1. Top Management’s Focus of Attention and Organizational Learning from Errors Ranga Ramanujam (Purdue University) Donna Keyser (RAND) Carl Sirio (UPMC) Debra Thompson (Pittsburgh Regional Healthcare Initiative)

2. Research objective To explore whether and how the focus of attention of hospital top management influences organizational learning from errors

3. Study context Pittsburgh Regional Healthcare Initiative (PRHI)  Coalition of 39 hospitals implemented a common system for data-sharing on medication errors (MedMarx ® )  Initiated by top management in hospitals  Expectation that increased incident reporting will improve patient safety

4. Incident reporting-underlying premise

5. Reporting increased significantly > 20,000 medication errors reported by 30 hospitals during 2002-03 Compared to 400 other hospitals that also used MedMarx  Higher volume and rate of reporting  Higher proportion of errors not reaching the patient

6. But, no conclusive or even suggestive evidence of learning from these data Trend analysis confirmed increase in rate of reporting of errors but not of corrective actions ( latent growth curve analysis; Anderson, Ramanujam, et al 2007 ) Key informants from 8 hospitals accounting for over 60% of the reporting could not identify specific improvements directly linked to these data  Verifiable improvements linked to other independent initiatives e.g. implementation of Toyota Production System in an ICU

7. Role of top management What could the top management of hospitals that initiated the process do to facilitate learning? Inadequately studied question that calls for an exploratory and observation-based methodology  Year-long case studies of 4 hospitals (Yin, 1984)

8. Sample – 4 hospitals Pittsburgh Region Community Hospital System Hospital (member of a corporate system) Acute Care Hospital Outside Pittsburgh University Hospital

9. Case study methods 58 interviews with CEOs, direct reports, committee chairpersons, and a sample of care providers Analysis of archival records (e.g., mission statements, minutes, annual reports) 70 hours of participation in meetings where incident data were discussed 40 separate observations of medication administration process in 12 departments

10. Key Variables Community HospitalSystem HospitalAcute Care HospitalUniversity Hospital (non-PRHI) Age100 years> 100 years< 10 years> 100 years Number of beds265700155683 Teaching?NoYesNoYes Current CEO tenure > 25 years< 5 years >15 years Increase in Medication Error Reporting (2002- 04) 125%100%170%200% Meetings observed  P & T  Patient Safety  Medication Error Task Force  P & T  Patient Safety  P & T  Patient Safety  Incident Tracking  P & T  Patient Safety

11. Initial conclusions (T1): Absence of organizational design for learning from incidents

12. Evidence of organizational learning from other data Community hospital initiated programs in response to changes in patient transfer rates Acute care hospital reduced staffing in response to changes in length of stay

13. What was top management attending to? Community HospitalSystem HospitalAcute Care HospitalUniversity Hospital (non- PRHI) Key metrics monitored daily by CEOs Patient transfer rates, average length of stay Occupancy, case mixReimbursementsMultiple clinical/financial - reviewed monthly Typical frequency of review of medication error data by senior leaders (CEO & direct reports) QuarterlyMonthlyWeeklyMonthly Major CEO pre- occupation Malpractice insuranceFinancial restructuringProspective Payer System Strategic Planning

14. Two hospitals initiated changes during case study period Acute care hospital  Introduced a balanced score card with patient safety as a lead indicator  Developed new metrics (e.g., # error-free days of stay per patient)  CEO started reviewing incident reports daily; moved office to patient floor  Increased involvement of physicians (e.g., one-on-one meetings with CEO regarding illegible handwriting)  Staff underwent training in problem solving techniques

15. Community hospital - Changes Mission statement revised to include specific reference to improving patient safety CEO carried out process observations; weekly review of data Increased involvement of physicians

16. Revised conclusions

17. Conclusions Increased top management attention facilitates the creation of formal and informal structures for learning from errors proactively  Specific goals  Increased awareness  Streamlined reporting  Widespread information sharing  Enhanced problem solving capabilities  Implementation of prevention strategies In the absence of such attention, data used primarily for after-event review, management control, and regulatory compliance but not for deliberate learning

18. Implications Questions the premise that increased incident- reporting will automatically promote learning How can the reduction of operational errors be elevated to the level of a strategic priority?