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.
by Paul Guttry

Bumping up against accepted theories in process improvement, a new research paper from Harvard Business School questions the value of prioritizing problems identified by frontline employees.

Citing a hospital safety improvement program based on employee suggestions, researchers Anita L. Tucker and Sara J. Singer show that the commonly accepted "analysis" approach, wherein great attention is given to identifying and prioritizing a large number of problems, is not associated with success.

Instead, an "action" approach is preferable. According to their research, hospital units that focused on fixing easy-to-solve problems had greater improvement in safety climate than those focused on identifying a bunch of hard-to-solve ones.

"To our knowledge, this tradeoff between analysis and action in process improvement programs has not been empirically examined," write Tucker and Singer in their June 2012 working paper, Key Drivers of Successful Implementation of an Employee Suggestion-Driven Improvement Program. Tucker is an associate professor in the Technology and Operations Management unit, and the Marvin Bower Fellow at HBS. Singer is an assistant professor of health care management and policy at the Harvard School of Public Health.

Trained as an industrial engineer, Tucker is interested in the perspective of frontline workers in productivity and process improvement, including how internal supply chains and other processes get them what they need to do their jobs. Her interest in health care has led her to study nurses, who, as direct care providers, are at the center of the web of supply chains of equipment, supplies, medications, and even physicians.

Singer received a grant from the Agency for Healthcare Research and Quality to develop an instrument to measure safety climate in hospitals. One condition of funding was that she also create a tool to improve the safety climate and encourage senior managers to become more engaged in hospital safety initiatives.

“It was not that senior leaders were solving problems, but that they were just making sure things didn't fall through the cracks.”

Fixing By Walking Around

The program the researchers tested was modeled on Allan Frankel's "Leadership WalkRounds," which has been shown to improve safety in various medical facilities. His hypothesis was that "management by walking around" (MBWA) enabled senior leaders to put together a task list of issues that, if addressed appropriately, would make for safer conditions.

Tucker and Singer randomly selected 20 hospitals to conduct an MBWA-based program for 18 months, starting in 2005. A total of 58 departments participated, or roughly three departments from each hospital. Most frequently involved were the emergency department, medical/surgical, operating room, and post-anesthesia care units, but some hospitals also included labs, the pharmacy, or medical records.

The senior leadership teams engaged in MWRA were usually composed of chief executive, operating, nursing, and medical officers. Each officer went out for roughly an hour at a time and was encouraged to obtain feedback from nurses, doctors, respiratory therapists, and administrators. Later, the officers held large staff meetings in each unit to gather more information and discuss safety concerns, which previous research suggests increases such programs' positive impact on culture. The process generated a tick list of approximately 20 items, which was evaluated by the senior and unit leadership together in a debriefing.

Is It A Priority?

The commonly accepted wisdom in the process-improvement literature—including Frankel's work—is that since not all problems identified by frontline staff are of equal importance, it is worth time and money to perform extensive prioritization. Suggestions that will produce the greatest improvement should be focused on first. Then, as Tucker says, "you work down the list until you run out of either time or money." But Tucker and Singer's findings diverge from previous research and theory.

About half the hospitals that participated in their study chose to do some kind of prioritization—the analysis approach. Using a system similar to that adopted in Frankel's work, Tucker and Singer assigned each suggestion a priority score based on importance, likelihood, severity, and difficulty of correction.

Identifying the hospitals with the most improved safety scores turned up some surprising findings. For one, management intervention helps. "Regardless of how we analyzed the data (at the level of the respondent, the unit, or the hospital), where a higher percentage of the problems were assigned to a senior leader for action, there was a greater improvement in safety climate."

The quality-improvement literature devotes a great deal of time to the idea that because frontline staff is empowered to fix problems, senior leaders should sometimes cede responsibility. Thus, Tucker and Singer's paper puzzled some readers, who found it counterintuitive that improvements came when senior leaders seemed to be taking away employee power.

Tucker has a different perspective. "I believe it was not that senior leaders were solving problems, but that they were just making sure things didn't fall through the cracks," she says.

Tucker also explains this finding in terms of "boundary spanning." Nurses are at the far end of an internal supply chain. Even if they discover a gap between what the supply chain is providing and what the patient needs, they usually don't have the authority or knowledge to go back to those supply departments and fix the problem; a higher-level person needs to be involved.

"This finding tells us that process improvement in hospitals will require people to work across departmental boundaries, where the problems happen, rather than within a particular department," Tucker says.

Analysis Versus Action

The next thing Tucker and Singer looked at was analysis versus action in problem solving, which describes how an organization spends its resources. The analysis approach holds that by identifying lots of issues, a high-value problem will turn up, which if solved will yield a disproportionately high benefit. However, the researchers were in for another revelation.

"We found that the analysis approach was not associated with success at all, which surprised us, since it's so ingrained in the process improvement literature," says Tucker. "We found instead that the action approach was more successful: fix what you know about first. Units that solved a higher percentage of easy-to-solve problems—'low-hanging fruit'—showed greater improvement in safety climate."

“They're not going to get better by picking the right problem. They're going to get better by becoming better problem-solvers.”

One reason for this is that employees are more likely to buy into improvement programs when their suggestions are actually implemented. The analysis approach yields a large number of potential fixes, but only a frustratingly few, from the employee's perspective, are acted upon. And the analysis process can be time-consuming.

The paper cites a hospital where lab results took a long time to be completed, causing patient backups. Managers held a safety forum to surface possible solutions. "We observed the manager spent the entire time getting staff input on prioritizing the items—such as severity, frequency of occurrence, and ease of solution—leaving no time to discuss how the issues might be resolved," the authors write.

Conversely, another hospital identified that a medication room was too small for more than one nurse to work in at a time, delaying patient care. Senior managers discussed the issue with staff and they collectively made a plan to move the medication room to a larger space.

In addition to the importance of senior management cooperation and more doing than analyzing, the findings yield several other practical applications. For one, process improvement appears to be like a muscle, Tucker says. The more you exercise it the stronger it becomes.

"Especially with boundary-crossing changes, practicing and spreading that skill set through the organization can solve more and bigger problems," Tucker says. "They're not going to get better by picking the right problem. They're going to get better by becoming better problem-solvers."

Decision Bias

The findings mesh well with Tucker's recent readings on decision-making biases.

"Basically, people place more value on a good outcome today than a better outcome for which they would have to wait for two weeks," she says. "That's why I think process improvement needs to be reconceived as today's work. It's not something discretionary that will make my job easier next week or two months from now; I do it today because I have to do it today to get my job done."

Tucker experienced this in other research where she studied nurses confronted with a problem. Would they speak up and try to solve the issue permanently over time—the better outcome—or create an expedient work around? The nurses overwhelmingly chose to work around a problem, because that is what allows them to get their very demanding jobs done in the most efficient way.

Tucker's future research will continue focus on how human behavior intersects with process improvement. "I've come out of this with the goal of designing process improvement systems that take into account how people really behave, not how we want them to behave," she says.

About the Author

Paul Guttry is a freelance writer based in Jamaica Plain, Massachusetts.
    • Cristine
    • CI Director, DEED
    Great article! Can you share more information on how to launch a MBWA/Gemba programs?
    • Rebecca Mott
    • Project Manager
    Very interesting that the bias for individuals is toward action, even if it means a workaround. And workarounds are what are most likely to produce unpredictable results with risks to safety and a bend towards errors. When workarounds can result in catastrophic failure (such as the death of a patient), I don't believe it is a good thing to just accept that people will workaround established practices. I have mixed feelings about the direction of this type of research.
    • farhat zaheer
    • supervisor pharmacy, aku,karachi
    very informative article.

    As a Corporate Consultant I identified a problem at one of America's major medical centers that could have cost millions in lawsuits. CEO, all the top administrators passed daily, the problem spots. They were so used to seeing them that they stopped seeing them.
    When the CFO heard "I'll save you money" he retained me to do a study and make recommendations. His 'team' was annoyed he was spending "our money" on an outside consultant. THEY hadn't identified anything "serious".
    As you wrote, sometimes the small, immediate can potentially be a MAJOR co$t. This was a rare CFO who didn't feel he needed a consensus. TOOOO many don't have the courage to make a small investment that will save a fortune. Their egos supercede their commonsense. With a minimum of expenditure the problems were fixed, quickly.
    • Vimi Jain
    A Kaizen culture is very important for an organization to value small and continuous improvements. And that is irrespective of the nature of the industry. An company-wide program that enables front-line employees to submit suggestions (online for obvious benefits) of how the day-to-day processes that they work on can be improved; and a review and feedback mecahnism comprising mid-level managers goes a long way in keeping the clock ticking. As they say - "An ant on the move does more than a dozing ox."
    • Kapil Kumar Sopory
    • Company Secretary, SMEC(India) Private Limited
    Employees, particulrly those at the grass-roots level, get a proper feel of what is happening around and their views, opinions and suggestions matter. It depends on the way these outputs are extracted, considered and made use of. Only in case there is an open culture and an atmosphere of taking such communications - indicated , oral or written - seriously,would the employees feel encouraged to come out with their suggestions for improving work processes, systems and procedures and business development keeping interests of stakeholders in view.
    Many companies have set up suggestion drop boxes. This is generally seen as a mere formality when the droppings are not turned over regularly and actioned upon. The least the person taking out time to jot down his/her views would expect is an acknowledgement. Passivity on the part of those responsible to examine such suggestions discourages everyone to avoid venting out their views and as such lot of important and useful feedback does not see the order of the day.
    The importance of frontline staff, who can make or mar an organisation, has to be properly understood. The present is in fact and is expected to be a generation of the empowered employee ignoring whom is bound to ultimately be against the organisational interests.
    Management by walking is a very useful tool to give the management a spot indication of what's going around. In the non-computerised era, I recall my days as the head of commercial bank branches where I would come out of my cabin off andon to myself see what was happening at the counters and whether those being served were getting proper attention. This kept the staff alert and led to satisfactory outcomes. If there is just a brief round in tsome areas of he workplace by rotation, lot can be learnt for taking steps for as-required betterment and achievement of the optimum growth.
    • Pritam Kamath
    • Freelance CG-Consultant
    This is need of the hour,walk around and work around is the most effective process to involve the front line people first in contributing solutions to their own issues.Rather than any higher ups giving out of book solutions or hiring outsider for it.
    Well it should not be confined to Health care industries alone.The classic case is recent disturbance in Manesar unit of Suzuki.
    • Bradley
    • Project Manager
    Delayed gratification is often used as a marker for intelligence in young people. The Stanford marshmallow experiment is an example of this.

    The reported preference for a good fix now over a better fix in two weeks highlights the importance of making considered decisions when selecting solutions to process problems.

    Rarely have I found workarounds to be the "most efficient way".

    Very interesting research with some challenging insights. Thanks
    • Peter McCann
    • Consultant, McCann Corporate Consulting Associates
    As the CEO of a small chemical distributor undergoing a turnaround I tried the analysis and prioritizing approach - and we made no progress: there were few suggestions, and managers killed ideas as being too difficult, too expensive and too little benefit.

    After six months, I changed to 'just fix the damned thing, and if doesn't work, we'll fix it again.' The results were a much more rapid and positive change in conditions and environment and at lower effective cost. The other result were disgruntled managers who could no longer kill off inconvenient ideas.

    Obviously, if a fix required large dollars or large time, then analysis is appropriate; but for 80% or more of the ideas, it's far better to have a brief (5 minutes) discussion and then make the improvement either as suggested or as fine-tuned. Just get it done and move on the next improvement.
    • Peter A Hunter
    • Director, HBC Ltd
    This article promises so much, "Get them what they need to do their jobs."
    There are professional public servants in, health care, the police, education who after years of training and many more on the job experience who know exactly what they need to do their jobs but after a lifetime of frustration fighting the system all they ever wanted was to be allowed to do their jobs.

    The people who prevented them from doing their jobs were their senior management who by pursuing targets and budgets actively withheld from their staff the resources they needed to do their jobs.

    Get senior staff more engaged, you must be joking, get rid of them and give front line staff the authority to get what they need to do their own jobs.

    Senior management are the furthest removed from the front line in both distance and time. This means that they have the least idea about what is going on and what is required, anything they do on the front line is almost inevitably wrong and uses up the time of frontline staff undoing the mess that they make.

    When frontline staff take control of what they need the fear of senior staff is that they will go out of control.

    This attitude assumes that frontline staff are not capable of understanding how logistics work or are not capable of the simplest accounting task.
    That is the message frontline staff receive when they are told that if they want another pencil they have to go to the spotty youth in stores and show him the used pencil before a new one can be issued.

    For professional people this sort of management behaviour is incredibly demeaning.

    If frontline staff are trusted they will return that trust.
    If pencils are freely available staff will not suddenly steal them all and flee to a tax free pencil haven in the sun.

    If they are trusted they will in turn be trustworthy, they will use pencils responsibly and order new ones when they are needed.
    When senior management take control they invariably create this non trusting behaviour in the workforce by the way they behave towards them.

    For crying out loud, keep senior management away from the workforce.

    This will prevent them from making extra work for the workforce and when senior management are not present it should be no surprise to anyone that the workforce can look after themselves pretty well on their own, just give them a chance.

    Peter A Hunter
    • Sam Chandar
    • CEO, GOF
    Harking back to the 80s I recall my experience on the manufacturing shop floor where every morning and evening the Plant Head would take a walk round the various units along with the Supervisor. He would stop by at a table to go through the register, talk to a couple of operators on work related issues and simultaneously have the Supervisor respond to concerns if any. Where an issue appeared to require further attention, it would be included in the weekly meeting agenda. As a culture building exercise to demonstrate direct involvement, personal attention and a collaborative approach to improvement, I found this extremely successful. Of course better discipline, shop floor cleanliness and cordial relationships were positive spin-offs.
    • Dalia Sinha
    • Assistant Manager, Intec Capital
    very informative, its true that we spend more time to discuss the problem & then to decide what to do ? how to do ? rather then solving the same. Focusing on the solution can make the work life-environment more pleasant.
    • danielihsan
    • ambank
    The article is very true in almost all organisations, especially in human intensive enviroments. Even in the present AmBank enviroment. The utmost importance is the readiness of the leaders at all levels to see, hear, talk, discuss, understand and implement what are needed, starting from the easiest to "cure" to the hardest and/or from the immediate-result actions to a future-result actions!