Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change

by Anita Tucker, Amy Edmondson


  PDF
 

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 U.S. 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 implications of each for process improvement. A dynamic model of the system in which front-line workers operate reveals an illusory equilibrium in which small process failures actually erode organizational effectiveness rather than driving 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.

California Management Review

Berkeley-Haas's Premier Management Journal

Published at Berkeley Haas for more than sixty years, California Management Review seeks to share knowledge that challenges convention and shows a better way of doing business.

Learn more
Follow Us