TFME 2013 Organizational Professionalism Conference

1. The Case for Organizational Professionalism
Tim Vogus
October 20, 2012

2. Agenda
 Creating a professional culture
 Infusing professionalism
 Mindful organizing

3. Enacting
Frontline actions that
•Surface latent and manifest
threats to professionalism
•Mobilize resources to
reduce threats
Professional Culture
Enabling
Leader actions that
•Direct attention to
professionalism
•Create contexts safe to
speak up and act in ways
that improve it
Outcomes
Elaborating
Learning practices that
•Develop comprehensive
representations of outcomes
•Provide feedback that
modifies enabling and
enacting

4. Enacting
Frontline actions that
improve patient safety
- Interpersonal processes
(e.g., teamwork)
- Reporting and voicing
concerns
- Coordinating at care
transitions (handovers)
and across interdependent
functions (checklists)
Culture
Enabling
Actions that motivate the
pursuit of safety
External actions:
- Accrediting and advocacy
organizations
- Survey tools
- Work hours rules
Internal actions:
- Leader behaviors and
practices
- HR practices
- Technology (EMR)
Improved Reliability
Fewer hospital errors
Elaborating
Learning practices that
extend safe practices
- Learning-oriented
interventions
- Education (simulation)
- Frontline system
improvement
- Case-based analysis
(M&M)
- System monitoring
(prospective,
retrospective, concurrent)
Culture
Culture
Culture
Culture
Safety Climate
Frontline
interpretations of
safety-related
leader actions and
organizational
practices

5. Emulate “Reliability Professionals”
High reliability organizations
(HROs)
Roberts, 1990; Weick & Roberts, 1993
Schulman, 1993
LaPorte & Consolini, 1991

6. Reliability Professionals
 Couple “the need for anticipation and careful causal
analysis with the need for flexibility and
improvisation” (Roe and Schulman 2008, p. 64)
 Actions foster nearly error-free operations in
contexts that are extremely
 Complex
 Dynamic
 Interdependent

7. Why Reliability Professionals?
 Reliability a persistent and costly
problem
 98,000 deaths annually (IOM, 2000)
 May be significantly higher
(Classen, et al. 2011)
 Improvement efforts have yielded
little (Wachter, 2010)
 Despite significant effort
(Landrigan, et al., 2010)

8. Why Reliability Professionals?
(cont.)
 Complex
 Cognitively demanding (Aiken, et al.,
2002)
 Dynamic
 Highly uncertain (Argote, 1982)
 Numerous exceptions (Tucker, 2004)
 Interdependent
 Across shifts
 Distributed expertise (Benner, et al.,
1996)

9. How do reliability
professionals do their work in a
nearly error-free manner?

10. Mindful Organizing
 A social practice enacted collectively
 Not an intra-psychic process (cf. Langer, 1989)
 Consists of
 Preoccupation with failure
 Reluctance to simplify interpretations
 Commitment to resilience
 Sensitivity to operations
 Deference to expertise
 Mindful organizing allows for the rapid detection and
correction of errors and unexpected events

11. Mindful Organizing Occurs When
 People are
 Spending time identifying what could go wrong
 Discussing alternatives as to how to go about
everyday activities
 Developing an understanding of who knows what
 Talking about mistakes and ways to learn from
them
 Taking advantage of the unique skills of one’s
colleagues (even if the person is of lower status in
the organization)

12. Concept Survey Item(s)
Preoccupation with failure
• Chronic wariness of the unexpected
When giving report to an oncoming nurse, we usually
discuss what to look out for.
We spend time identifying activities we do not want
to go wrong.
Reluctance to simplify interpretations
• Questioning assumptions and received wisdom
We discuss alternatives as to how to go about our
normal work activities.
Sensitivity to operations
• Up-to-date knowledge of where expertise resides
We have a good “map” of each other’s talents and
skills.
We discuss our unique skills with each other so we
know who on the unit has relevant specialized
skills and knowledge.
Commitment to resilience
• Deliberate learning from experience
We talk about mistakes and ways to learn from them.
When errors happen, we discuss how we could have
prevented them.
Deference to expertise
• Migrating decision-making to person with most
expertise, not most authority
When attempting to resolve a problem, we take
advantage of the unique skills of our colleagues.
When a patient crisis occurs, we rapidly pool our
collective expertise to attempt to resolve it.
Measuring Mindful Organizing

13. Research Questions
 Is mindful organizing associated with
reliability?
 Do complementary practices enhance its effects?
 What factors enable mindful organizing?
 What interventions enhance mindful
organizing?

14. Is Mindful Organizing Associated
with Reliability?
 95 nursing units
 A one unit increase in mindful organizing associated with 35% fewer
medication errors
 7 fewer errors per year per unit
 A one unit increase in mindful organizing associated with 69% fewer
patient falls
 13 fewer falls per year per unit
 125 nursing units
 Mindful organizing positively related to manager ratings of safety
and quality
 184 software firms
 Increases innovation and stock price over time

15. Do Complementary Practices
Enhance These Effects?
 Mindful organizing doesn’t occur in a
vacuum
 Potentially enhanced by complementary practices
 Care pathways
 Standardization of care according to best practice
 Structure interactions
 Build connections (Feldman and Rafaeli, 2002)
 Facilitate coordination (Gittell, 2002)
 “The majority of our patients are on care
pathways” (Gittell, 2002)

16. Joint Effects – Mindful Organizing
and Care Pathways
0
2
4
6
8
10
12
Low Mean High
ReportedMedicationErrors
Level of Mindful Organizing
Minimal use of Pathways
Extensive use of Pathways

17. What Enables Mindful
Organizing?
 Mindful organizing is a function of the skilled efforts
of “reliability professionals” (Roe & Schulman,
2008)
 Experience (Klein, 1998)
 Communication (Weick & Sutcliffe, 2007)
 Commitment (Levinthal & Rerup, 2006; Schulman, 1993)

18. What Enables Mindful
Organizing?
Mindful Organizing
Workgroup
Professional
Experience
Workgroup Quality
Performance
Workgroup Safety
Performance
H1a + H4 +
H3 +
H2 -
H1b -
Professional
Experience
Variability
Workgroup
Professional
Commitment

19. Methods
 Survey of frontline registered nurses in a large Catholic
health system
 Mailed to 3,298 nurses using multi-contact strategy (Dillman, 2000)
 51.1% response rate (1,685 responses); No evident non-
respondent bias
 125 units; average of 12 responses per unit, 13 hospitals
 95% female
 Age 40.99 years (s.d. = 9.75)
 Tenure 15.29 years (s.d. = 10.18)

20. Results
Mindful Organizing
Workgroup
Professional
Experience
Workgroup Quality
Performance
Workgroup Safety
Performance
.015* .95***
.04*
-.05**
-.003**
Professional
Experience
Variability
Workgroup
Professional
Commitment
.79**

21. Mindful Organizing and
Professional Experience

22. Mindful
Organizing, Experience, and
Experience Variability
LOW PROF EXPERIENCE
VARIABILITY (-1SD)
HIGH PROF EXPERIENCE
VARIABILITY (-1SD)

23. Mindful Organizing,
Experience, and Commitment

24. What Enables Mindful
Organizing?
 HR practices
 Selective staffing
 Hiring for interpersonal as well as technical skills
 Extensive training
 Preceptor programs, training in interpersonal skills, ongoing
informal training
 Developmental performance appraisal
 Ongoing, 360-degree, and focused on learning
 Employee involvement
 Discretion over work practice
 Reward suggestions
 Job Security

25. How Do HR Practices Help?
 Through signaling
 Signaling the behaviors expected, supported, and
rewarded
 Signaling about what?
 How work is to be carried out
 Developmental performance appraisal and coaching signal
the importance of learning and feedback seeking
 They foster a psychological contract
 Employees are valued and treated fairly, so they
reciprocate and generalize

26. What Enables Mindful
Organizing?
HR
Practices
Respectful
Interaction
Mindful
Organizing
+
+
+
Patient
Safety
+
• HR Practices
include
• Selective staffing
• Developmental
performance
appraisal
Dyadic interactions – trust,
honesty, and self-respect
Capabilities for detecting and
correcting the unexpected
+
Employee
Commitment
OCB+
+

27. Findings
HR Practices
Mindful
Organizing
Respectful
Interaction Med. Errors
OCB
.09*
.78*
.30*
-.36*
.48*
Commit
.08* Pat. Falls
.28*
-.51*
-.27*
-.16*
χ 2 = 91.05, df = 12, CFI = .93, SRMR = .053

28. What interventions enhance
mindful organizing?

29. Interventions
 Change the conversation
 Leader rounding
 Managers on their units
 Top management on all units
 Huddles
 Post-event cross-profession debriefs; what, why, and
lessons to learn
 Create mechanisms for change
 Safety action teams

30. Emerging Evidence
 Increased leader engagement
 More regular rounding
 More consistent follow up actions
 Institutionalization of huddles
 Increased reporting of errors and threats to safety
 “The list”
 Safety action teams a mechanism for frontline
change and dissemination of reliability information
 Highly variable and contingent

31. What Does This Mean for
Clinical Practice?
 A potential guide for making M&M
conferences more impactful
 A road map for debriefing close calls, errors,
and uncomfortable situations
 A framework for planned change (e.g., QI
projects)

32. Preoccupation with Failure
 A wariness about what could go wrong
 Questions to ask
 What are we most worried about?
 Where are we most vulnerable?
 What is the “worst case scenario”?

33. Reluctance to Simplify
Interpretations
 Questioning assumptions to develop better ways
of working
 Questions to ask
 What assumptions are we making?
 Are there data that disconfirm our assumptions?
 What other assumptions could we make?
 What are alternative ways to carry out our work?

34. Sensitivity to Operations
 A shared understanding of current status and
where necessary expertise resides
 Questions to Ask
 Who will be most impacted by our work?
 Where does the necessary expertise reside?
 Who needs to be at the table?

35. Commitment to Resilience
 Regularly reflecting on and learning from
outcomes to build group capabilities
 How do we know we need to stop and huddle or
debrief?
 What went well? How can we replicate it?
 What went wrong? How can we avoid the same
mistakes?

36. Deference to Expertise
 Decision-making based on problem-specific
expertise, not formal authority
 Questions to ask
 Who has the most experience with this situation?
 Who has knowledge we need to consider?
 How will we get their perspective?
 What barriers will prevent us from drawing upon the
appropriate expertise?

37. Conclusions
 Mindful organizing is associated with reliability
 Quality, safety, and innovation
 Effects are enhanced by complementary practices
 Mindful organizing is enabled by
 Workgroup professional characteristics
 HR practices
 Mindful organizing responsive to interventions
 Rounding, huddles/debriefing, and questions

38. A well-designed organization is
not a stable solution to achieve,
but a developmental process to
keep active.
(Starbuck & Nystrom, 1981, p. 14)

39. That means:
You NEVER get
High Reliability Organizing
behind you!

40. Reliability and Mindful
Organizing Resources
 Roberts, K. H. and R. G. Bea (2001). "When Systems Fail." Organizational Dynamics 29(3):
179-191.
 Rosenthal, M. M., and K. M. Sutcliffe (2002). Medical Error: What Do We Know? What Do
We Do? San Francisco, CA, Jossey-Bass.
 Sutcliffe, K. M., E. Lewton, et al. (2004). "Communication Failures: An Insidious Contributor
to Medical Mishaps." Academic Medicine 79(2): 186-194.
 Weick, K. E. (1987). "Organizational Culture as a Source of High-Reliability." California
Management Review 29: 112-127.
 Weick, K. E. and K. M. Sutcliffe (2001). Managing the Unexpected: Assuring High
Performance in an Age of Complexity. San Francisco, Jossey-Bass.
 Weick, K. E. and K. M. Sutcliffe (2003). "Hospitals as Cultures of Entrapment: A Reanalysis
of the Bristol Royal Infirmary." California Management Review 45(2): 73-84.
 Weick, K. E. and K. M. Sutcliffe (2007). Managing the Unexpected: Resilient Performance in
and Age of Uncertainty, Second Edition. San Francisco, CA, Jossey-Bass.

41. Shameless Self-Promotion
 Singer, S.J., & Vogus, T.J. (Forthcoming). “Safety Climate Research: Reflections and New
Directions.” BMJ Quality and Safety.
 Vogus, T.J., Sutcliffe, K.M., & Weick, K.E. (Forthcoming). “Searching for Safety Culture: An
Integration and Research Agenda.” Academy of Management Annals.
 Singer, S.J., & Vogus, T.J. (Forthcoming). “Reducing Hospital Errors: Interventions that Build
Safety Culture.” Annual Review of Public Health.
 Vogus, T.J., & Sutcliffe, K.M. (Forthcoming). “Organizational Mindfulness and Mindful
Organizing: A Reconciliation and Path Forward.” Academy of Management Learning &
Education.
 Vogus, T.J., Sutcliffe, K.M., & Weick, K.E. (2010). “Doing No Harm: Enabling, Enacting, and
Embedding a Culture of Safety in Health Care Delivery.” Academy of Management
Perspectives, 24(4): 60-77.
 Vogus, T.J., & Sutcliffe, K.M. (2007b). “The Impact of Safety Organizing, Trusted
Leadership, and Care Pathways on Reported Medication Errors in Hospital Nursing Units.”
Medical Care, 45: 997-1002.
 Vogus, T. J. and K. M. Sutcliffe (2007a). "The Safety Organizing Scale: Development and
Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units." Medical Care
45(1): 46-54.

42. Back Up Slides

43. Workgroup Professional
Experience
 Greater experience
 Frees up attention (Levinthal & Rerup, 2006)
 Enables sensing anomalies (Benner, et al. 1996; Weick &
Sutcliffe, 2007)
 Increases recognition of importance of collaboration
(Sonnentag, 2001) and collective learning (Barton &
Sutcliffe, 2009)
 Diminishing returns to experience result from
 Fewer novel experiences (Reason, 2008)
 Infrequent updating (Finkelstein & Hambrick, 1990)

44. Professional Experience
Variability
 Variability (disparity) in experience inhibits drawing upon
collective experience
 Reduce cohesion and increase conflict (Williams & O’Reilly, 1998)
 Less informal communication (Smith, et al., 1994)
 Makes experience inaccessible
 Status differences
 Less likely to seek out expertise (Barton & Sutcliffe, 2009; Weick &
Sutcliffe, 2007)
 Over-deference to experience (Blatt, et al., 2006; Morrison &
Rothman, 2009)
 Experts have difficulty understanding and helping novices
 Different language (Hinds, et al., 2001)

45. Professional commitment
 Mindful organizing is effortful (Levinthal & Rerup, 2006)
 Requires extra-role behaviors (Schulman, 1993)
 Professional commitment motivates and directs extra-role
behavior (Meyer, et al., 2004)
 Directs it behaviors consistent with professional values (Johnson, et al.,
2009)
 More likely to share experiences to prevent errors (Hofmann, et al.,
2009)
 Professional commitment coalesces because
 Common frame of reference (Abbott, 1988; Pfeffer & O’Reilly, 1989)
 ASA processes (Schneider, 1987)
 Social information processing (Salancik & Pfeffer, 1978)

46. So what?
 What does a 0.4 to 0.6 change in mindful
organizing mean?
 A 0.4 unit increase in mindful organizing leads to
14% fewer medication errors on a nursing unit
 3 fewer errors per year per unit
 A 0.4 unit increase in mindful organizing leads to
28% fewer patient falls on a nursing unit
 5 fewer falls per year per unit
 30% or more result in moderate to severe injuries
 $15,000 - $30,000 for each severe fall

47. Respectful Interaction
 The basis for socially shared cognition (Campbell,
1990; Asch, 1952)
 Honestly reporting what we perceive to each other.
 Demonstrating a great deal of mutual respect for each
other.
 When discussing patient information, attempting to
integrate our interpretations without belittling our own
opinions or another nurse’s.
 Exhibiting trustworthiness.
 Respectful interaction enables people to
 Come to a shared and nuanced understanding
 Surface information that conflicts with the majority view

48. Unexpected Finding
 Why is OCB associated with higher levels of errors
and falls?
 Interruptions and tough cognitive shifts (Tucker &
Edmondson, 2003; Leroy, 2010)
 Culture of heroes
 Acting outside of competence
 Inadequate systems
 Normalizing deviance (Vaughan, 1996)
 If these are plausible, a mindful system should
mitigate the negative impacts

49. What About Edmondson (1996)?
 Didn’t measure reporting, used chart review
 Someone else makes the determination if there was an error
or not
 Differences in culture of reporting now and in mid 1990s
 Cross-sectional study, I’m modeling over time
 Why should effective practice be associated with reporting
more errors/falls over time?
 I control for ratings of whether or not a unit was a “good” unit
 If better units report more, should see a positive relationship
 Observe a negative relationship
 What Edmondson captured consistent with my OCB effect