurie D. 2001. The work of leadership. Harvard Business Review 79(11):131–140. Heller F. 2003. Participation and power: A critical assessment. Applied Psychology: An International Review 52:144–163. Hewison A. 1997. Evidence-based medicine: What about evidence-based management? Journal of Nursing Management 5:195–198. Hinshaw A. 2002. Building magnetism into health organizations. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing. Ho S, Chan L, Kidwell R. 1999. The implementation of business process reengineering in American and Canadian hospitals. Health Care Management Review 24:19–31. Huselid M. 1995. The impact of human resource practices on turnover, productivity, and corporate financial performance. Academy of Management Journal 38:635–672. Ilinitch A, D’Aveni R, Lewin A. 1996. New organizational forms and strategies for managing in hyper competitive environments. Organization Science 7:211–220. Ingersoll G, Fisher M, Ross B, Soja M, Kidd N. 2001. Employee response to major organizational redesign. Applied Nursing Research 14(1):18–28. Institute for Healthcare Improvement. Undated. Collaboratives. [Online]. Available: http://www.ihi.org/collaboratives/ [accessed May 7, 2003]. IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. Kimberly J, Quinn R. 1984. Managing Organizational Transitions. Homewood, IL: Dow Jones-Irwin. Knox S, Irving J. 1997. Nurse manager perceptions of healthcare executive behaviors during organizational change. Journal of Nursing Administration 27(11):33–39. Kovner A, Elton J, Billings J. 2000. Evidence-Based Management. Frontiers of Health Services Management 16(4):3–24. Kramer M. 1990a. The magnet hospitals: Excellence revisited. Journal of Nursing Administration 20(9):35–44. Kramer M. 1990b. Trends to watch at the magnet hospital. Nursing 2(4):67–74. Kramer M, Schmalenberg C. 1988a. Magnet hospitals—Part I: Institutions of excellence. Journal of Nursing Administration 18(1):13–24. Kramer M, Schmalenberg C. 1988b. Magnet hospitals—Part II: Institutions of excellence. Journal of Nursing Administration 18(2):1–11. Kramer M, Hafner L. 1989. Shared values: Impact on staff nurse job satisfaction and perceived productivity. Nursing Research 38(3):172–177. Kramer M, Schmalenberg C. 1991. Job satisfaction and retention: Insights for the 90s, Part I. Nursing 3(3):50–55. Kramer M, Schmalenberg C. 1993. Learning from success: Autonomy and empowerment. Nursing Management 24(5):58–64. Kramer M, Schmalenberg C. 2002. Staff nurses identify essentials of magnetism. In: McClure M, Hinshaw A, eds. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing. Pp. 25–59. Kramer M, Schmalenberg C. 2003. Magnet hospital staff nurses describe clinical autonomy. Nursing Outlook 51(1):13–19. Kramer M, Schmalenberg C, Hafner L. 1989. What causes job satisfaction and perceived productivity of quality nursing care? Managing the Nursing Shortage: A Guide to Recruitment and Retention. Rockville, MD: Aspen. Pp. 12–32.

OCR for page 108
Keeping Patients Safe: Transforming the Work Environment of Nurses Laschinger H, Havens D. 1996. Staff nurse work empowerment and perceived control over nursing practice: Conditions for work effectiveness. Journal of Nursing Administration 26(9):27–35. Laschinger H, Finegan J, Shamian J, Casier S. 2000. Organizational trust and empowerment in restructured healthcare settings: Effects on staff nurse commitment. Journal of Nursing Administration 30(9):413–425. Laschinger H, Finegan J, Shamian J. 2001a. The impact of workplace empowerment, organizational trust on staff nurses’ work satisfaction and organizational commitment. Health Care Management Review 26(3):7–23. Laschinger H, Shamian J, Thomson D. 2001b. Impact of magnet hospital characteristics on nurses’ perceptions of trust, burnout, quality of care, and work satisfaction. Nursing Economics 19(5):209–219. Leana C, Rousseau D. 2000. Relational Wealth: The Advantages of Stability in a Changing Economy. New York, NY: Oxford University Press. Lowin A, Craig J. 1968. The influence of level of performance on managerial style: An experimental object lesson in the ambiguity of correlational data. Organizational Behavior and Human Performance 3:440–458. Maas M, Specht J. 2001. Shared governance models in nursing: What is shared, who governs, and who benefits. Current Issues in Nursing (6th Edition). St. Louis, MO: Mosby, Inc. MacDuffie J. 1995. Human resource bundles and manufacturing performance: Organizational logic and flexible production systems in the world auto industry. Industrial and Labor Relations Review 48:197–221. MacDuffie J, Pil F. 1996. “High Involvement” Work Practices and Human Resource Policies: An International Overview. Kochan T, Lansbury R, Macduffie J, eds. New York, NY: Oxford University Press. Mayer R, Davis J, Schoorman F. 1995. An integrative model of organizational trust. The Academy of Management Review 20(3):709–734. McClure M, Poulin M, Sovie M. 1983. Magnet Hospitals: Attraction and Retention of Professional Nurses. Kansas City, MO: American Academy of Nurses. McClure M, Poulin M, Sovie M, Wandelt M. 2002. Magnet hospitals: Attraction and retention of professional nurses (The Original Study). In: McClure M, Hinshaw A, eds. Magnet Hospitals Revisited. Washington, DC: American Nurses Publishing. Pp. 1–24. McNeese-Smith D. 1995. Job satisfaction, productivity, and organizational commitment: The result of leadership. Journal of Nursing Administration 25(9):17–26. McNeese-Smith D. 1997. The influence of manager behavior on nurses’ job satisfaction, productivity, and commitment. Journal of Nursing Administration 27(9):47–55. Miles R, Snow C. 1984. Designing strategic human resource systems. Organizational Dynamics Summer:36–52. Miles R, Creed W. 1995. Organizational forms and managerial philosophies: A descriptive and analytical review. In: Cummings L, Staw B, eds. Research in Organizational Behavior. Vol. 17. Greenwich, CT: JAI Press. Pp. 333–372. Mintzberg H. 1997. Toward healthier hospitals. Health Care Management Review 22(34):9–18. Mohr J, Abelson H, Barach P. 2002. Creating effective leadership for improving patient safety. Quality Management in Health Care 11(1):69–78. Moorman C, Miner A. 1998. Organizational improvisation and organizational memory. Academy of Management Review 23:698–723. Norrish B, Rundall T. 2001. Hospital restructuring and the work of registered nurses. Milbank Quarterly 79(1):55–79. O’May F, Buchan J. 1999. Shared governance: A literature review. International Journal of Nursing Studies 36:281–300.

OCR for page 108
Keeping Patients Safe: Transforming the Work Environment of Nurses Parker S. 1998. Enhancing role breadth self-efficacy: The role of job enrichment and other organizational interventions. Journal of Applied Psychology 83:835–852. Pearce J. 2000. Trustworthiness. Relational Wealth: Advantages of Stability in a Changing Economy. New York, NY: Oxford University Press. Petersen D. 1996. Human Error Reduction and Safety Management. New York, NY: Van Nostrand Reinhold. Quinn J. 1992. Intelligent Enterprise: A Knowledge and Service Based Paradigm for Industry. New York, NY: The Free Press, a division of Macmillan, Inc. Reason J. 1990. Human Error. Cambridge, UK: Cambridge University Press. Roberts K. 1990. Managing high reliability organizations. California Management Review 32:101–113. Roberts K, Bea R. 2001a. Must accidents happen? Lessons from high-reliability organizations. Academy of Management Executive 15(3):70–78. Roberts K, Bea R. 2001b. When systems fail. Organizational Dynamics 29(3):179–191. Roberts K, Stout S, Halpern J. 1994. Decision dynamics in two high reliability military organizations. Management Science 40:614–24. Robinet J. 2002, January 4. Regional healthcare initiative moves forward in relative obscurity. Pittsburgh Business Times Journal. p. 6. Rousseau D. 1995. Psychological Contracts in Organizations: Understanding Written and Unwritten Agreements. Newbury Park, CA: Sage Publications. Rousseau D, Tijoriwala S. 1999. What’s a good reason to change? Motivated reasoning and social accounts in organizational change. Journal of Applied Psychology 84:514–528. Rousseau D, Sitkin S, Burt R, Camerer C. 1998. Not so different after all: A cross-disciplinary view of trust. Academy of Management Review 23:1–12. Sabiston J, Laschinger H. 1995. Staff nurse work empowerment and perceived autonomy: Testing Kanter’s theory of structural power in organizations. Journal of Nursing Administration 25(9):42–50. Sackett D, Rosenberg W, Muir-Gray J, Haynes R, Richardson W. 1996. Evidence-based medicine: What it is and what it isn’t. British Medical Journal 312(7023):71–72. Schiff G. 2000. Fatal distraction: Finance vs. vigilance in our nation’s hospitals. JGIM: Journal of General Internal Medicine 15(4):269. Scott JG, Sochalski J, Aiken L. 1999. Review of magnet hospital research: Findings and implications for professional nursing practice. Journal of Nursing Administration 29(1):9–19. SEIU Nurse Alliance. 2001. The Shortage of Care. Washington, DC: Service Employees International Union, AFL-CIO, CLC. Sovie M, Jawad A. 2001. Hospital restructuring and its impact on outcomes. The Journal of Nursing Administration 31(12):588–600. Spath P. 2000. Does your facility have a “patient-safe” climate? Hospital Peer Review 25:80–82. Spear S, Bowen H. 1999. Decoding the DNA of the Toyota Production System. Harvard Business Review 77(5):97–106. Stewart T. 1999. Telling tales at BP Amoco. Fortune 139(11):220. Stone R, Reinhard S, Bowers B, Zimmerman D, Phillips C, Hawes C, Fielding J, Jacobson N. 2002. Evaluation of the Wellspring Model for Improving Nursing Home Quality. The Commonwealth Fund. Strebel P. 1996. Why do employees resist change? Harvard Business Review May–June:86–92. The Campbell Collaboration. Undated. About the Campbell Collaboration. [Online]. Available: http://www.campbellcollaboration.org/About.html [accessed April 18, 2002]. The Health Technology Center (HealthTech). 2003. Learn About HealthTech. [Online]. Available: www.healthtech.org/Common_site/learn_about_healthtech.asp [accessed May 7, 2003].

OCR for page 108
Keeping Patients Safe: Transforming the Work Environment of Nurses The Jewish Healthcare Foundation of Pittsburgh. 2002. The Pittsburgh Perfecting Patient Care System: A New Design for Delivering Health. Branches, January:1-16. Branches is a publication of the Jewish Healthcare Foundation; Pittsburgh, PA. [Online]. Available: http://jhf.org/reports/branches/pdfs/bran_jan.pdf. Thomas E, Orav J, Brennan T. 2000. Hospital ownership and preventable adverse events. Journal of General Internal Medicine 15:211–219. Thompson J, Bunderson J. In press. Violations of principle: Ideology currency in the psychological contract. Academy of Management Review. Tucker A, Edmondson A. 2002. Managing routine exceptions: A model of nurse problem solving behavior. Advances in Health Care Management 3:87–113. Tucker A, Edmondson A. 2003. Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system change. California Management Review 45(2):1–18. Tucker A, Edmondson A, Spear S. 2002. When problem solving prevents organizational learning. Journal of Organizational Change Management 15(2):122–137. VHA. 2003. What Is VHA? [Online]. Available: https://www.vha.com/aboutvha/public/about_whatisvha.asp [accessed May 7, 2003]. Walshe K, Rundall T. 2001. Evidence-based management: From theory to practice in health care. The Milbank Quarterly 79(3):429–458. Walston S, Kimberly J. 1997. Reengineering hospitals: Evidence from the field. Hospital and Health Services Administration 42(2):143–163. Walston S, Burns J, Kimberley J. 2000. Does reengineering really work? An examination of the context and outcomes of hospital reengineering initiatives. Health Services Research 34(6):1363–1388. Ward G, Burns R, Burns K. 1990. The Civil War. Warner Home Video, an AOL Time Warner Company. 1990 DVD Video. A production of Florentine Films and WETA-TV. Weick K, Roberts K. 1993. Collective mind and organizational reliability: The case of flight operations on an aircraft carrier deck. Administrative Science Quarterly 38:357–381. Zucker L. 1986. Production of trust: Institutional sources of economic structure, 1840–1920. In: Staw B, Cummings L, eds. Research in Organizational Behavior. Greenwich, CT: JAI Press. Pp. 53–111.