Medical errors and quality of care: From control to commitment

California Management Review

Volumn 48, Issue 3, 2006, Pages

  Khatri, Naresh ^a   Baveja, Alok ^b   Boren, Suzanne A ^a   Mammo, Abate ^c  

^a University of Missouri   (United States)

^b RUTGERS UNIVERSITY   (United States)

^c Senior Services   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 33744770620     PISSN: 00081256     EISSN: None     Source Type: Journal    
DOI: 10.2307/41166353     Document Type: Article

References (161)

1. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., Committee on Quality of Health Care in America, Institute of Medicine, To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 1999).
2. J. Rovner, "Washington Wakes up to Medical Mistakes," Business and Health, 18/1 (2000): 19.
3. G.C. Benjamin, "Addressing Medical Errors: The Key to a Safer Health Care System," Physician Executive, 26/2 (2000): 66-67.
4. L.L. Leape, "Making Health Care Safe: Are We Up to It?" Journal of Pediatric Surgery, 39/3 (2004): 258-266.
5. Health Grades, Inc., "Patient Safety in American Hospitals," Health Grades Quality Study, 2004)
6. MedPAC, "Quality of Care for Medicare Beneficiaries," Report to the Congress, Medicare Payment Policy, March 2004.
7. The noted patient safety scholar, Professor L.L. Leape, M.D., once commented: "We lose more lives each year from medical errors than NIH's scientific and technological advances save. We should spend as much trying to do something about it." He thinks that changing the culture of medicine is just as important as funding new research. See L.L. Leape, "Learning from Mistakes: Toward Error-Free Medicine," Research in Profile, 11/1 (August 2004), Investigator Awards in Health Policy Research, The Robert Wood Johnson Foundation.
8. B. Zhao and F. Olivera, "Understanding Individuals' Error Reporting in Organizations," Academy of Management Annual Meeting, New Orleans, LA, 2004.
9. Health Grades, Academy of Management Annual Meeting, op. cit.;
10. Leape (2004), Academy of Management Annual Meeting, op. cit.
11. Several scholars have looked at organizational and management issues affecting medical errors. Clearly, more work is needed. Some notable studies examining management issues and their impact on medical errors include P.S. Adler, P. Riley, S.K. Kwon, J. Signer, B. Lee, and R. Satrasala, "Performance Improvement Capability: Keys to Accelerating Performance Improvement in Hospitals," California Management Review, 45/2 (Winter 2003): 12-33;
12. A.C. Edmondson, "Learning from Mistakes Is Easier Said than Done: Group and Organizational Influences on the Detection and Correction of Human Errors," Journal of Applied Behavioral Science, 32 (1996): 5-28;
13. D.M. Gaba, "Structural and Organizational Issues in Patient Safety: A Comparison of Health Care to Other High-Hazard Industries," California Management Review, 43/1 (Fall 2000): 83-102;
14. J.B. Sexton, E.J. Thomas, and R.L. Helmreich, "Errors, Stress, and Teamwork in Medicine and Aviation: Cross-Sectional Surveys," British Medical Journal, 320/7237 (2000): 745-749;
15. A.L. Tucker and A.C. Edmondson, "Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change," California Management Review, 45/2 (Winter 2003): 55-71;
16. K. Walshe and S.M. Shortell, "When Things Go Wrong: How Health Care Organizations Deal with Major Failures," Health Affairs, 23/3 (2004): 103-111;
17. K.E. Weick and K.M. Sutcliffe, "Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary," California Management Review, 45/2 (Winter 2003): 73-84.
18. L.L. Leape, D.M. Berwick, and D.W. Bates, "What Practices Will Most Improve Safety? Evidence-Based Medicine Meets Patient Safety," JAMA, 288/4 (2002): 501-507.
19. B.D. Gifford, R.F. Zammuto, and E.A. Goodman, "The Relationship between Hospital Unit Culture and Nurses' Quality of Work Life," Journal of Health Care Management, 47/1 (2002): 13-25;
20. R.M. Goldberg, G. Kuhn, L.B. Andrew, and H.A. Thomas, "Coping with Medical Mistakes and Errors in Judgment," Annals of Emergency Medicine, 39/3 (2002): 287-292.
21. Walshe and Shortell, Annals of Emergency Medicine, op. cit.
22. T. Hoff, L. Jameson, E. Hannan, and E. Flink, "A Review of the Literature Examining Linkages between Organizational Factors, Medical Errors, and Patient Safety," Medical Care Research and Review, 61/1 (2004): 3-37. The quote appears on page 21.
23. A.F. Al-Assaf, L.J. Bumpus, D. Carter, and S.B. Dixon, "Preventing Errors in Health Care: A Call for Action," Hospital Topics: Research and Perspectives on Health Care, 81/3 (2003): 5-12.
24. M. Koehoorn, G.S. Lowe, K.V. Rondeau, G. Schellenberg, and T.H. Wagar, "Creating High-Quality Health Care Workplaces," Work Network Discussion Paper, W/14 2002, Canadian Policy Research Networks, Inc., Ottawa, Canada.
25. See D. McGregor, The Human Side of Enterprise, 25th Anniversary Printing (New York, NY: McGraw-Hill, 1985).
26. Also, see Truss's arguments on "soft" and "hard" models of management. C. Truss, "Soft and Hard Models of Human Resource Management," in L. Gratton, V. Hope Hailey, P. Stiles, and C. Truss, eds., Strategic Human Resource Management: Corporate Rhetoric and Human Reality (New York, NY: Oxford University Press, 1999), pp. 79-100.
27. She uses the terms "soft" and "hard' to denote commitment-based and control-based management, respectively. She suggests that "control" in the soft model is accomplished through commitment and that trust and self-regulated behavior lie at the core of the soft model. In the hard model, on the other hand, individuals are managed on an instrumental basis, with their activities monitored closely. R.E. Walton, "From Control to Commitment in the Workplace," Harvard Business Review, 63/2 (March/April 1985): 77-84.
28. McGregor, Harvard Business Review, op. cit.
29. A. Baveja and G. Porter, "Creating an Environment for Personal Growth: The Challenge of Leading Teams," Advances in Interdisciplinary Studies of Work Teams, 3 (1996): 127-143;
30. L. Gratton, "People Processes as a Source of Competitive Advantage," in L. Gratton, V. Hope Hailey, P. Stiles, and C. Truss, eds., Strategic Human Resource Management: Corporate Rhetoric and Human Reality (Oxford University Press: New York, 1999), pp. 170-198;
31. P. Miller and N. Rose, Governing Economic Life (London: Routledge, 1993);
32. H. Mintzberg, The Rise and Fall of Strategic Planning (New York, NY: The Free Press, 1993).
33. Miller and Rose, The Rise and Fall of Strategic Planning, op. cit.
34. Baveja and Porter, The Rise and Fall of Strategic Planning, op. cit.
35. Gratton, The Rise and Fall of Strategic Planning, op. cit.
36. N. Khatri and P. Budhwar, "A Study of Strategic HR Issues in an Asian Context," Personnel Review, 31/2 (2002): 166-188;
37. J. Pfeffer, Competitive Advantage Through People (Boston, MA: Harvard Business School Press, 1994);
38. Walton, Competitive Advantage Through People, op. cit.
39. M.S. De Lorenzo, "Absenteeism: Work-induced Stress Illnesses, and Hidden Mental Illnesses," Ph.D. Thesis, Faculty of Business and Economics, Monash University, Melbourne, Australia, 2003;
40. McGregor, Absenteeism: Work-induced Stress Illnesses, and Hidden Mental Illnesses, op. cit.
41. N. Khatri, The Human Dimension of Organizations (London: Spiro Press, 2003).
42. De Lorenzo, The Human Dimension of Organizations, op. cit.
43. De Lorenzo, The Human Dimension of Organizations, 2003, Ibid.
44. De Lorenzo, The Human Dimension of Organizations, 2003, Ibid.
45. De Lorenzo, The Human Dimension of Organizations, 2003, Ibid.
46. Health Grades, The Human Dimension of Organizations, op. cit.;
47. F. Williams, "ILO Warns of Epidemic of Stress," Financial Times October 10, 2000.
48. F. Herzberg, The Managerial Choice: To be Efficient and to be Human (Homewood, IL: Dow Jones-Irwin, 1976).
49. Gallup Management Journal, "What Your Disaffected Workers Cost," 〈www.gallupjournal.com/GMJarchive/issue1/2001315g.asp〉. Dated March 15, 2001. According to the Gallup estimate, actively disengaged workers cost the U.S. economy about $300 billion, the British Economy about $65 billion, and the Singaporean economy about $4.9 billion a year.
50. Gallup Management Journal, "Great Britain's Workforce Lacks Inspiration," 〈http://gmj.gallup.com〉. Dated December 11, 2003.
51. Walton, Gallup Management Journal, op. cit.
52. M.D. Cannon and A.C. Edmondson, "Confronting Failure: Antecedents and Consequences of Shared Beliefs about Failure in Organizational Work Groups," Journal of Organizational Behavior, 22 (2001): 161-177;
53. T.J. Hoff, H. Pohl, and J. Bartfield, "Creating a Learning Environment to Produce Competent Residents: The Role of Culture and Context," Acad Med. 79 (2004): 532-539;
54. B. Zhao and F. Olivera, "Understanding Individuals' Error Reporting in Organizations," Academy of Management Annual Meeting, New Orleans, LA, 2004.
55. Adler et al., Academy of Management Annual Meeting, op. cit.
56. McGregor, Academy of Management Annual Meeting, op. cit.;
57. T.J. Peters and R.H. Waterman, In Search of Excellence: Lessons from America's Best-run Companies (New York, NY: Harper and Row, 1982);
58. Walton, In Search of Excellence: Lessons from America's Best-run Companies, op. cit.
59. N. Khatri, L.L., Hicks, and G.D. Brown, "HR and IT Capabilities and Complementarities in Health Care Organizations," Health Care Division, Academy of Management Conference, Hawaii 2005. The authors argue that health care organizations are service-oriented and knowledge-based and that managing people using a commitment-based approach is fundamental to effective management of such organizations. The service logic of health care organizations (more complex processes and employees coming in direct contact with customers) dictates that HR practices play a central rather than supportive role in managing them.
60. We have begun seeing health care organizations that are breaking the typical mold and embracing the latest management innovations and practices. This trend is likely to get stronger in the years to come. See also M.D. Merry, "21st Century Health Care," Trustee Leadership Forum, MHA Annual Convention and Trade Show, Billings, Montana, 2003.
61. Although the proper implementation of the control-based model does not maximize the utilization of human capacity in organizations, it does produce reliable level of performance through formal, systematic, and standardized work processes. There are a number of health care organizations that use control-based model but have not implemented it well. These organizations may be able to improve their clinical outcomes by improving their controlbased design. We would, however, suggest that health care organizations, rather than strengthening the control-based practices, should move in the direction of commitment-based management, because changing from a control-based model to a commitment-based model later would be a difficult, long process.
62. D.E. Detmer, "A New Health System and Its Quality Agenda," Frontiers of Health Services Management, 18/1 (2001): 3-52.
63. Weick and Sutcliffe, Frontiers of Health Services Management, op. cit.
64. A. Hornblow, "New Zealand's Health Reforms: A Clash of Cultures," British Medical Journal, 314/7098 (1997): 1892;
65. M. Laurence, L. Wright, P. Barnett, and C. Hendry, "Building a Successful Partnership between Management and Clinical Leadership: Experience from New Zealand," British Medical Journal, 326/7390 (2003): 653-654;
66. Tucker and Edmondson, British Medical Journal, op. cit.
67. Hornblow, British Medical Journal, op. cit.;
68. Merry, British Medical Journal, op. cit.;
69. Tucker and Edmondson, British Medical Journal, op. cit.
70. Adler et al., British Medical Journal, op. cit.
71. S. Bach, "HR and New Approaches to Public Sector Management: Improving HRM Capacity," Department of Organization of Health Services Delivery, World Health Organization, Geneva, Switzerland, 2001;
72. J. Buchan, "What Difference Does ("Good") HRM Make?" Human Resources for Health, 2/6 (June 2004): 1-7.
73. Adler et al., Human Resources for Health, op. cit.;
74. N. Khatri and J. Kauk, "The Relationship between Management Approach and Medical Errors: A Qualitative Study," Academy of Health Services Research, Annual Research Meeting, San Diego, CA, 2004.
75. Tucker and Edmondson, Academy of Health Services Research, Annual Research Meeting, op. cit.
76. M. Meterko, D.C. Mohr, and G.J. Young, "Teamwork Culture and Patient Satisfaction in Hospitals," Medical Care, 42/5 (2004): 492-498.
77. A. Kaissi, J. Kralewski, A. Curoe, B. Dowd, and J. Silversmith, "How Does the Culture of Medical Group Practices Influence the Types of Programs Used to Assure Quality of Care?" Health Care Management Review, 29/2 (2004): 129-138.
78. Gaba, Health Care Management Review, op. cit.
79. Merry, Health Care Management Review, op. cit.
80. J. Reason, "Human Error: Models and Management," British Medical Journal, 320 (2000): 768-770.
81. Edmondson, British Medical Journal, op. cit.;
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83. H.H. Cook, K. Guttmannova, and J.C. Joyner, "An Error by Any Other Name," American Journal of Nursing 104/6 (2004): 32-43;
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88. Valentine and Behara, Annals of Internal Medicine, op. cit.
89. Crow and Hartman, Annals of Internal Medicine, op. cit.
90. Cook et al., Annals of Internal Medicine, op. cit.
91. Pronovost et al., Annals of Internal Medicine, op. cit.
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93. Sexton et al., Critical Care Medicine, op. cit.
94. Merry, Critical Care Medicine, op. cit.
95. Weick and Sutcliffe, Critical Care Medicine, op. cit.
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97. Adler et al., Employment Relations Today, op. cit.
98. Stone, Employment Relations Today, op. cit.
99. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, D.C.: The National Academies Press, 2001).
100. Adler et al., Crossing the Quality Chasm: A New Health System for the 21st Century, op. cit.;
101. Leape et al. (2002), Crossing the Quality Chasm: A New Health System for the 21st Century, op. cit.
102. Adler et al., Crossing the Quality Chasm: A New Health System for the 21st Century, op. cit.
103. Al-Assaf et al., Crossing the Quality Chasm: A New Health System for the 21st Century, op. cit.
104. Gifford et al., Crossing the Quality Chasm: A New Health System for the 21st Century, op. cit.;
105. McGregor, Crossing the Quality Chasm: A New Health System for the 21st Century, op. cit.;
106. H. Mintzberg, The Rise and Fall of Strategic Planning (New York, NY: The Free Press, 1994).
107. st Century Challenge (Princeton, NJ: The Robert Wood Johnson Foundation, 1996).
108. st Century Challenge, op. cit.
109. st Century Challenge, op. cit.
110. st Century Challenge, op. cit., p. 66.
111. Jobs with high demands and low controllability are typical of control-based organizations. The expectations from employees tend to be greater than resources provided to them by the organization to perform the required tasks.
112. M.L. Fox, D.J. Dwyer, and D.C. Ganster, "Effects of Stressful Job Demands and Control on Physiological and Attitudinal Outcomes in a Hospital Setting," Academy of Management Journal, 36/2 (1993): 289-318.
113. Koehoorn et al., Academy of Management Journal, op. cit.
114. A.C. Edmondson, "Learning from Failure in Health Care: Frequent Opportunities, Pervasive Barriers," Qual Saf Health Care, 13 (2004): ii3-ii9.
115. See J.H. Gittell, The Southwest Airlines Way: Using the Power of Relationships to Achieve High Performance (McGraw-Hill, 2002);
116. J.H. Gittell, "Paradox of Coordination and Control," California Management Review, 42/3 (Spring 2000): 117-134.
117. Health care industry professionals seem to think that their industry is too complex (more complex than other industries) and as a result more difficult to manage than other industries. We believe that there are several other industries that are far more difficult and challenging to manage than health care (e.g., the airline industry, retail industry, and computer manufacturing, to cite a few). As compared to these industries, health care may be a relatively benign, munificent environment.
118. C.A. O'Reilly III and J. Pfeffer, Hidden Value (Boston, MA: Harvard Business School Press, 2000).
119. C.A. O'Reilly III and J. Pfeffer, Hidden Value, 2000, Ibid.
120. M. Meterko, D.C. Mohr, and G.J. Young, "Teamwork Culture and Patient Satisfaction in Hospitals," Medical Care, 42/5 (2004): 492-498.
121. K.V. Rondeau and T.H. Wagar, "Impact of Human Resource Management Practices on Nursing Home Performance," Health Services Management Research, 14/3 (2001): 192-202.
122. Truss, Health Services Management Research, op. cit.
123. Adler et al., Health Services Management Research, op. cit.
124. Management scholars and consultants have studied teams and team-based performance fairly intensely for the past two decades. Consequently, there is a large body of literature on the subject and substantial consensus on the properties of effective teams. The book Creating Teams with an Edge: The Complete Skill Set to Build Powerful and Influential Teams (Harvard Business School Press, Boston, 2004) synthesize the literature on teams and describe the different types of teams used by organizations, the costs and benefits of team-based work, and what every team must have to be successful. The qualities of effective teams suggested in the book include competence (collective talent, knowledge, experience, and organizational clout of team members), a clear goal, committed and contributing members, an enabling structure, a supportive organizational environment, and alignment of team goals and rewards with organizational goals.
125. See the above note and also Detmer, Creating Teams with an Edge: The Complete Skill Set to Build Powerful and Influential Teams, op. cit.
126. Cook et al., Creating Teams with an Edge: The Complete Skill Set to Build Powerful and Influential Teams, op. cit.;
127. Pronovost et al., Creating Teams with an Edge: The Complete Skill Set to Build Powerful and Influential Teams, op. cit.
128. Empowerment, another term used for employee participation, is an intrinsic task motivation manifested in a set of cognitions reflecting an individual's orientations to his or her work role in which an individual wishes or feels able to shape his or work role and context. The control-based approach and empowerment are inconsistent with each other. According to McGregor, Creating Teams with an Edge: The Complete Skill Set to Build Powerful and Influential Teams, [op. cit.], participation works only when it grows out of a commitment-based approach in which managers have a genuine confidence in the potentialities of subordinates. The involvement of employees in decisions can vary from a little to a lot, dictated entirely by the situation and the subordinate at hand. A vast amount of literature on employee participation or high-involvement practices has emerged in the last 20 to 25 years.
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131. Gratton, Health Care Management Review, op. cit.
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133. Detmer, Development of Objective Indicators of Employee Morale, op. cit.;
134. Edmondson (2004), Development of Objective Indicators of Employee Morale, op. cit.;
135. Merry, Development of Objective Indicators of Employee Morale, op. cit.
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140. J.R. Hackman and G.R. Oldham, Work Redesign (Reading, MA: Addison-Wesley, 1980).
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147. Pfeffer, Sales and Marketing Management, op. cit.
148. D.C. Grabowski and N.G. Castle, "Nursing Homes with Persistent High and Low Quality," Medical Care Research and Review, 61/1 (2003): 89-115.
149. Walshe and Shortell, Medical Care Research and Review, op. cit.
150. G. Pare, "Implementing Clinical Information Systems: A Multiple-Case Study within a U.S. Hospital," Health Services Management Research, 15 (2002): 71-92.
151. I.R. Lazarus, "Developing Internet Strategies is a Top Priority for Hospital Systems," Health Care Strategic Management, 12 (2001): 12-13.
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153. E. Ortiz and C.M. Clancy, "Use of Information Technology to Improve the Quality of Health Care in the United States," Health Services Research, 38/2 (2003): xi-xxi.
154. D.W. Bates, N. Spell, D.J. Cullen, E., Burdick, N. Laird, L.A. Peterson, S.D. Small, B.Z., Sweitzer, and L.L. Leape, "The Costs of Adverse Drug Events in Hospitalized Patients. Adverse Drug Events Prevention Study Group," JAMA, 277/4 (1997): 307-311;
155. Leape (2004), JAMA, op. cit.
156. Agency for Health Care Research and Quality, "Reducing and Preventing Adverse Drug Events to Decrease Hospitals Costs," Research in Action, Issue 1, AHRQ Publication Number 01-0020, (March 2001).
157. Health Grades, Research in Action, op. cit.
158. Leape (2004), Research in Action, op. cit. page 264.
159. Pfeffer, Research in Action, op. cit.
160. W.B. Runciman, A.F. Merry, and F. Tito, "Error, Blame, and the Law in Health Care - An Antipodean Perspective," Annals of Internal Medicine, 138/12 (2003): 974-980.
161. Leape (2004), Annals of Internal Medicine, op. cit., p. 264.