Front-Line Staff Perspectives on Opportunities for Improving the Safety and Efficiency of Hospital Work Systems

Hospitals face a daunting challenge: providing safe, effective care in complex organizations strapped by heavy patient loads, limited staffing, and shrinking financial resources. Hospitals are improving their ability to provide safe, effective care, but experts agree that further gains must be achieved (Leape and Berwick 2005; Pronovost, Miller, and Wachter 2006). To achieve this goal, the patient safety literature advises managers to improve faulty work systems rather than blame individuals for poor outcomes (Institute of Medicine 2001; Bates 2002; Cleary 2003; Leape and Berwick 2005; Shannon et al. 2007). However, the literature offers less insight into what work systems are, which ones should be prioritized for improvement, and how to utilize employees’ expertise. In addition, rather than targeting faulty work systems that may affect all patients, many improvement efforts focus on specific clinical issues or patient populations, such as deploying bundles of evidence-based interventions for heart attack patients (Leape and Berwick 2005; Bradley et al. 2006). Finally, health care professionals may perceive a tradeoff between investing scarce resources in safety-related improvements as opposed to productivity-related changes. This belief can reduce progress toward both goals because of the assumptions that improving safety will reduce staff efficiency (e.g., through double-checks and redundant systems) and that improving efficiency will increase safety risks as staff are stretched thin (Pauker, Zane, and Salem 2005). The intervention that provided data for this study required senior managers to elicit safety-related concerns from front-line staff about hospital work systems. Hospital work systems are sets of interconnected routines through which specific patient care services are accomplished. Work systems include the employees, technologies, and organizational environment required to provide the services (Carayon et al. 2006). We refer to breakdowns in the materials, information, or equipment necessary for safe patient care as “operational failures” (Tucker and Edmondson 2003; Frankel et al. 2005). We enlisted senior manager participation because managers can facilitate both resource allocation and organizational change necessary for resolving problems that cross departmental boundaries (Frankel et al. 2005). We focused on user-identified operational failures because research has shown that front-line employees are an excellent source of work-system improvement ideas (Mukherjee, Lapre, and Wassenhove 1998; Field and Sinha 2005). In addition, high reliability organizations, organizations that operate under hazardous conditions with extremely low rates of failure, rely on front-line expertise to address system complexities (Roberts, Stout, and Halpern 1994). Thus, an essential element of work system improvement is empowering front-line staff to identify and prioritize issues that need to be addressed (Frankel et al. 2005). Similar to other studies that have considered the front-line perspective of patient safety (Pronovost et al. 2004; Frankel et al. 2005; Rathert, Fleig-Palmer, and Palmer 2006), our methodology yielded concerns that were grounded in the context of direct patient care. Our findings suggest that front-line workers experience routine breakdowns in work systems that impede safety and efficiency. Therefore, both safety and efficiency—which together create value for patients—can benefit from improving work system performance.