Lucy MacPhail

Lucy MacPhail

Senior Director, Corporate Strategy, The Advisory Board Company

Dissertation Title:  "Work Process Failure and Organizational Learning in Health Care Delivery Settings"

This dissertation examines behavioral influences on the emergence and management of work process failure in health care delivery organizations. In three chapters, I explore relational and institutional factors in this complex setting that contribute to work process dysfunction and shape managerial action within organizational structures designed to foster learning from error.

Chapter 1 explores role-based sources of work process failure arising from interdependencies among health care professionals in an organizational context featuring an electronic medical record (EMR). Interviews with providers and patients revealed professional work routines containing relational vulnerabilities to coordination failure that persisted despite—and, indeed, were potentially exacerbated by—introduction of a technology enabling high informational continuity. These findings demonstrate limitations of information processing as the dominant paradigm through which to improve coordination in complex settings and urge managers and policy-makers to complement information technology with interventions that directly address behavior within institutionalized work roles.

Chapters 2 and 3 employ a mixed methodological approach to examine organizational responses to work process failure at a high-performing teaching hospital. In Chapter 2, I explore predictors of managerial attention to identified failure within the hospital’s adverse event review system. Internalization of external regulatory priorities during review activities shifted managerial attention toward adverse events yielding less new knowledge, such as those caused by involuntary slips during practiced skills, and away from events richer in learning value, such as those involving interdisciplinary process failure. These findings reveal unintended effects of harm-driven event reporting regulation on internal learning processes and suggest the need for separate learning and compliance mechanisms in health care and other high-risk settings.

Chapter 3 examines factors associated with corrective organizational action in response to work process failure. Corrective action following an adverse event was influenced by the dual institutional forces of regulation and professionalism, manifesting in tendencies to intervene on tangible risk factors that did not interfere with autonomous practice. Findings indicate that organizations may respond to failure with varying aggressiveness and success depending on the conditions of error, demonstrating the importance of goal-setting and resource appropriation that are aligned with the challenges confronting change in complex institutionalized environments.

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