Inside the OR: Disrupted Routines and New Technologies
A hospital operating room may seem an unlikely place to attract the attention of a group of management professors. But for HBS faculty members Amy Edmondson, Richard Bohmer and Gary Pisano it's a setting that offers great insights into work teams and the ways they adapt and learn.
Why did a group of Harvard Business School professors become interested in an innovative new heart surgery technique? It turns out that a hospital's operating room provides an excellent controlled arena from which to explore the role that teamwork plays in the successful adaptation of new technology.
Much of the research to date on innovation has focused on factors in an organization—timing of adoption decisions, overall organizational support of innovation, and an organization's history of innovation—that are one step removed from the actual process of technology integration.
Through the lens of a surgical team implementing a revolutionary new procedure called MICS (minimally invasive cardiac surgery), professors Amy C. Edmondson, Richard M. Bohmer, and Gary P. Pisano have looked beyond organizational factors to provide a fresh perspective on how, and under what conditions, organizations successfully integrate new technologies into their operations.
"In an industry context in which individual heroism and skill are assumed to be critical determinants of important outcomes," they write, "this study produces evidence that empowering a team and managing a learning process matter greatly for an organization's ability to learn in response to external innovation."
In undertaking their study, Edmondson, Bohmer and Pisano drew on their respective expertise in organizational behavior, medicine and economics. The result was a detailed examination of technology adaptation in this specific setting combined with a look at the broader implications that new technologies have for management at a time when the competitive imperative of innovation is leaving virtually no business untouched.
The model that comes of out the study addresses team learning dynamics in the specialized arena of MICS, but can be applied, they write, to technologies of a much broader scope, such as enterprise resource planning (ERP) systems in manufacturing, or interactive software tools that continue to revolutionize the way we work and share information within and between industries.
What is MICS?
Minimally invasive cardiac surgery (MICS) is performed by accessing the heart through incisions made between the ribs and employing a balloon device that is threaded into the heart through a vein to serve as an internal arterial clamp. The benefit of this new technology is that it eliminates the need to open the rib cage, a procedure that leads to much of the pain and extended recovery time of traditional heart surgery.
The benefits of MICS may be clear, but it was the challenges of implementing it— especially the disruption of well-established operating room (OR) routines—that piqued the interest of Edmondson, Bohmer, and Pisano. To study the group and organizational level factors affecting the adaptation of this new technology, they examined the successes and failures of 16 varied hospitals across the U.S as they implemented the procedure.
Their report on the study, the HBS working paper "Disrupted Routines: Effects of Team Learning on New Technology Adaptation" delves into the disruptive nature of MICS technology on the dynamic of the surgical team in an arena that has a notoriously rigid protocol.
"Unlike conventional surgery, in which surgeons receive information from direct sensation, MICS calls for team members to supply the surgeon with vital information displayed on digital and visual monitors in the OR," write Edmondson, Bohmer and Pisano. "The improvement for patients promised by the technology comes at a high learning cost for surgeons and OR teams. As one surgeon we interviewed joked, '[MICS] represents a transfer of the pain—from the patient to the surgeon.'
"The new technology not only changes team member's tasks," they continue, "it also dramatically increases team interdependence. The anesthesiologist and perfusionist [the technician who runs the heart-lung bypass machine] now must work closely together to regulate blood pressure, the surgeon and the anesthesiologist must coordinate to monitor the position of the balloon clamp, and all members must coordinate to monitor the patients vital pressures.
"The new technology thus disrupts a well established OR team routine and requires new communication patterns and information flows. Successfully enacting this change affects deeply engrained status relationships in the OR team, as the surgeon's role shifts from that of an order giver to a team member in an interdependent process."
Making a Team Successful in the Face of Disrupted Routines
Through the analysis of detailed qualitative and quantitative data gathered from interviews with members of surgical teams across the U.S., Edmondson, Bohmer, and Pisano sought, first, to develop a deep understanding of the implementation process for MICS and, second, to identify factors that might differentiate successful adopters from unsuccessful ones.
"The data in this study did not tell a story of greater skill, superior organizational resources, or more past experience with innovation as drivers of innovation," they write. "Instead they suggested that face-to-face leadership and teamwork might allow some organizations to adapt when confronted with new technology that threatens existing routines."
Several key factors emerged:
Surgeon leadership style was a critical variable. "On the one hand, the proposition that team leader behavior fosters project success is not surprising," write Edmondson, Bohmer and Pisano. "On the other hand, deeply engrained institutional structures and cultural norms in cardiac surgery do not foster the proactive team coaching behavior that we observed in many of the successful adopters.
"The kind of teamwork members of the cardiac surgery community understand well is one in which every member's job is important to the outcome, albeit some less important than others, while roles that dictate speaking patterns are sharply delineated. Thus, practicing a new kind of the team interdependence went deeply against the norm."
Psychological safety—how comfortable team members felt in speaking up in the group—facilitates the sharing of information and the behavioral changes necessary for successful adoption of new technologies.
"You have to talk. I have no qualms about it," said a member of one of the successful teams. "In a regular case, you clam up, but it's too late in MICS. There is no time for recovery."
But the feeling of psychological safety can be highly dependent on the attitude of the team leader and can vary greatly across teams. "[The surgeon] is very regimented," said the member of one team. "Proper decorum is his big thing." "In Doctor D's room," said another, "he doesn't want unnecessary chatter. Period."
Behaviors in which team members interact with each other and with the technology in a learning-oriented way help overcome the disruptive effect on existing routines. These behaviors, facilitated by the team leader, include preparation as a team; change in team communication and coordination; and engagement in process innovation.
Teams that prepare by setting aside time to gather together and preview all aspects of a disruptive procedure, for example, are more likely to successfully implement the technology. At one of the successful hospitals, an OR nurse reported that the team got the instruments ready and wrote up new protocol sheets for every group. "[W]e talked about how the communication would be important, and everyone was involved in [this] conversation, nurses, surgeons, everyone." By contrast, at one of the unsuccessful implementers, preparation as a group was minimal: "[We did] one dry run the afternoon before," said an anesthesiologist. "I don't even think the surgeon showed up."
Boundary spanning—communicating and coordinating with areas of the organization outside that of the team—facilitates the successful adoption of new technologies.
Successful teams in the study led open and deliberate efforts to expand the boundary of MICS awareness into related areas of the hospital such as the cardiology and intensive care units. A nurse described her role, "We studied the manual then took it back to the [floor and ICU] nursing units and gave talks. We introduced the concept and what we were trying to do and how it would change the nursing role [in the units]. We looked for input from them."
When unsuccessful adopters exhibited boundary spanning behavior, report the authors, the efforts were sporadic and had no lasting effect, as reflected in this nurse's comment: "I had to take a patient to the [ICU] and [the procedure] had never been heard of, so I had to diagram it out for them. Should this be my responsibility? No. But it happened more than once, so the information didn't get to them."
At the same time, found Edmondson, Bohmer and Pisano, other factors, such as hospital type, history of innovation and position of the adopting surgeon in the department, were shown not to be factors in the successful adoption of MICS. And the stability of a team's membership, while helping improve efficiency, was likewise not a factor in the adoption of the new technology.
"[L]ittle is known about conditions in which teams accustomed to precise routines can adapt to fundamentally new ways of working together," write the authors in discussing the implications of their work. "This study takes a first step in exploring this issue and suggests a critical role for team leader coaching and psychological safety in making this shift."
"These findings," they add, "suggest the potential to impose an additional challenge on surgeons—and other team project leaders—who already carry the weight of many burdens. Adding to their need to be skilled individual contributors, maintaining sophisticated technical expertise, they may also need to be skilled leaders who can manage a project and environment in which team learning can occur.
"Similarly, engineers are asked to be leaders in technical firms, which increasingly rely on teams to carry out strategically important projects, including adopting external innovations and developing new technologies internally.
"As teams become even more widely used to promote innovation in organizations, the need for team leadership skills and team learning behaviors explored in this paper may become even more acute."