Anita L. Tucker

16 Results

 

The Diseconomies of Queue Pooling: An Empirical Investigation of Emergency Department Length of Stay

Improving efficiency and customer experience are key objectives for managers of service organizations including hospitals. In this paper, the authors investigate queue management, a key operational decision, in the setting of a hospital emergency department. Specifically, they explore the impact on throughput time depending on whether an emergency department uses a pooled queuing system (in which a physician is assigned to a patient once the patient is placed in an emergency department bed) or a dedicated queuing system (in which physicians are assigned to specific patients at the point of triage). The authors measured throughput time based on individual patients' length of stay in the emergency department, starting with arrival to the emergency department and ending with a bed request for admission to the hospital or the discharge of a patient to home or to an outside facility. The findings show that, on average, the use of a dedicated queuing system decreased patients' lengths of stay by 10 percent. This represented a 32-minute reduction in length of stay—a meaningful time-savings for the emergency department and patients alike. The authors argue that physicians in the dedicated queuing system had both the incentive and ability to make sure their patients' care progressed efficiently, so that patients in the waiting room could be treated sooner than they otherwise would have. Read More

Increased Speed Equals Increased Wait: The Impact of a Reduction in Emergency Department Ultrasound Order Processing Time

This study of ultrasound test orders in hospital emergency departments (EDs) shows that, paradoxically, increasing capacity in a service setting may not alleviate congestion, and can actually increase it due to increased resource use. Specifically, the study finds that reducing the time it takes to order an ultrasound counter intuitively increases patient throughput time as a result of increased ultrasound use without a corresponding increase in quality of care. Furthermore, the authors show that in the complex, interconnected system or hospitals, changes in resource capacity affects not only the patients who receive the additional resources, but also other patients who share the resource, in this case, radiology. These results highlight how demand can be influenced by capacity due to behavioral responses to changes in resource availability, and that this change in demand has far reaching effects on multiple types of patients. Interestingly, the increased ultrasound ordering capacity was achieved by removing what appeared to be a "wasteful" step in the process. However, the results suggest that the step may not have been wasteful as it reduced inefficient ultrasound orders. In healthcare, these results are very important as they provide an explanation for some of the ever-increasing costs: reducing congestion through increased capacity results in even more congestion due to higher resource use. Overall, the study suggests an operations-based solution of increasing the cost/difficulty of ordering discretionary but sometimes low-efficacy treatments to address the rise in healthcare spending. Therefore, to improve hospital performance it could be optimal to put into place "inefficiencies" to become more efficient. Read More

Organizational Factors that Contribute to Operational Failures in Hospitals

Despite a pressing need to do so, hospitals are struggling to improve efficiency, quality of care, and patient experience. Operational failures—defined as instances where an employee does not have the supplies, equipment, information, or people needed to complete work tasks—contribute to hospitals' poor performance. Such failures waste at least 10 percent of caregivers' time, delay care, and contribute to safety lapses. This paper seeks to increase hospital productivity and quality of care by uncovering organizational factors associated with operational failures so that hospitals can reduce the frequency with which these failures occur. The authors, together with a team of 25 people, conducted direct observations of nurses on the medical/surgical wards of two hospitals, which surfaced 120 operational failures. The team also shadowed employees from the support departments that provided materials, medications, and equipment needed for patient care, tracing the flow of materials through the organizations' internal supply chains. This approach made it possible to discover organizational factors associated with the occurrence and persistence of operational failures. Overall, the study develops propositions that low levels of internal integration among upstream supply departments contributed to operational failures experienced by downstream frontline staff, thus negatively impacting performance outcomes, such as quality, timeliness, and efficiency. Read More

The Impact of Conformance and Experiential Quality on Healthcare Cost and Clinical Performance

This study examines the relationship between hospital's focus on both conformance and experiential dimensions of quality and their impact on financial and clinical outcomes. Conformance quality measures the level of adherence to evidence-based standards of care achieved by the hospitals. Experiential quality, on the other hand, measures the extent to which caregivers consider the specific needs of the patient in care and communication, as perceived by the patient. These are important dimensions to investigate because hospitals may face a tension between improving clinical outcomes and maintaining their financial bottom-line. However, little has been known on the joint impact of these dimensions on hospital performance in terms of cost and clinical quality. The authors' study, which examined data from multiple sources for the 3,458 U.S. acute care hospitals, is a first step towards understanding these relationships. Results show that hospitals with high levels of combined quality are typically associated with higher costs, but better clinical outcomes, as measured by length of stay and readmissions. These results suggest that hospitals face a tradeoff between cost performance and clinical outcomes. The study also finds that the effect of conformance quality on length of stay is dependent on the level of experiential quality. Taken together, these findings underline the important synergy that exists between conformance and experiential quality with regards to clinical outcomes, a topic that has been completely overlooked in the extant literature. Read More

The Impact of Pooling on Throughput Time in Discretionary Work Settings: An Empirical Investigation of Emergency Department Length of Stay

Improving the productivity of their organizations' operating systems is an important objective for managers. Pooling—an operations management technique—has been proposed as a way to improve performance by reducing the negative impact of variability in demand for services. The idea is that pooling enables incoming work to be processed by any one of a bank of servers, which deceases the odds that an incoming unit of work will have to wait. Does pooling have a downside? The authors analyze data from a hospital's emergency department over four years. Findings show that, counter to what queuing theory would predict, pooling may actually increase procesdsing times in discretionary work settings. More specifically, patients have longer lengths of stay when emergency department physicians work in systems with pooled tasks and resources versus dedicated ones. Overall, the study suggests that managers of discretionary work systems should design control mechanisms to mitigate behaviors that benefit the employee to the detriment of customers or the organization. One mechanism is to make the workload constant regardless of work pace, which removes the benefit of slowing down. Read More

Hurry Up and Wait: Differential Impacts of Congestion, Bottleneck Pressure, and Predictability on Patient Length of Stay

This paper quantifies and analyzes trends related to the effects of increased workload on processing time across more than 250 hospitals. Hospitals are useful settings because they have varying levels of workload. In addition, these settings have high worker autonomy, which enables workers to more easily adjust their processing times in response to workload. Findings show that heavy load plays a significant role in processing times. Congestion is associated with longer lengths of stay. More surprisingly, when there is a high load of incoming patients from a low pressure area (emergency medical patients), current hospital inpatients' stays are longer compared to when incoming patients are from a high pressure area (emergency surgical patients). Furthermore, high predictability of the incoming patients (e.g. scheduled surgical patients) is associated with shorter lengths of stays for the current inpatients than when the incoming patients are less predictable (emergency surgical patients). In this study, there was no decrease in quality of care for patients with shorter lengths of stay. Read More

Fostering Organizational Learning: The Impact of Work Design on Workarounds, Errors, and Speaking Up About Internal Supply Chain Problems

In competitive environments, it is essential that organizations develop techniques that increase the willingness of employees to improve organizational performance. This is especially true in complex service organizations, such as hospitals, where employees have a wide range of discretionary activities that they can perform and lower levels of supervision. For this paper, the author conducted a series of laboratory experiments to test the possibility that managers can manipulate specific work circumstances to increase employees' willingness to speak up about problems, regardless of the employees' individual characteristics. Findings show that participants were more likely to contribute improvement suggestions when employees' role orientation was primed to include process improvement as part of daily work activities and when deliberate blockages made it difficult to work around problems in a way that conformed with policy. The study supports the notion that employee positive behavior can stem from deliberate work design, which falls under managers' jurisdiction, rather than solely from self-motivated employees. Overall, the research advances understanding of the influence of work design on two important employee behaviors-improvement-oriented action and risky workarounds that may harm customers. Read More

Employee-Suggestion Programs That Work

The key to operating a successful employee-suggestion program is to stop spending so much time on big-bang projects and focus on solving "low-hanging-fruit" problems. Research by Anita L. Tucker and Sara J. Singer. Closed for comment; 13 Comments posted.

Key Drivers of Successful Implementation of an Employee Suggestion-Driven Improvement Program

Service organizations frequently implement improvement programs to increase quality. These programs often rely on employees' suggestions about improvement opportunities. Yet organizations face a trade-off with suggestion-driven improvement programs. Should managers use an "analysis-oriented" approach to surface a large number of problems, prioritize these, and select a small set of high priority ones for solution efforts? Or is it better to take an "action-oriented" approach, addressing problems raised by frontline staff regardless of priority ranking? In this paper the authors weigh the tradeoff between these two different approaches. Using data from 58 work groups in 20 hospitals that implemented an 18-month-long employee suggestion-driven improvement program, the authors find that an action-oriented approach was associated with higher perceived improvement in performance, while an analysis-oriented approach was not. The study suggests that the analysis-oriented approach negatively impacted employees' perceptions of improvement because it solicited, but not act on, employees' ideas. Read More

A Randomized Field Study of a Leadership WalkRounds™-Based Intervention

Hospitals face an imperative to improve quality, increase efficiency, and improve customer experience. Many hospitals utilize process improvement techniques to achieve these goals. One technique to involve senior managers, known in hospitals most commonly as Leadership WalkRounds™, is a program of visiting the organization's frontlines to observe and talk with employees while they do their work. The intention is that managers and frontline staff will work together to identify and resolve obstacles to efficiency, quality, or safety. (For brevity, the authors refer to it in this paper as WalkRounds™.) Rigorous testing of the effectiveness of process improvement interventions generally, and WalkRounds™ particularly, however, has been rare. This paper presents results from a field study that tested the effectiveness of a safety improvement program inspired by WalkRounds™. The authors compare pre-program and post-program measures of perceived improvement in performance (PIP) from work areas in hospitals that were randomly selected to implement the program, with pre- and post- measures from the same types of work areas in control hospitals. Findings show that, contrary to expectations, the WalkRounds™-based program was associated with decreased PIP. This study calls into question the general effectiveness of WalkRounds™ on employees' perceptions, which had been assumed in prior literature. Read More

The Work-Around Culture: Unintended Consequences of Organizational Heroes

Professor Anita Tucker shares findings from her research on the problems caused by "work-around cultures" in hospitals. Read More

Cincinnati Children’s Hospital Medical Center

A recent Harvard Business School case by HBS professors Amy C. Edmondson and Anita Tucker explores how one hospital implemented its own version of health-care reform, taking overall performance levels from below average to the top 10 percent in the industry. From the HBS Alumni Bulletin. Read More

Manager Visibility No Guarantee of Fixing Problems

Managers who merely put in time "walking the floor" are not doing enough when it comes to problem solving; in fact, it can make employees feel worse about their situation, says HBS professor Anita Tucker. Read More

Going Through the Motions: An Empirical Test of Management Involvement in Process Improvement

How can managers better lead their organizations to improve work processes? Describing their study of hospitals over an 18-month period, HBS professor Anita L. Tucker and Harvard School of Public Health professor Sara J. Singer detail how and why managers' taking action was more effective than their communicating about actions taken. Findings suggest, first, that taking action on known problems in specific work areas on at least a quarterly basis may improve the organizational climate for improvement. Second, the study indicates that managers would be well advised to take action-preferably substantive and intense action-in response to frontline workers' communications about problems. Overall, the research provides insight for senior managers who want to improve their organization's climate for process improvement. Read More

Improving Patient Outcomes: The Effects of Staff Participation and Collaboration in Healthcare Delivery

Health-care organizations have a well-documented, industry-wide need to improve their processes. To that aim, the Institute of Medicine has made at least 2 recommendations that focus on front-line staff—physicians, nurses, and respiratory therapists. The first recommendation states that front-line staff should be involved in unit decision-making and the design of work processes and workflow (participation). The second emphasizes respectful interactions among front-line staff, including information-sharing and coordinating activities to achieve organizational goals (collaboration). This study provides preliminary supporting evidence for the Institute of Medicine's recommendations to use a dual, front-line strategy of participation and collaboration to improve patient outcomes. Read More

Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units

How do hospital units, as complex service organizations, successfully implement best practices? Practices involve people and knowledge; people must apply knowledge to particular situations, so changing practices requires changing behavior. This study is a starting point for healthcare organizations to improve work practices. The researchers drew from literature on best practice transfer, team learning, and process change and developed four hypotheses to test at highly specialized hospital units that care for premature infants and critically ill newborns. Read More