From Turf Wars to Learning Curves: How Hospitals Adopt New Technology

Turf wars and learning curves influence how new technology is adopted in hospitals. HBS professors Gary Pisano and Robert Huckman discuss the implications of their research for your organization.
by Sara Grant

Harvard Business School professors are more likely to be found in the pages of the Academy of Management Review than the New England Journal of Medicine, but recently Gary Pisano and Robert Huckman used the latter to discuss their findings on how new technologies are learned and adopted in hospitals.

In the March 3, 2005, story Turf Wars in Coronary Revascularization, Pisano and Huckman looked at competing treatment methods for coronary artery disease and discovered a tough battleground brewing for a new technology called PTCA, or percutaneous transluminal coronary angioplasty. Not only was PTCA going up against an established and effective procedure known as coronary-artery bypass grafting (CABG), but also against the surgeons and other interests in hospitals invested in the older procedure.

The authors found that "in hospitals in which cardiac surgeons are highly influential…, PTCA has been used less frequently than in hospitals with less influential surgeons." And even if PTCA and other innovations make it past initial gatekeepers, it's a long road to adoption because of learning curves disrupted by existing work routines and patterns of professional interactions.

So, how well can hospitals adopt new technologies? And is this a blueprint for organizational learning and technology adoption in general?

Sara Grant: Why did you choose a hospital setting to study technology adoption issues?

Gary Pisano and Robert Huckman: We chose the hospital setting for several reasons. First, we both had been involved with prior research in hospitals and found them to be fascinating organizations. They are filled with highly trained professionals working in team settings on a regular basis.

What's more, many of these skilled individuals—specifically physicians—are not employed by the hospitals in which they work. The resulting social interactions between these individuals and groups within hospitals provide a fruitful setting for examining issues that are of relevance to organizations in a broader range of industries.

The hospital industry provides phenomenal data for the study of technological adoption and performance.

On a more practical level, we chose the hospital industry because of its sheer importance to the overall economy. For example, in 2003 total hospital spending in the United States alone was roughly $500 billion, or nearly 5 percent of the U.S. GDP.

Finally, the hospital industry provides phenomenal data for the study of technological adoption and performance, as information is tracked at a transaction level across much of the industry.

Q: In studying the adoption of innovation in hospitals, you note an interesting road block: turf wars. Can you describe how turf wars influence hospital decisions to buy new technology? Have you seen similar turf war issues in other industries?

A: Hospitals are characterized by the presence of multiple groups of highly trained specialists, each of which has its specific technological and clinical approaches. When multiple specialty groups converge on the treatment of a particular patient population—as is the case with cardiac surgeons and cardiologists—turf wars can emerge. Very often, these turf wars are created because hospitals have already made initial investments in two or more competing technologies, thereby leading to the development of a constituency of physicians around each technology.

For example, when angioplasty entered mainstream use in the 1980s, most hospitals that already had cardiac surgery programs felt that they needed to adopt angioplasty to "round out" their portfolio of cardiac services. At the time, this decision did not create much conflict between surgeons and cardiologists, as the two technologies were not great substitutes for each other. As angioplasty's performance improved over time, however, the two technologies became increasingly substitutable and the physician groups associated with each moved into closer competition with each other.

Where turf wars do seem to have more of an impact is in how aggressively a hospital supports its initial investment in a given therapeutic area in terms of ongoing financial support for updated technology, marketing to patients, and recruitment of new physicians. These turf wars clearly exist in other industries, though unlike the hospital settings, these battles are often fought before initial investments in a technology are made by the firm.

Q: Once an innovation is brought into a hospital, staff must learn it. What were the variables you saw in a team learning a new technique or technology? What role did "psychological safety" play in the ability of a team to master an innovation?

A: Most people think that the skills of the individual surgeon are the most important driver of success, but we found that what really mattered was how the entire surgical team was managed and how it prepared for the adoption.

We found that teams that learned a new technique fastest had a very different approach to adoption. They didn't just look at adoption as a technical problem, but instead focused on what the new technique meant for each member's role and responsibilities. The surgeon's role was critical, not just as an individual user of the technology, but as the leader of the team and the individual responsible for framing the challenge.

Where the challenge was framed narrowly as a technical problem, adoption was more problematic. But where the surgeon framed the challenge as one of organizational learning, we saw much more success with adoption.

Psychological safety, a concept originally developed by one of our colleagues, Amy Edmondson, played a critical role in successful adoption. Adoption was much more rapid in teams where the surgeon promoted open discussion of problems and "speaking up" by individual members.

Q: From your study, what lessons are there to be learned about organizational learning?

A: First, organizational learning is not automatic. Too often it is assumed that with practice and experience, performance improves. That's true on average, but there is a lot of variance. Learning has to be actively managed.

Learning depends on the climate you create in the organization.

Second, learning depends on the climate you create in the organization. If people are afraid to speak up and discuss problems, you lose a critical source of feedback, and you can't learn without feedback.

Finally, learning must occur in real time. That is, while after-action reviews can be helpful, reflection on the spot is often the best source of knowledge. You can't always do this reflection immediately, but the longer you wait, the less you will learn.

Q: What can managers in other industries learn from your research when assessing, adopting, and employing technological innovations in their companies?

A: The key lesson for managers is to be aware of the social context, or environment, of their organizations and to understand what aspects of that context interact with the specific requirements of a given technology.

For example, if it is clear that a new technology transfers more responsibility from the leader of a team to the team's members, it is important to think about how that requirement meshes with the social context of the firm. This assessment of fit will help a manager determine whether the technology is incompatible with the social context of the organization and, as a result, should not be adopted. If the technology is compatible, it may be the case that it is appropriate only for particular groups or individuals within the firm. If a manager decides to adopt a new technology for only part of the organization, he or she will need to remain aware of how that decision may affect the relationship between formal or informal social groups within the firm.

The key in such situations is for managers to use their knowledge of a firm's particular social context to prevent turf battles from hindering the adoption of technologies that would otherwise improve productivity.

Q: What are you working on now?

A: We are now working on a series of studies in the hospital sector as well as in the broader healthcare industry. These include additional studies of how the movement of physicians into and out of specific hospitals affects their performance. In one of these projects, we examine cardiac surgeons as independent contractors who, in many cases, perform identical procedures in two or more hospitals during the course of a given week. We have found that this movement has negative effects on the degree to which surgeons are able to leverage their prior experience to improve future performance. We have also begun a series of studies that examine the interaction between organizational form and decision making in the biotechnology and pharmaceutical sectors.

About the Author

Sara Grant is publications coordinator of HBS Working Knowledge.