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Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

1057 — Improving Safety and Reliability through Organizational Design

Rudolph JW (Center for Organization, Leadership and Management Research, Boston VAMC) , Carroll JS (MIT, Sloan School of Management)

Leading healthcare researchers and administrators have long argued that healthcare organizations should adapt high-reliability practices from other industries rather than “reinventing the wheel”. But how to do this is often unclear. This theory-building study aims to develop a practical conceptual guide to help healthcare organizations identify their safety and reliability stage of development and efficiently develop structures and practices to address safety issues at each stage.

Blending findings from our own five-year study of safety management in the nuclear power and chemical processing industries with an extensive literature review of safety and reliability in healthcare, we extrapolated other industries’ best practices with respect to organizational design into the healthcare arena. The nuclear and chemical processing industry research included case studies, surveys, in-depth interviews, multi-rater coding of accident investigation reports, and direct observation of problem investigation teams.

Our results are a practical conceptual model to guide organizational design in healthcare. Healthcare organizations may fall into one of four stages with respect to high reliability. Each stage poses specific challenges to safety and reliability which managers need to address. The local autonomy stage (where informal modes of organizing and local knowledge are primary) requires organization-wide systems to enhance reliability; the formal control stage (in which organization-wide systems track and reduce variance from formal policies) requires more open communication and diversity of perspectives; the open inquiry stage (in which multiple points of view begin to be surfaced and are valued) requires the linking of local knowledge and organization-wide control with multiple perspectives; and the deep self-understanding stage (in which local knowledge, organization-wide controls, and multiple perspectives are valued and linked via systems thinking and analysis) combines the strengths of all previous stages.

To improve their reliability, healthcare organizations will need to tolerate and manage the tension between formal bureaucratic controls and improvisational adjustments. Organizational design — including formal structures, procedures, and incentives, and informal culture and communication — is crucial to developing and sustaining high reliability healthcare organizations. Designing organizations to achieve goals that appear to be in conflict, such as safety and cost, can lead to deeper understanding that improves systems of care.

The impact of this study is to provide concrete suggestions for VA healthcare providers and administrators on how to enhance safety and reliability.

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