Discuss and Explain the managerial tool of management by walking around (MBWA) and its impact on creating a strategy ready culture.

Discuss and Explain the managerial tool of management by walking around (MBWA) and its impact on creating a strategy ready culture.

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? Discuss and Explain the managerial tool of management by walking around (MBWA) and its impact on creating a strategy ready culture.

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The Effectiveness of Management-By-Walking-Around:
A Randomized Field Study
Anita L. Tucker
Harvard Business School, Soldiers Field Road, Morgan Hall 413, Boston, Massachusetts 02163, USA, atucker@hbs.edu
Sara J. Singer
Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts 02115, USA, ssinger@hsph.harvard.edu
Management-by-walking-around (MBWA) is a widely adopted technique in hospitals that involves senior managers
directly observing frontline work. However, few studies have rigorously examined its impact on organizational outcomes.
This study examines an improvement program based on MBWA in which senior managers observe frontline
employees, solicit ideas about improvement opportunities, and work with staff to resolve the issues. We randomly
selected hospitals to implement the 18-month-long, MBWA-based improvement program; 56 work areas participated. We
find that the program, on average, had a negative impact on performance. To explain this surprising finding, we use
mixed methods to examine the impact of the work area?s problem-solving approach. Results suggest that prioritizing
easy-to-solve problems was associated with improved performance. We believe this was because it resulted in greater
action-taking. A different approach was characterized by prioritizing high-value problems, which was not successful in
our study. We also find that assigning to senior managers responsibility for ensuring that identified problems get resolved
resulted in better performance. Overall, our study suggests that senior managers? physical presence in their organizations?
front lines was not helpful unless it enabled active problem solving.
Key words: health care; implementation research; patient safety; quality improvement; survey research
History: Received: February 2013; Accepted: January 2014 by Edward G. Anderson, Jr. after 2 revisions
1. Introduction
Hospitals face an imperative to improve quality of
care and decrease medical errors that harm patients.
Healthcare thought leaders and policy makers have
advocated for the adoption of ?management-by-walking-around?
(MBWA) to achieve these goals, resulting
in widespread adoption in the United States and
the United Kingdom. (Frankel 2004, National Patient
Safety Agency 2011). These types of programs?in
which senior managers visit the front lines to work
with staff to identify and resolve obstacles?came to
the attention of hospitals with the publication of one
health-care system?s success at improving safety climate
through its MBWA-based intervention (Frankel
et al. 2003).
Despite the intuitive appeal of MBWA and history
of use in manufacturing organizations, empirical evidence
on the program?s efficacy in the hospital setting
is mixed. Of seven hospitals that implemented an
MBWA-based program, only two were able to sustain
the effort over a 3-year period (Frankel et al. 2008).
Those two reported a positive impact on staffs? perceptions
of safety climate, but the effect on the five
aborting hospitals was not reported. A study of one
Veterans Affairs hospital found that patient safety climate
worsened on two units that implemented the
program, while it improved or stayed the same on
two control units that did not implement the program
(Singer et al. 2013). Another found that hospitals that
implemented a general improvement program with
an MBWA component did not improve on a variety
of measures compared to control hospitals (Benning
et al. 2011).
These mixed findings provide only modest support
for widespread implementation of this program in
hospitals. The lackluster performance of MBWA in
health care may be that health care?s specialized and
diverse disciplinary knowledge bases (e.g., cardiology,
pulmonary, surgery, pharmacy, nursing, etc.)
creates a complex environment where it is difficult for
senior executives to effectively observe frontline work
and provide improvement suggestions (Aflaki et al.
2013). In addition, the highly regulated nature of
health care may minimize the marginal effectiveness
of MBWA because other audit programs, such as government-mandated
inspections or incident-reporting
systems, already focused senior managers? attention
on the front lines of care (Iyer et al. 2013). Furthermore,
the mixed results may be due to implementation
253
Vol. 24, No. 2, February 2015, pp. 253?271 DOI 10.1111/poms.12226
ISSN 1059-1478|EISSN 1937-5956|15|2402|0253 ? 2014 Production and Operations Management Society
differences, such as the prioritization methods used
to determine which problems get resolved. However,
prior studies have not assessed MBWA programs at a
more granular level. As a result of the contextual
differences in health care and limitations of prior
research, much remains to be discovered about
what factors and implementation approaches are
associated with the success of MBWA in hospitals.
To test more systematically the impact of MBWAbased
improvement programs and to identify factors
associated with its success, we implemented one
such program in 19 randomly selected hospitals. We
compared nurses? perceptions of improvement in
performance (PIP) in work areas that implemented
the program to the same type of areas at 68 randomly
selected control hospitals that did not implement
the program. A contribution of our study is
thus a rigorous testing of an MBWA program. More
specifically, our study design minimizes two methodological
challenges of research on improvement
programs. First, we minimize selection bias by randomly
assigning organizations to the treatment condition.
Our study thus provides insight into the
program?s generalizability beyond those where
senior managers decided on their own to implement
such a program. Second, the use of control organizations
reduces the possibility that positive (or negative)
results were caused by time-dependent
variables, such as changes in technology, policies, or
awareness over time. Surprisingly, we find that, on
average, our MBWA-based program had a negative
impact on nurses? perceptions of performance, suggesting
that senior managers? presence in hospital
front lines to solicit improvement ideas could be detrimental
to workers? perceptions.
A second contribution of our study is developing a
categorization of problem-solving approaches that
explains the conditions under which improvement
solicitation programs, such as MBWA, are successful.
We find that our MBWA-based program was associated
with improved perceptions of performance
under two conditions: (1) when a higher percentage
of solved problems were considered ?easy? to solve,
enabling more problem solving and (2) when senior
managers took responsibility for ensuring that identi-
fied problems were resolved. This suggests that the
action-taking that results from the program, rather
than the mere physical presence of the senior managers,
is what positively impacts the frontline staff.
In section 2, we describe prior research on MBWA
programs and develop four hypotheses linking the
program to performance. In section 3, we describe
the intervention, the sample of hospitals that participated
in the research project, and our qualitative and
quantitative data, measures, and analytic approach.
We present the results in section 4 and discuss the
implications for research, practice, and policy in
section 5.
2. MBWA-based Improvement
Program?s Impact on Performance
Research has found that quality improvement programs
that solicit frontline workers? ideas, such as
MBWA, can have a beneficial impact on organizational
outcomes (Dow et al. 1999, Powell 1995).
MBWA relies on managers to make frequent, learning-oriented
visits to their organization?s front lines to
observe work and solicit employees? opinions (Packard
1995). Hewlett-Packard, the company in which
MBWA originated, attributed its success using
MBWA to good listening skills, willing participation,
a belief that every job is important and every
employee is trustworthy, and a culture where
employees felt comfortable raising concerns (Packard
1995). MBWA is similar to the Toyota Production System?s
?gemba walks? (Mann 2009, Toussaint et al.
2010, Womack 2011). In a gemba walk, managers go
to the location where work is performed, observe the
process, and talk with the employees (Mann 2009).
The purpose is to see problems in context, which aids
problem solution (Mann 2009, Toussaint et al. 2010,
Womack 2011).
MBWA has resulted in positive organizational
change in some hospitals (Frankel et al. 2003, Pronovost
et al. 2004). One explanation is that MBWA leads
to successful problem resolution because seeing a
problem in context improves managers? understanding
of the problem, its negative impact, and its causes.
This understanding increases managers? motivation
and ability to work with frontline staff and midlevel
managers to resolve the issue (Mann 2009, Toussaint
et al. 2010, Von Hippel 1994, Womack 2011). Theory
further suggests that MBWA?s repeated cycles of
identifying and resolving problems may create an
organizational capability for improvement that
reduces the cost of future improvement efforts, creating
a positive dynamic (Fine 1986, Fine and Porteus
1989, Ittner et al. 2001). This virtuous cycle is further
strengthened because communication from frontline
workers about problems aligns managers? perspectives
with customers? experiences (Hansen et al. 2010,
Hofmann and Mark 2006, Huang et al. 2010, Singer
et al. 2009), enabling managers to effectively allocate
scarce resources among the organization?s multiple
improvement opportunities. Performance is also
enhanced because managers? presence on the front
lines sends a visible signal that the organization is
serious about resolving problems. This increases
employees? beliefs that leadership values improvement,
which in turn spurs employees to engage in the
discretionary behaviors necessary for process
Tucker and Singer: The Effectiveness of MBWA
254 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
improvement (Mcfadden et al. 2009, Zohar and Luria
2003). For these reasons, we hypothesize that MBWA
will positively impact performance.
Hypothesis 1 (H1). Participation in a MBWAtype
program leads to improved performance.
2.1. The Effect of Problem-Solving Approach
Although we hypothesize a positive impact from
MBWA, programs that solicit employee suggestions
can uncover more problems than an organization can
resolve, given limited problem-solving resources
(Bohn 2000, Frankel et al. 2003, Repenning and Sterman
2002). When this happens, the organization?s
problem-solving support personnel must decide
which of the identified issues they will work to
resolve and which ones will be ignored or delayed
(Keating et al. 1999, Morrison and Repenning 2011).
Thus, an MBWA?s program?s success may be contingent
upon which problems the organization decides
to address.
We examine two different prioritization
approaches, discuss their benefits and limitations,
and develop two hypotheses. We explore two dimensions
of problems: solution difficulty and value
gained by solving the problem (Aflaki et al. 2013). To
simplify the discussion, we consider only two levels
of each dimension: problems are either easy to solve
or difficult to solve; and they can yield either a small
or large value if solved. Organizations are likely to
prioritize problems that are of high value and/or
problems that are easy to solve. Although we develop
hypotheses based on the assumption that organizations
have a dominant prioritization scheme (such as
addressing high-value problems), we recognize that
organizations could combine the two approaches.
This implies that they would emphasize high-value,
easy-to-solve problems while ignoring problems that
were both difficult to solve and of low value (Aflaki
et al. 2013).
The first prioritization approach that we consider is
one that addresses issues that are causing?or have
the potential to cause?large disruptions. This highvalue
prioritization approach ranks problems according
to a value score and solves the highest-valued problems.
Many structured approaches to improvement,
such as six-sigma and risk management, use a highvalue
prioritization approach (Anderson et al. 2013a,
b). In the health-care context, hospital incident-reporting
systems (Bagian et al. 2001) and MBWA-based
programs (Frankel et al. 2003) advocate calculating a
problem?s ?value? by multiplying the problem?s score
for severity with its frequency of occurrence (Bagian
et al. 2001, Frankel et al. 2003). The hospital then
resolves the highest-value problem first, followed by
the second highest, continuing until problem-solving
resources are depleted or remaining problems fall
below a threshold value (Bagian et al. 2001). Surfacing
and solving the highest-valued problems should yield
substantial gain in performance (Bagian et al. 2001,
Girotra et al. 2010). To provide an example in the hospital
setting, medication-related problems are often of
high value because they can be fatal and can impact
many patients (Bates et al. 1995). In response, many
hospitals have implemented computerized physician
order entry systems which reduce medication errors
by preventing transcription errors and alerting physicians
to potential drug allergies or interactions (Bates
et al. 1999).
This approach is beneficial because it ensures that
limited resources are preserved for problems with
the highest values (Frankel et al. 2003). It also helps
prevent the queue of unsolved problems from growing
unmanageably long by permitting the organization
to discard the subset of problems that are
deemed too little valued to justify solution efforts
(Bohn 2000).
However, there is a downside to focusing exclusively
on high-value problems. The ignored problems
constitute the ?useful many? which individually do
not have a large negative impact on performance
(Juran et al. 1999), but which collectively could contribute
to serious problems such as medical errors
(Reason 2000).
Thus, the second approach that we consider is
prioritizing easy-to-solve problems (Johnson 2003,
Repenning and Sterman 2002). An easy-to-solve prioritization
approach enables the organization to address
problems that are straightforward and quick to
remedy?the so-called ?low-hanging fruit.? This
approach may free up resources for addressing problems
because the more formal approach of assigning
a prioritization score based on severity and occurrence
has required significant resources in the case of
incident-reporting systems in both aviation and
health care (Johnson 2003).
An easy-to-solve prioritization approach may also
be helpful in health-care settings because the cumulative
benefit of resolving many small problems can
add up to be a significant source of improvement
(Jimmerson et al. 2005). Similarly, research has found
that major accidents typically result from an unpredictable
combination of small magnitude problems
rather than from a single large magnitude problem
(Perrow 1984, Reason 2000). According to the ?Swiss
Cheese Theory,? multiple small-scale problems can
align in an unfortunate way that enables an error to
harm the customer (Cook and Woods 1994, Reason
2000). Consequently, resolving seemingly low-value
problems can be beneficial, because they otherwise
might contribute to the next major accident (Perrow
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 255
1984). To illustrate, a study of medical harm in cardiac
surgery found that adverse events were more likely to
be caused by multiple, simultaneous ?minor? issues
than by a single, ?major? issue. This was because surgeons
were less able to perceive and compensate for
multiple, simultaneous minor issues while they were
able to recognize and remedy a single, major issue
that occurred during surgery (De Leval et al. 2000).
This line of research implies that it is difficult to
assign a ?value? to problems because their negative
impact is determined in part by the specific situation
in which they occur.
Another situation in which the easy-to-solve prioritization
approach may be superior is where the organization
has a ?flat landscape? of small magnitude
problems. In flat landscapes, the difference between a
local high point and the global high point is too small
to justify an extensive search effort (Sommer and Loch
2004). This can occur in hospitals for two reasons.
First, managers typically address issues that result in
patient death or other serious injury such as wrong
site surgery. Thus, the only problems that remain
may be small magnitude issues. Second, there are
many unique opportunities for patient care to fail
because work is divided among specialties, departments,
and shifts. Problems can occur at any of these
handoffs. Thus, unlike manufacturing settings where
an undetected malfunction in a machine can be the
dominant source of defective product, it is less likely
that there is a single, dominant source of repeated failures
in hospitals. When there is a flat landscape,
improvement arises from solving the lower tail of
problems.
It may also be that organizations need to address
basic, fundamental problems before they can benefit
from trying to address more complex organizational
issues. For example, research suggests that problemsolving
efforts are most successful when organizations
use relatively straightforward problems to
develop sufficient problem-solving capacity before
tackling larger, more complex issues (Keating et al.
1999, Morrison and Repenning 2011). Addressing
easy-to-solve problems enables frequent problemsolving
cycles, which develops employees? expertise
at problem solving (Adler et al. 2003). These dynamics
suggest that organizational problem-solving
capacity is more like a muscle that strengthens with
exercise rather than a resource that gets depleted with
use (Fine 1986, Fine and Porteus 1989, Ittner et al.
2001).
We draw on the arguments outlined in the above
paragraphs to develop two hypotheses. When problem-solving
resources are limited and become
depleted with use, the organization should focus its
scarce human and financial capital on removing the
problems that pose the biggest threat. Thus, a highvalue
prioritization approach will be associated with
improved performance.
Hypothesis 2 (H2). Work areas that resolve a
higher percentage of high-value problems will
have greater improvement in performance than
work areas that solve a lower percentage of
high-value problems.
An easy-to-solve prioritization approach should be
associated with improvement because it fosters solution
of all problems that can be solved, regardless of
their hypothetical value. In the health-care setting,
this might benefit the organization because seemingly
small-value problems can nonetheless negatively
impact patient safety. Furthermore, the act of solving
problems develops the organization?s capability to
solve more problems in the future. Thus,
Hypothesis 3 (H3). Work areas that solve a
higher percentage of easy-to-solve problems will
have greater improvement in performance than
work areas that solve a lower percentage of
easy-to-solve problems.
2.2. The Role of Senior Managers in Problem
Solving
In addition to the prioritization approach, the success
of an MBWA program depends on senior managers?
willingness to take responsibility for ensuring that
problems identified through the program are resolved
(Frankel et al. 2005, Pronovost et al. 2004).
Senior managers can be helpful to frontline workers?
resolution efforts because they control financial
resources needed to address issues that involve capital
investment (Carroll et al. 2006). In addition, they
possess the perspective necessary to resolve conflicts
that arise when problems cross organizational boundaries
(MacDuffie 1997). This insight is valuable particularly
because high-value problems are likely to cross
organizational boundaries or require financial
resources to resolve.
On the other hand, easy-to-solve problems impact
only one department and do not require substantial
financial resources to resolve. Under these conditions,
frontline employees can be empowered to identify
and resolve problems (Jimmerson et al. 2005). However,
involving frontline workers in resolution efforts
requires them to take time away from their direct production
responsibilities (Repenning and Sterman
2002, Victor et al. 2000). This can be difficult for frontline
employees, especially for health-care workers
who provide direct patient care. Under these conditions,
senior managers need to allocate funds for overtime
or coverage so that care providers can spend
time away from patient care and on resolution efforts.
Tucker and Singer: The Effectiveness of MBWA
256 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
As outlined in the two above paragraphs, both
high-value and easy-to-solve problems require manager
support for successful resolution. Therefore, we
hypothesize that hospital work areas will achieve better
results from the MBWA program when they
assign to senior managers the responsibility for ensuring
that a problem gets addressed.
Hypothesis 4 (H4). Work areas with a higher
percentage of problems assigned to a senior
manager to ensure resolution exhibit greater
improvement than those with a lower percentage
of problems assigned to a senior manager.
These four hypotheses outline the theoretical links
between our MBWA-based program and improved
performance. Figure 1 depicts these relationships.
3. Methodology
We test our hypotheses in a field study of US hospitals
randomly selected to participate in a patient
safety research study, with a subset of the hospitals
randomly selected (a second time) to implement our
MBWA-based program. The program was launched
in January 2005 and lasted for 18 months.
3.1. The MBWA-based Program
We drew on prior research to design our MBWAbased
program (Frankel et al. 2008, Pronovost et al.
2004, Thomas et al. 2005). It consisted of repeated
cycles of senior manager?staff interaction, debriefing,
problem solving, and follow-up. Senior managers
such as the chief executive, operating, medical, and
nursing officers (CEO, COO, CMO, and CNO, respectively),
interacted with frontline staff in a work area
to generate, select, and solve improvement ideas. The
work area manager was also involved in the selection
and solution activities. Senior manager interactions
took two forms: visits, called ?work system visits,? to
work areas to observe frontline work; and special
meetings, called ?safety forums,? with a larger group
of frontline staff from the area to discuss safety concerns.
The activities were coordinated with the work
area manager.
In work system visits, four senior managers would
spend 30 minutes to 2 hours visiting the same work
area. The senior managers would each observe a different
process, such as medication administration, or
a different person, such as a nurse or physician, to
shed cross-disciplinary insight into the work done in
the area. The purpose was to build senior managers?
understanding of the frontline work context and
gather grounded information about problems (Frankel
et al. 2008).
Senior managers also facilitated a safety forum in
the work area, which was an informal meeting
between senior managers and the frontline staff from
the work area, held in the work area, during which
the staff talked about their work area?s safety weaknesses
and strengths. We added this component to
our MBWA-based intervention for two reasons. First,
a San Diego children?s hospital improved its organizational
climate by holding meetings where frontline
staff spoke directly to the hospital CEO about their
concerns and ideas (Sobo and Sadler 2002). Second,
a prior research project on an MBWA-based program
found that the program only improved the
perceptions of frontline staff who participated in a
work system visit (Thomas et al. 2005). Because it is
not feasible for senior managers to conduct a work
system visit with every single hospital employee
within a short time period, Thomas? finding suggests
that work system visits on their own will be insuffi-
cient to change the perceptions of most hospital
employees.
The MBWA-based program continued with a
?debrief meeting,? which organized information collected
from the work system visits and safety forums.
Senior managers attended, as did work area managers,
selected frontline workers, and the hospitals?
patient safety officers. The group compiled the
improvement ideas identified, discussed and in some
work areas prioritized them, and decided next steps,
ranging from doing nothing to suggesting solutions
and assigning responsibility. Action to address problems
selected for resolution followed the debriefing.
Managers were encouraged to communicate with
staff about implementation efforts, describing what
changes, if any, were made in response to identified
ideas. Patient safety officers entered the ideas
MBWA
Program Performance
Problem solving activities
used in MBWA
Address highvalue
problems
Address ?easy-tosolve?
problems
Managers ensure
problems are
resolved
H1+
H2+
H3+
H4+
Figure 1 Model of Management-By-Walking-Around?s Impact on Performance
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 257
generated and actions taken into an electronic spreadsheet
we provided and sent this spreadsheet to our
research team for analysis.
Each round of work system visits, safety forums,
debrief meeting, solution activities, and communication
constituted one cycle. A cycle focused on one
work area and took approximately 3 months, which
research has shown is the time required to solve problems
in an organization (Pronovost et al. 2004). See
Figure 2 for a diagram of the process. After completing
a cycle, the management team would repeat the
activities in a different work area. The program
focused on the four main work areas in hospitals:
operating room or postanesthesia care unit (OR/
PACU), intensive care unit (ICU), emergency department
(ED), and medical or surgical ward (Med/Surg).
Cycles continued over the 18-month implementation,
with hospitals conducting an average of one cycle in
four work areas.
3.2. Recruitment
Our study employed an experimental design which
included a pre-test and post-test of similar work areas
in treatment and control hospitals. We randomly
selected 92 US acute-care hospitals, stratified by size
and geographic region, to participate in a patient
safety climate survey. We provided no financial
incentive, but participation in the safety climate study
fulfilled a national accreditation requirement. At
enrollment, all hospitals were aware that they may be
invited to participate in a program to improve patient
safety, but details regarding the program were withheld
to prevent contamination of control hospitals. To
select hospitals to participate in the MBWA-based
program, we drew a second, stratified, random sample
of 24 hospitals from the sample of 92. The remaining
68 hospitals not selected were control hospitals.
Data on staff perceptions of performance were
collected at control and treatment hospitals through
surveys before implementation of program activities
(2004, ?pre?) and again after the program was completed
(2006, ?post?). At each hospital, we surveyed a
random sample of 10% of the frontline workers, with
additional oversampling in OR/PACUs, EDs, and
ICUs in the post-survey period to improve sample
size. The baseline ?pre? response rate was 52%; and
the follow-up ?post? response rate was 39%. For our
analyses, we used data from registered and licensed
vocational nurses (n = 1117 pre and n = 903 post).
Of the 24 treatment hospitals, 20 completed the program
in at least two work areas. Of the four that did
not complete the treatment, one went out of business,
one was purchased, and two experienced significant
senior management turnover. As a result, they were
unable to complete more than one cycle of activities
and did not provide data. We thus excluded these
four from our analysis. There was no difference in
staff perceptions of performance in the pre-period
between the four hospitals that dropped out of the
treatment and the 20 that did not. Of the original 68
control hospitals, 48 completed the post-test survey,
making an initial total sample of 68 hospitals. There
was no difference in survey measures in the pre-period
between the 20 control hospitals that dropped out
of the post-survey and the remaining hospitals. There
was also no difference between treatment and control
work areas on pre-period measures of staff perceptions
of performance.
3.3. Data and Measures
Using the data collection spreadsheet that we provided
(Figure 3), treatment work areas reported 1245
patient safety problems identified during the visits
and forums. Each hospital also provided a list of the
C
E O
C
N O
C
M O
C
F O
Work
site visit
by CEO
Time
Work
site visit
by CNO
Work
site visit
by CMO
Work
site visit
by CFO
Safety
Form
Debrief
Meeting
Solution Activities &
Communication
Figure 2 Depiction of the MBWA-based Program Activities in a Work Area
Tucker and Singer: The Effectiveness of MBWA
258 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
senior managers, which we used to determine
whether a senior manager attended the program
activity and whether a senior manager was assigned
responsibility for the problem. The spreadsheet also
contained three columns that the work areas could
use to prioritize identified problems. Twenty-four
work areas in eight hospitals filled out this information.
3.3.1. Independent Variables. To test the overall
impact of the MBWA-based program (H1), we created
a treatment variable, ?MBWA in the work area,?
which indicated whether the work area received the
MBWA-based treatment (=1) or was a work area from
a control hospital (=0). To test the high-value prioritization
approach (H2), we calculated a value score for
each problem by multiplying problem severity (column
7 in Figure 3; 1 = low; to 10, could cause death)
by estimated frequency of occurrence (column 8;
1 = very unlikely, 3 = very likely) (Bagian et al. 2001,
Frankel et al. 2003). This method for calculating the
potential value of solving a problem is similar to sixsigma?s
risk prioritization number, which uses the
product of the scores (on a scale from 1 to 10) of a
problem?s frequency of occurrence, detectability, and
severity (Evans and Lindsay 2005). It is also similar to
risk registers used for risk management. A risk register
scores each potential risk to a project by multiplying
the risk?s likelihood of occurrence by severity of
the impact if it does occur (Anderson et al. 2013a,b).
We used our value score in combination with whether
or not the problem was addressed (column 10 in Figure
3) to create a unit-level variable that represented
the percentage of problems in the top quartile
(ranked by value) that were resolved, which we call
?% of top quartile that were resolved.? As an alternate
test of H2, we also created a dummy variable,
?Top ranked problem resolved?? A dichotomous
variable that indicated whether or not the top-ranked
problem in the work area was resolved. The alternate
specification for H2 allowed us to test our prediction
using innovation literature theory, which asserts that
success can come from identifying and solving even
just one high-value idea (Girotra et al. 2010). To test
the easy-to-solve prioritization approach (H3), we
calculated, from a work area?s set of problems that
were resolved, the percentage that were rated ?easyto-solve,?
a ?1? on a 3-point scale, meaning it is was
1 2 3 4 5 6 7 8 9 10 11 12 13
Hospital
#
Date of
Activity
Activity
Type:
Worksite
Visit or
Safety
Town
Meeting
Participant
from
Executive
team
Location “Hinderers” to
patient safety, or
system weaknesses
observed during
worksite visit, or
brought up during
safety town meeting
(one item per row)
Safety Risk:
1: Low
3: Mild
discomfort
5: Would require
intervention
10: Could cause
harm or death
Likelihood or
frequency of
risk
1=Very
unlikely
2=Possible
3=Very likely
Ease of implementation
1=Easy, within 30
days
2=Moderate-multiple
departments (90 days)
3 = Difficult-process
changes and/or major
budget (6 months)
Action items
or proposed
changes to
hinderers
Team
member(s)
responsible
for follow up
C-Suite
Yes = 1
No = 0
Date
change
completed
100 3/16/2
006
Worksite
Visit
Betsy
Green,
CNO
Medical/
Surgical
Unit
New diabetics?
insurance won’t pay
for glucometers.
Staff concerned
about patients’
inability to get the
devices and their
own need to learn
many different
devices based upon
what the patient
purchased. The delay
decreases the
amount of time
nursing staff have to
teach patients about
using the device.
10 2 2 Director of
Laboratory
Services
communicat
-ed the need
to a vendor
of diabetic
supplies.
Director of
Laboratory
Services and
CNO
1 Mar-06
100 Another problem of lower value would be here 2
100 Another problem of lower value would be here 2
100 3/14/
2006
Worksite
Visit
Jen
Calhoun,
Safety
Director
Medical/
Surgical
Unit
Overbed tables being
used to hold Personal
Protective Equipment
(PPE).
5 1 1 Isolation
Carts have
been
purchased
to hold and
store PPE
outside of
patient
rooms.
CNO and
Director of
Medical/
Surgical
Unit
1 1st cart
arrived
03/20/20
06
To test H2: % of the top quartile (of value) that were resolved =100%
To test H3: % of resolved problems that were ?easy-to-solve? =50%
To test H4: % of problems assigned to senior manager =50%
Value = 10*2 = 20
Top quartile? = 1 (yes)
Addressed? = 1 (yes)
Top quartile & addressed? = 1 yes
Figure 3 Data Collection Sheet Used by Treatment Hospitals and Two Problems as Examples
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 259
?easy and could be resolved within 30 days? (column
9 in Figure 3). The higher the percentage, the
more the unit solved easy-to-solve problems. We
called this variable ?% of problems solved that were
low-hanging fruit.? Finally, to test our hypothesis
about senior managers (H4), at the work area level
we found the percentage of problems for which a
chief executive level manager was assigned responsibility
for ensuring that the problem was resolved
(column 12 in Figure 3). See Figure 3 for details on
these variables.
3.3.2. Measure. In accordance with prior research
(Chandrasekaran and Mishra 2012, Frankel et al.
2003, 2005, 2008), we evaluated the program?s performance
using staff ?PIP.? To measure PIP, we used
four survey items (see Appendix A) from validated
survey instruments that measured the effectiveness of
quality improvement efforts (Shortell et al. 1995,
Singer et al. 2009). Respondents rated each item using
a 5-point scale ranging from 1 = strongly disagree to
5 = strongly agree. Agreement indicated that respondents
thought quality and safety performance were
improving. The scale exhibited high reliability (Nunnally
1967), with a Cronbach?s alpha of 0.84 (n = 1147
nurses) in the pre-period and 0.88 (n = 1103 nurses)
in the post-period.
We used perception of performance for four reasons.
First, employee perceptions are an important
outcome because they influence behaviors, which in
turn impact objective measures (Zohar and Luria
2003). Second, staff perceptions of performance are a
valid indicator of performance (Ketokivi and Schroeder
2004). This is because employees are close to the
work and often know if system failures are decreasing
or increasing. Research has found that nurses? perceptions
of safety are correlated with objective measures
of safety outcomes, such as mortality, readmissions,
and length of stay (Hansen et al. 2010, Hofmann and
Mark 2006, Huang et al. 2010, Singer et al. 2009).
Third, employee perceptions have been widely used
as outcome measures in operations management
research because they enable comparison across organizations
(Anderson et al. 2013a,b, Atuahene-Gima
2003, Bardhan et al. 2012, Chandrasekaran and Mishra
2012, Flynn et al. 1995, Kaynak 2003, Swink et al.
2006). Finally, the use of a perceptual measure was
necessitated by hospitals? unwillingness to share data
on safety incidents.
Our dependent variable was the change in PIP from
the pre- to the post-period. The use of change scores
allowed us to examine change over time (Fitzmaurice
2001). To create a composite change score for each
work area, we used the pre-data to calculate the
mean of the four items for each nurse, and then averaged
by work area. We repeated this process for the
post-data and subtracted each work area?s pre-score
from its post-score. We calculated intra-class correlations
(ICC) and a mean inter-rater agreement score
(rWG) to test whether aggregation of PIP was appropriate.
Significant (ICC[1] = 0.06, F = 5.69, p < 0.000,
and ICC[2] = 0.82) supported aggregation (Bliese
2000). The rWG for nurses? rating of PIP was 0.60,
which also was sufficient for aggregation (ZellmerBruhn
2003). Furthermore, our use of a change score
as our dependent variables met the two conditions
specified by Bergh and Fairbank (2002): the reliabilities
of our survey measures for PIP in pre- and postperiods
were high (0.84 and 0.86, respectively) and
the correlation between the measures from the two
different time periods was low (q = 0.24, p < 0.001).
As is common in studies using a change score (Bergh
and Fairbank 2002), the correlation between the
change score and the PIP measure in the pre-period
was negative (q = 0.67, p < 0.001). This indicates
that there was a greater opportunity for improvement
in PIP among work areas with a low PIP in the
pre-period (Fitzmaurice 2001). Therefore, to control
for impact of a work area?s starting point on the
change in PIP, we included a dichotomous variable
indicating whether PIP in the pre-period was in the
lower quartile (?bottom quartile for 2004 PIP?).
The variable was coded ?1? if the work area was in
the bottom quartile of work areas in PIP in the preperiod
and ?0? for all others. This method enabled us
to test for the change in PIP while controlling for a
low starting point.
3.3.3. Control Variables. For H1, which tested the
overall impact of our MBWA-based program, the
large sample size enabled us to include the following
control variables: major teaching hospital (1 = yes,
0 = no); Dun & Bradstreet?s measure of the hospital?s
financial stress, with higher numbers indicating a
higher likelihood that the business will seek legal
relief from creditors or cease operations without paying
creditors in full over the next 12 months; a set
of dummy variables for the number of hospital beds
(reference group = less than 100 beds; medium =
100?250 beds; large = more than 250 beds); and a set
of dummy variables for type of work area (reference
group = non-clinical; OR/PACU; ICU; ED; Med/
Surg unit; and other clinical unit). Data on size and
teaching came from the 2004 American Hospital
Association Survey of Hospitals.
For the hypotheses about problem prioritization
(H2 and H3), our sample size was limited to the 24
work areas that formally prioritized their problems in
the data collection spreadsheet. As a result, for these
hypotheses, we did not have a large enough sample
size to include non-significant control variables in
our regression. However, our random selection of
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260 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
hospitals helps alleviate concerns that our model may
be subject to omitted variable bias (Antonakis et al.
2010). We did not include control variables for unit
type (e.g., ED, ICU, and OR/PACU) as none were significant
and their inclusion did not change our results.
We also tested for hospital-level control variables,
such as teaching status and number of beds, but none
were significant and their inclusion did not change
our results. We controlled for availability of ?lowhanging
fruit,? which was the percentage of identified
problems that were rated as easy to solve. We also
controlled for the average value of the top quartile of
identified problems.
Our regression equation for H4, the impact of a
senior manager being assigned responsibility for
problem resolution, included the full set of 58 intervention
work areas. We controlled for the percentage
of problems within a work area that were
resolved (% of problems resolved) by coding a problem
as having had solution effort if there was evidence
in the dataset that action had been taken to
address the problem, and taking the average of this
variable at the work area level. We also controlled
for the fidelity of implementation with the following
variables: the number of work system visits that
were conducted, whether a work system visit was
conducted by a senior manager (1 = yes, 0 = no),
and whether a safety forum was conducted in the
area (1 = yes, 0 = no).
3.4. Sample Size and Analysis
We used linear regression with robust standard errors
and clustered by hospital (Rabe-Hesketh and Everitt
2004) in Stata 11.1TM to test our hypotheses. The Shapiro?Wilk
test for all regressions showed that the residuals
were normally distributed (V close to 1 and
p > 0.10) (Royston 1992). Multicollinearity was also
not an issue as all variance inflation factors for all of
our equations were less than 2.5, well below the
upper threshold of 10 (Chatterjee and Hadi 1986).
To test the overall impact of our MBWA-based
program (H1), we use data from the four main clinical
work areas (OR/PACU, ICU, ED, and Med/
Surg). We had data for both pre- and post-PIP measures
from 58 intervention work areas in 20 treatment
hospitals and 138 work areas in 48 control
hospitals. However, missing data for a control variable
(financial stress) in two intervention work areas
resulted in a final sample size of 56 intervention
work areas. To test the impact of problem selection
(H2 and H3), we used data from the 24 work areas
from eight treatment hospitals that formally prioritized
their problems. Finally, to test the impact of
senior manager assignment to problem resolution
(H4), we used the full set of intervention work areas
(n = 58).
3.5. Qualitative Data Collection and Analysis
During the intervention, we visited each treatment
hospital to tour the clinical areas and to observe
MBWA activities, including work system visits, safety
forums, and debrief meetings. In addition, we discussed
and observed examples of changes implemented
in response to problems identified through
the program to verify accuracy of the data submitted.
There were no discrepancies. We also conducted
semi-structured interviews with a frontline staff
member, a department manager, and the CEO from
each hospital (see Appendix B). Interviews addressed
the nature of performance improvement in the hospital
in general and as it related to implementing the
MBWA-based program. Interviews and notes from
the meetings were recorded and transcribed. Investigators
also wrote a journal of the day?s activities from
notes taken during the day. The journal and transcripts
from each hospital were combined into a single
document, which served as our source of
qualitative data.
After the intervention was complete, we used
these qualitative data in combination with the problem
data submitted by the work areas to illuminate
differences among work areas in the types of issues
identified, actions taken to resolve them, and managers?
attitudes. We analyzed transcripts using the procedure
described in Miles and Huberman (1994, pp.
58?62). We initially used a list of codes based on our
interview questions. We read the transcripts multiple
times, revising the codes as we deepened our understanding
of similarities and contrasts among the
implementation of the program. How the managers
prioritized problems for solution efforts emerged as
a main theme. One author went through the qualitative
data to select all relevant quotes for this theme.
Both authors independently reviewed the quotes
while blinded from the performance results. We
compared our perceptions to come to a consensus.
We use the quotations to illustrate differences in
implementation approach that impacted the effectiveness
of the intervention. Table 6 in the results
section displays representative quotations from the
five work areas that improved the most over the
course of the intervention and the five that decreased
the most.
4. Results
4.1. Summary Statistics
Average PIP in the 56 treatment work areas was 3.78
in the pre-period and 3.69 in the post-period. The difference
of 0.09 was not statistically significant at the
10% significance level. The same four types of work
areas (n = 138) in control hospitals had a mean PIP of
3.8 in both time periods. Table 1 shows descriptive
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 261
statistics. Using the subset of work areas that prioritized
their problems (n = 24), the mean value score
for all identified problems was seven on the scale of 1
(lowest) to 30 (highest). Descriptive statistics and correlations
are shown in Table 2. On average, the mean
value score was 17 for the top quartile of identified
problems. The highest score, on average, was about
19.
4.2. Regression Results
Contrary to our prediction, the MBWA-based treatment
was associated with a statistically significant
decrease in PIP (0.17, p < 0.05) compared to the same
types of work areas in control hospitals (H1, Table 3,
Model 1). A possible explanation is that some treatment
work areas failed to conduct the recommended
activities (Nembhard et al., 2009). However, the following
statistics provide evidence that treatment
areas did indeed implement the MBWA-based program:
91% had a work system visit; each treatment
work area received a mean of 3.41 visits (SD = 3.16,
maximum of 12); 50% had a safety forum; on average,
they identified 19 problems and took action on 11
(Table 1).
The effectiveness of the program did vary, however,
among work areas. As shown in Model 1, our
control variable for whether or not the work area was
in the bottom quartile for pre-period PIP was signifi-
cant (b = 0.75, p < 0.001), suggesting that work areas
with the lowest PIP scores in the pre-intervention period
exhibited a positive change in PIP over the course
of the intervention. Additional analysis revealed that
the work areas that were in the bottom quartile for
our dependent.
variable, change in PIP, had a decline in PIP ranging
from 0.375 to 2.25. Of these 15 work areas that
experienced the greatest decline in PIP, four were
already below median in the pre-period, suggesting
that their decline was not merely a regression to the
mean effect. The work areas in the top quartile of
change in PIP experienced an increase in PIP ranging
from 0.38 to 1.33 points. This large variation in results
prompted us to examine factors associated with
success.
Model 1 in Table 4 shows results from testing H2
and H3. A higher percentage of problems solved that
were rated as ?easy-to-solve? was associated with
higher% change in PIP (coefficient = 1.00, p < 0.05),
providing support for H3. A one standard deviation
(27%) increase in the percent of solved problems that
were easy-to-solve was associated with a 1.0 point
increase in change in PIP, which was a 26% improvement.
However, the percentage of problems rated in
the top quartile for value that were solved was not
significant. Thus, H2 is not supported.
Testing H2 using highest-value score instead of the
mean priority of the top quartile and a dummy for
whether the top-ranked problem for value was
resolved instead of the percentage of problems rated
in the top quartile for value that was solved was also
not significant (Table 4, Model 2). This result fails to
support theory from the innovation literature suggesting
that solving the highest-value idea drives performance
in our context. However, the percentage of
problems resolved that were rated ?easy-to-solve?
remained significant in this model (coefficient = 0.82,
p < 0.01), providing additional support for H3. Prioritizing
easy-to-solve problems appeared to increase
PIP.
An alternate explanation for our finding could be
that work areas were more successful because they
spent more money on problem solving rather than
because they prioritized easy problems. To control for
this ?spend more? explanation, the authors individually
rated the rough cost of each solved problem on a
scale of 1?3 with 1 = low (cost = $500), 2 = medium
(cost > $500 < $150,000), and 3 = high (cost =
$150,000) based on the description of how work areas
solved the problem and independent research to
check the cost of products or services mentioned in
the description. We used these ranges because they
represented different categories of solutions. The
cheapest category was solutions that involved a onetime
purchase of a relatively low-cost supply (<$500).
An example is applying a coating to one window to
improve patient privacy. The second category was
intended to cover mid-range solutions such as the
purchase of equipment or consumable supplies. An
Table 1 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas (N = 56 work areas)
Variable Mean SD Min Max 1 2 3 4 5 6
1 Postperiod PIP 3.69 0.61 1.92 5.00
2 Change in PIP 0.09 0.67 2.25 1.33 0.639***
3 Had work system visit 91% 29% 0 1 0.195 0.197
4 Number of work system visits in area 3.41 3.16 0 12 0.055 0.1 0.342*
5 Had safety forum 50% 50% 0 1 0.056 0.028 0.313* 0.097
6 Percent of problems addressed 62% 31% 0 1 0.088 0.079 0.083 0.043 0.074
7 Percent of problems assigned to
senior manager
10.4% 23.7% 0 93% 0.186 0.175 0.114 0.359** 0.176 0.065
***p < 0.001, **p < 0.01, *p < 0.05.
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262 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
example is the purchase and installation of new lighting
in a catheterization laboratory to illuminate procedures.
The most expensive category was for solutions
that involved construction or hiring of multiple people.
An example is a solution that involved hiring
multiple people to transport patients within the hospital.
We compared scores and discussed our rationale
until we reached consensus for all solved
problems. We then summed the total estimated solution
costs, estimating 1 = $250; 2 = $5000; and
3 = $150,000, for all of the solved problems in each
work area.
Another possible explanation is that variation in
quality of solution efforts impacted the results (e.g.,
some work areas might have engaged in only superfi-
cial steps while others might have systematically
resolved underlying causes). We also controlled for
this ?higher quality? explanation by hiring 10 nurses
not affiliated with our study hospitals to rate the solution
effectiveness of the proposed solution for each
Table 2 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas and Identified Problems (n = 24)
Variable Mean SD Min Max 1 2 3 4 5 6 7
1 Change in PIP 0.02 0.53 1.17 1.1
2 Avg value of top quartile of
identified problems
17.23 6.67 6 30 0.298 1
3 Highest-valued score 18.75 7.43 6 30 0.325 0.952*** 1
4 Availability of
low-hanging fruit
36% 26% 0% 100% 0.016 0.305 0.289 1
5 Percentof top quartile
problems solved
88% 29% 0% 100% 0.186 0.091 0.109 0.045 1
6 Highest-valued problem
was solved
88% 34% 0 1 0.209 0.110 0.039 0.086 0.799***
7 Percent of solved problems that
were low-hanging fruit
33% 27% 0% 83% 0.327 0.097 0.099 0.551** 0.432* 0.350?
8 Percent of problems
assigned to senior manager
22.5% 32.4% 0% 93% 0.308 0.582** 0.576** 0.136 0.054 0.242 0.457*
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Table 3 Linear Regression testing Hypothesis 1 (the Change in PIP in
Treatment Work Areas vs. the Same Types of Work Areas
from Control Hospitals) Clustered by Hospital with Robust
Standard Errors in Parentheses
Model 1
H1. Treatment work area (1 = yes) 0.17*(0.08)
Bottom quartile PIP (pre-period) 0.75*** (0.10)
Major teaching hospital (1 = yes) 0.21? (0.13)
Financial stress 0.00 (0.00)
Medium-size hospital (100?250 beds) 0.43*(0.10)
Large-size hospital (>250 beds) (1 = yes) 0.26* (0.12)
OR/PACU (1 = yes) 0.08 (0.11)
ICU (1 = yes) 0.00 (0.13)
ED (1 = yes) 0.15 (0.13)
Was a work system visit conducted? Not in model
Was a safety forum conducted? Not in model
Constant 0.02 (0.20)
Observations 194
Treatment and control work areas 56 & 138
Degrees of freedom F (9, 55)
F-statistic 9.06***
Adjusted R2 0.20
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Table 4 Regression Comparing Change in PIP in Treatment Work
Areas that Rated the Severity, Frequency, and Ease of
Solution of the Problems, Clustered by Hospital with Robust
Standard errors in parentheses (H2 and H3)
Model 1 Model 2 Model 3
Mean value of top
quartile of
identified
problems
0.02 (0.02) ? ?
Highest-value score of
identified problems
? 0.02 (0.02) ?
Availability of
low-hanging fruit
0.60 (0.49) 0.45 (0.45) 0.90? (0.42)
H2. Percent oftop
quartile value
resolved
0.22 (0.23) ? ?
H2. Was top-ranked
value problem
resolved (1 = yes)
? 0.01 (0.26) ?
H3. Percent of
solved
problems that were
low-hanging fruit
1.00* (0.30) 0.82** (0.21) 1.22* (0.46)
Bottom quartile
2004
PIP pre (1 = yes)
0.39* (0.16) 0.36^ (0.19) 0.38* (0.13)
Cum. cost of solving
problems
? ? 0.00 (0.00)
Avg effectiveness of
solution effort
? ? 0.11 (0.10)
Constant 0.25 (0.48) 0.47 (0.46) 0.61 (0.62)
Observations 24 24 24
Degrees of freedom F (5, 7) F (5, 7) F (5, 7)
F-statistic 10.99** 5.28* 7.08*
Adjusted R2 0.06 0.07 0.08
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 263
problem using a scale from 1 to 10. The low end of the
scale was used for problems that were not resolved
(1 = ?no information given?; 2 = management dismissed
the issue or it was not a safety issue; and
3 = issue not considered due to lack of funds or issue
passed off to someone else without any follow-up).
The higher the number, the more substantial and systematic
the solution (e.g., 9 = major investment or
change; 10 = systemic fix that would prevent recurrence).
The scale is available from authors. Agreement
among nurses on their ratings was acceptable
(j = 0.23) (Landis and Koch 1977). The mean rating
for solution effectiveness was higher at 5.9 for solved
problems (?solution action in progress? on our scale)
than 2.7 (?no solution implemented?) for unsolved
problems, which validates their coding.
Given our small sample size, in this secondary
analysis we omitted the high-value prioritization variables,
as they were not significant in our primary
analyses. As Model 3 shows, the variable for the
cumulative ?cost of solving problems? was not significant.
This may be because work areas could improve
PIP without having to spend a lot of money on solutions.
Solution effectiveness was also not significant.
The percentage of solved problems that were lowhanging
fruit remained significant (coefficient = 1.22,
p < 0.05), indicating that the results are similar after
accounting for spending and solution effectiveness.
The evidence in the three models supports H3, which
predicted that prioritizing easy-to-solve problems
would be associated with higher PIP.
Table 5 shows the results from testing H4, which
proposed that senior managers taking responsibility
for ensuring that identified problems get resolved
would be associated with higher% change in PIP. H4
was supported (coefficient = 0.79, p < 0.05). Increasing
the percent of problems assigned to senior managers
by one standard deviation (23%) was associated
with a 0.79 increase in PIP. This equates to a 21%
increase in PIP.
4.3. Robustness Check
Other scholars have used a different approach for
testing improvement over time by using the postmeasure
as the outcome variable and the pre-measure
as a control variable (Fitzmaurice 2001). We tested
our hypotheses using this method and the results
were the same (results not shown).
4.4. Qualitative Results
To provide insight into the nature of implementation
of MBWA-based programs, Table 6 presents qualitative
data from the five work areas that improved the
most and the five that decreased the most. Between
pre- and post-periods, on average PIP improved by
0.85 for the top five work areas and decreased by 1.4
for the bottom five. Our examination of issues identi-
fied and actions taken suggests that the top work
areas identified meaningful problems and managers
took these problems seriously. For example, hospital
88s Med/Surg unit was one of the most improved
work areas. One of the identified issues was that the
small size of the medication room prevented two
nurses from preparing medications simultaneously,
which was an inconvenience and delayed patient
care. Senior managers discussed the issue with staff
and they collectively made a plan to move the medication
room to a larger space. The COO commented,
?It?s a little thing, but when you actually see them
doing the process, you say, ?Wait a minute, that is dif-
ficult for them.?? An interview with a nurse highlighted
management?s willingness to address issues.
She commented, ?These people address safety issues.
It may not always get addressed the way you want,
but it still gets addressed.?
Conversely, in the bottom work areas, an emphasis
on prioritizing the highest-valued problems limited
solution efforts. For example, hospital 129s ED identi-
fied valid issues, such as long lead times to receive lab
results. However, in the safety forum, we observed
the manager spend the entire time getting staff input
on prioritizing the items, leaving no time to discuss
how the issues might be resolved. This work area did
not solve any of the problems they had identified,
despite investing substantial time in identifying and
prioritizing them. As Table 6 shows, this pattern was
common. Two of the six bottom work areas did not
resolve any problems, another?s ?solutions? were largely
to re-educate staff, and a fourth area provided us
with no information about solved problems. These
implementation details suggest an inability to make
meaningful progress on solving the problems. The
lack of solution efforts illustrates how relying too
heavily on a high-value prioritization approach can
Table 5 Impact of the Percentage of Problems Assigned to Senior
Managers on Change in PIP in Treatment Work Areas (H4)
Model 1
H4. Percentage of problems
assigned to senior managers for resolving
0.79* (0.32)
Bottom quartile PIP pre (1 = yes) 0.56** (0.15)
Percentage of problems solved 0.12 (0.33)
Number of work system visits in the area 0.04? (0.02)
Senior manager participated in
work system visit (1 = yes)
0.12 (0.23)
Safety forum in the area (1 = yes) 0.12 (0.14)
Constant 0.08 (0.31)
Observations 58
Degrees of freedom F (6, 19)
F-statistic 2.96*
Adjusted R2 0.10
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
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264 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
Table 6 Illustrative Problems, Solutions, and Quotes from Top and Bottom Quartile Work Areas
Hospital
ID Work area
2004
Score
2006
Score
%
Change Examples Solution efforts Illustrative quotes and examples about prioritization
116 OR/PACU 3.3 4.6 41% Need more clinic space Made new clinic rooms The associates will prioritize with the managers, who
have a good idea of what the staff want to do
100 Med/Surg 2.6 3.6 38% Newly diagnosed diabetic patients
cannot get glucometers from
insurance; buy different kinds,
hard for nurses to teach
Vendor donated glucometers, in-serviced nurses,
made kits for newly diagnosed diabetic patients
Manager ordered new isolation carts to keep supplies
for each patient outside the door to prevent spread of MRSA
88 Med/Surg 3.6 4.7 31% Medication room is very
small for two people
After discussing with staff, changed medication
preparation to a larger room.
These people address safety issues. It may not always get
addressed the way you want it to, but it still gets addressed.
47 ED 3.0 3.8 28% Need prompt response from
pharmacy for selected meds;
need lift equipment for obese
patients; Pyxis* IT display
disposed to medication errors
Installed phone system with priority access to
pharmacy; identified or added lift equipment;
reprogrammed Pyxis IT display
We understand what needs to be done – trying to get rid of
verbal orders, trying to set up our Pyxis machine differently
39 ED 4.0 5.0 25% Feel like ?dumping ground?
when the clinic closes;
Roof leaks, need more
blood pressure machines
Relocated clinic in to expand ED patients; hired
additional ED staff; fixed roof; provided blood
pressure equipment
Nurse almost gave wrong medication because two similar
drugs next to each other in Pyxis. Told CNO. Pharmacist
came up right away and changed drawer
34 OR/PACU 5.0 3.8 25% OR table not safe for bariatric
patients; insufficient checking
of patient labs prior to surgery
No solutions listed Anyone can submit safety idea to their vice president. It gets
sent out for review to applicable departments
119 OR/PACU 3.8 2.6 31% Need exhaust air, some equipment
(chairs), backup of patients in ED,
beds not ready
Changes to improve air, equipment ordered
or repaired, working on flow in ED
It is hard to find the time and energy [to sustain this program]
because there are other demands that pour in.
129 ED 4.4 3.0 31% Long lead times for radiology and
lab, ties up rooms, long waits
in ED, units not taking patients
No solutions listed Spent 30 minutes deciding on priority scores with no discussion
of actions to resolve them
9 ED 2.9 1.9 33% 13/22 problems were audit items
by managers such as: Not
washing hands, leaving
cabinet unlocked
Nine solutions were to ?educate staff? No data about their solution efforts.
65 ED 4.3 2.0 53% Police bringing in dangerous
patients with only two people
on at night
Talk to police department about patients,
have security cameras, and panic buttons
You cannot fix them all, but you have to prioritize. Our patient
safety committee will end up doing that
PyxisTM is an automated medication-dispensing device used by nurses to administer medications to their patients.
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271,
? 2014 Production and Operations Management Society 265
preclude taking action. Furthermore, in some of the
work areas in the bottom quartile for change in PIP
scores, such as hospital 34s OR/PACU and hospital
65s ED, identified issues had to be validated by an
external group, such as the patient safety committee,
before resolution efforts would be authorized. This
additional step substantially slowed the pace of
change. Hospital 65s CEO explained his prioritization
philosophy, ?You can?t fix them all, but you have to
prioritize. Our patient safety committee will end up
doing that.? However, the safety officer from that hospital
explained the negative effect this had on staffs?
perceptions, ?What happens is you heighten the
awareness among people and then, if they don?t see
resolutions, then it becomes a bone of contention.?
5. Discussion, Implications, and
Limitations
In this study, we investigated the effectiveness of an
MBWA-based program in randomly selected hospitals.
We found evidence that participating in this particular
program decreased performance on average.
Given that many quality-improvement initiatives
fail to achieve expected gains (Beer 2003, Nair 2006,
Repenning and Sterman 2002), it is perhaps not surprising
that our program failed to yield positive
results for all work areas. Nonetheless, this is an
important result because many hospitals throughout
the United States and United Kingdom have implemented?and
continue to implement?similar programs.
Our study provides a cautionary tale that visits
by senior managers to the front lines of the organization
to solicit improvement ideas will not necessarily
increase staffs? perceptions of performance improvement.
There may be negative repercussions if senior
managers attempt, but fail, to engage meaningfully
with frontline staff. We suspect that the negative consequences
arose from soliciting, but not sufficiently
addressing, frontline staffs? concerns (Keating et al.
1999, Morrison and Repenning 2011). Failure to meet
expectations, once raised, can frustrate employees,
negatively impact organizational climate, and dampen
employees? willingness to provide future input
(Tucker 2007). Thus, our study suggests that there is a
hidden, psychological cost of asking employees for
ideas that are subsequently disregarded.
To understand why some units had better results
than others, we examined two approaches to problem
solving. Solving a higher percentage of the highestvalued
problems was not associated with increased
PIP. This result is similar to an earlier finding in the
TQM literature that formalization could overwhelm
actual improvement efforts, leading to employee dissatisfaction
with the program (Mathews and Katel
1992). Conversely, solving a higher percentage of
easy-to-solve problems was successful, lending support
for approaches that create a bias toward action.
This signals the value in addressing ?low-hanging
fruit,? at least in the short term (Keating et al. 1999,
Morrison and Repenning 2011). Our research does
not find that a focus on surfacing and resolving only
high-value problems yields improved staff perceptions.
Senior managers can facilitate a bias for action. We
found that having senior managers assume responsibility
for ensuring that problems get resolved was
associated with increased PIP. One explanation for
this finding is that organizational change often
requires senior managers to provide financial
resources to pay for required equipment, materials, or
labor; and organizational support to get an upstream
department in the organization to change how they
do their work if benefits accrue downstream. In other
words, senior managers can help ensure that action
happens. Given the improvement literature?s emphasis
on empowering frontline employees to solve problems
(Powell 1995), our finding may be interpreted as
highlighting the importance of empowering frontline
employees to identify and solve problems while supporting
those efforts by ensuring that organizational
obstacles to improvement are removed.
5.1. Implications for Theory
Manager commitment is associated with successful
implementation of performance improvement programs
that rely on frontline employee participation
(Ahire and O?Shaughnessy 1998, Coronado and
Antony 2002, Kaynak 2003, Nair 2006, Worley and
Doolen 2006). We found that a program that stimulated
managerial involvement was productive for
some, but not all, work areas. An explanation of the
negative result of our MBWA-based program was
that asking employees for their suggestions and then
not implementing them sent the message that
employees? ideas were not valued and that the program
was symbolic. Research by Miles supports this
explanation (1965). He postulated that managers hold
one of two beliefs about the value of employee participation
programs. One belief was that frontline staff
participation was valuable because it increased morale,
though the actual ideas they contributed were
unhelpful. These managers believed in the symbolic
value of employee participation programs, such as
MBWA. Miles (1965) found that improvement programs
failed when managers held this belief. The second
belief?which was associated with success in
Miles? study?was that interactions with frontline
staff were valuable because their ideas were actually
useful. The belief in the substantive value of employees?
ideas underlies a core TPS principle: respect for
people (Liker 2004). Miles? study suggests that senior
Tucker and Singer: The Effectiveness of MBWA
266 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
managers? respect for frontline employees? concerns
may have been an important but unmeasured moderator
variable for our MBWA program. An implication
is that rather than just seeking to increase manager
involvement, it may be critical first to ensure that
managers value the ideas raised by frontline staff.
An explanation for the lack of positive impact from
the high-value prioritization approach may be that
problem values in the hospital work areas in our
study had a relatively flat landscape. As a result, pursuing
a high-value prioritization approach did not
yield a substantial improvement over focusing on
easy-to-solve problems. The flat landscape may be
because the work areas had already addressed their
large-value problems or because the fragmented service
environment of health care creates a wide range
of small-scale problems. The easy-to-solve prioritization
approach may have been successful in our study,
because the work areas needed to first tackle fundamental,
lower-value problems before advancing to
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). Taking care of the basic
infrastructure and requirements is a necessary precursor
to more comprehensive organizational change
required by higher priority score problems (Keating
et al. 1999, Morrison and Repenning 2011).
There are likely circumstances under which prioritizing
high-value problems is helpful, such as when
only one idea can be fully developed, like implementation
of an enterprise-wide information system. We
also believe that organizations benefit from resolving
high-value problems, which tend to be top-down,
strategic improvements, as well as easy-to-solve problems,
which tend to be bottom-up, tactical initiatives.
Organizations should try to nurture both kinds of
problem-solving capabilities. For example, organizations
may have experts working on identifying and
solving high-value problems through six-sigma projects,
while frontline employees simultaneously work
on resolving smaller scale issues in their local work
area through lean initiatives. Furthermore, it may be
that organizations begin their improvement journey
by successfully resolving relatively easy problems,
but then need to develop new capabilities to resolve
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). For example, reducing the
time required to find vital sign monitor equipment on
a nursing unit likely requires different problem-solving
skills than reducing patients? lengths of stay in the
hospital.
5.2. Implications for Policy
Our study suggests that policy makers can play an
important role in improving safety in hospitals by
encouraging organizations to build problem-solving
capacity. Rather than requiring hospitals to participate
in a specific change program, such as MBWA,
that may not be fully validated, policy makers could
instead provide incentives for hospitals to build the
generic capacity to solve frontline problems. Given
the trend toward requiring hospital to implement
multiple quality-improvement initiatives concurrently,
we suspect that it is likely that many programs
are being implemented superficially and in ways that
lead to harmful results similar to those we observed
in this study. This could be contributing to the oftreported
failure to achieve gains through improvement
initiatives that frustrate the health-care industry
(Landrigan et al. 2010). Our study provides a warning
about mandating implementation of improvement
programs before fully understanding the conditions
required for the programs to yield successful outcomes.
The financial incentives used to encourage adoption
of electronic health records in the United States
may be instructive. Policy makers rewarded ?meaningful
use,? as demonstrated by the functionality that
was achieved, rather than rewarding implementation
of a particular software (Blumenthal 2010). Similarly,
policy makers could provide incentives for building
problem-solving capabilities that improve patientcentered
performance rather than advocate for a specific
improvement program.
5.3. Implications for Practice
Many initiatives to improve safety begin by trying to
increase employees? reports of near misses, errors,
and incidents (Bagian et al. 2001, Evans et al. 2007).
Implied assumptions are that increasing the number
of reports enables organizations to conduct trend
analysis that illuminates high-value problems which
can then be solved; and that many issues will be of
sufficiently low value that they can be ignored at low
or no cost to the organization. In contrast, our study
suggests that there may be little benefit, and some
potential harm, to this approach. Rather than increasing
reporting, organizations might be better served by
addressing known problems, which builds problemsolving
capabilities, which in turn enables actiontaking
on more problems. Our finding corroborates
prior research that highlighted the importance of
problem-solving capacity for successful improvement
programs (Adler et al. 2003, Keating et al. 1999, Morrison
and Repenning 2011). This advice is consistent
with the vision for a continuously learning health-care
system articulated by the US Institute of Medicine,
requirements for which include systematic problem
solving. Our study also resembles Kaizen, a structured
problem-solving approach involving managers
and frontline workers. However, important differences
that may make Kaizen more successful than our
program are that Kaizen occurs after managers and
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 267
frontline staff have been trained on a standardized
problem-solving technique and that it emphasizes
taking action to solve as many problems as possible
within the given time period (Imai 1986). Thus, it prevents
resource depletion by limiting the time spent
identifying and solving problems rather than by
selecting among them.
5.4. Limitations
Our findings must be considered in light of study
limitations. First, our small sample size limited our
analysis. Our sample was small for several reasons.
The cost- and time-intensive nature of conducting an
experiment with hospitals over 18 months made it
challenging to conduct our field-based, interventional
program with 24 organizations, and we would
have struggled if there were more. In addition,
despite our providing a method of prioritizing problems,
many organizations chose not to assign prioritization
values and therefore work-area coded data
on problem value were not available for all treatment
work areas. Future research with larger sample sizes
could test more nuanced theory. For example, an
easy-to-solve prioritization approach may be most
successful for work areas that start from a weak
position and can benefit most from action, whereas a
high-value prioritization approach may be most
helpful for experienced work areas that can be more
selective.
A second limitation is the perceptual measure of
improvement. Hospitals were unwilling to share
actual safety incident measures with us. In addition,
publicly available clinical measures, such as mortality,
readmissions, and process of care measures,
started being reported publicly only after the initiation
of this study. Although we conducted analyses
using these ?post study? clinical outcome data, the
regressions were not significant in explaining variation.
However, for reasons detailed above, a perceptual
measure is an important indicator of the impact
of the intervention we tested. Furthermore, prior
research on an MBWA-based intervention that did
have access to clinical outcome data did not find links
between multiple clinical outcomes and the intervention
(Benning et al. 2011), corroborating our study
results.
Third, hospitals did not track resources spent on
solution efforts. Therefore, estimation was the only
way of testing the alternate explanation that spending
more money on process improvement yielded better
outcomes. Future research could contribute to
improvement theory by examining the cost of
improvement efforts compared to benefits. A fourth
limitation is that we did not randomize an easy-tosolve
prioritization approach vs. a high-value prioritization
approach among work areas. Instead, those
differences emerged naturally. A randomized assignment
of these two prioritization approaches would
provide a stronger test of the hypotheses.
5.5. Conclusions
Understanding the impact of MBWA-based programs
is helpful for organizations that may be considering
implementing them. In our study, organizations
whose managers ensured that problems were
addressed achieved better results. This suggests that
improvement programs are more likely to change
employees? perceptions when they result in action
being taken to resolve problems than when they are a
symbolic show of manager interest. On the basis of
study findings, we recommend that organizations
focus on increasing their capacity to act on improvement
suggestions rather than expending further effort
on generating more suggestions and prioritizing
them.
Acknowledgments
Funding was provided by Agency for Healthcare Research
and Quality RO1 HSO13920. Additional funding was
obtained from Fishman Davidson Center at Wharton. Jennifer
E. Hayes provided valuable data coding assistance.
Appendix A: Survey Questions for
Perceived Improvement in Performance
The quality of services I help provide is currently the
best it has ever been.
We are getting fewer complaints about our work.
Overall, the level of patient safety at this facility is
improving.
The overall quality of service at this facility is
improving.
Appendix B: Interview Questions
B.1. FrontLine Personnel Interview Protocol
I wanted to ask you some questions about the patient
safety culture at this hospital. We recognize that most
hospital personnel experience problems in the course
of their work and that these are not a reflection of
their skill level or of the quality of care provided at
their facility. My goal is to understand differences in
safety culture among organizations.
1. Do personnel on this unit talk openly about
safety issues and errors?
2. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
Tucker and Singer: The Effectiveness of MBWA
268 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
care to patients think about reporting incidents
related to patient safety.
3. Have you ever reported something? What
made you decide to report that incident? What
happened as a result of reporting? Did you
ever learn the outcome?
Can you recall a specific adverse event that
was caused by an error or series of errors?
What happened? Can you describe the investigation
process (i.e., what happened to people
involved, what changes, if any, resulted from
the investigation)?
My last question relates to a major change in a
care process at your hospital.
4. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced in your unit?
Probe: What training did you receive? Has
implementation required any workarounds of
the built-in features of the system?
B.2. Manager Interview Protocol
I wanted to ask you some questions about the
patient safety culture at this hospital. We recognize
that most hospital personnel experience problems
in the course of their work and that these are not a
reflection of their skill level or of the quality of
care provided at their facility. My goal is to understand
differences in safety culture among organizations.
1. Do you feel comfortable talking about safety
issues and errors in your manager meetings
with senior leadership?
2. Do you encourage your staff to speak up?
How?
3. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
care to patients think about reporting incidents
related to patient safety.
4. Can you step through a recent ?near-miss?
safety report that you addressed? Briefly (do
not need details) what was the situation and
what was the response, if any?
5. Can you recall a specific adverse event that
was caused by an error or series of errors?
Briefly, what happened? Can you describe the
investigation process (i.e., what happened to
people involved, what changes, if any, resulted
from the investigation)?
My last question relates to a major change in a
care process at your hospital.
6. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced to a unit? Probe:
What training was provided? Has implementation
required any workarounds of the built-in
features of the system?
B.3. Hospital Administrator Interview Protocol
I wanted to ask you some questions about your daily
activities as a hospital executive and your views on
the patient safety culture at your hospital. We recognize
that leadership styles and organizational cultures
are unique at every institution and none is necessarily
better than any other. My goal is to understand the
full variation among organizations.
1. What are your primary priorities for the hospital?
[Prompt if it is not mentioned] Where does
patient safety fall in your list of priorities?
2. How do you see your role in patient safety? In
what ways do you provide leadership in this
area?
3. How would you describe the general attitude
of health-care professionals and employees
within the hospital toward patient safety?
4. It is well known that middle managers are a
key to implementation, and these people are
often extremely pressed due to budget constraints.
What is the situation with middle
managers in your hospital?
5. How do you obtain information about the hazards
present at the front lines of your organization?
6. Thinking about the most recent major organizational
change related to patient safety, can
you describe the change, your decision-making
process, and its implementation? Probe: Did
some event or new piece of information
prompt your decision to implement the
change? Did you evaluate the business case
before making the change?
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Write a 2 page paper addressing the following elements in your paper:
? Discuss and Explain the managerial tool of management by walking around (MBWA) and its impact on creating a strategy ready culture.

Include a title page and 3-5 references. Only one reference may be from the internet (not Wikipedia). The other references must be from the attached. Please adhere to the Publication Manual of the American Psychological Association (APA), (6th ed. 2nd printing) when writing and submitting assignments and papers.

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The Effectiveness of Management-By-Walking-Around:
A Randomized Field Study
Anita L. Tucker
Harvard Business School, Soldiers Field Road, Morgan Hall 413, Boston, Massachusetts 02163, USA, atucker@hbs.edu
Sara J. Singer
Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts 02115, USA, ssinger@hsph.harvard.edu
Management-by-walking-around (MBWA) is a widely adopted technique in hospitals that involves senior managers
directly observing frontline work. However, few studies have rigorously examined its impact on organizational outcomes.
This study examines an improvement program based on MBWA in which senior managers observe frontline
employees, solicit ideas about improvement opportunities, and work with staff to resolve the issues. We randomly
selected hospitals to implement the 18-month-long, MBWA-based improvement program; 56 work areas participated. We
find that the program, on average, had a negative impact on performance. To explain this surprising finding, we use
mixed methods to examine the impact of the work area?s problem-solving approach. Results suggest that prioritizing
easy-to-solve problems was associated with improved performance. We believe this was because it resulted in greater
action-taking. A different approach was characterized by prioritizing high-value problems, which was not successful in
our study. We also find that assigning to senior managers responsibility for ensuring that identified problems get resolved
resulted in better performance. Overall, our study suggests that senior managers? physical presence in their organizations?
front lines was not helpful unless it enabled active problem solving.
Key words: health care; implementation research; patient safety; quality improvement; survey research
History: Received: February 2013; Accepted: January 2014 by Edward G. Anderson, Jr. after 2 revisions
1. Introduction
Hospitals face an imperative to improve quality of
care and decrease medical errors that harm patients.
Healthcare thought leaders and policy makers have
advocated for the adoption of ?management-by-walking-around?
(MBWA) to achieve these goals, resulting
in widespread adoption in the United States and
the United Kingdom. (Frankel 2004, National Patient
Safety Agency 2011). These types of programs?in
which senior managers visit the front lines to work
with staff to identify and resolve obstacles?came to
the attention of hospitals with the publication of one
health-care system?s success at improving safety climate
through its MBWA-based intervention (Frankel
et al. 2003).
Despite the intuitive appeal of MBWA and history
of use in manufacturing organizations, empirical evidence
on the program?s efficacy in the hospital setting
is mixed. Of seven hospitals that implemented an
MBWA-based program, only two were able to sustain
the effort over a 3-year period (Frankel et al. 2008).
Those two reported a positive impact on staffs? perceptions
of safety climate, but the effect on the five
aborting hospitals was not reported. A study of one
Veterans Affairs hospital found that patient safety climate
worsened on two units that implemented the
program, while it improved or stayed the same on
two control units that did not implement the program
(Singer et al. 2013). Another found that hospitals that
implemented a general improvement program with
an MBWA component did not improve on a variety
of measures compared to control hospitals (Benning
et al. 2011).
These mixed findings provide only modest support
for widespread implementation of this program in
hospitals. The lackluster performance of MBWA in
health care may be that health care?s specialized and
diverse disciplinary knowledge bases (e.g., cardiology,
pulmonary, surgery, pharmacy, nursing, etc.)
creates a complex environment where it is difficult for
senior executives to effectively observe frontline work
and provide improvement suggestions (Aflaki et al.
2013). In addition, the highly regulated nature of
health care may minimize the marginal effectiveness
of MBWA because other audit programs, such as government-mandated
inspections or incident-reporting
systems, already focused senior managers? attention
on the front lines of care (Iyer et al. 2013). Furthermore,
the mixed results may be due to implementation
253
Vol. 24, No. 2, February 2015, pp. 253?271 DOI 10.1111/poms.12226
ISSN 1059-1478|EISSN 1937-5956|15|2402|0253 ? 2014 Production and Operations Management Society
differences, such as the prioritization methods used
to determine which problems get resolved. However,
prior studies have not assessed MBWA programs at a
more granular level. As a result of the contextual
differences in health care and limitations of prior
research, much remains to be discovered about
what factors and implementation approaches are
associated with the success of MBWA in hospitals.
To test more systematically the impact of MBWAbased
improvement programs and to identify factors
associated with its success, we implemented one
such program in 19 randomly selected hospitals. We
compared nurses? perceptions of improvement in
performance (PIP) in work areas that implemented
the program to the same type of areas at 68 randomly
selected control hospitals that did not implement
the program. A contribution of our study is
thus a rigorous testing of an MBWA program. More
specifically, our study design minimizes two methodological
challenges of research on improvement
programs. First, we minimize selection bias by randomly
assigning organizations to the treatment condition.
Our study thus provides insight into the
program?s generalizability beyond those where
senior managers decided on their own to implement
such a program. Second, the use of control organizations
reduces the possibility that positive (or negative)
results were caused by time-dependent
variables, such as changes in technology, policies, or
awareness over time. Surprisingly, we find that, on
average, our MBWA-based program had a negative
impact on nurses? perceptions of performance, suggesting
that senior managers? presence in hospital
front lines to solicit improvement ideas could be detrimental
to workers? perceptions.
A second contribution of our study is developing a
categorization of problem-solving approaches that
explains the conditions under which improvement
solicitation programs, such as MBWA, are successful.
We find that our MBWA-based program was associated
with improved perceptions of performance
under two conditions: (1) when a higher percentage
of solved problems were considered ?easy? to solve,
enabling more problem solving and (2) when senior
managers took responsibility for ensuring that identi-
fied problems were resolved. This suggests that the
action-taking that results from the program, rather
than the mere physical presence of the senior managers,
is what positively impacts the frontline staff.
In section 2, we describe prior research on MBWA
programs and develop four hypotheses linking the
program to performance. In section 3, we describe
the intervention, the sample of hospitals that participated
in the research project, and our qualitative and
quantitative data, measures, and analytic approach.
We present the results in section 4 and discuss the
implications for research, practice, and policy in
section 5.
2. MBWA-based Improvement
Program?s Impact on Performance
Research has found that quality improvement programs
that solicit frontline workers? ideas, such as
MBWA, can have a beneficial impact on organizational
outcomes (Dow et al. 1999, Powell 1995).
MBWA relies on managers to make frequent, learning-oriented
visits to their organization?s front lines to
observe work and solicit employees? opinions (Packard
1995). Hewlett-Packard, the company in which
MBWA originated, attributed its success using
MBWA to good listening skills, willing participation,
a belief that every job is important and every
employee is trustworthy, and a culture where
employees felt comfortable raising concerns (Packard
1995). MBWA is similar to the Toyota Production System?s
?gemba walks? (Mann 2009, Toussaint et al.
2010, Womack 2011). In a gemba walk, managers go
to the location where work is performed, observe the
process, and talk with the employees (Mann 2009).
The purpose is to see problems in context, which aids
problem solution (Mann 2009, Toussaint et al. 2010,
Womack 2011).
MBWA has resulted in positive organizational
change in some hospitals (Frankel et al. 2003, Pronovost
et al. 2004). One explanation is that MBWA leads
to successful problem resolution because seeing a
problem in context improves managers? understanding
of the problem, its negative impact, and its causes.
This understanding increases managers? motivation
and ability to work with frontline staff and midlevel
managers to resolve the issue (Mann 2009, Toussaint
et al. 2010, Von Hippel 1994, Womack 2011). Theory
further suggests that MBWA?s repeated cycles of
identifying and resolving problems may create an
organizational capability for improvement that
reduces the cost of future improvement efforts, creating
a positive dynamic (Fine 1986, Fine and Porteus
1989, Ittner et al. 2001). This virtuous cycle is further
strengthened because communication from frontline
workers about problems aligns managers? perspectives
with customers? experiences (Hansen et al. 2010,
Hofmann and Mark 2006, Huang et al. 2010, Singer
et al. 2009), enabling managers to effectively allocate
scarce resources among the organization?s multiple
improvement opportunities. Performance is also
enhanced because managers? presence on the front
lines sends a visible signal that the organization is
serious about resolving problems. This increases
employees? beliefs that leadership values improvement,
which in turn spurs employees to engage in the
discretionary behaviors necessary for process
Tucker and Singer: The Effectiveness of MBWA
254 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
improvement (Mcfadden et al. 2009, Zohar and Luria
2003). For these reasons, we hypothesize that MBWA
will positively impact performance.
Hypothesis 1 (H1). Participation in a MBWAtype
program leads to improved performance.
2.1. The Effect of Problem-Solving Approach
Although we hypothesize a positive impact from
MBWA, programs that solicit employee suggestions
can uncover more problems than an organization can
resolve, given limited problem-solving resources
(Bohn 2000, Frankel et al. 2003, Repenning and Sterman
2002). When this happens, the organization?s
problem-solving support personnel must decide
which of the identified issues they will work to
resolve and which ones will be ignored or delayed
(Keating et al. 1999, Morrison and Repenning 2011).
Thus, an MBWA?s program?s success may be contingent
upon which problems the organization decides
to address.
We examine two different prioritization
approaches, discuss their benefits and limitations,
and develop two hypotheses. We explore two dimensions
of problems: solution difficulty and value
gained by solving the problem (Aflaki et al. 2013). To
simplify the discussion, we consider only two levels
of each dimension: problems are either easy to solve
or difficult to solve; and they can yield either a small
or large value if solved. Organizations are likely to
prioritize problems that are of high value and/or
problems that are easy to solve. Although we develop
hypotheses based on the assumption that organizations
have a dominant prioritization scheme (such as
addressing high-value problems), we recognize that
organizations could combine the two approaches.
This implies that they would emphasize high-value,
easy-to-solve problems while ignoring problems that
were both difficult to solve and of low value (Aflaki
et al. 2013).
The first prioritization approach that we consider is
one that addresses issues that are causing?or have
the potential to cause?large disruptions. This highvalue
prioritization approach ranks problems according
to a value score and solves the highest-valued problems.
Many structured approaches to improvement,
such as six-sigma and risk management, use a highvalue
prioritization approach (Anderson et al. 2013a,
b). In the health-care context, hospital incident-reporting
systems (Bagian et al. 2001) and MBWA-based
programs (Frankel et al. 2003) advocate calculating a
problem?s ?value? by multiplying the problem?s score
for severity with its frequency of occurrence (Bagian
et al. 2001, Frankel et al. 2003). The hospital then
resolves the highest-value problem first, followed by
the second highest, continuing until problem-solving
resources are depleted or remaining problems fall
below a threshold value (Bagian et al. 2001). Surfacing
and solving the highest-valued problems should yield
substantial gain in performance (Bagian et al. 2001,
Girotra et al. 2010). To provide an example in the hospital
setting, medication-related problems are often of
high value because they can be fatal and can impact
many patients (Bates et al. 1995). In response, many
hospitals have implemented computerized physician
order entry systems which reduce medication errors
by preventing transcription errors and alerting physicians
to potential drug allergies or interactions (Bates
et al. 1999).
This approach is beneficial because it ensures that
limited resources are preserved for problems with
the highest values (Frankel et al. 2003). It also helps
prevent the queue of unsolved problems from growing
unmanageably long by permitting the organization
to discard the subset of problems that are
deemed too little valued to justify solution efforts
(Bohn 2000).
However, there is a downside to focusing exclusively
on high-value problems. The ignored problems
constitute the ?useful many? which individually do
not have a large negative impact on performance
(Juran et al. 1999), but which collectively could contribute
to serious problems such as medical errors
(Reason 2000).
Thus, the second approach that we consider is
prioritizing easy-to-solve problems (Johnson 2003,
Repenning and Sterman 2002). An easy-to-solve prioritization
approach enables the organization to address
problems that are straightforward and quick to
remedy?the so-called ?low-hanging fruit.? This
approach may free up resources for addressing problems
because the more formal approach of assigning
a prioritization score based on severity and occurrence
has required significant resources in the case of
incident-reporting systems in both aviation and
health care (Johnson 2003).
An easy-to-solve prioritization approach may also
be helpful in health-care settings because the cumulative
benefit of resolving many small problems can
add up to be a significant source of improvement
(Jimmerson et al. 2005). Similarly, research has found
that major accidents typically result from an unpredictable
combination of small magnitude problems
rather than from a single large magnitude problem
(Perrow 1984, Reason 2000). According to the ?Swiss
Cheese Theory,? multiple small-scale problems can
align in an unfortunate way that enables an error to
harm the customer (Cook and Woods 1994, Reason
2000). Consequently, resolving seemingly low-value
problems can be beneficial, because they otherwise
might contribute to the next major accident (Perrow
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 255
1984). To illustrate, a study of medical harm in cardiac
surgery found that adverse events were more likely to
be caused by multiple, simultaneous ?minor? issues
than by a single, ?major? issue. This was because surgeons
were less able to perceive and compensate for
multiple, simultaneous minor issues while they were
able to recognize and remedy a single, major issue
that occurred during surgery (De Leval et al. 2000).
This line of research implies that it is difficult to
assign a ?value? to problems because their negative
impact is determined in part by the specific situation
in which they occur.
Another situation in which the easy-to-solve prioritization
approach may be superior is where the organization
has a ?flat landscape? of small magnitude
problems. In flat landscapes, the difference between a
local high point and the global high point is too small
to justify an extensive search effort (Sommer and Loch
2004). This can occur in hospitals for two reasons.
First, managers typically address issues that result in
patient death or other serious injury such as wrong
site surgery. Thus, the only problems that remain
may be small magnitude issues. Second, there are
many unique opportunities for patient care to fail
because work is divided among specialties, departments,
and shifts. Problems can occur at any of these
handoffs. Thus, unlike manufacturing settings where
an undetected malfunction in a machine can be the
dominant source of defective product, it is less likely
that there is a single, dominant source of repeated failures
in hospitals. When there is a flat landscape,
improvement arises from solving the lower tail of
problems.
It may also be that organizations need to address
basic, fundamental problems before they can benefit
from trying to address more complex organizational
issues. For example, research suggests that problemsolving
efforts are most successful when organizations
use relatively straightforward problems to
develop sufficient problem-solving capacity before
tackling larger, more complex issues (Keating et al.
1999, Morrison and Repenning 2011). Addressing
easy-to-solve problems enables frequent problemsolving
cycles, which develops employees? expertise
at problem solving (Adler et al. 2003). These dynamics
suggest that organizational problem-solving
capacity is more like a muscle that strengthens with
exercise rather than a resource that gets depleted with
use (Fine 1986, Fine and Porteus 1989, Ittner et al.
2001).
We draw on the arguments outlined in the above
paragraphs to develop two hypotheses. When problem-solving
resources are limited and become
depleted with use, the organization should focus its
scarce human and financial capital on removing the
problems that pose the biggest threat. Thus, a highvalue
prioritization approach will be associated with
improved performance.
Hypothesis 2 (H2). Work areas that resolve a
higher percentage of high-value problems will
have greater improvement in performance than
work areas that solve a lower percentage of
high-value problems.
An easy-to-solve prioritization approach should be
associated with improvement because it fosters solution
of all problems that can be solved, regardless of
their hypothetical value. In the health-care setting,
this might benefit the organization because seemingly
small-value problems can nonetheless negatively
impact patient safety. Furthermore, the act of solving
problems develops the organization?s capability to
solve more problems in the future. Thus,
Hypothesis 3 (H3). Work areas that solve a
higher percentage of easy-to-solve problems will
have greater improvement in performance than
work areas that solve a lower percentage of
easy-to-solve problems.
2.2. The Role of Senior Managers in Problem
Solving
In addition to the prioritization approach, the success
of an MBWA program depends on senior managers?
willingness to take responsibility for ensuring that
problems identified through the program are resolved
(Frankel et al. 2005, Pronovost et al. 2004).
Senior managers can be helpful to frontline workers?
resolution efforts because they control financial
resources needed to address issues that involve capital
investment (Carroll et al. 2006). In addition, they
possess the perspective necessary to resolve conflicts
that arise when problems cross organizational boundaries
(MacDuffie 1997). This insight is valuable particularly
because high-value problems are likely to cross
organizational boundaries or require financial
resources to resolve.
On the other hand, easy-to-solve problems impact
only one department and do not require substantial
financial resources to resolve. Under these conditions,
frontline employees can be empowered to identify
and resolve problems (Jimmerson et al. 2005). However,
involving frontline workers in resolution efforts
requires them to take time away from their direct production
responsibilities (Repenning and Sterman
2002, Victor et al. 2000). This can be difficult for frontline
employees, especially for health-care workers
who provide direct patient care. Under these conditions,
senior managers need to allocate funds for overtime
or coverage so that care providers can spend
time away from patient care and on resolution efforts.
Tucker and Singer: The Effectiveness of MBWA
256 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
As outlined in the two above paragraphs, both
high-value and easy-to-solve problems require manager
support for successful resolution. Therefore, we
hypothesize that hospital work areas will achieve better
results from the MBWA program when they
assign to senior managers the responsibility for ensuring
that a problem gets addressed.
Hypothesis 4 (H4). Work areas with a higher
percentage of problems assigned to a senior
manager to ensure resolution exhibit greater
improvement than those with a lower percentage
of problems assigned to a senior manager.
These four hypotheses outline the theoretical links
between our MBWA-based program and improved
performance. Figure 1 depicts these relationships.
3. Methodology
We test our hypotheses in a field study of US hospitals
randomly selected to participate in a patient
safety research study, with a subset of the hospitals
randomly selected (a second time) to implement our
MBWA-based program. The program was launched
in January 2005 and lasted for 18 months.
3.1. The MBWA-based Program
We drew on prior research to design our MBWAbased
program (Frankel et al. 2008, Pronovost et al.
2004, Thomas et al. 2005). It consisted of repeated
cycles of senior manager?staff interaction, debriefing,
problem solving, and follow-up. Senior managers
such as the chief executive, operating, medical, and
nursing officers (CEO, COO, CMO, and CNO, respectively),
interacted with frontline staff in a work area
to generate, select, and solve improvement ideas. The
work area manager was also involved in the selection
and solution activities. Senior manager interactions
took two forms: visits, called ?work system visits,? to
work areas to observe frontline work; and special
meetings, called ?safety forums,? with a larger group
of frontline staff from the area to discuss safety concerns.
The activities were coordinated with the work
area manager.
In work system visits, four senior managers would
spend 30 minutes to 2 hours visiting the same work
area. The senior managers would each observe a different
process, such as medication administration, or
a different person, such as a nurse or physician, to
shed cross-disciplinary insight into the work done in
the area. The purpose was to build senior managers?
understanding of the frontline work context and
gather grounded information about problems (Frankel
et al. 2008).
Senior managers also facilitated a safety forum in
the work area, which was an informal meeting
between senior managers and the frontline staff from
the work area, held in the work area, during which
the staff talked about their work area?s safety weaknesses
and strengths. We added this component to
our MBWA-based intervention for two reasons. First,
a San Diego children?s hospital improved its organizational
climate by holding meetings where frontline
staff spoke directly to the hospital CEO about their
concerns and ideas (Sobo and Sadler 2002). Second,
a prior research project on an MBWA-based program
found that the program only improved the
perceptions of frontline staff who participated in a
work system visit (Thomas et al. 2005). Because it is
not feasible for senior managers to conduct a work
system visit with every single hospital employee
within a short time period, Thomas? finding suggests
that work system visits on their own will be insuffi-
cient to change the perceptions of most hospital
employees.
The MBWA-based program continued with a
?debrief meeting,? which organized information collected
from the work system visits and safety forums.
Senior managers attended, as did work area managers,
selected frontline workers, and the hospitals?
patient safety officers. The group compiled the
improvement ideas identified, discussed and in some
work areas prioritized them, and decided next steps,
ranging from doing nothing to suggesting solutions
and assigning responsibility. Action to address problems
selected for resolution followed the debriefing.
Managers were encouraged to communicate with
staff about implementation efforts, describing what
changes, if any, were made in response to identified
ideas. Patient safety officers entered the ideas
MBWA
Program Performance
Problem solving activities
used in MBWA
Address highvalue
problems
Address ?easy-tosolve?
problems
Managers ensure
problems are
resolved
H1+
H2+
H3+
H4+
Figure 1 Model of Management-By-Walking-Around?s Impact on Performance
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 257
generated and actions taken into an electronic spreadsheet
we provided and sent this spreadsheet to our
research team for analysis.
Each round of work system visits, safety forums,
debrief meeting, solution activities, and communication
constituted one cycle. A cycle focused on one
work area and took approximately 3 months, which
research has shown is the time required to solve problems
in an organization (Pronovost et al. 2004). See
Figure 2 for a diagram of the process. After completing
a cycle, the management team would repeat the
activities in a different work area. The program
focused on the four main work areas in hospitals:
operating room or postanesthesia care unit (OR/
PACU), intensive care unit (ICU), emergency department
(ED), and medical or surgical ward (Med/Surg).
Cycles continued over the 18-month implementation,
with hospitals conducting an average of one cycle in
four work areas.
3.2. Recruitment
Our study employed an experimental design which
included a pre-test and post-test of similar work areas
in treatment and control hospitals. We randomly
selected 92 US acute-care hospitals, stratified by size
and geographic region, to participate in a patient
safety climate survey. We provided no financial
incentive, but participation in the safety climate study
fulfilled a national accreditation requirement. At
enrollment, all hospitals were aware that they may be
invited to participate in a program to improve patient
safety, but details regarding the program were withheld
to prevent contamination of control hospitals. To
select hospitals to participate in the MBWA-based
program, we drew a second, stratified, random sample
of 24 hospitals from the sample of 92. The remaining
68 hospitals not selected were control hospitals.
Data on staff perceptions of performance were
collected at control and treatment hospitals through
surveys before implementation of program activities
(2004, ?pre?) and again after the program was completed
(2006, ?post?). At each hospital, we surveyed a
random sample of 10% of the frontline workers, with
additional oversampling in OR/PACUs, EDs, and
ICUs in the post-survey period to improve sample
size. The baseline ?pre? response rate was 52%; and
the follow-up ?post? response rate was 39%. For our
analyses, we used data from registered and licensed
vocational nurses (n = 1117 pre and n = 903 post).
Of the 24 treatment hospitals, 20 completed the program
in at least two work areas. Of the four that did
not complete the treatment, one went out of business,
one was purchased, and two experienced significant
senior management turnover. As a result, they were
unable to complete more than one cycle of activities
and did not provide data. We thus excluded these
four from our analysis. There was no difference in
staff perceptions of performance in the pre-period
between the four hospitals that dropped out of the
treatment and the 20 that did not. Of the original 68
control hospitals, 48 completed the post-test survey,
making an initial total sample of 68 hospitals. There
was no difference in survey measures in the pre-period
between the 20 control hospitals that dropped out
of the post-survey and the remaining hospitals. There
was also no difference between treatment and control
work areas on pre-period measures of staff perceptions
of performance.
3.3. Data and Measures
Using the data collection spreadsheet that we provided
(Figure 3), treatment work areas reported 1245
patient safety problems identified during the visits
and forums. Each hospital also provided a list of the
C
E O
C
N O
C
M O
C
F O
Work
site visit
by CEO
Time
Work
site visit
by CNO
Work
site visit
by CMO
Work
site visit
by CFO
Safety
Form
Debrief
Meeting
Solution Activities &
Communication
Figure 2 Depiction of the MBWA-based Program Activities in a Work Area
Tucker and Singer: The Effectiveness of MBWA
258 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
senior managers, which we used to determine
whether a senior manager attended the program
activity and whether a senior manager was assigned
responsibility for the problem. The spreadsheet also
contained three columns that the work areas could
use to prioritize identified problems. Twenty-four
work areas in eight hospitals filled out this information.
3.3.1. Independent Variables. To test the overall
impact of the MBWA-based program (H1), we created
a treatment variable, ?MBWA in the work area,?
which indicated whether the work area received the
MBWA-based treatment (=1) or was a work area from
a control hospital (=0). To test the high-value prioritization
approach (H2), we calculated a value score for
each problem by multiplying problem severity (column
7 in Figure 3; 1 = low; to 10, could cause death)
by estimated frequency of occurrence (column 8;
1 = very unlikely, 3 = very likely) (Bagian et al. 2001,
Frankel et al. 2003). This method for calculating the
potential value of solving a problem is similar to sixsigma?s
risk prioritization number, which uses the
product of the scores (on a scale from 1 to 10) of a
problem?s frequency of occurrence, detectability, and
severity (Evans and Lindsay 2005). It is also similar to
risk registers used for risk management. A risk register
scores each potential risk to a project by multiplying
the risk?s likelihood of occurrence by severity of
the impact if it does occur (Anderson et al. 2013a,b).
We used our value score in combination with whether
or not the problem was addressed (column 10 in Figure
3) to create a unit-level variable that represented
the percentage of problems in the top quartile
(ranked by value) that were resolved, which we call
?% of top quartile that were resolved.? As an alternate
test of H2, we also created a dummy variable,
?Top ranked problem resolved?? A dichotomous
variable that indicated whether or not the top-ranked
problem in the work area was resolved. The alternate
specification for H2 allowed us to test our prediction
using innovation literature theory, which asserts that
success can come from identifying and solving even
just one high-value idea (Girotra et al. 2010). To test
the easy-to-solve prioritization approach (H3), we
calculated, from a work area?s set of problems that
were resolved, the percentage that were rated ?easyto-solve,?
a ?1? on a 3-point scale, meaning it is was
1 2 3 4 5 6 7 8 9 10 11 12 13
Hospital
#
Date of
Activity
Activity
Type:
Worksite
Visit or
Safety
Town
Meeting
Participant
from
Executive
team
Location “Hinderers” to
patient safety, or
system weaknesses
observed during
worksite visit, or
brought up during
safety town meeting
(one item per row)
Safety Risk:
1: Low
3: Mild
discomfort
5: Would require
intervention
10: Could cause
harm or death
Likelihood or
frequency of
risk
1=Very
unlikely
2=Possible
3=Very likely
Ease of implementation
1=Easy, within 30
days
2=Moderate-multiple
departments (90 days)
3 = Difficult-process
changes and/or major
budget (6 months)
Action items
or proposed
changes to
hinderers
Team
member(s)
responsible
for follow up
C-Suite
Yes = 1
No = 0
Date
change
completed
100 3/16/2
006
Worksite
Visit
Betsy
Green,
CNO
Medical/
Surgical
Unit
New diabetics?
insurance won’t pay
for glucometers.
Staff concerned
about patients’
inability to get the
devices and their
own need to learn
many different
devices based upon
what the patient
purchased. The delay
decreases the
amount of time
nursing staff have to
teach patients about
using the device.
10 2 2 Director of
Laboratory
Services
communicat
-ed the need
to a vendor
of diabetic
supplies.
Director of
Laboratory
Services and
CNO
1 Mar-06
100 Another problem of lower value would be here 2
100 Another problem of lower value would be here 2
100 3/14/
2006
Worksite
Visit
Jen
Calhoun,
Safety
Director
Medical/
Surgical
Unit
Overbed tables being
used to hold Personal
Protective Equipment
(PPE).
5 1 1 Isolation
Carts have
been
purchased
to hold and
store PPE
outside of
patient
rooms.
CNO and
Director of
Medical/
Surgical
Unit
1 1st cart
arrived
03/20/20
06
To test H2: % of the top quartile (of value) that were resolved =100%
To test H3: % of resolved problems that were ?easy-to-solve? =50%
To test H4: % of problems assigned to senior manager =50%
Value = 10*2 = 20
Top quartile? = 1 (yes)
Addressed? = 1 (yes)
Top quartile & addressed? = 1 yes
Figure 3 Data Collection Sheet Used by Treatment Hospitals and Two Problems as Examples
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 259
?easy and could be resolved within 30 days? (column
9 in Figure 3). The higher the percentage, the
more the unit solved easy-to-solve problems. We
called this variable ?% of problems solved that were
low-hanging fruit.? Finally, to test our hypothesis
about senior managers (H4), at the work area level
we found the percentage of problems for which a
chief executive level manager was assigned responsibility
for ensuring that the problem was resolved
(column 12 in Figure 3). See Figure 3 for details on
these variables.
3.3.2. Measure. In accordance with prior research
(Chandrasekaran and Mishra 2012, Frankel et al.
2003, 2005, 2008), we evaluated the program?s performance
using staff ?PIP.? To measure PIP, we used
four survey items (see Appendix A) from validated
survey instruments that measured the effectiveness of
quality improvement efforts (Shortell et al. 1995,
Singer et al. 2009). Respondents rated each item using
a 5-point scale ranging from 1 = strongly disagree to
5 = strongly agree. Agreement indicated that respondents
thought quality and safety performance were
improving. The scale exhibited high reliability (Nunnally
1967), with a Cronbach?s alpha of 0.84 (n = 1147
nurses) in the pre-period and 0.88 (n = 1103 nurses)
in the post-period.
We used perception of performance for four reasons.
First, employee perceptions are an important
outcome because they influence behaviors, which in
turn impact objective measures (Zohar and Luria
2003). Second, staff perceptions of performance are a
valid indicator of performance (Ketokivi and Schroeder
2004). This is because employees are close to the
work and often know if system failures are decreasing
or increasing. Research has found that nurses? perceptions
of safety are correlated with objective measures
of safety outcomes, such as mortality, readmissions,
and length of stay (Hansen et al. 2010, Hofmann and
Mark 2006, Huang et al. 2010, Singer et al. 2009).
Third, employee perceptions have been widely used
as outcome measures in operations management
research because they enable comparison across organizations
(Anderson et al. 2013a,b, Atuahene-Gima
2003, Bardhan et al. 2012, Chandrasekaran and Mishra
2012, Flynn et al. 1995, Kaynak 2003, Swink et al.
2006). Finally, the use of a perceptual measure was
necessitated by hospitals? unwillingness to share data
on safety incidents.
Our dependent variable was the change in PIP from
the pre- to the post-period. The use of change scores
allowed us to examine change over time (Fitzmaurice
2001). To create a composite change score for each
work area, we used the pre-data to calculate the
mean of the four items for each nurse, and then averaged
by work area. We repeated this process for the
post-data and subtracted each work area?s pre-score
from its post-score. We calculated intra-class correlations
(ICC) and a mean inter-rater agreement score
(rWG) to test whether aggregation of PIP was appropriate.
Significant (ICC[1] = 0.06, F = 5.69, p < 0.000,
and ICC[2] = 0.82) supported aggregation (Bliese
2000). The rWG for nurses? rating of PIP was 0.60,
which also was sufficient for aggregation (ZellmerBruhn
2003). Furthermore, our use of a change score
as our dependent variables met the two conditions
specified by Bergh and Fairbank (2002): the reliabilities
of our survey measures for PIP in pre- and postperiods
were high (0.84 and 0.86, respectively) and
the correlation between the measures from the two
different time periods was low (q = 0.24, p < 0.001).
As is common in studies using a change score (Bergh
and Fairbank 2002), the correlation between the
change score and the PIP measure in the pre-period
was negative (q = 0.67, p < 0.001). This indicates
that there was a greater opportunity for improvement
in PIP among work areas with a low PIP in the
pre-period (Fitzmaurice 2001). Therefore, to control
for impact of a work area?s starting point on the
change in PIP, we included a dichotomous variable
indicating whether PIP in the pre-period was in the
lower quartile (?bottom quartile for 2004 PIP?).
The variable was coded ?1? if the work area was in
the bottom quartile of work areas in PIP in the preperiod
and ?0? for all others. This method enabled us
to test for the change in PIP while controlling for a
low starting point.
3.3.3. Control Variables. For H1, which tested the
overall impact of our MBWA-based program, the
large sample size enabled us to include the following
control variables: major teaching hospital (1 = yes,
0 = no); Dun & Bradstreet?s measure of the hospital?s
financial stress, with higher numbers indicating a
higher likelihood that the business will seek legal
relief from creditors or cease operations without paying
creditors in full over the next 12 months; a set
of dummy variables for the number of hospital beds
(reference group = less than 100 beds; medium =
100?250 beds; large = more than 250 beds); and a set
of dummy variables for type of work area (reference
group = non-clinical; OR/PACU; ICU; ED; Med/
Surg unit; and other clinical unit). Data on size and
teaching came from the 2004 American Hospital
Association Survey of Hospitals.
For the hypotheses about problem prioritization
(H2 and H3), our sample size was limited to the 24
work areas that formally prioritized their problems in
the data collection spreadsheet. As a result, for these
hypotheses, we did not have a large enough sample
size to include non-significant control variables in
our regression. However, our random selection of
Tucker and Singer: The Effectiveness of MBWA
260 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
hospitals helps alleviate concerns that our model may
be subject to omitted variable bias (Antonakis et al.
2010). We did not include control variables for unit
type (e.g., ED, ICU, and OR/PACU) as none were significant
and their inclusion did not change our results.
We also tested for hospital-level control variables,
such as teaching status and number of beds, but none
were significant and their inclusion did not change
our results. We controlled for availability of ?lowhanging
fruit,? which was the percentage of identified
problems that were rated as easy to solve. We also
controlled for the average value of the top quartile of
identified problems.
Our regression equation for H4, the impact of a
senior manager being assigned responsibility for
problem resolution, included the full set of 58 intervention
work areas. We controlled for the percentage
of problems within a work area that were
resolved (% of problems resolved) by coding a problem
as having had solution effort if there was evidence
in the dataset that action had been taken to
address the problem, and taking the average of this
variable at the work area level. We also controlled
for the fidelity of implementation with the following
variables: the number of work system visits that
were conducted, whether a work system visit was
conducted by a senior manager (1 = yes, 0 = no),
and whether a safety forum was conducted in the
area (1 = yes, 0 = no).
3.4. Sample Size and Analysis
We used linear regression with robust standard errors
and clustered by hospital (Rabe-Hesketh and Everitt
2004) in Stata 11.1TM to test our hypotheses. The Shapiro?Wilk
test for all regressions showed that the residuals
were normally distributed (V close to 1 and
p > 0.10) (Royston 1992). Multicollinearity was also
not an issue as all variance inflation factors for all of
our equations were less than 2.5, well below the
upper threshold of 10 (Chatterjee and Hadi 1986).
To test the overall impact of our MBWA-based
program (H1), we use data from the four main clinical
work areas (OR/PACU, ICU, ED, and Med/
Surg). We had data for both pre- and post-PIP measures
from 58 intervention work areas in 20 treatment
hospitals and 138 work areas in 48 control
hospitals. However, missing data for a control variable
(financial stress) in two intervention work areas
resulted in a final sample size of 56 intervention
work areas. To test the impact of problem selection
(H2 and H3), we used data from the 24 work areas
from eight treatment hospitals that formally prioritized
their problems. Finally, to test the impact of
senior manager assignment to problem resolution
(H4), we used the full set of intervention work areas
(n = 58).
3.5. Qualitative Data Collection and Analysis
During the intervention, we visited each treatment
hospital to tour the clinical areas and to observe
MBWA activities, including work system visits, safety
forums, and debrief meetings. In addition, we discussed
and observed examples of changes implemented
in response to problems identified through
the program to verify accuracy of the data submitted.
There were no discrepancies. We also conducted
semi-structured interviews with a frontline staff
member, a department manager, and the CEO from
each hospital (see Appendix B). Interviews addressed
the nature of performance improvement in the hospital
in general and as it related to implementing the
MBWA-based program. Interviews and notes from
the meetings were recorded and transcribed. Investigators
also wrote a journal of the day?s activities from
notes taken during the day. The journal and transcripts
from each hospital were combined into a single
document, which served as our source of
qualitative data.
After the intervention was complete, we used
these qualitative data in combination with the problem
data submitted by the work areas to illuminate
differences among work areas in the types of issues
identified, actions taken to resolve them, and managers?
attitudes. We analyzed transcripts using the procedure
described in Miles and Huberman (1994, pp.
58?62). We initially used a list of codes based on our
interview questions. We read the transcripts multiple
times, revising the codes as we deepened our understanding
of similarities and contrasts among the
implementation of the program. How the managers
prioritized problems for solution efforts emerged as
a main theme. One author went through the qualitative
data to select all relevant quotes for this theme.
Both authors independently reviewed the quotes
while blinded from the performance results. We
compared our perceptions to come to a consensus.
We use the quotations to illustrate differences in
implementation approach that impacted the effectiveness
of the intervention. Table 6 in the results
section displays representative quotations from the
five work areas that improved the most over the
course of the intervention and the five that decreased
the most.
4. Results
4.1. Summary Statistics
Average PIP in the 56 treatment work areas was 3.78
in the pre-period and 3.69 in the post-period. The difference
of 0.09 was not statistically significant at the
10% significance level. The same four types of work
areas (n = 138) in control hospitals had a mean PIP of
3.8 in both time periods. Table 1 shows descriptive
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 261
statistics. Using the subset of work areas that prioritized
their problems (n = 24), the mean value score
for all identified problems was seven on the scale of 1
(lowest) to 30 (highest). Descriptive statistics and correlations
are shown in Table 2. On average, the mean
value score was 17 for the top quartile of identified
problems. The highest score, on average, was about
19.
4.2. Regression Results
Contrary to our prediction, the MBWA-based treatment
was associated with a statistically significant
decrease in PIP (0.17, p < 0.05) compared to the same
types of work areas in control hospitals (H1, Table 3,
Model 1). A possible explanation is that some treatment
work areas failed to conduct the recommended
activities (Nembhard et al., 2009). However, the following
statistics provide evidence that treatment
areas did indeed implement the MBWA-based program:
91% had a work system visit; each treatment
work area received a mean of 3.41 visits (SD = 3.16,
maximum of 12); 50% had a safety forum; on average,
they identified 19 problems and took action on 11
(Table 1).
The effectiveness of the program did vary, however,
among work areas. As shown in Model 1, our
control variable for whether or not the work area was
in the bottom quartile for pre-period PIP was signifi-
cant (b = 0.75, p < 0.001), suggesting that work areas
with the lowest PIP scores in the pre-intervention period
exhibited a positive change in PIP over the course
of the intervention. Additional analysis revealed that
the work areas that were in the bottom quartile for
our dependent.
variable, change in PIP, had a decline in PIP ranging
from 0.375 to 2.25. Of these 15 work areas that
experienced the greatest decline in PIP, four were
already below median in the pre-period, suggesting
that their decline was not merely a regression to the
mean effect. The work areas in the top quartile of
change in PIP experienced an increase in PIP ranging
from 0.38 to 1.33 points. This large variation in results
prompted us to examine factors associated with
success.
Model 1 in Table 4 shows results from testing H2
and H3. A higher percentage of problems solved that
were rated as ?easy-to-solve? was associated with
higher% change in PIP (coefficient = 1.00, p < 0.05),
providing support for H3. A one standard deviation
(27%) increase in the percent of solved problems that
were easy-to-solve was associated with a 1.0 point
increase in change in PIP, which was a 26% improvement.
However, the percentage of problems rated in
the top quartile for value that were solved was not
significant. Thus, H2 is not supported.
Testing H2 using highest-value score instead of the
mean priority of the top quartile and a dummy for
whether the top-ranked problem for value was
resolved instead of the percentage of problems rated
in the top quartile for value that was solved was also
not significant (Table 4, Model 2). This result fails to
support theory from the innovation literature suggesting
that solving the highest-value idea drives performance
in our context. However, the percentage of
problems resolved that were rated ?easy-to-solve?
remained significant in this model (coefficient = 0.82,
p < 0.01), providing additional support for H3. Prioritizing
easy-to-solve problems appeared to increase
PIP.
An alternate explanation for our finding could be
that work areas were more successful because they
spent more money on problem solving rather than
because they prioritized easy problems. To control for
this ?spend more? explanation, the authors individually
rated the rough cost of each solved problem on a
scale of 1?3 with 1 = low (cost = $500), 2 = medium
(cost > $500 < $150,000), and 3 = high (cost =
$150,000) based on the description of how work areas
solved the problem and independent research to
check the cost of products or services mentioned in
the description. We used these ranges because they
represented different categories of solutions. The
cheapest category was solutions that involved a onetime
purchase of a relatively low-cost supply (<$500).
An example is applying a coating to one window to
improve patient privacy. The second category was
intended to cover mid-range solutions such as the
purchase of equipment or consumable supplies. An
Table 1 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas (N = 56 work areas)
Variable Mean SD Min Max 1 2 3 4 5 6
1 Postperiod PIP 3.69 0.61 1.92 5.00
2 Change in PIP 0.09 0.67 2.25 1.33 0.639***
3 Had work system visit 91% 29% 0 1 0.195 0.197
4 Number of work system visits in area 3.41 3.16 0 12 0.055 0.1 0.342*
5 Had safety forum 50% 50% 0 1 0.056 0.028 0.313* 0.097
6 Percent of problems addressed 62% 31% 0 1 0.088 0.079 0.083 0.043 0.074
7 Percent of problems assigned to
senior manager
10.4% 23.7% 0 93% 0.186 0.175 0.114 0.359** 0.176 0.065
***p < 0.001, **p < 0.01, *p < 0.05.
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262 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
example is the purchase and installation of new lighting
in a catheterization laboratory to illuminate procedures.
The most expensive category was for solutions
that involved construction or hiring of multiple people.
An example is a solution that involved hiring
multiple people to transport patients within the hospital.
We compared scores and discussed our rationale
until we reached consensus for all solved
problems. We then summed the total estimated solution
costs, estimating 1 = $250; 2 = $5000; and
3 = $150,000, for all of the solved problems in each
work area.
Another possible explanation is that variation in
quality of solution efforts impacted the results (e.g.,
some work areas might have engaged in only superfi-
cial steps while others might have systematically
resolved underlying causes). We also controlled for
this ?higher quality? explanation by hiring 10 nurses
not affiliated with our study hospitals to rate the solution
effectiveness of the proposed solution for each
Table 2 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas and Identified Problems (n = 24)
Variable Mean SD Min Max 1 2 3 4 5 6 7
1 Change in PIP 0.02 0.53 1.17 1.1
2 Avg value of top quartile of
identified problems
17.23 6.67 6 30 0.298 1
3 Highest-valued score 18.75 7.43 6 30 0.325 0.952*** 1
4 Availability of
low-hanging fruit
36% 26% 0% 100% 0.016 0.305 0.289 1
5 Percentof top quartile
problems solved
88% 29% 0% 100% 0.186 0.091 0.109 0.045 1
6 Highest-valued problem
was solved
88% 34% 0 1 0.209 0.110 0.039 0.086 0.799***
7 Percent of solved problems that
were low-hanging fruit
33% 27% 0% 83% 0.327 0.097 0.099 0.551** 0.432* 0.350?
8 Percent of problems
assigned to senior manager
22.5% 32.4% 0% 93% 0.308 0.582** 0.576** 0.136 0.054 0.242 0.457*
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Table 3 Linear Regression testing Hypothesis 1 (the Change in PIP in
Treatment Work Areas vs. the Same Types of Work Areas
from Control Hospitals) Clustered by Hospital with Robust
Standard Errors in Parentheses
Model 1
H1. Treatment work area (1 = yes) 0.17*(0.08)
Bottom quartile PIP (pre-period) 0.75*** (0.10)
Major teaching hospital (1 = yes) 0.21? (0.13)
Financial stress 0.00 (0.00)
Medium-size hospital (100?250 beds) 0.43*(0.10)
Large-size hospital (>250 beds) (1 = yes) 0.26* (0.12)
OR/PACU (1 = yes) 0.08 (0.11)
ICU (1 = yes) 0.00 (0.13)
ED (1 = yes) 0.15 (0.13)
Was a work system visit conducted? Not in model
Was a safety forum conducted? Not in model
Constant 0.02 (0.20)
Observations 194
Treatment and control work areas 56 & 138
Degrees of freedom F (9, 55)
F-statistic 9.06***
Adjusted R2 0.20
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Table 4 Regression Comparing Change in PIP in Treatment Work
Areas that Rated the Severity, Frequency, and Ease of
Solution of the Problems, Clustered by Hospital with Robust
Standard errors in parentheses (H2 and H3)
Model 1 Model 2 Model 3
Mean value of top
quartile of
identified
problems
0.02 (0.02) ? ?
Highest-value score of
identified problems
? 0.02 (0.02) ?
Availability of
low-hanging fruit
0.60 (0.49) 0.45 (0.45) 0.90? (0.42)
H2. Percent oftop
quartile value
resolved
0.22 (0.23) ? ?
H2. Was top-ranked
value problem
resolved (1 = yes)
? 0.01 (0.26) ?
H3. Percent of
solved
problems that were
low-hanging fruit
1.00* (0.30) 0.82** (0.21) 1.22* (0.46)
Bottom quartile
2004
PIP pre (1 = yes)
0.39* (0.16) 0.36^ (0.19) 0.38* (0.13)
Cum. cost of solving
problems
? ? 0.00 (0.00)
Avg effectiveness of
solution effort
? ? 0.11 (0.10)
Constant 0.25 (0.48) 0.47 (0.46) 0.61 (0.62)
Observations 24 24 24
Degrees of freedom F (5, 7) F (5, 7) F (5, 7)
F-statistic 10.99** 5.28* 7.08*
Adjusted R2 0.06 0.07 0.08
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 263
problem using a scale from 1 to 10. The low end of the
scale was used for problems that were not resolved
(1 = ?no information given?; 2 = management dismissed
the issue or it was not a safety issue; and
3 = issue not considered due to lack of funds or issue
passed off to someone else without any follow-up).
The higher the number, the more substantial and systematic
the solution (e.g., 9 = major investment or
change; 10 = systemic fix that would prevent recurrence).
The scale is available from authors. Agreement
among nurses on their ratings was acceptable
(j = 0.23) (Landis and Koch 1977). The mean rating
for solution effectiveness was higher at 5.9 for solved
problems (?solution action in progress? on our scale)
than 2.7 (?no solution implemented?) for unsolved
problems, which validates their coding.
Given our small sample size, in this secondary
analysis we omitted the high-value prioritization variables,
as they were not significant in our primary
analyses. As Model 3 shows, the variable for the
cumulative ?cost of solving problems? was not significant.
This may be because work areas could improve
PIP without having to spend a lot of money on solutions.
Solution effectiveness was also not significant.
The percentage of solved problems that were lowhanging
fruit remained significant (coefficient = 1.22,
p < 0.05), indicating that the results are similar after
accounting for spending and solution effectiveness.
The evidence in the three models supports H3, which
predicted that prioritizing easy-to-solve problems
would be associated with higher PIP.
Table 5 shows the results from testing H4, which
proposed that senior managers taking responsibility
for ensuring that identified problems get resolved
would be associated with higher% change in PIP. H4
was supported (coefficient = 0.79, p < 0.05). Increasing
the percent of problems assigned to senior managers
by one standard deviation (23%) was associated
with a 0.79 increase in PIP. This equates to a 21%
increase in PIP.
4.3. Robustness Check
Other scholars have used a different approach for
testing improvement over time by using the postmeasure
as the outcome variable and the pre-measure
as a control variable (Fitzmaurice 2001). We tested
our hypotheses using this method and the results
were the same (results not shown).
4.4. Qualitative Results
To provide insight into the nature of implementation
of MBWA-based programs, Table 6 presents qualitative
data from the five work areas that improved the
most and the five that decreased the most. Between
pre- and post-periods, on average PIP improved by
0.85 for the top five work areas and decreased by 1.4
for the bottom five. Our examination of issues identi-
fied and actions taken suggests that the top work
areas identified meaningful problems and managers
took these problems seriously. For example, hospital
88s Med/Surg unit was one of the most improved
work areas. One of the identified issues was that the
small size of the medication room prevented two
nurses from preparing medications simultaneously,
which was an inconvenience and delayed patient
care. Senior managers discussed the issue with staff
and they collectively made a plan to move the medication
room to a larger space. The COO commented,
?It?s a little thing, but when you actually see them
doing the process, you say, ?Wait a minute, that is dif-
ficult for them.?? An interview with a nurse highlighted
management?s willingness to address issues.
She commented, ?These people address safety issues.
It may not always get addressed the way you want,
but it still gets addressed.?
Conversely, in the bottom work areas, an emphasis
on prioritizing the highest-valued problems limited
solution efforts. For example, hospital 129s ED identi-
fied valid issues, such as long lead times to receive lab
results. However, in the safety forum, we observed
the manager spend the entire time getting staff input
on prioritizing the items, leaving no time to discuss
how the issues might be resolved. This work area did
not solve any of the problems they had identified,
despite investing substantial time in identifying and
prioritizing them. As Table 6 shows, this pattern was
common. Two of the six bottom work areas did not
resolve any problems, another?s ?solutions? were largely
to re-educate staff, and a fourth area provided us
with no information about solved problems. These
implementation details suggest an inability to make
meaningful progress on solving the problems. The
lack of solution efforts illustrates how relying too
heavily on a high-value prioritization approach can
Table 5 Impact of the Percentage of Problems Assigned to Senior
Managers on Change in PIP in Treatment Work Areas (H4)
Model 1
H4. Percentage of problems
assigned to senior managers for resolving
0.79* (0.32)
Bottom quartile PIP pre (1 = yes) 0.56** (0.15)
Percentage of problems solved 0.12 (0.33)
Number of work system visits in the area 0.04? (0.02)
Senior manager participated in
work system visit (1 = yes)
0.12 (0.23)
Safety forum in the area (1 = yes) 0.12 (0.14)
Constant 0.08 (0.31)
Observations 58
Degrees of freedom F (6, 19)
F-statistic 2.96*
Adjusted R2 0.10
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Tucker and Singer: The Effectiveness of MBWA
264 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
Table 6 Illustrative Problems, Solutions, and Quotes from Top and Bottom Quartile Work Areas
Hospital
ID Work area
2004
Score
2006
Score
%
Change Examples Solution efforts Illustrative quotes and examples about prioritization
116 OR/PACU 3.3 4.6 41% Need more clinic space Made new clinic rooms The associates will prioritize with the managers, who
have a good idea of what the staff want to do
100 Med/Surg 2.6 3.6 38% Newly diagnosed diabetic patients
cannot get glucometers from
insurance; buy different kinds,
hard for nurses to teach
Vendor donated glucometers, in-serviced nurses,
made kits for newly diagnosed diabetic patients
Manager ordered new isolation carts to keep supplies
for each patient outside the door to prevent spread of MRSA
88 Med/Surg 3.6 4.7 31% Medication room is very
small for two people
After discussing with staff, changed medication
preparation to a larger room.
These people address safety issues. It may not always get
addressed the way you want it to, but it still gets addressed.
47 ED 3.0 3.8 28% Need prompt response from
pharmacy for selected meds;
need lift equipment for obese
patients; Pyxis* IT display
disposed to medication errors
Installed phone system with priority access to
pharmacy; identified or added lift equipment;
reprogrammed Pyxis IT display
We understand what needs to be done – trying to get rid of
verbal orders, trying to set up our Pyxis machine differently
39 ED 4.0 5.0 25% Feel like ?dumping ground?
when the clinic closes;
Roof leaks, need more
blood pressure machines
Relocated clinic in to expand ED patients; hired
additional ED staff; fixed roof; provided blood
pressure equipment
Nurse almost gave wrong medication because two similar
drugs next to each other in Pyxis. Told CNO. Pharmacist
came up right away and changed drawer
34 OR/PACU 5.0 3.8 25% OR table not safe for bariatric
patients; insufficient checking
of patient labs prior to surgery
No solutions listed Anyone can submit safety idea to their vice president. It gets
sent out for review to applicable departments
119 OR/PACU 3.8 2.6 31% Need exhaust air, some equipment
(chairs), backup of patients in ED,
beds not ready
Changes to improve air, equipment ordered
or repaired, working on flow in ED
It is hard to find the time and energy [to sustain this program]
because there are other demands that pour in.
129 ED 4.4 3.0 31% Long lead times for radiology and
lab, ties up rooms, long waits
in ED, units not taking patients
No solutions listed Spent 30 minutes deciding on priority scores with no discussion
of actions to resolve them
9 ED 2.9 1.9 33% 13/22 problems were audit items
by managers such as: Not
washing hands, leaving
cabinet unlocked
Nine solutions were to ?educate staff? No data about their solution efforts.
65 ED 4.3 2.0 53% Police bringing in dangerous
patients with only two people
on at night
Talk to police department about patients,
have security cameras, and panic buttons
You cannot fix them all, but you have to prioritize. Our patient
safety committee will end up doing that
PyxisTM is an automated medication-dispensing device used by nurses to administer medications to their patients.
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271,
? 2014 Production and Operations Management Society 265
preclude taking action. Furthermore, in some of the
work areas in the bottom quartile for change in PIP
scores, such as hospital 34s OR/PACU and hospital
65s ED, identified issues had to be validated by an
external group, such as the patient safety committee,
before resolution efforts would be authorized. This
additional step substantially slowed the pace of
change. Hospital 65s CEO explained his prioritization
philosophy, ?You can?t fix them all, but you have to
prioritize. Our patient safety committee will end up
doing that.? However, the safety officer from that hospital
explained the negative effect this had on staffs?
perceptions, ?What happens is you heighten the
awareness among people and then, if they don?t see
resolutions, then it becomes a bone of contention.?
5. Discussion, Implications, and
Limitations
In this study, we investigated the effectiveness of an
MBWA-based program in randomly selected hospitals.
We found evidence that participating in this particular
program decreased performance on average.
Given that many quality-improvement initiatives
fail to achieve expected gains (Beer 2003, Nair 2006,
Repenning and Sterman 2002), it is perhaps not surprising
that our program failed to yield positive
results for all work areas. Nonetheless, this is an
important result because many hospitals throughout
the United States and United Kingdom have implemented?and
continue to implement?similar programs.
Our study provides a cautionary tale that visits
by senior managers to the front lines of the organization
to solicit improvement ideas will not necessarily
increase staffs? perceptions of performance improvement.
There may be negative repercussions if senior
managers attempt, but fail, to engage meaningfully
with frontline staff. We suspect that the negative consequences
arose from soliciting, but not sufficiently
addressing, frontline staffs? concerns (Keating et al.
1999, Morrison and Repenning 2011). Failure to meet
expectations, once raised, can frustrate employees,
negatively impact organizational climate, and dampen
employees? willingness to provide future input
(Tucker 2007). Thus, our study suggests that there is a
hidden, psychological cost of asking employees for
ideas that are subsequently disregarded.
To understand why some units had better results
than others, we examined two approaches to problem
solving. Solving a higher percentage of the highestvalued
problems was not associated with increased
PIP. This result is similar to an earlier finding in the
TQM literature that formalization could overwhelm
actual improvement efforts, leading to employee dissatisfaction
with the program (Mathews and Katel
1992). Conversely, solving a higher percentage of
easy-to-solve problems was successful, lending support
for approaches that create a bias toward action.
This signals the value in addressing ?low-hanging
fruit,? at least in the short term (Keating et al. 1999,
Morrison and Repenning 2011). Our research does
not find that a focus on surfacing and resolving only
high-value problems yields improved staff perceptions.
Senior managers can facilitate a bias for action. We
found that having senior managers assume responsibility
for ensuring that problems get resolved was
associated with increased PIP. One explanation for
this finding is that organizational change often
requires senior managers to provide financial
resources to pay for required equipment, materials, or
labor; and organizational support to get an upstream
department in the organization to change how they
do their work if benefits accrue downstream. In other
words, senior managers can help ensure that action
happens. Given the improvement literature?s emphasis
on empowering frontline employees to solve problems
(Powell 1995), our finding may be interpreted as
highlighting the importance of empowering frontline
employees to identify and solve problems while supporting
those efforts by ensuring that organizational
obstacles to improvement are removed.
5.1. Implications for Theory
Manager commitment is associated with successful
implementation of performance improvement programs
that rely on frontline employee participation
(Ahire and O?Shaughnessy 1998, Coronado and
Antony 2002, Kaynak 2003, Nair 2006, Worley and
Doolen 2006). We found that a program that stimulated
managerial involvement was productive for
some, but not all, work areas. An explanation of the
negative result of our MBWA-based program was
that asking employees for their suggestions and then
not implementing them sent the message that
employees? ideas were not valued and that the program
was symbolic. Research by Miles supports this
explanation (1965). He postulated that managers hold
one of two beliefs about the value of employee participation
programs. One belief was that frontline staff
participation was valuable because it increased morale,
though the actual ideas they contributed were
unhelpful. These managers believed in the symbolic
value of employee participation programs, such as
MBWA. Miles (1965) found that improvement programs
failed when managers held this belief. The second
belief?which was associated with success in
Miles? study?was that interactions with frontline
staff were valuable because their ideas were actually
useful. The belief in the substantive value of employees?
ideas underlies a core TPS principle: respect for
people (Liker 2004). Miles? study suggests that senior
Tucker and Singer: The Effectiveness of MBWA
266 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
managers? respect for frontline employees? concerns
may have been an important but unmeasured moderator
variable for our MBWA program. An implication
is that rather than just seeking to increase manager
involvement, it may be critical first to ensure that
managers value the ideas raised by frontline staff.
An explanation for the lack of positive impact from
the high-value prioritization approach may be that
problem values in the hospital work areas in our
study had a relatively flat landscape. As a result, pursuing
a high-value prioritization approach did not
yield a substantial improvement over focusing on
easy-to-solve problems. The flat landscape may be
because the work areas had already addressed their
large-value problems or because the fragmented service
environment of health care creates a wide range
of small-scale problems. The easy-to-solve prioritization
approach may have been successful in our study,
because the work areas needed to first tackle fundamental,
lower-value problems before advancing to
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). Taking care of the basic
infrastructure and requirements is a necessary precursor
to more comprehensive organizational change
required by higher priority score problems (Keating
et al. 1999, Morrison and Repenning 2011).
There are likely circumstances under which prioritizing
high-value problems is helpful, such as when
only one idea can be fully developed, like implementation
of an enterprise-wide information system. We
also believe that organizations benefit from resolving
high-value problems, which tend to be top-down,
strategic improvements, as well as easy-to-solve problems,
which tend to be bottom-up, tactical initiatives.
Organizations should try to nurture both kinds of
problem-solving capabilities. For example, organizations
may have experts working on identifying and
solving high-value problems through six-sigma projects,
while frontline employees simultaneously work
on resolving smaller scale issues in their local work
area through lean initiatives. Furthermore, it may be
that organizations begin their improvement journey
by successfully resolving relatively easy problems,
but then need to develop new capabilities to resolve
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). For example, reducing the
time required to find vital sign monitor equipment on
a nursing unit likely requires different problem-solving
skills than reducing patients? lengths of stay in the
hospital.
5.2. Implications for Policy
Our study suggests that policy makers can play an
important role in improving safety in hospitals by
encouraging organizations to build problem-solving
capacity. Rather than requiring hospitals to participate
in a specific change program, such as MBWA,
that may not be fully validated, policy makers could
instead provide incentives for hospitals to build the
generic capacity to solve frontline problems. Given
the trend toward requiring hospital to implement
multiple quality-improvement initiatives concurrently,
we suspect that it is likely that many programs
are being implemented superficially and in ways that
lead to harmful results similar to those we observed
in this study. This could be contributing to the oftreported
failure to achieve gains through improvement
initiatives that frustrate the health-care industry
(Landrigan et al. 2010). Our study provides a warning
about mandating implementation of improvement
programs before fully understanding the conditions
required for the programs to yield successful outcomes.
The financial incentives used to encourage adoption
of electronic health records in the United States
may be instructive. Policy makers rewarded ?meaningful
use,? as demonstrated by the functionality that
was achieved, rather than rewarding implementation
of a particular software (Blumenthal 2010). Similarly,
policy makers could provide incentives for building
problem-solving capabilities that improve patientcentered
performance rather than advocate for a specific
improvement program.
5.3. Implications for Practice
Many initiatives to improve safety begin by trying to
increase employees? reports of near misses, errors,
and incidents (Bagian et al. 2001, Evans et al. 2007).
Implied assumptions are that increasing the number
of reports enables organizations to conduct trend
analysis that illuminates high-value problems which
can then be solved; and that many issues will be of
sufficiently low value that they can be ignored at low
or no cost to the organization. In contrast, our study
suggests that there may be little benefit, and some
potential harm, to this approach. Rather than increasing
reporting, organizations might be better served by
addressing known problems, which builds problemsolving
capabilities, which in turn enables actiontaking
on more problems. Our finding corroborates
prior research that highlighted the importance of
problem-solving capacity for successful improvement
programs (Adler et al. 2003, Keating et al. 1999, Morrison
and Repenning 2011). This advice is consistent
with the vision for a continuously learning health-care
system articulated by the US Institute of Medicine,
requirements for which include systematic problem
solving. Our study also resembles Kaizen, a structured
problem-solving approach involving managers
and frontline workers. However, important differences
that may make Kaizen more successful than our
program are that Kaizen occurs after managers and
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 267
frontline staff have been trained on a standardized
problem-solving technique and that it emphasizes
taking action to solve as many problems as possible
within the given time period (Imai 1986). Thus, it prevents
resource depletion by limiting the time spent
identifying and solving problems rather than by
selecting among them.
5.4. Limitations
Our findings must be considered in light of study
limitations. First, our small sample size limited our
analysis. Our sample was small for several reasons.
The cost- and time-intensive nature of conducting an
experiment with hospitals over 18 months made it
challenging to conduct our field-based, interventional
program with 24 organizations, and we would
have struggled if there were more. In addition,
despite our providing a method of prioritizing problems,
many organizations chose not to assign prioritization
values and therefore work-area coded data
on problem value were not available for all treatment
work areas. Future research with larger sample sizes
could test more nuanced theory. For example, an
easy-to-solve prioritization approach may be most
successful for work areas that start from a weak
position and can benefit most from action, whereas a
high-value prioritization approach may be most
helpful for experienced work areas that can be more
selective.
A second limitation is the perceptual measure of
improvement. Hospitals were unwilling to share
actual safety incident measures with us. In addition,
publicly available clinical measures, such as mortality,
readmissions, and process of care measures,
started being reported publicly only after the initiation
of this study. Although we conducted analyses
using these ?post study? clinical outcome data, the
regressions were not significant in explaining variation.
However, for reasons detailed above, a perceptual
measure is an important indicator of the impact
of the intervention we tested. Furthermore, prior
research on an MBWA-based intervention that did
have access to clinical outcome data did not find links
between multiple clinical outcomes and the intervention
(Benning et al. 2011), corroborating our study
results.
Third, hospitals did not track resources spent on
solution efforts. Therefore, estimation was the only
way of testing the alternate explanation that spending
more money on process improvement yielded better
outcomes. Future research could contribute to
improvement theory by examining the cost of
improvement efforts compared to benefits. A fourth
limitation is that we did not randomize an easy-tosolve
prioritization approach vs. a high-value prioritization
approach among work areas. Instead, those
differences emerged naturally. A randomized assignment
of these two prioritization approaches would
provide a stronger test of the hypotheses.
5.5. Conclusions
Understanding the impact of MBWA-based programs
is helpful for organizations that may be considering
implementing them. In our study, organizations
whose managers ensured that problems were
addressed achieved better results. This suggests that
improvement programs are more likely to change
employees? perceptions when they result in action
being taken to resolve problems than when they are a
symbolic show of manager interest. On the basis of
study findings, we recommend that organizations
focus on increasing their capacity to act on improvement
suggestions rather than expending further effort
on generating more suggestions and prioritizing
them.
Acknowledgments
Funding was provided by Agency for Healthcare Research
and Quality RO1 HSO13920. Additional funding was
obtained from Fishman Davidson Center at Wharton. Jennifer
E. Hayes provided valuable data coding assistance.
Appendix A: Survey Questions for
Perceived Improvement in Performance
The quality of services I help provide is currently the
best it has ever been.
We are getting fewer complaints about our work.
Overall, the level of patient safety at this facility is
improving.
The overall quality of service at this facility is
improving.
Appendix B: Interview Questions
B.1. FrontLine Personnel Interview Protocol
I wanted to ask you some questions about the patient
safety culture at this hospital. We recognize that most
hospital personnel experience problems in the course
of their work and that these are not a reflection of
their skill level or of the quality of care provided at
their facility. My goal is to understand differences in
safety culture among organizations.
1. Do personnel on this unit talk openly about
safety issues and errors?
2. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
Tucker and Singer: The Effectiveness of MBWA
268 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
care to patients think about reporting incidents
related to patient safety.
3. Have you ever reported something? What
made you decide to report that incident? What
happened as a result of reporting? Did you
ever learn the outcome?
Can you recall a specific adverse event that
was caused by an error or series of errors?
What happened? Can you describe the investigation
process (i.e., what happened to people
involved, what changes, if any, resulted from
the investigation)?
My last question relates to a major change in a
care process at your hospital.
4. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced in your unit?
Probe: What training did you receive? Has
implementation required any workarounds of
the built-in features of the system?
B.2. Manager Interview Protocol
I wanted to ask you some questions about the
patient safety culture at this hospital. We recognize
that most hospital personnel experience problems
in the course of their work and that these are not a
reflection of their skill level or of the quality of
care provided at their facility. My goal is to understand
differences in safety culture among organizations.
1. Do you feel comfortable talking about safety
issues and errors in your manager meetings
with senior leadership?
2. Do you encourage your staff to speak up?
How?
3. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
care to patients think about reporting incidents
related to patient safety.
4. Can you step through a recent ?near-miss?
safety report that you addressed? Briefly (do
not need details) what was the situation and
what was the response, if any?
5. Can you recall a specific adverse event that
was caused by an error or series of errors?
Briefly, what happened? Can you describe the
investigation process (i.e., what happened to
people involved, what changes, if any, resulted
from the investigation)?
My last question relates to a major change in a
care process at your hospital.
6. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced to a unit? Probe:
What training was provided? Has implementation
required any workarounds of the built-in
features of the system?
B.3. Hospital Administrator Interview Protocol
I wanted to ask you some questions about your daily
activities as a hospital executive and your views on
the patient safety culture at your hospital. We recognize
that leadership styles and organizational cultures
are unique at every institution and none is necessarily
better than any other. My goal is to understand the
full variation among organizations.
1. What are your primary priorities for the hospital?
[Prompt if it is not mentioned] Where does
patient safety fall in your list of priorities?
2. How do you see your role in patient safety? In
what ways do you provide leadership in this
area?
3. How would you describe the general attitude
of health-care professionals and employees
within the hospital toward patient safety?
4. It is well known that middle managers are a
key to implementation, and these people are
often extremely pressed due to budget constraints.
What is the situation with middle
managers in your hospital?
5. How do you obtain information about the hazards
present at the front lines of your organization?
6. Thinking about the most recent major organizational
change related to patient safety, can
you describe the change, your decision-making
process, and its implementation? Probe: Did
some event or new piece of information
prompt your decision to implement the
change? Did you evaluate the business case
before making the change?
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Write a 2 page paper addressing the following elements in your paper:
? Discuss and Explain the managerial tool of management by walking around (MBWA) and its impact on creating a strategy ready culture.

Include a title page and 3-5 references. Only one reference may be from the internet (not Wikipedia). The other references must be from the attached. Please adhere to the Publication Manual of the American Psychological Association (APA), (6th ed. 2nd printing) when writing and submitting assignments and papers.

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The Effectiveness of Management-By-Walking-Around:
A Randomized Field Study
Anita L. Tucker
Harvard Business School, Soldiers Field Road, Morgan Hall 413, Boston, Massachusetts 02163, USA, atucker@hbs.edu
Sara J. Singer
Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts 02115, USA, ssinger@hsph.harvard.edu
Management-by-walking-around (MBWA) is a widely adopted technique in hospitals that involves senior managers
directly observing frontline work. However, few studies have rigorously examined its impact on organizational outcomes.
This study examines an improvement program based on MBWA in which senior managers observe frontline
employees, solicit ideas about improvement opportunities, and work with staff to resolve the issues. We randomly
selected hospitals to implement the 18-month-long, MBWA-based improvement program; 56 work areas participated. We
find that the program, on average, had a negative impact on performance. To explain this surprising finding, we use
mixed methods to examine the impact of the work area?s problem-solving approach. Results suggest that prioritizing
easy-to-solve problems was associated with improved performance. We believe this was because it resulted in greater
action-taking. A different approach was characterized by prioritizing high-value problems, which was not successful in
our study. We also find that assigning to senior managers responsibility for ensuring that identified problems get resolved
resulted in better performance. Overall, our study suggests that senior managers? physical presence in their organizations?
front lines was not helpful unless it enabled active problem solving.
Key words: health care; implementation research; patient safety; quality improvement; survey research
History: Received: February 2013; Accepted: January 2014 by Edward G. Anderson, Jr. after 2 revisions
1. Introduction
Hospitals face an imperative to improve quality of
care and decrease medical errors that harm patients.
Healthcare thought leaders and policy makers have
advocated for the adoption of ?management-by-walking-around?
(MBWA) to achieve these goals, resulting
in widespread adoption in the United States and
the United Kingdom. (Frankel 2004, National Patient
Safety Agency 2011). These types of programs?in
which senior managers visit the front lines to work
with staff to identify and resolve obstacles?came to
the attention of hospitals with the publication of one
health-care system?s success at improving safety climate
through its MBWA-based intervention (Frankel
et al. 2003).
Despite the intuitive appeal of MBWA and history
of use in manufacturing organizations, empirical evidence
on the program?s efficacy in the hospital setting
is mixed. Of seven hospitals that implemented an
MBWA-based program, only two were able to sustain
the effort over a 3-year period (Frankel et al. 2008).
Those two reported a positive impact on staffs? perceptions
of safety climate, but the effect on the five
aborting hospitals was not reported. A study of one
Veterans Affairs hospital found that patient safety climate
worsened on two units that implemented the
program, while it improved or stayed the same on
two control units that did not implement the program
(Singer et al. 2013). Another found that hospitals that
implemented a general improvement program with
an MBWA component did not improve on a variety
of measures compared to control hospitals (Benning
et al. 2011).
These mixed findings provide only modest support
for widespread implementation of this program in
hospitals. The lackluster performance of MBWA in
health care may be that health care?s specialized and
diverse disciplinary knowledge bases (e.g., cardiology,
pulmonary, surgery, pharmacy, nursing, etc.)
creates a complex environment where it is difficult for
senior executives to effectively observe frontline work
and provide improvement suggestions (Aflaki et al.
2013). In addition, the highly regulated nature of
health care may minimize the marginal effectiveness
of MBWA because other audit programs, such as government-mandated
inspections or incident-reporting
systems, already focused senior managers? attention
on the front lines of care (Iyer et al. 2013). Furthermore,
the mixed results may be due to implementation
253
Vol. 24, No. 2, February 2015, pp. 253?271 DOI 10.1111/poms.12226
ISSN 1059-1478|EISSN 1937-5956|15|2402|0253 ? 2014 Production and Operations Management Society
differences, such as the prioritization methods used
to determine which problems get resolved. However,
prior studies have not assessed MBWA programs at a
more granular level. As a result of the contextual
differences in health care and limitations of prior
research, much remains to be discovered about
what factors and implementation approaches are
associated with the success of MBWA in hospitals.
To test more systematically the impact of MBWAbased
improvement programs and to identify factors
associated with its success, we implemented one
such program in 19 randomly selected hospitals. We
compared nurses? perceptions of improvement in
performance (PIP) in work areas that implemented
the program to the same type of areas at 68 randomly
selected control hospitals that did not implement
the program. A contribution of our study is
thus a rigorous testing of an MBWA program. More
specifically, our study design minimizes two methodological
challenges of research on improvement
programs. First, we minimize selection bias by randomly
assigning organizations to the treatment condition.
Our study thus provides insight into the
program?s generalizability beyond those where
senior managers decided on their own to implement
such a program. Second, the use of control organizations
reduces the possibility that positive (or negative)
results were caused by time-dependent
variables, such as changes in technology, policies, or
awareness over time. Surprisingly, we find that, on
average, our MBWA-based program had a negative
impact on nurses? perceptions of performance, suggesting
that senior managers? presence in hospital
front lines to solicit improvement ideas could be detrimental
to workers? perceptions.
A second contribution of our study is developing a
categorization of problem-solving approaches that
explains the conditions under which improvement
solicitation programs, such as MBWA, are successful.
We find that our MBWA-based program was associated
with improved perceptions of performance
under two conditions: (1) when a higher percentage
of solved problems were considered ?easy? to solve,
enabling more problem solving and (2) when senior
managers took responsibility for ensuring that identi-
fied problems were resolved. This suggests that the
action-taking that results from the program, rather
than the mere physical presence of the senior managers,
is what positively impacts the frontline staff.
In section 2, we describe prior research on MBWA
programs and develop four hypotheses linking the
program to performance. In section 3, we describe
the intervention, the sample of hospitals that participated
in the research project, and our qualitative and
quantitative data, measures, and analytic approach.
We present the results in section 4 and discuss the
implications for research, practice, and policy in
section 5.
2. MBWA-based Improvement
Program?s Impact on Performance
Research has found that quality improvement programs
that solicit frontline workers? ideas, such as
MBWA, can have a beneficial impact on organizational
outcomes (Dow et al. 1999, Powell 1995).
MBWA relies on managers to make frequent, learning-oriented
visits to their organization?s front lines to
observe work and solicit employees? opinions (Packard
1995). Hewlett-Packard, the company in which
MBWA originated, attributed its success using
MBWA to good listening skills, willing participation,
a belief that every job is important and every
employee is trustworthy, and a culture where
employees felt comfortable raising concerns (Packard
1995). MBWA is similar to the Toyota Production System?s
?gemba walks? (Mann 2009, Toussaint et al.
2010, Womack 2011). In a gemba walk, managers go
to the location where work is performed, observe the
process, and talk with the employees (Mann 2009).
The purpose is to see problems in context, which aids
problem solution (Mann 2009, Toussaint et al. 2010,
Womack 2011).
MBWA has resulted in positive organizational
change in some hospitals (Frankel et al. 2003, Pronovost
et al. 2004). One explanation is that MBWA leads
to successful problem resolution because seeing a
problem in context improves managers? understanding
of the problem, its negative impact, and its causes.
This understanding increases managers? motivation
and ability to work with frontline staff and midlevel
managers to resolve the issue (Mann 2009, Toussaint
et al. 2010, Von Hippel 1994, Womack 2011). Theory
further suggests that MBWA?s repeated cycles of
identifying and resolving problems may create an
organizational capability for improvement that
reduces the cost of future improvement efforts, creating
a positive dynamic (Fine 1986, Fine and Porteus
1989, Ittner et al. 2001). This virtuous cycle is further
strengthened because communication from frontline
workers about problems aligns managers? perspectives
with customers? experiences (Hansen et al. 2010,
Hofmann and Mark 2006, Huang et al. 2010, Singer
et al. 2009), enabling managers to effectively allocate
scarce resources among the organization?s multiple
improvement opportunities. Performance is also
enhanced because managers? presence on the front
lines sends a visible signal that the organization is
serious about resolving problems. This increases
employees? beliefs that leadership values improvement,
which in turn spurs employees to engage in the
discretionary behaviors necessary for process
Tucker and Singer: The Effectiveness of MBWA
254 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
improvement (Mcfadden et al. 2009, Zohar and Luria
2003). For these reasons, we hypothesize that MBWA
will positively impact performance.
Hypothesis 1 (H1). Participation in a MBWAtype
program leads to improved performance.
2.1. The Effect of Problem-Solving Approach
Although we hypothesize a positive impact from
MBWA, programs that solicit employee suggestions
can uncover more problems than an organization can
resolve, given limited problem-solving resources
(Bohn 2000, Frankel et al. 2003, Repenning and Sterman
2002). When this happens, the organization?s
problem-solving support personnel must decide
which of the identified issues they will work to
resolve and which ones will be ignored or delayed
(Keating et al. 1999, Morrison and Repenning 2011).
Thus, an MBWA?s program?s success may be contingent
upon which problems the organization decides
to address.
We examine two different prioritization
approaches, discuss their benefits and limitations,
and develop two hypotheses. We explore two dimensions
of problems: solution difficulty and value
gained by solving the problem (Aflaki et al. 2013). To
simplify the discussion, we consider only two levels
of each dimension: problems are either easy to solve
or difficult to solve; and they can yield either a small
or large value if solved. Organizations are likely to
prioritize problems that are of high value and/or
problems that are easy to solve. Although we develop
hypotheses based on the assumption that organizations
have a dominant prioritization scheme (such as
addressing high-value problems), we recognize that
organizations could combine the two approaches.
This implies that they would emphasize high-value,
easy-to-solve problems while ignoring problems that
were both difficult to solve and of low value (Aflaki
et al. 2013).
The first prioritization approach that we consider is
one that addresses issues that are causing?or have
the potential to cause?large disruptions. This highvalue
prioritization approach ranks problems according
to a value score and solves the highest-valued problems.
Many structured approaches to improvement,
such as six-sigma and risk management, use a highvalue
prioritization approach (Anderson et al. 2013a,
b). In the health-care context, hospital incident-reporting
systems (Bagian et al. 2001) and MBWA-based
programs (Frankel et al. 2003) advocate calculating a
problem?s ?value? by multiplying the problem?s score
for severity with its frequency of occurrence (Bagian
et al. 2001, Frankel et al. 2003). The hospital then
resolves the highest-value problem first, followed by
the second highest, continuing until problem-solving
resources are depleted or remaining problems fall
below a threshold value (Bagian et al. 2001). Surfacing
and solving the highest-valued problems should yield
substantial gain in performance (Bagian et al. 2001,
Girotra et al. 2010). To provide an example in the hospital
setting, medication-related problems are often of
high value because they can be fatal and can impact
many patients (Bates et al. 1995). In response, many
hospitals have implemented computerized physician
order entry systems which reduce medication errors
by preventing transcription errors and alerting physicians
to potential drug allergies or interactions (Bates
et al. 1999).
This approach is beneficial because it ensures that
limited resources are preserved for problems with
the highest values (Frankel et al. 2003). It also helps
prevent the queue of unsolved problems from growing
unmanageably long by permitting the organization
to discard the subset of problems that are
deemed too little valued to justify solution efforts
(Bohn 2000).
However, there is a downside to focusing exclusively
on high-value problems. The ignored problems
constitute the ?useful many? which individually do
not have a large negative impact on performance
(Juran et al. 1999), but which collectively could contribute
to serious problems such as medical errors
(Reason 2000).
Thus, the second approach that we consider is
prioritizing easy-to-solve problems (Johnson 2003,
Repenning and Sterman 2002). An easy-to-solve prioritization
approach enables the organization to address
problems that are straightforward and quick to
remedy?the so-called ?low-hanging fruit.? This
approach may free up resources for addressing problems
because the more formal approach of assigning
a prioritization score based on severity and occurrence
has required significant resources in the case of
incident-reporting systems in both aviation and
health care (Johnson 2003).
An easy-to-solve prioritization approach may also
be helpful in health-care settings because the cumulative
benefit of resolving many small problems can
add up to be a significant source of improvement
(Jimmerson et al. 2005). Similarly, research has found
that major accidents typically result from an unpredictable
combination of small magnitude problems
rather than from a single large magnitude problem
(Perrow 1984, Reason 2000). According to the ?Swiss
Cheese Theory,? multiple small-scale problems can
align in an unfortunate way that enables an error to
harm the customer (Cook and Woods 1994, Reason
2000). Consequently, resolving seemingly low-value
problems can be beneficial, because they otherwise
might contribute to the next major accident (Perrow
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 255
1984). To illustrate, a study of medical harm in cardiac
surgery found that adverse events were more likely to
be caused by multiple, simultaneous ?minor? issues
than by a single, ?major? issue. This was because surgeons
were less able to perceive and compensate for
multiple, simultaneous minor issues while they were
able to recognize and remedy a single, major issue
that occurred during surgery (De Leval et al. 2000).
This line of research implies that it is difficult to
assign a ?value? to problems because their negative
impact is determined in part by the specific situation
in which they occur.
Another situation in which the easy-to-solve prioritization
approach may be superior is where the organization
has a ?flat landscape? of small magnitude
problems. In flat landscapes, the difference between a
local high point and the global high point is too small
to justify an extensive search effort (Sommer and Loch
2004). This can occur in hospitals for two reasons.
First, managers typically address issues that result in
patient death or other serious injury such as wrong
site surgery. Thus, the only problems that remain
may be small magnitude issues. Second, there are
many unique opportunities for patient care to fail
because work is divided among specialties, departments,
and shifts. Problems can occur at any of these
handoffs. Thus, unlike manufacturing settings where
an undetected malfunction in a machine can be the
dominant source of defective product, it is less likely
that there is a single, dominant source of repeated failures
in hospitals. When there is a flat landscape,
improvement arises from solving the lower tail of
problems.
It may also be that organizations need to address
basic, fundamental problems before they can benefit
from trying to address more complex organizational
issues. For example, research suggests that problemsolving
efforts are most successful when organizations
use relatively straightforward problems to
develop sufficient problem-solving capacity before
tackling larger, more complex issues (Keating et al.
1999, Morrison and Repenning 2011). Addressing
easy-to-solve problems enables frequent problemsolving
cycles, which develops employees? expertise
at problem solving (Adler et al. 2003). These dynamics
suggest that organizational problem-solving
capacity is more like a muscle that strengthens with
exercise rather than a resource that gets depleted with
use (Fine 1986, Fine and Porteus 1989, Ittner et al.
2001).
We draw on the arguments outlined in the above
paragraphs to develop two hypotheses. When problem-solving
resources are limited and become
depleted with use, the organization should focus its
scarce human and financial capital on removing the
problems that pose the biggest threat. Thus, a highvalue
prioritization approach will be associated with
improved performance.
Hypothesis 2 (H2). Work areas that resolve a
higher percentage of high-value problems will
have greater improvement in performance than
work areas that solve a lower percentage of
high-value problems.
An easy-to-solve prioritization approach should be
associated with improvement because it fosters solution
of all problems that can be solved, regardless of
their hypothetical value. In the health-care setting,
this might benefit the organization because seemingly
small-value problems can nonetheless negatively
impact patient safety. Furthermore, the act of solving
problems develops the organization?s capability to
solve more problems in the future. Thus,
Hypothesis 3 (H3). Work areas that solve a
higher percentage of easy-to-solve problems will
have greater improvement in performance than
work areas that solve a lower percentage of
easy-to-solve problems.
2.2. The Role of Senior Managers in Problem
Solving
In addition to the prioritization approach, the success
of an MBWA program depends on senior managers?
willingness to take responsibility for ensuring that
problems identified through the program are resolved
(Frankel et al. 2005, Pronovost et al. 2004).
Senior managers can be helpful to frontline workers?
resolution efforts because they control financial
resources needed to address issues that involve capital
investment (Carroll et al. 2006). In addition, they
possess the perspective necessary to resolve conflicts
that arise when problems cross organizational boundaries
(MacDuffie 1997). This insight is valuable particularly
because high-value problems are likely to cross
organizational boundaries or require financial
resources to resolve.
On the other hand, easy-to-solve problems impact
only one department and do not require substantial
financial resources to resolve. Under these conditions,
frontline employees can be empowered to identify
and resolve problems (Jimmerson et al. 2005). However,
involving frontline workers in resolution efforts
requires them to take time away from their direct production
responsibilities (Repenning and Sterman
2002, Victor et al. 2000). This can be difficult for frontline
employees, especially for health-care workers
who provide direct patient care. Under these conditions,
senior managers need to allocate funds for overtime
or coverage so that care providers can spend
time away from patient care and on resolution efforts.
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256 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
As outlined in the two above paragraphs, both
high-value and easy-to-solve problems require manager
support for successful resolution. Therefore, we
hypothesize that hospital work areas will achieve better
results from the MBWA program when they
assign to senior managers the responsibility for ensuring
that a problem gets addressed.
Hypothesis 4 (H4). Work areas with a higher
percentage of problems assigned to a senior
manager to ensure resolution exhibit greater
improvement than those with a lower percentage
of problems assigned to a senior manager.
These four hypotheses outline the theoretical links
between our MBWA-based program and improved
performance. Figure 1 depicts these relationships.
3. Methodology
We test our hypotheses in a field study of US hospitals
randomly selected to participate in a patient
safety research study, with a subset of the hospitals
randomly selected (a second time) to implement our
MBWA-based program. The program was launched
in January 2005 and lasted for 18 months.
3.1. The MBWA-based Program
We drew on prior research to design our MBWAbased
program (Frankel et al. 2008, Pronovost et al.
2004, Thomas et al. 2005). It consisted of repeated
cycles of senior manager?staff interaction, debriefing,
problem solving, and follow-up. Senior managers
such as the chief executive, operating, medical, and
nursing officers (CEO, COO, CMO, and CNO, respectively),
interacted with frontline staff in a work area
to generate, select, and solve improvement ideas. The
work area manager was also involved in the selection
and solution activities. Senior manager interactions
took two forms: visits, called ?work system visits,? to
work areas to observe frontline work; and special
meetings, called ?safety forums,? with a larger group
of frontline staff from the area to discuss safety concerns.
The activities were coordinated with the work
area manager.
In work system visits, four senior managers would
spend 30 minutes to 2 hours visiting the same work
area. The senior managers would each observe a different
process, such as medication administration, or
a different person, such as a nurse or physician, to
shed cross-disciplinary insight into the work done in
the area. The purpose was to build senior managers?
understanding of the frontline work context and
gather grounded information about problems (Frankel
et al. 2008).
Senior managers also facilitated a safety forum in
the work area, which was an informal meeting
between senior managers and the frontline staff from
the work area, held in the work area, during which
the staff talked about their work area?s safety weaknesses
and strengths. We added this component to
our MBWA-based intervention for two reasons. First,
a San Diego children?s hospital improved its organizational
climate by holding meetings where frontline
staff spoke directly to the hospital CEO about their
concerns and ideas (Sobo and Sadler 2002). Second,
a prior research project on an MBWA-based program
found that the program only improved the
perceptions of frontline staff who participated in a
work system visit (Thomas et al. 2005). Because it is
not feasible for senior managers to conduct a work
system visit with every single hospital employee
within a short time period, Thomas? finding suggests
that work system visits on their own will be insuffi-
cient to change the perceptions of most hospital
employees.
The MBWA-based program continued with a
?debrief meeting,? which organized information collected
from the work system visits and safety forums.
Senior managers attended, as did work area managers,
selected frontline workers, and the hospitals?
patient safety officers. The group compiled the
improvement ideas identified, discussed and in some
work areas prioritized them, and decided next steps,
ranging from doing nothing to suggesting solutions
and assigning responsibility. Action to address problems
selected for resolution followed the debriefing.
Managers were encouraged to communicate with
staff about implementation efforts, describing what
changes, if any, were made in response to identified
ideas. Patient safety officers entered the ideas
MBWA
Program Performance
Problem solving activities
used in MBWA
Address highvalue
problems
Address ?easy-tosolve?
problems
Managers ensure
problems are
resolved
H1+
H2+
H3+
H4+
Figure 1 Model of Management-By-Walking-Around?s Impact on Performance
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 257
generated and actions taken into an electronic spreadsheet
we provided and sent this spreadsheet to our
research team for analysis.
Each round of work system visits, safety forums,
debrief meeting, solution activities, and communication
constituted one cycle. A cycle focused on one
work area and took approximately 3 months, which
research has shown is the time required to solve problems
in an organization (Pronovost et al. 2004). See
Figure 2 for a diagram of the process. After completing
a cycle, the management team would repeat the
activities in a different work area. The program
focused on the four main work areas in hospitals:
operating room or postanesthesia care unit (OR/
PACU), intensive care unit (ICU), emergency department
(ED), and medical or surgical ward (Med/Surg).
Cycles continued over the 18-month implementation,
with hospitals conducting an average of one cycle in
four work areas.
3.2. Recruitment
Our study employed an experimental design which
included a pre-test and post-test of similar work areas
in treatment and control hospitals. We randomly
selected 92 US acute-care hospitals, stratified by size
and geographic region, to participate in a patient
safety climate survey. We provided no financial
incentive, but participation in the safety climate study
fulfilled a national accreditation requirement. At
enrollment, all hospitals were aware that they may be
invited to participate in a program to improve patient
safety, but details regarding the program were withheld
to prevent contamination of control hospitals. To
select hospitals to participate in the MBWA-based
program, we drew a second, stratified, random sample
of 24 hospitals from the sample of 92. The remaining
68 hospitals not selected were control hospitals.
Data on staff perceptions of performance were
collected at control and treatment hospitals through
surveys before implementation of program activities
(2004, ?pre?) and again after the program was completed
(2006, ?post?). At each hospital, we surveyed a
random sample of 10% of the frontline workers, with
additional oversampling in OR/PACUs, EDs, and
ICUs in the post-survey period to improve sample
size. The baseline ?pre? response rate was 52%; and
the follow-up ?post? response rate was 39%. For our
analyses, we used data from registered and licensed
vocational nurses (n = 1117 pre and n = 903 post).
Of the 24 treatment hospitals, 20 completed the program
in at least two work areas. Of the four that did
not complete the treatment, one went out of business,
one was purchased, and two experienced significant
senior management turnover. As a result, they were
unable to complete more than one cycle of activities
and did not provide data. We thus excluded these
four from our analysis. There was no difference in
staff perceptions of performance in the pre-period
between the four hospitals that dropped out of the
treatment and the 20 that did not. Of the original 68
control hospitals, 48 completed the post-test survey,
making an initial total sample of 68 hospitals. There
was no difference in survey measures in the pre-period
between the 20 control hospitals that dropped out
of the post-survey and the remaining hospitals. There
was also no difference between treatment and control
work areas on pre-period measures of staff perceptions
of performance.
3.3. Data and Measures
Using the data collection spreadsheet that we provided
(Figure 3), treatment work areas reported 1245
patient safety problems identified during the visits
and forums. Each hospital also provided a list of the
C
E O
C
N O
C
M O
C
F O
Work
site visit
by CEO
Time
Work
site visit
by CNO
Work
site visit
by CMO
Work
site visit
by CFO
Safety
Form
Debrief
Meeting
Solution Activities &
Communication
Figure 2 Depiction of the MBWA-based Program Activities in a Work Area
Tucker and Singer: The Effectiveness of MBWA
258 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
senior managers, which we used to determine
whether a senior manager attended the program
activity and whether a senior manager was assigned
responsibility for the problem. The spreadsheet also
contained three columns that the work areas could
use to prioritize identified problems. Twenty-four
work areas in eight hospitals filled out this information.
3.3.1. Independent Variables. To test the overall
impact of the MBWA-based program (H1), we created
a treatment variable, ?MBWA in the work area,?
which indicated whether the work area received the
MBWA-based treatment (=1) or was a work area from
a control hospital (=0). To test the high-value prioritization
approach (H2), we calculated a value score for
each problem by multiplying problem severity (column
7 in Figure 3; 1 = low; to 10, could cause death)
by estimated frequency of occurrence (column 8;
1 = very unlikely, 3 = very likely) (Bagian et al. 2001,
Frankel et al. 2003). This method for calculating the
potential value of solving a problem is similar to sixsigma?s
risk prioritization number, which uses the
product of the scores (on a scale from 1 to 10) of a
problem?s frequency of occurrence, detectability, and
severity (Evans and Lindsay 2005). It is also similar to
risk registers used for risk management. A risk register
scores each potential risk to a project by multiplying
the risk?s likelihood of occurrence by severity of
the impact if it does occur (Anderson et al. 2013a,b).
We used our value score in combination with whether
or not the problem was addressed (column 10 in Figure
3) to create a unit-level variable that represented
the percentage of problems in the top quartile
(ranked by value) that were resolved, which we call
?% of top quartile that were resolved.? As an alternate
test of H2, we also created a dummy variable,
?Top ranked problem resolved?? A dichotomous
variable that indicated whether or not the top-ranked
problem in the work area was resolved. The alternate
specification for H2 allowed us to test our prediction
using innovation literature theory, which asserts that
success can come from identifying and solving even
just one high-value idea (Girotra et al. 2010). To test
the easy-to-solve prioritization approach (H3), we
calculated, from a work area?s set of problems that
were resolved, the percentage that were rated ?easyto-solve,?
a ?1? on a 3-point scale, meaning it is was
1 2 3 4 5 6 7 8 9 10 11 12 13
Hospital
#
Date of
Activity
Activity
Type:
Worksite
Visit or
Safety
Town
Meeting
Participant
from
Executive
team
Location “Hinderers” to
patient safety, or
system weaknesses
observed during
worksite visit, or
brought up during
safety town meeting
(one item per row)
Safety Risk:
1: Low
3: Mild
discomfort
5: Would require
intervention
10: Could cause
harm or death
Likelihood or
frequency of
risk
1=Very
unlikely
2=Possible
3=Very likely
Ease of implementation
1=Easy, within 30
days
2=Moderate-multiple
departments (90 days)
3 = Difficult-process
changes and/or major
budget (6 months)
Action items
or proposed
changes to
hinderers
Team
member(s)
responsible
for follow up
C-Suite
Yes = 1
No = 0
Date
change
completed
100 3/16/2
006
Worksite
Visit
Betsy
Green,
CNO
Medical/
Surgical
Unit
New diabetics?
insurance won’t pay
for glucometers.
Staff concerned
about patients’
inability to get the
devices and their
own need to learn
many different
devices based upon
what the patient
purchased. The delay
decreases the
amount of time
nursing staff have to
teach patients about
using the device.
10 2 2 Director of
Laboratory
Services
communicat
-ed the need
to a vendor
of diabetic
supplies.
Director of
Laboratory
Services and
CNO
1 Mar-06
100 Another problem of lower value would be here 2
100 Another problem of lower value would be here 2
100 3/14/
2006
Worksite
Visit
Jen
Calhoun,
Safety
Director
Medical/
Surgical
Unit
Overbed tables being
used to hold Personal
Protective Equipment
(PPE).
5 1 1 Isolation
Carts have
been
purchased
to hold and
store PPE
outside of
patient
rooms.
CNO and
Director of
Medical/
Surgical
Unit
1 1st cart
arrived
03/20/20
06
To test H2: % of the top quartile (of value) that were resolved =100%
To test H3: % of resolved problems that were ?easy-to-solve? =50%
To test H4: % of problems assigned to senior manager =50%
Value = 10*2 = 20
Top quartile? = 1 (yes)
Addressed? = 1 (yes)
Top quartile & addressed? = 1 yes
Figure 3 Data Collection Sheet Used by Treatment Hospitals and Two Problems as Examples
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 259
?easy and could be resolved within 30 days? (column
9 in Figure 3). The higher the percentage, the
more the unit solved easy-to-solve problems. We
called this variable ?% of problems solved that were
low-hanging fruit.? Finally, to test our hypothesis
about senior managers (H4), at the work area level
we found the percentage of problems for which a
chief executive level manager was assigned responsibility
for ensuring that the problem was resolved
(column 12 in Figure 3). See Figure 3 for details on
these variables.
3.3.2. Measure. In accordance with prior research
(Chandrasekaran and Mishra 2012, Frankel et al.
2003, 2005, 2008), we evaluated the program?s performance
using staff ?PIP.? To measure PIP, we used
four survey items (see Appendix A) from validated
survey instruments that measured the effectiveness of
quality improvement efforts (Shortell et al. 1995,
Singer et al. 2009). Respondents rated each item using
a 5-point scale ranging from 1 = strongly disagree to
5 = strongly agree. Agreement indicated that respondents
thought quality and safety performance were
improving. The scale exhibited high reliability (Nunnally
1967), with a Cronbach?s alpha of 0.84 (n = 1147
nurses) in the pre-period and 0.88 (n = 1103 nurses)
in the post-period.
We used perception of performance for four reasons.
First, employee perceptions are an important
outcome because they influence behaviors, which in
turn impact objective measures (Zohar and Luria
2003). Second, staff perceptions of performance are a
valid indicator of performance (Ketokivi and Schroeder
2004). This is because employees are close to the
work and often know if system failures are decreasing
or increasing. Research has found that nurses? perceptions
of safety are correlated with objective measures
of safety outcomes, such as mortality, readmissions,
and length of stay (Hansen et al. 2010, Hofmann and
Mark 2006, Huang et al. 2010, Singer et al. 2009).
Third, employee perceptions have been widely used
as outcome measures in operations management
research because they enable comparison across organizations
(Anderson et al. 2013a,b, Atuahene-Gima
2003, Bardhan et al. 2012, Chandrasekaran and Mishra
2012, Flynn et al. 1995, Kaynak 2003, Swink et al.
2006). Finally, the use of a perceptual measure was
necessitated by hospitals? unwillingness to share data
on safety incidents.
Our dependent variable was the change in PIP from
the pre- to the post-period. The use of change scores
allowed us to examine change over time (Fitzmaurice
2001). To create a composite change score for each
work area, we used the pre-data to calculate the
mean of the four items for each nurse, and then averaged
by work area. We repeated this process for the
post-data and subtracted each work area?s pre-score
from its post-score. We calculated intra-class correlations
(ICC) and a mean inter-rater agreement score
(rWG) to test whether aggregation of PIP was appropriate.
Significant (ICC[1] = 0.06, F = 5.69, p < 0.000,
and ICC[2] = 0.82) supported aggregation (Bliese
2000). The rWG for nurses? rating of PIP was 0.60,
which also was sufficient for aggregation (ZellmerBruhn
2003). Furthermore, our use of a change score
as our dependent variables met the two conditions
specified by Bergh and Fairbank (2002): the reliabilities
of our survey measures for PIP in pre- and postperiods
were high (0.84 and 0.86, respectively) and
the correlation between the measures from the two
different time periods was low (q = 0.24, p < 0.001).
As is common in studies using a change score (Bergh
and Fairbank 2002), the correlation between the
change score and the PIP measure in the pre-period
was negative (q = 0.67, p < 0.001). This indicates
that there was a greater opportunity for improvement
in PIP among work areas with a low PIP in the
pre-period (Fitzmaurice 2001). Therefore, to control
for impact of a work area?s starting point on the
change in PIP, we included a dichotomous variable
indicating whether PIP in the pre-period was in the
lower quartile (?bottom quartile for 2004 PIP?).
The variable was coded ?1? if the work area was in
the bottom quartile of work areas in PIP in the preperiod
and ?0? for all others. This method enabled us
to test for the change in PIP while controlling for a
low starting point.
3.3.3. Control Variables. For H1, which tested the
overall impact of our MBWA-based program, the
large sample size enabled us to include the following
control variables: major teaching hospital (1 = yes,
0 = no); Dun & Bradstreet?s measure of the hospital?s
financial stress, with higher numbers indicating a
higher likelihood that the business will seek legal
relief from creditors or cease operations without paying
creditors in full over the next 12 months; a set
of dummy variables for the number of hospital beds
(reference group = less than 100 beds; medium =
100?250 beds; large = more than 250 beds); and a set
of dummy variables for type of work area (reference
group = non-clinical; OR/PACU; ICU; ED; Med/
Surg unit; and other clinical unit). Data on size and
teaching came from the 2004 American Hospital
Association Survey of Hospitals.
For the hypotheses about problem prioritization
(H2 and H3), our sample size was limited to the 24
work areas that formally prioritized their problems in
the data collection spreadsheet. As a result, for these
hypotheses, we did not have a large enough sample
size to include non-significant control variables in
our regression. However, our random selection of
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260 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
hospitals helps alleviate concerns that our model may
be subject to omitted variable bias (Antonakis et al.
2010). We did not include control variables for unit
type (e.g., ED, ICU, and OR/PACU) as none were significant
and their inclusion did not change our results.
We also tested for hospital-level control variables,
such as teaching status and number of beds, but none
were significant and their inclusion did not change
our results. We controlled for availability of ?lowhanging
fruit,? which was the percentage of identified
problems that were rated as easy to solve. We also
controlled for the average value of the top quartile of
identified problems.
Our regression equation for H4, the impact of a
senior manager being assigned responsibility for
problem resolution, included the full set of 58 intervention
work areas. We controlled for the percentage
of problems within a work area that were
resolved (% of problems resolved) by coding a problem
as having had solution effort if there was evidence
in the dataset that action had been taken to
address the problem, and taking the average of this
variable at the work area level. We also controlled
for the fidelity of implementation with the following
variables: the number of work system visits that
were conducted, whether a work system visit was
conducted by a senior manager (1 = yes, 0 = no),
and whether a safety forum was conducted in the
area (1 = yes, 0 = no).
3.4. Sample Size and Analysis
We used linear regression with robust standard errors
and clustered by hospital (Rabe-Hesketh and Everitt
2004) in Stata 11.1TM to test our hypotheses. The Shapiro?Wilk
test for all regressions showed that the residuals
were normally distributed (V close to 1 and
p > 0.10) (Royston 1992). Multicollinearity was also
not an issue as all variance inflation factors for all of
our equations were less than 2.5, well below the
upper threshold of 10 (Chatterjee and Hadi 1986).
To test the overall impact of our MBWA-based
program (H1), we use data from the four main clinical
work areas (OR/PACU, ICU, ED, and Med/
Surg). We had data for both pre- and post-PIP measures
from 58 intervention work areas in 20 treatment
hospitals and 138 work areas in 48 control
hospitals. However, missing data for a control variable
(financial stress) in two intervention work areas
resulted in a final sample size of 56 intervention
work areas. To test the impact of problem selection
(H2 and H3), we used data from the 24 work areas
from eight treatment hospitals that formally prioritized
their problems. Finally, to test the impact of
senior manager assignment to problem resolution
(H4), we used the full set of intervention work areas
(n = 58).
3.5. Qualitative Data Collection and Analysis
During the intervention, we visited each treatment
hospital to tour the clinical areas and to observe
MBWA activities, including work system visits, safety
forums, and debrief meetings. In addition, we discussed
and observed examples of changes implemented
in response to problems identified through
the program to verify accuracy of the data submitted.
There were no discrepancies. We also conducted
semi-structured interviews with a frontline staff
member, a department manager, and the CEO from
each hospital (see Appendix B). Interviews addressed
the nature of performance improvement in the hospital
in general and as it related to implementing the
MBWA-based program. Interviews and notes from
the meetings were recorded and transcribed. Investigators
also wrote a journal of the day?s activities from
notes taken during the day. The journal and transcripts
from each hospital were combined into a single
document, which served as our source of
qualitative data.
After the intervention was complete, we used
these qualitative data in combination with the problem
data submitted by the work areas to illuminate
differences among work areas in the types of issues
identified, actions taken to resolve them, and managers?
attitudes. We analyzed transcripts using the procedure
described in Miles and Huberman (1994, pp.
58?62). We initially used a list of codes based on our
interview questions. We read the transcripts multiple
times, revising the codes as we deepened our understanding
of similarities and contrasts among the
implementation of the program. How the managers
prioritized problems for solution efforts emerged as
a main theme. One author went through the qualitative
data to select all relevant quotes for this theme.
Both authors independently reviewed the quotes
while blinded from the performance results. We
compared our perceptions to come to a consensus.
We use the quotations to illustrate differences in
implementation approach that impacted the effectiveness
of the intervention. Table 6 in the results
section displays representative quotations from the
five work areas that improved the most over the
course of the intervention and the five that decreased
the most.
4. Results
4.1. Summary Statistics
Average PIP in the 56 treatment work areas was 3.78
in the pre-period and 3.69 in the post-period. The difference
of 0.09 was not statistically significant at the
10% significance level. The same four types of work
areas (n = 138) in control hospitals had a mean PIP of
3.8 in both time periods. Table 1 shows descriptive
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 261
statistics. Using the subset of work areas that prioritized
their problems (n = 24), the mean value score
for all identified problems was seven on the scale of 1
(lowest) to 30 (highest). Descriptive statistics and correlations
are shown in Table 2. On average, the mean
value score was 17 for the top quartile of identified
problems. The highest score, on average, was about
19.
4.2. Regression Results
Contrary to our prediction, the MBWA-based treatment
was associated with a statistically significant
decrease in PIP (0.17, p < 0.05) compared to the same
types of work areas in control hospitals (H1, Table 3,
Model 1). A possible explanation is that some treatment
work areas failed to conduct the recommended
activities (Nembhard et al., 2009). However, the following
statistics provide evidence that treatment
areas did indeed implement the MBWA-based program:
91% had a work system visit; each treatment
work area received a mean of 3.41 visits (SD = 3.16,
maximum of 12); 50% had a safety forum; on average,
they identified 19 problems and took action on 11
(Table 1).
The effectiveness of the program did vary, however,
among work areas. As shown in Model 1, our
control variable for whether or not the work area was
in the bottom quartile for pre-period PIP was signifi-
cant (b = 0.75, p < 0.001), suggesting that work areas
with the lowest PIP scores in the pre-intervention period
exhibited a positive change in PIP over the course
of the intervention. Additional analysis revealed that
the work areas that were in the bottom quartile for
our dependent.
variable, change in PIP, had a decline in PIP ranging
from 0.375 to 2.25. Of these 15 work areas that
experienced the greatest decline in PIP, four were
already below median in the pre-period, suggesting
that their decline was not merely a regression to the
mean effect. The work areas in the top quartile of
change in PIP experienced an increase in PIP ranging
from 0.38 to 1.33 points. This large variation in results
prompted us to examine factors associated with
success.
Model 1 in Table 4 shows results from testing H2
and H3. A higher percentage of problems solved that
were rated as ?easy-to-solve? was associated with
higher% change in PIP (coefficient = 1.00, p < 0.05),
providing support for H3. A one standard deviation
(27%) increase in the percent of solved problems that
were easy-to-solve was associated with a 1.0 point
increase in change in PIP, which was a 26% improvement.
However, the percentage of problems rated in
the top quartile for value that were solved was not
significant. Thus, H2 is not supported.
Testing H2 using highest-value score instead of the
mean priority of the top quartile and a dummy for
whether the top-ranked problem for value was
resolved instead of the percentage of problems rated
in the top quartile for value that was solved was also
not significant (Table 4, Model 2). This result fails to
support theory from the innovation literature suggesting
that solving the highest-value idea drives performance
in our context. However, the percentage of
problems resolved that were rated ?easy-to-solve?
remained significant in this model (coefficient = 0.82,
p < 0.01), providing additional support for H3. Prioritizing
easy-to-solve problems appeared to increase
PIP.
An alternate explanation for our finding could be
that work areas were more successful because they
spent more money on problem solving rather than
because they prioritized easy problems. To control for
this ?spend more? explanation, the authors individually
rated the rough cost of each solved problem on a
scale of 1?3 with 1 = low (cost = $500), 2 = medium
(cost > $500 < $150,000), and 3 = high (cost =
$150,000) based on the description of how work areas
solved the problem and independent research to
check the cost of products or services mentioned in
the description. We used these ranges because they
represented different categories of solutions. The
cheapest category was solutions that involved a onetime
purchase of a relatively low-cost supply (<$500).
An example is applying a coating to one window to
improve patient privacy. The second category was
intended to cover mid-range solutions such as the
purchase of equipment or consumable supplies. An
Table 1 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas (N = 56 work areas)
Variable Mean SD Min Max 1 2 3 4 5 6
1 Postperiod PIP 3.69 0.61 1.92 5.00
2 Change in PIP 0.09 0.67 2.25 1.33 0.639***
3 Had work system visit 91% 29% 0 1 0.195 0.197
4 Number of work system visits in area 3.41 3.16 0 12 0.055 0.1 0.342*
5 Had safety forum 50% 50% 0 1 0.056 0.028 0.313* 0.097
6 Percent of problems addressed 62% 31% 0 1 0.088 0.079 0.083 0.043 0.074
7 Percent of problems assigned to
senior manager
10.4% 23.7% 0 93% 0.186 0.175 0.114 0.359** 0.176 0.065
***p < 0.001, **p < 0.01, *p < 0.05.
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262 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
example is the purchase and installation of new lighting
in a catheterization laboratory to illuminate procedures.
The most expensive category was for solutions
that involved construction or hiring of multiple people.
An example is a solution that involved hiring
multiple people to transport patients within the hospital.
We compared scores and discussed our rationale
until we reached consensus for all solved
problems. We then summed the total estimated solution
costs, estimating 1 = $250; 2 = $5000; and
3 = $150,000, for all of the solved problems in each
work area.
Another possible explanation is that variation in
quality of solution efforts impacted the results (e.g.,
some work areas might have engaged in only superfi-
cial steps while others might have systematically
resolved underlying causes). We also controlled for
this ?higher quality? explanation by hiring 10 nurses
not affiliated with our study hospitals to rate the solution
effectiveness of the proposed solution for each
Table 2 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas and Identified Problems (n = 24)
Variable Mean SD Min Max 1 2 3 4 5 6 7
1 Change in PIP 0.02 0.53 1.17 1.1
2 Avg value of top quartile of
identified problems
17.23 6.67 6 30 0.298 1
3 Highest-valued score 18.75 7.43 6 30 0.325 0.952*** 1
4 Availability of
low-hanging fruit
36% 26% 0% 100% 0.016 0.305 0.289 1
5 Percentof top quartile
problems solved
88% 29% 0% 100% 0.186 0.091 0.109 0.045 1
6 Highest-valued problem
was solved
88% 34% 0 1 0.209 0.110 0.039 0.086 0.799***
7 Percent of solved problems that
were low-hanging fruit
33% 27% 0% 83% 0.327 0.097 0.099 0.551** 0.432* 0.350?
8 Percent of problems
assigned to senior manager
22.5% 32.4% 0% 93% 0.308 0.582** 0.576** 0.136 0.054 0.242 0.457*
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Table 3 Linear Regression testing Hypothesis 1 (the Change in PIP in
Treatment Work Areas vs. the Same Types of Work Areas
from Control Hospitals) Clustered by Hospital with Robust
Standard Errors in Parentheses
Model 1
H1. Treatment work area (1 = yes) 0.17*(0.08)
Bottom quartile PIP (pre-period) 0.75*** (0.10)
Major teaching hospital (1 = yes) 0.21? (0.13)
Financial stress 0.00 (0.00)
Medium-size hospital (100?250 beds) 0.43*(0.10)
Large-size hospital (>250 beds) (1 = yes) 0.26* (0.12)
OR/PACU (1 = yes) 0.08 (0.11)
ICU (1 = yes) 0.00 (0.13)
ED (1 = yes) 0.15 (0.13)
Was a work system visit conducted? Not in model
Was a safety forum conducted? Not in model
Constant 0.02 (0.20)
Observations 194
Treatment and control work areas 56 & 138
Degrees of freedom F (9, 55)
F-statistic 9.06***
Adjusted R2 0.20
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Table 4 Regression Comparing Change in PIP in Treatment Work
Areas that Rated the Severity, Frequency, and Ease of
Solution of the Problems, Clustered by Hospital with Robust
Standard errors in parentheses (H2 and H3)
Model 1 Model 2 Model 3
Mean value of top
quartile of
identified
problems
0.02 (0.02) ? ?
Highest-value score of
identified problems
? 0.02 (0.02) ?
Availability of
low-hanging fruit
0.60 (0.49) 0.45 (0.45) 0.90? (0.42)
H2. Percent oftop
quartile value
resolved
0.22 (0.23) ? ?
H2. Was top-ranked
value problem
resolved (1 = yes)
? 0.01 (0.26) ?
H3. Percent of
solved
problems that were
low-hanging fruit
1.00* (0.30) 0.82** (0.21) 1.22* (0.46)
Bottom quartile
2004
PIP pre (1 = yes)
0.39* (0.16) 0.36^ (0.19) 0.38* (0.13)
Cum. cost of solving
problems
? ? 0.00 (0.00)
Avg effectiveness of
solution effort
? ? 0.11 (0.10)
Constant 0.25 (0.48) 0.47 (0.46) 0.61 (0.62)
Observations 24 24 24
Degrees of freedom F (5, 7) F (5, 7) F (5, 7)
F-statistic 10.99** 5.28* 7.08*
Adjusted R2 0.06 0.07 0.08
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
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problem using a scale from 1 to 10. The low end of the
scale was used for problems that were not resolved
(1 = ?no information given?; 2 = management dismissed
the issue or it was not a safety issue; and
3 = issue not considered due to lack of funds or issue
passed off to someone else without any follow-up).
The higher the number, the more substantial and systematic
the solution (e.g., 9 = major investment or
change; 10 = systemic fix that would prevent recurrence).
The scale is available from authors. Agreement
among nurses on their ratings was acceptable
(j = 0.23) (Landis and Koch 1977). The mean rating
for solution effectiveness was higher at 5.9 for solved
problems (?solution action in progress? on our scale)
than 2.7 (?no solution implemented?) for unsolved
problems, which validates their coding.
Given our small sample size, in this secondary
analysis we omitted the high-value prioritization variables,
as they were not significant in our primary
analyses. As Model 3 shows, the variable for the
cumulative ?cost of solving problems? was not significant.
This may be because work areas could improve
PIP without having to spend a lot of money on solutions.
Solution effectiveness was also not significant.
The percentage of solved problems that were lowhanging
fruit remained significant (coefficient = 1.22,
p < 0.05), indicating that the results are similar after
accounting for spending and solution effectiveness.
The evidence in the three models supports H3, which
predicted that prioritizing easy-to-solve problems
would be associated with higher PIP.
Table 5 shows the results from testing H4, which
proposed that senior managers taking responsibility
for ensuring that identified problems get resolved
would be associated with higher% change in PIP. H4
was supported (coefficient = 0.79, p < 0.05). Increasing
the percent of problems assigned to senior managers
by one standard deviation (23%) was associated
with a 0.79 increase in PIP. This equates to a 21%
increase in PIP.
4.3. Robustness Check
Other scholars have used a different approach for
testing improvement over time by using the postmeasure
as the outcome variable and the pre-measure
as a control variable (Fitzmaurice 2001). We tested
our hypotheses using this method and the results
were the same (results not shown).
4.4. Qualitative Results
To provide insight into the nature of implementation
of MBWA-based programs, Table 6 presents qualitative
data from the five work areas that improved the
most and the five that decreased the most. Between
pre- and post-periods, on average PIP improved by
0.85 for the top five work areas and decreased by 1.4
for the bottom five. Our examination of issues identi-
fied and actions taken suggests that the top work
areas identified meaningful problems and managers
took these problems seriously. For example, hospital
88s Med/Surg unit was one of the most improved
work areas. One of the identified issues was that the
small size of the medication room prevented two
nurses from preparing medications simultaneously,
which was an inconvenience and delayed patient
care. Senior managers discussed the issue with staff
and they collectively made a plan to move the medication
room to a larger space. The COO commented,
?It?s a little thing, but when you actually see them
doing the process, you say, ?Wait a minute, that is dif-
ficult for them.?? An interview with a nurse highlighted
management?s willingness to address issues.
She commented, ?These people address safety issues.
It may not always get addressed the way you want,
but it still gets addressed.?
Conversely, in the bottom work areas, an emphasis
on prioritizing the highest-valued problems limited
solution efforts. For example, hospital 129s ED identi-
fied valid issues, such as long lead times to receive lab
results. However, in the safety forum, we observed
the manager spend the entire time getting staff input
on prioritizing the items, leaving no time to discuss
how the issues might be resolved. This work area did
not solve any of the problems they had identified,
despite investing substantial time in identifying and
prioritizing them. As Table 6 shows, this pattern was
common. Two of the six bottom work areas did not
resolve any problems, another?s ?solutions? were largely
to re-educate staff, and a fourth area provided us
with no information about solved problems. These
implementation details suggest an inability to make
meaningful progress on solving the problems. The
lack of solution efforts illustrates how relying too
heavily on a high-value prioritization approach can
Table 5 Impact of the Percentage of Problems Assigned to Senior
Managers on Change in PIP in Treatment Work Areas (H4)
Model 1
H4. Percentage of problems
assigned to senior managers for resolving
0.79* (0.32)
Bottom quartile PIP pre (1 = yes) 0.56** (0.15)
Percentage of problems solved 0.12 (0.33)
Number of work system visits in the area 0.04? (0.02)
Senior manager participated in
work system visit (1 = yes)
0.12 (0.23)
Safety forum in the area (1 = yes) 0.12 (0.14)
Constant 0.08 (0.31)
Observations 58
Degrees of freedom F (6, 19)
F-statistic 2.96*
Adjusted R2 0.10
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
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Table 6 Illustrative Problems, Solutions, and Quotes from Top and Bottom Quartile Work Areas
Hospital
ID Work area
2004
Score
2006
Score
%
Change Examples Solution efforts Illustrative quotes and examples about prioritization
116 OR/PACU 3.3 4.6 41% Need more clinic space Made new clinic rooms The associates will prioritize with the managers, who
have a good idea of what the staff want to do
100 Med/Surg 2.6 3.6 38% Newly diagnosed diabetic patients
cannot get glucometers from
insurance; buy different kinds,
hard for nurses to teach
Vendor donated glucometers, in-serviced nurses,
made kits for newly diagnosed diabetic patients
Manager ordered new isolation carts to keep supplies
for each patient outside the door to prevent spread of MRSA
88 Med/Surg 3.6 4.7 31% Medication room is very
small for two people
After discussing with staff, changed medication
preparation to a larger room.
These people address safety issues. It may not always get
addressed the way you want it to, but it still gets addressed.
47 ED 3.0 3.8 28% Need prompt response from
pharmacy for selected meds;
need lift equipment for obese
patients; Pyxis* IT display
disposed to medication errors
Installed phone system with priority access to
pharmacy; identified or added lift equipment;
reprogrammed Pyxis IT display
We understand what needs to be done – trying to get rid of
verbal orders, trying to set up our Pyxis machine differently
39 ED 4.0 5.0 25% Feel like ?dumping ground?
when the clinic closes;
Roof leaks, need more
blood pressure machines
Relocated clinic in to expand ED patients; hired
additional ED staff; fixed roof; provided blood
pressure equipment
Nurse almost gave wrong medication because two similar
drugs next to each other in Pyxis. Told CNO. Pharmacist
came up right away and changed drawer
34 OR/PACU 5.0 3.8 25% OR table not safe for bariatric
patients; insufficient checking
of patient labs prior to surgery
No solutions listed Anyone can submit safety idea to their vice president. It gets
sent out for review to applicable departments
119 OR/PACU 3.8 2.6 31% Need exhaust air, some equipment
(chairs), backup of patients in ED,
beds not ready
Changes to improve air, equipment ordered
or repaired, working on flow in ED
It is hard to find the time and energy [to sustain this program]
because there are other demands that pour in.
129 ED 4.4 3.0 31% Long lead times for radiology and
lab, ties up rooms, long waits
in ED, units not taking patients
No solutions listed Spent 30 minutes deciding on priority scores with no discussion
of actions to resolve them
9 ED 2.9 1.9 33% 13/22 problems were audit items
by managers such as: Not
washing hands, leaving
cabinet unlocked
Nine solutions were to ?educate staff? No data about their solution efforts.
65 ED 4.3 2.0 53% Police bringing in dangerous
patients with only two people
on at night
Talk to police department about patients,
have security cameras, and panic buttons
You cannot fix them all, but you have to prioritize. Our patient
safety committee will end up doing that
PyxisTM is an automated medication-dispensing device used by nurses to administer medications to their patients.
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? 2014 Production and Operations Management Society 265
preclude taking action. Furthermore, in some of the
work areas in the bottom quartile for change in PIP
scores, such as hospital 34s OR/PACU and hospital
65s ED, identified issues had to be validated by an
external group, such as the patient safety committee,
before resolution efforts would be authorized. This
additional step substantially slowed the pace of
change. Hospital 65s CEO explained his prioritization
philosophy, ?You can?t fix them all, but you have to
prioritize. Our patient safety committee will end up
doing that.? However, the safety officer from that hospital
explained the negative effect this had on staffs?
perceptions, ?What happens is you heighten the
awareness among people and then, if they don?t see
resolutions, then it becomes a bone of contention.?
5. Discussion, Implications, and
Limitations
In this study, we investigated the effectiveness of an
MBWA-based program in randomly selected hospitals.
We found evidence that participating in this particular
program decreased performance on average.
Given that many quality-improvement initiatives
fail to achieve expected gains (Beer 2003, Nair 2006,
Repenning and Sterman 2002), it is perhaps not surprising
that our program failed to yield positive
results for all work areas. Nonetheless, this is an
important result because many hospitals throughout
the United States and United Kingdom have implemented?and
continue to implement?similar programs.
Our study provides a cautionary tale that visits
by senior managers to the front lines of the organization
to solicit improvement ideas will not necessarily
increase staffs? perceptions of performance improvement.
There may be negative repercussions if senior
managers attempt, but fail, to engage meaningfully
with frontline staff. We suspect that the negative consequences
arose from soliciting, but not sufficiently
addressing, frontline staffs? concerns (Keating et al.
1999, Morrison and Repenning 2011). Failure to meet
expectations, once raised, can frustrate employees,
negatively impact organizational climate, and dampen
employees? willingness to provide future input
(Tucker 2007). Thus, our study suggests that there is a
hidden, psychological cost of asking employees for
ideas that are subsequently disregarded.
To understand why some units had better results
than others, we examined two approaches to problem
solving. Solving a higher percentage of the highestvalued
problems was not associated with increased
PIP. This result is similar to an earlier finding in the
TQM literature that formalization could overwhelm
actual improvement efforts, leading to employee dissatisfaction
with the program (Mathews and Katel
1992). Conversely, solving a higher percentage of
easy-to-solve problems was successful, lending support
for approaches that create a bias toward action.
This signals the value in addressing ?low-hanging
fruit,? at least in the short term (Keating et al. 1999,
Morrison and Repenning 2011). Our research does
not find that a focus on surfacing and resolving only
high-value problems yields improved staff perceptions.
Senior managers can facilitate a bias for action. We
found that having senior managers assume responsibility
for ensuring that problems get resolved was
associated with increased PIP. One explanation for
this finding is that organizational change often
requires senior managers to provide financial
resources to pay for required equipment, materials, or
labor; and organizational support to get an upstream
department in the organization to change how they
do their work if benefits accrue downstream. In other
words, senior managers can help ensure that action
happens. Given the improvement literature?s emphasis
on empowering frontline employees to solve problems
(Powell 1995), our finding may be interpreted as
highlighting the importance of empowering frontline
employees to identify and solve problems while supporting
those efforts by ensuring that organizational
obstacles to improvement are removed.
5.1. Implications for Theory
Manager commitment is associated with successful
implementation of performance improvement programs
that rely on frontline employee participation
(Ahire and O?Shaughnessy 1998, Coronado and
Antony 2002, Kaynak 2003, Nair 2006, Worley and
Doolen 2006). We found that a program that stimulated
managerial involvement was productive for
some, but not all, work areas. An explanation of the
negative result of our MBWA-based program was
that asking employees for their suggestions and then
not implementing them sent the message that
employees? ideas were not valued and that the program
was symbolic. Research by Miles supports this
explanation (1965). He postulated that managers hold
one of two beliefs about the value of employee participation
programs. One belief was that frontline staff
participation was valuable because it increased morale,
though the actual ideas they contributed were
unhelpful. These managers believed in the symbolic
value of employee participation programs, such as
MBWA. Miles (1965) found that improvement programs
failed when managers held this belief. The second
belief?which was associated with success in
Miles? study?was that interactions with frontline
staff were valuable because their ideas were actually
useful. The belief in the substantive value of employees?
ideas underlies a core TPS principle: respect for
people (Liker 2004). Miles? study suggests that senior
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266 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
managers? respect for frontline employees? concerns
may have been an important but unmeasured moderator
variable for our MBWA program. An implication
is that rather than just seeking to increase manager
involvement, it may be critical first to ensure that
managers value the ideas raised by frontline staff.
An explanation for the lack of positive impact from
the high-value prioritization approach may be that
problem values in the hospital work areas in our
study had a relatively flat landscape. As a result, pursuing
a high-value prioritization approach did not
yield a substantial improvement over focusing on
easy-to-solve problems. The flat landscape may be
because the work areas had already addressed their
large-value problems or because the fragmented service
environment of health care creates a wide range
of small-scale problems. The easy-to-solve prioritization
approach may have been successful in our study,
because the work areas needed to first tackle fundamental,
lower-value problems before advancing to
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). Taking care of the basic
infrastructure and requirements is a necessary precursor
to more comprehensive organizational change
required by higher priority score problems (Keating
et al. 1999, Morrison and Repenning 2011).
There are likely circumstances under which prioritizing
high-value problems is helpful, such as when
only one idea can be fully developed, like implementation
of an enterprise-wide information system. We
also believe that organizations benefit from resolving
high-value problems, which tend to be top-down,
strategic improvements, as well as easy-to-solve problems,
which tend to be bottom-up, tactical initiatives.
Organizations should try to nurture both kinds of
problem-solving capabilities. For example, organizations
may have experts working on identifying and
solving high-value problems through six-sigma projects,
while frontline employees simultaneously work
on resolving smaller scale issues in their local work
area through lean initiatives. Furthermore, it may be
that organizations begin their improvement journey
by successfully resolving relatively easy problems,
but then need to develop new capabilities to resolve
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). For example, reducing the
time required to find vital sign monitor equipment on
a nursing unit likely requires different problem-solving
skills than reducing patients? lengths of stay in the
hospital.
5.2. Implications for Policy
Our study suggests that policy makers can play an
important role in improving safety in hospitals by
encouraging organizations to build problem-solving
capacity. Rather than requiring hospitals to participate
in a specific change program, such as MBWA,
that may not be fully validated, policy makers could
instead provide incentives for hospitals to build the
generic capacity to solve frontline problems. Given
the trend toward requiring hospital to implement
multiple quality-improvement initiatives concurrently,
we suspect that it is likely that many programs
are being implemented superficially and in ways that
lead to harmful results similar to those we observed
in this study. This could be contributing to the oftreported
failure to achieve gains through improvement
initiatives that frustrate the health-care industry
(Landrigan et al. 2010). Our study provides a warning
about mandating implementation of improvement
programs before fully understanding the conditions
required for the programs to yield successful outcomes.
The financial incentives used to encourage adoption
of electronic health records in the United States
may be instructive. Policy makers rewarded ?meaningful
use,? as demonstrated by the functionality that
was achieved, rather than rewarding implementation
of a particular software (Blumenthal 2010). Similarly,
policy makers could provide incentives for building
problem-solving capabilities that improve patientcentered
performance rather than advocate for a specific
improvement program.
5.3. Implications for Practice
Many initiatives to improve safety begin by trying to
increase employees? reports of near misses, errors,
and incidents (Bagian et al. 2001, Evans et al. 2007).
Implied assumptions are that increasing the number
of reports enables organizations to conduct trend
analysis that illuminates high-value problems which
can then be solved; and that many issues will be of
sufficiently low value that they can be ignored at low
or no cost to the organization. In contrast, our study
suggests that there may be little benefit, and some
potential harm, to this approach. Rather than increasing
reporting, organizations might be better served by
addressing known problems, which builds problemsolving
capabilities, which in turn enables actiontaking
on more problems. Our finding corroborates
prior research that highlighted the importance of
problem-solving capacity for successful improvement
programs (Adler et al. 2003, Keating et al. 1999, Morrison
and Repenning 2011). This advice is consistent
with the vision for a continuously learning health-care
system articulated by the US Institute of Medicine,
requirements for which include systematic problem
solving. Our study also resembles Kaizen, a structured
problem-solving approach involving managers
and frontline workers. However, important differences
that may make Kaizen more successful than our
program are that Kaizen occurs after managers and
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 267
frontline staff have been trained on a standardized
problem-solving technique and that it emphasizes
taking action to solve as many problems as possible
within the given time period (Imai 1986). Thus, it prevents
resource depletion by limiting the time spent
identifying and solving problems rather than by
selecting among them.
5.4. Limitations
Our findings must be considered in light of study
limitations. First, our small sample size limited our
analysis. Our sample was small for several reasons.
The cost- and time-intensive nature of conducting an
experiment with hospitals over 18 months made it
challenging to conduct our field-based, interventional
program with 24 organizations, and we would
have struggled if there were more. In addition,
despite our providing a method of prioritizing problems,
many organizations chose not to assign prioritization
values and therefore work-area coded data
on problem value were not available for all treatment
work areas. Future research with larger sample sizes
could test more nuanced theory. For example, an
easy-to-solve prioritization approach may be most
successful for work areas that start from a weak
position and can benefit most from action, whereas a
high-value prioritization approach may be most
helpful for experienced work areas that can be more
selective.
A second limitation is the perceptual measure of
improvement. Hospitals were unwilling to share
actual safety incident measures with us. In addition,
publicly available clinical measures, such as mortality,
readmissions, and process of care measures,
started being reported publicly only after the initiation
of this study. Although we conducted analyses
using these ?post study? clinical outcome data, the
regressions were not significant in explaining variation.
However, for reasons detailed above, a perceptual
measure is an important indicator of the impact
of the intervention we tested. Furthermore, prior
research on an MBWA-based intervention that did
have access to clinical outcome data did not find links
between multiple clinical outcomes and the intervention
(Benning et al. 2011), corroborating our study
results.
Third, hospitals did not track resources spent on
solution efforts. Therefore, estimation was the only
way of testing the alternate explanation that spending
more money on process improvement yielded better
outcomes. Future research could contribute to
improvement theory by examining the cost of
improvement efforts compared to benefits. A fourth
limitation is that we did not randomize an easy-tosolve
prioritization approach vs. a high-value prioritization
approach among work areas. Instead, those
differences emerged naturally. A randomized assignment
of these two prioritization approaches would
provide a stronger test of the hypotheses.
5.5. Conclusions
Understanding the impact of MBWA-based programs
is helpful for organizations that may be considering
implementing them. In our study, organizations
whose managers ensured that problems were
addressed achieved better results. This suggests that
improvement programs are more likely to change
employees? perceptions when they result in action
being taken to resolve problems than when they are a
symbolic show of manager interest. On the basis of
study findings, we recommend that organizations
focus on increasing their capacity to act on improvement
suggestions rather than expending further effort
on generating more suggestions and prioritizing
them.
Acknowledgments
Funding was provided by Agency for Healthcare Research
and Quality RO1 HSO13920. Additional funding was
obtained from Fishman Davidson Center at Wharton. Jennifer
E. Hayes provided valuable data coding assistance.
Appendix A: Survey Questions for
Perceived Improvement in Performance
The quality of services I help provide is currently the
best it has ever been.
We are getting fewer complaints about our work.
Overall, the level of patient safety at this facility is
improving.
The overall quality of service at this facility is
improving.
Appendix B: Interview Questions
B.1. FrontLine Personnel Interview Protocol
I wanted to ask you some questions about the patient
safety culture at this hospital. We recognize that most
hospital personnel experience problems in the course
of their work and that these are not a reflection of
their skill level or of the quality of care provided at
their facility. My goal is to understand differences in
safety culture among organizations.
1. Do personnel on this unit talk openly about
safety issues and errors?
2. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
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268 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
care to patients think about reporting incidents
related to patient safety.
3. Have you ever reported something? What
made you decide to report that incident? What
happened as a result of reporting? Did you
ever learn the outcome?
Can you recall a specific adverse event that
was caused by an error or series of errors?
What happened? Can you describe the investigation
process (i.e., what happened to people
involved, what changes, if any, resulted from
the investigation)?
My last question relates to a major change in a
care process at your hospital.
4. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced in your unit?
Probe: What training did you receive? Has
implementation required any workarounds of
the built-in features of the system?
B.2. Manager Interview Protocol
I wanted to ask you some questions about the
patient safety culture at this hospital. We recognize
that most hospital personnel experience problems
in the course of their work and that these are not a
reflection of their skill level or of the quality of
care provided at their facility. My goal is to understand
differences in safety culture among organizations.
1. Do you feel comfortable talking about safety
issues and errors in your manager meetings
with senior leadership?
2. Do you encourage your staff to speak up?
How?
3. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
care to patients think about reporting incidents
related to patient safety.
4. Can you step through a recent ?near-miss?
safety report that you addressed? Briefly (do
not need details) what was the situation and
what was the response, if any?
5. Can you recall a specific adverse event that
was caused by an error or series of errors?
Briefly, what happened? Can you describe the
investigation process (i.e., what happened to
people involved, what changes, if any, resulted
from the investigation)?
My last question relates to a major change in a
care process at your hospital.
6. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced to a unit? Probe:
What training was provided? Has implementation
required any workarounds of the built-in
features of the system?
B.3. Hospital Administrator Interview Protocol
I wanted to ask you some questions about your daily
activities as a hospital executive and your views on
the patient safety culture at your hospital. We recognize
that leadership styles and organizational cultures
are unique at every institution and none is necessarily
better than any other. My goal is to understand the
full variation among organizations.
1. What are your primary priorities for the hospital?
[Prompt if it is not mentioned] Where does
patient safety fall in your list of priorities?
2. How do you see your role in patient safety? In
what ways do you provide leadership in this
area?
3. How would you describe the general attitude
of health-care professionals and employees
within the hospital toward patient safety?
4. It is well known that middle managers are a
key to implementation, and these people are
often extremely pressed due to budget constraints.
What is the situation with middle
managers in your hospital?
5. How do you obtain information about the hazards
present at the front lines of your organization?
6. Thinking about the most recent major organizational
change related to patient safety, can
you describe the change, your decision-making
process, and its implementation? Probe: Did
some event or new piece of information
prompt your decision to implement the
change? Did you evaluate the business case
before making the change?
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Write a 2 page paper addressing the following elements in your paper:
? Discuss and Explain the managerial tool of management by walking around (MBWA) and its impact on creating a strategy ready culture.

Include a title page and 3-5 references. Only one reference may be from the internet (not Wikipedia). The other references must be from the attached. Please adhere to the Publication Manual of the American Psychological Association (APA), (6th ed. 2nd printing) when writing and submitting assignments and papers.

The paper needs to be grammarly correct, plagiarism free, and APA style correct.

The Effectiveness of Management-By-Walking-Around:
A Randomized Field Study
Anita L. Tucker
Harvard Business School, Soldiers Field Road, Morgan Hall 413, Boston, Massachusetts 02163, USA, atucker@hbs.edu
Sara J. Singer
Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts 02115, USA, ssinger@hsph.harvard.edu
Management-by-walking-around (MBWA) is a widely adopted technique in hospitals that involves senior managers
directly observing frontline work. However, few studies have rigorously examined its impact on organizational outcomes.
This study examines an improvement program based on MBWA in which senior managers observe frontline
employees, solicit ideas about improvement opportunities, and work with staff to resolve the issues. We randomly
selected hospitals to implement the 18-month-long, MBWA-based improvement program; 56 work areas participated. We
find that the program, on average, had a negative impact on performance. To explain this surprising finding, we use
mixed methods to examine the impact of the work area?s problem-solving approach. Results suggest that prioritizing
easy-to-solve problems was associated with improved performance. We believe this was because it resulted in greater
action-taking. A different approach was characterized by prioritizing high-value problems, which was not successful in
our study. We also find that assigning to senior managers responsibility for ensuring that identified problems get resolved
resulted in better performance. Overall, our study suggests that senior managers? physical presence in their organizations?
front lines was not helpful unless it enabled active problem solving.
Key words: health care; implementation research; patient safety; quality improvement; survey research
History: Received: February 2013; Accepted: January 2014 by Edward G. Anderson, Jr. after 2 revisions
1. Introduction
Hospitals face an imperative to improve quality of
care and decrease medical errors that harm patients.
Healthcare thought leaders and policy makers have
advocated for the adoption of ?management-by-walking-around?
(MBWA) to achieve these goals, resulting
in widespread adoption in the United States and
the United Kingdom. (Frankel 2004, National Patient
Safety Agency 2011). These types of programs?in
which senior managers visit the front lines to work
with staff to identify and resolve obstacles?came to
the attention of hospitals with the publication of one
health-care system?s success at improving safety climate
through its MBWA-based intervention (Frankel
et al. 2003).
Despite the intuitive appeal of MBWA and history
of use in manufacturing organizations, empirical evidence
on the program?s efficacy in the hospital setting
is mixed. Of seven hospitals that implemented an
MBWA-based program, only two were able to sustain
the effort over a 3-year period (Frankel et al. 2008).
Those two reported a positive impact on staffs? perceptions
of safety climate, but the effect on the five
aborting hospitals was not reported. A study of one
Veterans Affairs hospital found that patient safety climate
worsened on two units that implemented the
program, while it improved or stayed the same on
two control units that did not implement the program
(Singer et al. 2013). Another found that hospitals that
implemented a general improvement program with
an MBWA component did not improve on a variety
of measures compared to control hospitals (Benning
et al. 2011).
These mixed findings provide only modest support
for widespread implementation of this program in
hospitals. The lackluster performance of MBWA in
health care may be that health care?s specialized and
diverse disciplinary knowledge bases (e.g., cardiology,
pulmonary, surgery, pharmacy, nursing, etc.)
creates a complex environment where it is difficult for
senior executives to effectively observe frontline work
and provide improvement suggestions (Aflaki et al.
2013). In addition, the highly regulated nature of
health care may minimize the marginal effectiveness
of MBWA because other audit programs, such as government-mandated
inspections or incident-reporting
systems, already focused senior managers? attention
on the front lines of care (Iyer et al. 2013). Furthermore,
the mixed results may be due to implementation
253
Vol. 24, No. 2, February 2015, pp. 253?271 DOI 10.1111/poms.12226
ISSN 1059-1478|EISSN 1937-5956|15|2402|0253 ? 2014 Production and Operations Management Society
differences, such as the prioritization methods used
to determine which problems get resolved. However,
prior studies have not assessed MBWA programs at a
more granular level. As a result of the contextual
differences in health care and limitations of prior
research, much remains to be discovered about
what factors and implementation approaches are
associated with the success of MBWA in hospitals.
To test more systematically the impact of MBWAbased
improvement programs and to identify factors
associated with its success, we implemented one
such program in 19 randomly selected hospitals. We
compared nurses? perceptions of improvement in
performance (PIP) in work areas that implemented
the program to the same type of areas at 68 randomly
selected control hospitals that did not implement
the program. A contribution of our study is
thus a rigorous testing of an MBWA program. More
specifically, our study design minimizes two methodological
challenges of research on improvement
programs. First, we minimize selection bias by randomly
assigning organizations to the treatment condition.
Our study thus provides insight into the
program?s generalizability beyond those where
senior managers decided on their own to implement
such a program. Second, the use of control organizations
reduces the possibility that positive (or negative)
results were caused by time-dependent
variables, such as changes in technology, policies, or
awareness over time. Surprisingly, we find that, on
average, our MBWA-based program had a negative
impact on nurses? perceptions of performance, suggesting
that senior managers? presence in hospital
front lines to solicit improvement ideas could be detrimental
to workers? perceptions.
A second contribution of our study is developing a
categorization of problem-solving approaches that
explains the conditions under which improvement
solicitation programs, such as MBWA, are successful.
We find that our MBWA-based program was associated
with improved perceptions of performance
under two conditions: (1) when a higher percentage
of solved problems were considered ?easy? to solve,
enabling more problem solving and (2) when senior
managers took responsibility for ensuring that identi-
fied problems were resolved. This suggests that the
action-taking that results from the program, rather
than the mere physical presence of the senior managers,
is what positively impacts the frontline staff.
In section 2, we describe prior research on MBWA
programs and develop four hypotheses linking the
program to performance. In section 3, we describe
the intervention, the sample of hospitals that participated
in the research project, and our qualitative and
quantitative data, measures, and analytic approach.
We present the results in section 4 and discuss the
implications for research, practice, and policy in
section 5.
2. MBWA-based Improvement
Program?s Impact on Performance
Research has found that quality improvement programs
that solicit frontline workers? ideas, such as
MBWA, can have a beneficial impact on organizational
outcomes (Dow et al. 1999, Powell 1995).
MBWA relies on managers to make frequent, learning-oriented
visits to their organization?s front lines to
observe work and solicit employees? opinions (Packard
1995). Hewlett-Packard, the company in which
MBWA originated, attributed its success using
MBWA to good listening skills, willing participation,
a belief that every job is important and every
employee is trustworthy, and a culture where
employees felt comfortable raising concerns (Packard
1995). MBWA is similar to the Toyota Production System?s
?gemba walks? (Mann 2009, Toussaint et al.
2010, Womack 2011). In a gemba walk, managers go
to the location where work is performed, observe the
process, and talk with the employees (Mann 2009).
The purpose is to see problems in context, which aids
problem solution (Mann 2009, Toussaint et al. 2010,
Womack 2011).
MBWA has resulted in positive organizational
change in some hospitals (Frankel et al. 2003, Pronovost
et al. 2004). One explanation is that MBWA leads
to successful problem resolution because seeing a
problem in context improves managers? understanding
of the problem, its negative impact, and its causes.
This understanding increases managers? motivation
and ability to work with frontline staff and midlevel
managers to resolve the issue (Mann 2009, Toussaint
et al. 2010, Von Hippel 1994, Womack 2011). Theory
further suggests that MBWA?s repeated cycles of
identifying and resolving problems may create an
organizational capability for improvement that
reduces the cost of future improvement efforts, creating
a positive dynamic (Fine 1986, Fine and Porteus
1989, Ittner et al. 2001). This virtuous cycle is further
strengthened because communication from frontline
workers about problems aligns managers? perspectives
with customers? experiences (Hansen et al. 2010,
Hofmann and Mark 2006, Huang et al. 2010, Singer
et al. 2009), enabling managers to effectively allocate
scarce resources among the organization?s multiple
improvement opportunities. Performance is also
enhanced because managers? presence on the front
lines sends a visible signal that the organization is
serious about resolving problems. This increases
employees? beliefs that leadership values improvement,
which in turn spurs employees to engage in the
discretionary behaviors necessary for process
Tucker and Singer: The Effectiveness of MBWA
254 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
improvement (Mcfadden et al. 2009, Zohar and Luria
2003). For these reasons, we hypothesize that MBWA
will positively impact performance.
Hypothesis 1 (H1). Participation in a MBWAtype
program leads to improved performance.
2.1. The Effect of Problem-Solving Approach
Although we hypothesize a positive impact from
MBWA, programs that solicit employee suggestions
can uncover more problems than an organization can
resolve, given limited problem-solving resources
(Bohn 2000, Frankel et al. 2003, Repenning and Sterman
2002). When this happens, the organization?s
problem-solving support personnel must decide
which of the identified issues they will work to
resolve and which ones will be ignored or delayed
(Keating et al. 1999, Morrison and Repenning 2011).
Thus, an MBWA?s program?s success may be contingent
upon which problems the organization decides
to address.
We examine two different prioritization
approaches, discuss their benefits and limitations,
and develop two hypotheses. We explore two dimensions
of problems: solution difficulty and value
gained by solving the problem (Aflaki et al. 2013). To
simplify the discussion, we consider only two levels
of each dimension: problems are either easy to solve
or difficult to solve; and they can yield either a small
or large value if solved. Organizations are likely to
prioritize problems that are of high value and/or
problems that are easy to solve. Although we develop
hypotheses based on the assumption that organizations
have a dominant prioritization scheme (such as
addressing high-value problems), we recognize that
organizations could combine the two approaches.
This implies that they would emphasize high-value,
easy-to-solve problems while ignoring problems that
were both difficult to solve and of low value (Aflaki
et al. 2013).
The first prioritization approach that we consider is
one that addresses issues that are causing?or have
the potential to cause?large disruptions. This highvalue
prioritization approach ranks problems according
to a value score and solves the highest-valued problems.
Many structured approaches to improvement,
such as six-sigma and risk management, use a highvalue
prioritization approach (Anderson et al. 2013a,
b). In the health-care context, hospital incident-reporting
systems (Bagian et al. 2001) and MBWA-based
programs (Frankel et al. 2003) advocate calculating a
problem?s ?value? by multiplying the problem?s score
for severity with its frequency of occurrence (Bagian
et al. 2001, Frankel et al. 2003). The hospital then
resolves the highest-value problem first, followed by
the second highest, continuing until problem-solving
resources are depleted or remaining problems fall
below a threshold value (Bagian et al. 2001). Surfacing
and solving the highest-valued problems should yield
substantial gain in performance (Bagian et al. 2001,
Girotra et al. 2010). To provide an example in the hospital
setting, medication-related problems are often of
high value because they can be fatal and can impact
many patients (Bates et al. 1995). In response, many
hospitals have implemented computerized physician
order entry systems which reduce medication errors
by preventing transcription errors and alerting physicians
to potential drug allergies or interactions (Bates
et al. 1999).
This approach is beneficial because it ensures that
limited resources are preserved for problems with
the highest values (Frankel et al. 2003). It also helps
prevent the queue of unsolved problems from growing
unmanageably long by permitting the organization
to discard the subset of problems that are
deemed too little valued to justify solution efforts
(Bohn 2000).
However, there is a downside to focusing exclusively
on high-value problems. The ignored problems
constitute the ?useful many? which individually do
not have a large negative impact on performance
(Juran et al. 1999), but which collectively could contribute
to serious problems such as medical errors
(Reason 2000).
Thus, the second approach that we consider is
prioritizing easy-to-solve problems (Johnson 2003,
Repenning and Sterman 2002). An easy-to-solve prioritization
approach enables the organization to address
problems that are straightforward and quick to
remedy?the so-called ?low-hanging fruit.? This
approach may free up resources for addressing problems
because the more formal approach of assigning
a prioritization score based on severity and occurrence
has required significant resources in the case of
incident-reporting systems in both aviation and
health care (Johnson 2003).
An easy-to-solve prioritization approach may also
be helpful in health-care settings because the cumulative
benefit of resolving many small problems can
add up to be a significant source of improvement
(Jimmerson et al. 2005). Similarly, research has found
that major accidents typically result from an unpredictable
combination of small magnitude problems
rather than from a single large magnitude problem
(Perrow 1984, Reason 2000). According to the ?Swiss
Cheese Theory,? multiple small-scale problems can
align in an unfortunate way that enables an error to
harm the customer (Cook and Woods 1994, Reason
2000). Consequently, resolving seemingly low-value
problems can be beneficial, because they otherwise
might contribute to the next major accident (Perrow
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 255
1984). To illustrate, a study of medical harm in cardiac
surgery found that adverse events were more likely to
be caused by multiple, simultaneous ?minor? issues
than by a single, ?major? issue. This was because surgeons
were less able to perceive and compensate for
multiple, simultaneous minor issues while they were
able to recognize and remedy a single, major issue
that occurred during surgery (De Leval et al. 2000).
This line of research implies that it is difficult to
assign a ?value? to problems because their negative
impact is determined in part by the specific situation
in which they occur.
Another situation in which the easy-to-solve prioritization
approach may be superior is where the organization
has a ?flat landscape? of small magnitude
problems. In flat landscapes, the difference between a
local high point and the global high point is too small
to justify an extensive search effort (Sommer and Loch
2004). This can occur in hospitals for two reasons.
First, managers typically address issues that result in
patient death or other serious injury such as wrong
site surgery. Thus, the only problems that remain
may be small magnitude issues. Second, there are
many unique opportunities for patient care to fail
because work is divided among specialties, departments,
and shifts. Problems can occur at any of these
handoffs. Thus, unlike manufacturing settings where
an undetected malfunction in a machine can be the
dominant source of defective product, it is less likely
that there is a single, dominant source of repeated failures
in hospitals. When there is a flat landscape,
improvement arises from solving the lower tail of
problems.
It may also be that organizations need to address
basic, fundamental problems before they can benefit
from trying to address more complex organizational
issues. For example, research suggests that problemsolving
efforts are most successful when organizations
use relatively straightforward problems to
develop sufficient problem-solving capacity before
tackling larger, more complex issues (Keating et al.
1999, Morrison and Repenning 2011). Addressing
easy-to-solve problems enables frequent problemsolving
cycles, which develops employees? expertise
at problem solving (Adler et al. 2003). These dynamics
suggest that organizational problem-solving
capacity is more like a muscle that strengthens with
exercise rather than a resource that gets depleted with
use (Fine 1986, Fine and Porteus 1989, Ittner et al.
2001).
We draw on the arguments outlined in the above
paragraphs to develop two hypotheses. When problem-solving
resources are limited and become
depleted with use, the organization should focus its
scarce human and financial capital on removing the
problems that pose the biggest threat. Thus, a highvalue
prioritization approach will be associated with
improved performance.
Hypothesis 2 (H2). Work areas that resolve a
higher percentage of high-value problems will
have greater improvement in performance than
work areas that solve a lower percentage of
high-value problems.
An easy-to-solve prioritization approach should be
associated with improvement because it fosters solution
of all problems that can be solved, regardless of
their hypothetical value. In the health-care setting,
this might benefit the organization because seemingly
small-value problems can nonetheless negatively
impact patient safety. Furthermore, the act of solving
problems develops the organization?s capability to
solve more problems in the future. Thus,
Hypothesis 3 (H3). Work areas that solve a
higher percentage of easy-to-solve problems will
have greater improvement in performance than
work areas that solve a lower percentage of
easy-to-solve problems.
2.2. The Role of Senior Managers in Problem
Solving
In addition to the prioritization approach, the success
of an MBWA program depends on senior managers?
willingness to take responsibility for ensuring that
problems identified through the program are resolved
(Frankel et al. 2005, Pronovost et al. 2004).
Senior managers can be helpful to frontline workers?
resolution efforts because they control financial
resources needed to address issues that involve capital
investment (Carroll et al. 2006). In addition, they
possess the perspective necessary to resolve conflicts
that arise when problems cross organizational boundaries
(MacDuffie 1997). This insight is valuable particularly
because high-value problems are likely to cross
organizational boundaries or require financial
resources to resolve.
On the other hand, easy-to-solve problems impact
only one department and do not require substantial
financial resources to resolve. Under these conditions,
frontline employees can be empowered to identify
and resolve problems (Jimmerson et al. 2005). However,
involving frontline workers in resolution efforts
requires them to take time away from their direct production
responsibilities (Repenning and Sterman
2002, Victor et al. 2000). This can be difficult for frontline
employees, especially for health-care workers
who provide direct patient care. Under these conditions,
senior managers need to allocate funds for overtime
or coverage so that care providers can spend
time away from patient care and on resolution efforts.
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256 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
As outlined in the two above paragraphs, both
high-value and easy-to-solve problems require manager
support for successful resolution. Therefore, we
hypothesize that hospital work areas will achieve better
results from the MBWA program when they
assign to senior managers the responsibility for ensuring
that a problem gets addressed.
Hypothesis 4 (H4). Work areas with a higher
percentage of problems assigned to a senior
manager to ensure resolution exhibit greater
improvement than those with a lower percentage
of problems assigned to a senior manager.
These four hypotheses outline the theoretical links
between our MBWA-based program and improved
performance. Figure 1 depicts these relationships.
3. Methodology
We test our hypotheses in a field study of US hospitals
randomly selected to participate in a patient
safety research study, with a subset of the hospitals
randomly selected (a second time) to implement our
MBWA-based program. The program was launched
in January 2005 and lasted for 18 months.
3.1. The MBWA-based Program
We drew on prior research to design our MBWAbased
program (Frankel et al. 2008, Pronovost et al.
2004, Thomas et al. 2005). It consisted of repeated
cycles of senior manager?staff interaction, debriefing,
problem solving, and follow-up. Senior managers
such as the chief executive, operating, medical, and
nursing officers (CEO, COO, CMO, and CNO, respectively),
interacted with frontline staff in a work area
to generate, select, and solve improvement ideas. The
work area manager was also involved in the selection
and solution activities. Senior manager interactions
took two forms: visits, called ?work system visits,? to
work areas to observe frontline work; and special
meetings, called ?safety forums,? with a larger group
of frontline staff from the area to discuss safety concerns.
The activities were coordinated with the work
area manager.
In work system visits, four senior managers would
spend 30 minutes to 2 hours visiting the same work
area. The senior managers would each observe a different
process, such as medication administration, or
a different person, such as a nurse or physician, to
shed cross-disciplinary insight into the work done in
the area. The purpose was to build senior managers?
understanding of the frontline work context and
gather grounded information about problems (Frankel
et al. 2008).
Senior managers also facilitated a safety forum in
the work area, which was an informal meeting
between senior managers and the frontline staff from
the work area, held in the work area, during which
the staff talked about their work area?s safety weaknesses
and strengths. We added this component to
our MBWA-based intervention for two reasons. First,
a San Diego children?s hospital improved its organizational
climate by holding meetings where frontline
staff spoke directly to the hospital CEO about their
concerns and ideas (Sobo and Sadler 2002). Second,
a prior research project on an MBWA-based program
found that the program only improved the
perceptions of frontline staff who participated in a
work system visit (Thomas et al. 2005). Because it is
not feasible for senior managers to conduct a work
system visit with every single hospital employee
within a short time period, Thomas? finding suggests
that work system visits on their own will be insuffi-
cient to change the perceptions of most hospital
employees.
The MBWA-based program continued with a
?debrief meeting,? which organized information collected
from the work system visits and safety forums.
Senior managers attended, as did work area managers,
selected frontline workers, and the hospitals?
patient safety officers. The group compiled the
improvement ideas identified, discussed and in some
work areas prioritized them, and decided next steps,
ranging from doing nothing to suggesting solutions
and assigning responsibility. Action to address problems
selected for resolution followed the debriefing.
Managers were encouraged to communicate with
staff about implementation efforts, describing what
changes, if any, were made in response to identified
ideas. Patient safety officers entered the ideas
MBWA
Program Performance
Problem solving activities
used in MBWA
Address highvalue
problems
Address ?easy-tosolve?
problems
Managers ensure
problems are
resolved
H1+
H2+
H3+
H4+
Figure 1 Model of Management-By-Walking-Around?s Impact on Performance
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 257
generated and actions taken into an electronic spreadsheet
we provided and sent this spreadsheet to our
research team for analysis.
Each round of work system visits, safety forums,
debrief meeting, solution activities, and communication
constituted one cycle. A cycle focused on one
work area and took approximately 3 months, which
research has shown is the time required to solve problems
in an organization (Pronovost et al. 2004). See
Figure 2 for a diagram of the process. After completing
a cycle, the management team would repeat the
activities in a different work area. The program
focused on the four main work areas in hospitals:
operating room or postanesthesia care unit (OR/
PACU), intensive care unit (ICU), emergency department
(ED), and medical or surgical ward (Med/Surg).
Cycles continued over the 18-month implementation,
with hospitals conducting an average of one cycle in
four work areas.
3.2. Recruitment
Our study employed an experimental design which
included a pre-test and post-test of similar work areas
in treatment and control hospitals. We randomly
selected 92 US acute-care hospitals, stratified by size
and geographic region, to participate in a patient
safety climate survey. We provided no financial
incentive, but participation in the safety climate study
fulfilled a national accreditation requirement. At
enrollment, all hospitals were aware that they may be
invited to participate in a program to improve patient
safety, but details regarding the program were withheld
to prevent contamination of control hospitals. To
select hospitals to participate in the MBWA-based
program, we drew a second, stratified, random sample
of 24 hospitals from the sample of 92. The remaining
68 hospitals not selected were control hospitals.
Data on staff perceptions of performance were
collected at control and treatment hospitals through
surveys before implementation of program activities
(2004, ?pre?) and again after the program was completed
(2006, ?post?). At each hospital, we surveyed a
random sample of 10% of the frontline workers, with
additional oversampling in OR/PACUs, EDs, and
ICUs in the post-survey period to improve sample
size. The baseline ?pre? response rate was 52%; and
the follow-up ?post? response rate was 39%. For our
analyses, we used data from registered and licensed
vocational nurses (n = 1117 pre and n = 903 post).
Of the 24 treatment hospitals, 20 completed the program
in at least two work areas. Of the four that did
not complete the treatment, one went out of business,
one was purchased, and two experienced significant
senior management turnover. As a result, they were
unable to complete more than one cycle of activities
and did not provide data. We thus excluded these
four from our analysis. There was no difference in
staff perceptions of performance in the pre-period
between the four hospitals that dropped out of the
treatment and the 20 that did not. Of the original 68
control hospitals, 48 completed the post-test survey,
making an initial total sample of 68 hospitals. There
was no difference in survey measures in the pre-period
between the 20 control hospitals that dropped out
of the post-survey and the remaining hospitals. There
was also no difference between treatment and control
work areas on pre-period measures of staff perceptions
of performance.
3.3. Data and Measures
Using the data collection spreadsheet that we provided
(Figure 3), treatment work areas reported 1245
patient safety problems identified during the visits
and forums. Each hospital also provided a list of the
C
E O
C
N O
C
M O
C
F O
Work
site visit
by CEO
Time
Work
site visit
by CNO
Work
site visit
by CMO
Work
site visit
by CFO
Safety
Form
Debrief
Meeting
Solution Activities &
Communication
Figure 2 Depiction of the MBWA-based Program Activities in a Work Area
Tucker and Singer: The Effectiveness of MBWA
258 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
senior managers, which we used to determine
whether a senior manager attended the program
activity and whether a senior manager was assigned
responsibility for the problem. The spreadsheet also
contained three columns that the work areas could
use to prioritize identified problems. Twenty-four
work areas in eight hospitals filled out this information.
3.3.1. Independent Variables. To test the overall
impact of the MBWA-based program (H1), we created
a treatment variable, ?MBWA in the work area,?
which indicated whether the work area received the
MBWA-based treatment (=1) or was a work area from
a control hospital (=0). To test the high-value prioritization
approach (H2), we calculated a value score for
each problem by multiplying problem severity (column
7 in Figure 3; 1 = low; to 10, could cause death)
by estimated frequency of occurrence (column 8;
1 = very unlikely, 3 = very likely) (Bagian et al. 2001,
Frankel et al. 2003). This method for calculating the
potential value of solving a problem is similar to sixsigma?s
risk prioritization number, which uses the
product of the scores (on a scale from 1 to 10) of a
problem?s frequency of occurrence, detectability, and
severity (Evans and Lindsay 2005). It is also similar to
risk registers used for risk management. A risk register
scores each potential risk to a project by multiplying
the risk?s likelihood of occurrence by severity of
the impact if it does occur (Anderson et al. 2013a,b).
We used our value score in combination with whether
or not the problem was addressed (column 10 in Figure
3) to create a unit-level variable that represented
the percentage of problems in the top quartile
(ranked by value) that were resolved, which we call
?% of top quartile that were resolved.? As an alternate
test of H2, we also created a dummy variable,
?Top ranked problem resolved?? A dichotomous
variable that indicated whether or not the top-ranked
problem in the work area was resolved. The alternate
specification for H2 allowed us to test our prediction
using innovation literature theory, which asserts that
success can come from identifying and solving even
just one high-value idea (Girotra et al. 2010). To test
the easy-to-solve prioritization approach (H3), we
calculated, from a work area?s set of problems that
were resolved, the percentage that were rated ?easyto-solve,?
a ?1? on a 3-point scale, meaning it is was
1 2 3 4 5 6 7 8 9 10 11 12 13
Hospital
#
Date of
Activity
Activity
Type:
Worksite
Visit or
Safety
Town
Meeting
Participant
from
Executive
team
Location “Hinderers” to
patient safety, or
system weaknesses
observed during
worksite visit, or
brought up during
safety town meeting
(one item per row)
Safety Risk:
1: Low
3: Mild
discomfort
5: Would require
intervention
10: Could cause
harm or death
Likelihood or
frequency of
risk
1=Very
unlikely
2=Possible
3=Very likely
Ease of implementation
1=Easy, within 30
days
2=Moderate-multiple
departments (90 days)
3 = Difficult-process
changes and/or major
budget (6 months)
Action items
or proposed
changes to
hinderers
Team
member(s)
responsible
for follow up
C-Suite
Yes = 1
No = 0
Date
change
completed
100 3/16/2
006
Worksite
Visit
Betsy
Green,
CNO
Medical/
Surgical
Unit
New diabetics?
insurance won’t pay
for glucometers.
Staff concerned
about patients’
inability to get the
devices and their
own need to learn
many different
devices based upon
what the patient
purchased. The delay
decreases the
amount of time
nursing staff have to
teach patients about
using the device.
10 2 2 Director of
Laboratory
Services
communicat
-ed the need
to a vendor
of diabetic
supplies.
Director of
Laboratory
Services and
CNO
1 Mar-06
100 Another problem of lower value would be here 2
100 Another problem of lower value would be here 2
100 3/14/
2006
Worksite
Visit
Jen
Calhoun,
Safety
Director
Medical/
Surgical
Unit
Overbed tables being
used to hold Personal
Protective Equipment
(PPE).
5 1 1 Isolation
Carts have
been
purchased
to hold and
store PPE
outside of
patient
rooms.
CNO and
Director of
Medical/
Surgical
Unit
1 1st cart
arrived
03/20/20
06
To test H2: % of the top quartile (of value) that were resolved =100%
To test H3: % of resolved problems that were ?easy-to-solve? =50%
To test H4: % of problems assigned to senior manager =50%
Value = 10*2 = 20
Top quartile? = 1 (yes)
Addressed? = 1 (yes)
Top quartile & addressed? = 1 yes
Figure 3 Data Collection Sheet Used by Treatment Hospitals and Two Problems as Examples
Tucker and Singer: The Effectiveness of MBWA
Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 259
?easy and could be resolved within 30 days? (column
9 in Figure 3). The higher the percentage, the
more the unit solved easy-to-solve problems. We
called this variable ?% of problems solved that were
low-hanging fruit.? Finally, to test our hypothesis
about senior managers (H4), at the work area level
we found the percentage of problems for which a
chief executive level manager was assigned responsibility
for ensuring that the problem was resolved
(column 12 in Figure 3). See Figure 3 for details on
these variables.
3.3.2. Measure. In accordance with prior research
(Chandrasekaran and Mishra 2012, Frankel et al.
2003, 2005, 2008), we evaluated the program?s performance
using staff ?PIP.? To measure PIP, we used
four survey items (see Appendix A) from validated
survey instruments that measured the effectiveness of
quality improvement efforts (Shortell et al. 1995,
Singer et al. 2009). Respondents rated each item using
a 5-point scale ranging from 1 = strongly disagree to
5 = strongly agree. Agreement indicated that respondents
thought quality and safety performance were
improving. The scale exhibited high reliability (Nunnally
1967), with a Cronbach?s alpha of 0.84 (n = 1147
nurses) in the pre-period and 0.88 (n = 1103 nurses)
in the post-period.
We used perception of performance for four reasons.
First, employee perceptions are an important
outcome because they influence behaviors, which in
turn impact objective measures (Zohar and Luria
2003). Second, staff perceptions of performance are a
valid indicator of performance (Ketokivi and Schroeder
2004). This is because employees are close to the
work and often know if system failures are decreasing
or increasing. Research has found that nurses? perceptions
of safety are correlated with objective measures
of safety outcomes, such as mortality, readmissions,
and length of stay (Hansen et al. 2010, Hofmann and
Mark 2006, Huang et al. 2010, Singer et al. 2009).
Third, employee perceptions have been widely used
as outcome measures in operations management
research because they enable comparison across organizations
(Anderson et al. 2013a,b, Atuahene-Gima
2003, Bardhan et al. 2012, Chandrasekaran and Mishra
2012, Flynn et al. 1995, Kaynak 2003, Swink et al.
2006). Finally, the use of a perceptual measure was
necessitated by hospitals? unwillingness to share data
on safety incidents.
Our dependent variable was the change in PIP from
the pre- to the post-period. The use of change scores
allowed us to examine change over time (Fitzmaurice
2001). To create a composite change score for each
work area, we used the pre-data to calculate the
mean of the four items for each nurse, and then averaged
by work area. We repeated this process for the
post-data and subtracted each work area?s pre-score
from its post-score. We calculated intra-class correlations
(ICC) and a mean inter-rater agreement score
(rWG) to test whether aggregation of PIP was appropriate.
Significant (ICC[1] = 0.06, F = 5.69, p < 0.000,
and ICC[2] = 0.82) supported aggregation (Bliese
2000). The rWG for nurses? rating of PIP was 0.60,
which also was sufficient for aggregation (ZellmerBruhn
2003). Furthermore, our use of a change score
as our dependent variables met the two conditions
specified by Bergh and Fairbank (2002): the reliabilities
of our survey measures for PIP in pre- and postperiods
were high (0.84 and 0.86, respectively) and
the correlation between the measures from the two
different time periods was low (q = 0.24, p < 0.001).
As is common in studies using a change score (Bergh
and Fairbank 2002), the correlation between the
change score and the PIP measure in the pre-period
was negative (q = 0.67, p < 0.001). This indicates that there was a greater opportunity for improvement in PIP among work areas with a low PIP in the pre-period (Fitzmaurice 2001). Therefore, to control for impact of a work area?s starting point on the change in PIP, we included a dichotomous variable indicating whether PIP in the pre-period was in the lower quartile (?bottom quartile for 2004 PIP?). The variable was coded ?1? if the work area was in the bottom quartile of work areas in PIP in the preperiod and ?0? for all others. This method enabled us to test for the change in PIP while controlling for a low starting point. 3.3.3. Control Variables. For H1, which tested the overall impact of our MBWA-based program, the large sample size enabled us to include the following control variables: major teaching hospital (1 = yes, 0 = no); Dun & Bradstreet?s measure of the hospital?s financial stress, with higher numbers indicating a higher likelihood that the business will seek legal relief from creditors or cease operations without paying creditors in full over the next 12 months; a set of dummy variables for the number of hospital beds (reference group = less than 100 beds; medium = 100?250 beds; large = more than 250 beds); and a set of dummy variables for type of work area (reference group = non-clinical; OR/PACU; ICU; ED; Med/ Surg unit; and other clinical unit). Data on size and teaching came from the 2004 American Hospital Association Survey of Hospitals. For the hypotheses about problem prioritization (H2 and H3), our sample size was limited to the 24 work areas that formally prioritized their problems in the data collection spreadsheet. As a result, for these hypotheses, we did not have a large enough sample size to include non-significant control variables in our regression. However, our random selection of Tucker and Singer: The Effectiveness of MBWA 260 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society hospitals helps alleviate concerns that our model may be subject to omitted variable bias (Antonakis et al. 2010). We did not include control variables for unit type (e.g., ED, ICU, and OR/PACU) as none were significant and their inclusion did not change our results. We also tested for hospital-level control variables, such as teaching status and number of beds, but none were significant and their inclusion did not change our results. We controlled for availability of ?lowhanging fruit,? which was the percentage of identified problems that were rated as easy to solve. We also controlled for the average value of the top quartile of identified problems. Our regression equation for H4, the impact of a senior manager being assigned responsibility for problem resolution, included the full set of 58 intervention work areas. We controlled for the percentage of problems within a work area that were resolved (% of problems resolved) by coding a problem as having had solution effort if there was evidence in the dataset that action had been taken to address the problem, and taking the average of this variable at the work area level. We also controlled for the fidelity of implementation with the following variables: the number of work system visits that were conducted, whether a work system visit was conducted by a senior manager (1 = yes, 0 = no), and whether a safety forum was conducted in the area (1 = yes, 0 = no). 3.4. Sample Size and Analysis We used linear regression with robust standard errors and clustered by hospital (Rabe-Hesketh and Everitt 2004) in Stata 11.1TM to test our hypotheses. The Shapiro?Wilk test for all regressions showed that the residuals were normally distributed (V close to 1 and p > 0.10) (Royston 1992). Multicollinearity was also
not an issue as all variance inflation factors for all of
our equations were less than 2.5, well below the
upper threshold of 10 (Chatterjee and Hadi 1986).
To test the overall impact of our MBWA-based
program (H1), we use data from the four main clinical
work areas (OR/PACU, ICU, ED, and Med/
Surg). We had data for both pre- and post-PIP measures
from 58 intervention work areas in 20 treatment
hospitals and 138 work areas in 48 control
hospitals. However, missing data for a control variable
(financial stress) in two intervention work areas
resulted in a final sample size of 56 intervention
work areas. To test the impact of problem selection
(H2 and H3), we used data from the 24 work areas
from eight treatment hospitals that formally prioritized
their problems. Finally, to test the impact of
senior manager assignment to problem resolution
(H4), we used the full set of intervention work areas
(n = 58).
3.5. Qualitative Data Collection and Analysis
During the intervention, we visited each treatment
hospital to tour the clinical areas and to observe
MBWA activities, including work system visits, safety
forums, and debrief meetings. In addition, we discussed
and observed examples of changes implemented
in response to problems identified through
the program to verify accuracy of the data submitted.
There were no discrepancies. We also conducted
semi-structured interviews with a frontline staff
member, a department manager, and the CEO from
each hospital (see Appendix B). Interviews addressed
the nature of performance improvement in the hospital
in general and as it related to implementing the
MBWA-based program. Interviews and notes from
the meetings were recorded and transcribed. Investigators
also wrote a journal of the day?s activities from
notes taken during the day. The journal and transcripts
from each hospital were combined into a single
document, which served as our source of
qualitative data.
After the intervention was complete, we used
these qualitative data in combination with the problem
data submitted by the work areas to illuminate
differences among work areas in the types of issues
identified, actions taken to resolve them, and managers?
attitudes. We analyzed transcripts using the procedure
described in Miles and Huberman (1994, pp.
58?62). We initially used a list of codes based on our
interview questions. We read the transcripts multiple
times, revising the codes as we deepened our understanding
of similarities and contrasts among the
implementation of the program. How the managers
prioritized problems for solution efforts emerged as
a main theme. One author went through the qualitative
data to select all relevant quotes for this theme.
Both authors independently reviewed the quotes
while blinded from the performance results. We
compared our perceptions to come to a consensus.
We use the quotations to illustrate differences in
implementation approach that impacted the effectiveness
of the intervention. Table 6 in the results
section displays representative quotations from the
five work areas that improved the most over the
course of the intervention and the five that decreased
the most.
4. Results
4.1. Summary Statistics
Average PIP in the 56 treatment work areas was 3.78
in the pre-period and 3.69 in the post-period. The difference
of 0.09 was not statistically significant at the
10% significance level. The same four types of work
areas (n = 138) in control hospitals had a mean PIP of
3.8 in both time periods. Table 1 shows descriptive
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statistics. Using the subset of work areas that prioritized
their problems (n = 24), the mean value score
for all identified problems was seven on the scale of 1
(lowest) to 30 (highest). Descriptive statistics and correlations
are shown in Table 2. On average, the mean
value score was 17 for the top quartile of identified
problems. The highest score, on average, was about
19.
4.2. Regression Results
Contrary to our prediction, the MBWA-based treatment
was associated with a statistically significant
decrease in PIP (0.17, p < 0.05) compared to the same
types of work areas in control hospitals (H1, Table 3,
Model 1). A possible explanation is that some treatment
work areas failed to conduct the recommended
activities (Nembhard et al., 2009). However, the following
statistics provide evidence that treatment
areas did indeed implement the MBWA-based program:
91% had a work system visit; each treatment
work area received a mean of 3.41 visits (SD = 3.16,
maximum of 12); 50% had a safety forum; on average,
they identified 19 problems and took action on 11
(Table 1).
The effectiveness of the program did vary, however,
among work areas. As shown in Model 1, our
control variable for whether or not the work area was
in the bottom quartile for pre-period PIP was signifi-
cant (b = 0.75, p < 0.001), suggesting that work areas
with the lowest PIP scores in the pre-intervention period
exhibited a positive change in PIP over the course
of the intervention. Additional analysis revealed that
the work areas that were in the bottom quartile for
our dependent.
variable, change in PIP, had a decline in PIP ranging
from 0.375 to 2.25. Of these 15 work areas that
experienced the greatest decline in PIP, four were
already below median in the pre-period, suggesting
that their decline was not merely a regression to the
mean effect. The work areas in the top quartile of
change in PIP experienced an increase in PIP ranging
from 0.38 to 1.33 points. This large variation in results
prompted us to examine factors associated with
success.
Model 1 in Table 4 shows results from testing H2
and H3. A higher percentage of problems solved that
were rated as ?easy-to-solve? was associated with
higher% change in PIP (coefficient = 1.00, p < 0.05),
providing support for H3. A one standard deviation
(27%) increase in the percent of solved problems that
were easy-to-solve was associated with a 1.0 point
increase in change in PIP, which was a 26% improvement.
However, the percentage of problems rated in
the top quartile for value that were solved was not
significant. Thus, H2 is not supported.
Testing H2 using highest-value score instead of the
mean priority of the top quartile and a dummy for
whether the top-ranked problem for value was
resolved instead of the percentage of problems rated
in the top quartile for value that was solved was also
not significant (Table 4, Model 2). This result fails to
support theory from the innovation literature suggesting
that solving the highest-value idea drives performance
in our context. However, the percentage of
problems resolved that were rated ?easy-to-solve?
remained significant in this model (coefficient = 0.82,
p < 0.01), providing additional support for H3. Prioritizing easy-to-solve problems appeared to increase PIP. An alternate explanation for our finding could be that work areas were more successful because they spent more money on problem solving rather than because they prioritized easy problems. To control for this ?spend more? explanation, the authors individually rated the rough cost of each solved problem on a scale of 1?3 with 1 = low (cost = $500), 2 = medium (cost > $500 < $150,000), and 3 = high (cost =
$150,000) based on the description of how work areas
solved the problem and independent research to
check the cost of products or services mentioned in
the description. We used these ranges because they
represented different categories of solutions. The
cheapest category was solutions that involved a onetime
purchase of a relatively low-cost supply (<$500).
An example is applying a coating to one window to
improve patient privacy. The second category was
intended to cover mid-range solutions such as the
purchase of equipment or consumable supplies. An
Table 1 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas (N = 56 work areas)
Variable Mean SD Min Max 1 2 3 4 5 6
1 Postperiod PIP 3.69 0.61 1.92 5.00
2 Change in PIP 0.09 0.67 2.25 1.33 0.639***
3 Had work system visit 91% 29% 0 1 0.195 0.197
4 Number of work system visits in area 3.41 3.16 0 12 0.055 0.1 0.342*
5 Had safety forum 50% 50% 0 1 0.056 0.028 0.313* 0.097
6 Percent of problems addressed 62% 31% 0 1 0.088 0.079 0.083 0.043 0.074
7 Percent of problems assigned to
senior manager
10.4% 23.7% 0 93% 0.186 0.175 0.114 0.359** 0.176 0.065
***p < 0.001, **p < 0.01, *p < 0.05.
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example is the purchase and installation of new lighting
in a catheterization laboratory to illuminate procedures.
The most expensive category was for solutions
that involved construction or hiring of multiple people.
An example is a solution that involved hiring
multiple people to transport patients within the hospital.
We compared scores and discussed our rationale
until we reached consensus for all solved
problems. We then summed the total estimated solution
costs, estimating 1 = $250; 2 = $5000; and
3 = $150,000, for all of the solved problems in each
work area.
Another possible explanation is that variation in
quality of solution efforts impacted the results (e.g.,
some work areas might have engaged in only superfi-
cial steps while others might have systematically
resolved underlying causes). We also controlled for
this ?higher quality? explanation by hiring 10 nurses
not affiliated with our study hospitals to rate the solution
effectiveness of the proposed solution for each
Table 2 Mean, Standard Deviation (SD), and Correlations for Treatment Work Areas and Identified Problems (n = 24)
Variable Mean SD Min Max 1 2 3 4 5 6 7
1 Change in PIP 0.02 0.53 1.17 1.1
2 Avg value of top quartile of
identified problems
17.23 6.67 6 30 0.298 1
3 Highest-valued score 18.75 7.43 6 30 0.325 0.952*** 1
4 Availability of
low-hanging fruit
36% 26% 0% 100% 0.016 0.305 0.289 1
5 Percentof top quartile
problems solved
88% 29% 0% 100% 0.186 0.091 0.109 0.045 1
6 Highest-valued problem
was solved
88% 34% 0 1 0.209 0.110 0.039 0.086 0.799***
7 Percent of solved problems that
were low-hanging fruit
33% 27% 0% 83% 0.327 0.097 0.099 0.551** 0.432* 0.350?
8 Percent of problems
assigned to senior manager
22.5% 32.4% 0% 93% 0.308 0.582** 0.576** 0.136 0.054 0.242 0.457*
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10. Table 3 Linear Regression testing Hypothesis 1 (the Change in PIP in Treatment Work Areas vs. the Same Types of Work Areas from Control Hospitals) Clustered by Hospital with Robust Standard Errors in Parentheses Model 1 H1. Treatment work area (1 = yes) 0.17*(0.08) Bottom quartile PIP (pre-period) 0.75*** (0.10) Major teaching hospital (1 = yes) 0.21? (0.13) Financial stress 0.00 (0.00) Medium-size hospital (100?250 beds) 0.43*(0.10) Large-size hospital (>250 beds) (1 = yes) 0.26* (0.12)
OR/PACU (1 = yes) 0.08 (0.11)
ICU (1 = yes) 0.00 (0.13)
ED (1 = yes) 0.15 (0.13)
Was a work system visit conducted? Not in model
Was a safety forum conducted? Not in model
Constant 0.02 (0.20)
Observations 194
Treatment and control work areas 56 & 138
Degrees of freedom F (9, 55)
F-statistic 9.06***
Adjusted R2 0.20
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
Table 4 Regression Comparing Change in PIP in Treatment Work
Areas that Rated the Severity, Frequency, and Ease of
Solution of the Problems, Clustered by Hospital with Robust
Standard errors in parentheses (H2 and H3)
Model 1 Model 2 Model 3
Mean value of top
quartile of
identified
problems
0.02 (0.02) ? ?
Highest-value score of
identified problems
? 0.02 (0.02) ?
Availability of
low-hanging fruit
0.60 (0.49) 0.45 (0.45) 0.90? (0.42)
H2. Percent oftop
quartile value
resolved
0.22 (0.23) ? ?
H2. Was top-ranked
value problem
resolved (1 = yes)
? 0.01 (0.26) ?
H3. Percent of
solved
problems that were
low-hanging fruit
1.00* (0.30) 0.82** (0.21) 1.22* (0.46)
Bottom quartile
2004
PIP pre (1 = yes)
0.39* (0.16) 0.36^ (0.19) 0.38* (0.13)
Cum. cost of solving
problems
? ? 0.00 (0.00)
Avg effectiveness of
solution effort
? ? 0.11 (0.10)
Constant 0.25 (0.48) 0.47 (0.46) 0.61 (0.62)
Observations 24 24 24
Degrees of freedom F (5, 7) F (5, 7) F (5, 7)
F-statistic 10.99** 5.28* 7.08*
Adjusted R2 0.06 0.07 0.08
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
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problem using a scale from 1 to 10. The low end of the
scale was used for problems that were not resolved
(1 = ?no information given?; 2 = management dismissed
the issue or it was not a safety issue; and
3 = issue not considered due to lack of funds or issue
passed off to someone else without any follow-up).
The higher the number, the more substantial and systematic
the solution (e.g., 9 = major investment or
change; 10 = systemic fix that would prevent recurrence).
The scale is available from authors. Agreement
among nurses on their ratings was acceptable
(j = 0.23) (Landis and Koch 1977). The mean rating
for solution effectiveness was higher at 5.9 for solved
problems (?solution action in progress? on our scale)
than 2.7 (?no solution implemented?) for unsolved
problems, which validates their coding.
Given our small sample size, in this secondary
analysis we omitted the high-value prioritization variables,
as they were not significant in our primary
analyses. As Model 3 shows, the variable for the
cumulative ?cost of solving problems? was not significant.
This may be because work areas could improve
PIP without having to spend a lot of money on solutions.
Solution effectiveness was also not significant.
The percentage of solved problems that were lowhanging
fruit remained significant (coefficient = 1.22,
p < 0.05), indicating that the results are similar after
accounting for spending and solution effectiveness.
The evidence in the three models supports H3, which
predicted that prioritizing easy-to-solve problems
would be associated with higher PIP.
Table 5 shows the results from testing H4, which
proposed that senior managers taking responsibility
for ensuring that identified problems get resolved
would be associated with higher% change in PIP. H4
was supported (coefficient = 0.79, p < 0.05). Increasing
the percent of problems assigned to senior managers
by one standard deviation (23%) was associated
with a 0.79 increase in PIP. This equates to a 21%
increase in PIP.
4.3. Robustness Check
Other scholars have used a different approach for
testing improvement over time by using the postmeasure
as the outcome variable and the pre-measure
as a control variable (Fitzmaurice 2001). We tested
our hypotheses using this method and the results
were the same (results not shown).
4.4. Qualitative Results
To provide insight into the nature of implementation
of MBWA-based programs, Table 6 presents qualitative
data from the five work areas that improved the
most and the five that decreased the most. Between
pre- and post-periods, on average PIP improved by
0.85 for the top five work areas and decreased by 1.4
for the bottom five. Our examination of issues identi-
fied and actions taken suggests that the top work
areas identified meaningful problems and managers
took these problems seriously. For example, hospital
88s Med/Surg unit was one of the most improved
work areas. One of the identified issues was that the
small size of the medication room prevented two
nurses from preparing medications simultaneously,
which was an inconvenience and delayed patient
care. Senior managers discussed the issue with staff
and they collectively made a plan to move the medication
room to a larger space. The COO commented,
?It?s a little thing, but when you actually see them
doing the process, you say, ?Wait a minute, that is dif-
ficult for them.?? An interview with a nurse highlighted
management?s willingness to address issues.
She commented, ?These people address safety issues.
It may not always get addressed the way you want,
but it still gets addressed.?
Conversely, in the bottom work areas, an emphasis
on prioritizing the highest-valued problems limited
solution efforts. For example, hospital 129s ED identi-
fied valid issues, such as long lead times to receive lab
results. However, in the safety forum, we observed
the manager spend the entire time getting staff input
on prioritizing the items, leaving no time to discuss
how the issues might be resolved. This work area did
not solve any of the problems they had identified,
despite investing substantial time in identifying and
prioritizing them. As Table 6 shows, this pattern was
common. Two of the six bottom work areas did not
resolve any problems, another?s ?solutions? were largely
to re-educate staff, and a fourth area provided us
with no information about solved problems. These
implementation details suggest an inability to make
meaningful progress on solving the problems. The
lack of solution efforts illustrates how relying too
heavily on a high-value prioritization approach can
Table 5 Impact of the Percentage of Problems Assigned to Senior
Managers on Change in PIP in Treatment Work Areas (H4)
Model 1
H4. Percentage of problems
assigned to senior managers for resolving
0.79* (0.32)
Bottom quartile PIP pre (1 = yes) 0.56** (0.15)
Percentage of problems solved 0.12 (0.33)
Number of work system visits in the area 0.04? (0.02)
Senior manager participated in
work system visit (1 = yes)
0.12 (0.23)
Safety forum in the area (1 = yes) 0.12 (0.14)
Constant 0.08 (0.31)
Observations 58
Degrees of freedom F (6, 19)
F-statistic 2.96*
Adjusted R2 0.10
***p < 0.001, **p < 0.01, *p < 0.05, ?
p < 0.10.
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Table 6 Illustrative Problems, Solutions, and Quotes from Top and Bottom Quartile Work Areas
Hospital
ID Work area
2004
Score
2006
Score
%
Change Examples Solution efforts Illustrative quotes and examples about prioritization
116 OR/PACU 3.3 4.6 41% Need more clinic space Made new clinic rooms The associates will prioritize with the managers, who
have a good idea of what the staff want to do
100 Med/Surg 2.6 3.6 38% Newly diagnosed diabetic patients
cannot get glucometers from
insurance; buy different kinds,
hard for nurses to teach
Vendor donated glucometers, in-serviced nurses,
made kits for newly diagnosed diabetic patients
Manager ordered new isolation carts to keep supplies
for each patient outside the door to prevent spread of MRSA
88 Med/Surg 3.6 4.7 31% Medication room is very
small for two people
After discussing with staff, changed medication
preparation to a larger room.
These people address safety issues. It may not always get
addressed the way you want it to, but it still gets addressed.
47 ED 3.0 3.8 28% Need prompt response from
pharmacy for selected meds;
need lift equipment for obese
patients; Pyxis* IT display
disposed to medication errors
Installed phone system with priority access to
pharmacy; identified or added lift equipment;
reprogrammed Pyxis IT display
We understand what needs to be done – trying to get rid of
verbal orders, trying to set up our Pyxis machine differently
39 ED 4.0 5.0 25% Feel like ?dumping ground?
when the clinic closes;
Roof leaks, need more
blood pressure machines
Relocated clinic in to expand ED patients; hired
additional ED staff; fixed roof; provided blood
pressure equipment
Nurse almost gave wrong medication because two similar
drugs next to each other in Pyxis. Told CNO. Pharmacist
came up right away and changed drawer
34 OR/PACU 5.0 3.8 25% OR table not safe for bariatric
patients; insufficient checking
of patient labs prior to surgery
No solutions listed Anyone can submit safety idea to their vice president. It gets
sent out for review to applicable departments
119 OR/PACU 3.8 2.6 31% Need exhaust air, some equipment
(chairs), backup of patients in ED,
beds not ready
Changes to improve air, equipment ordered
or repaired, working on flow in ED
It is hard to find the time and energy [to sustain this program]
because there are other demands that pour in.
129 ED 4.4 3.0 31% Long lead times for radiology and
lab, ties up rooms, long waits
in ED, units not taking patients
No solutions listed Spent 30 minutes deciding on priority scores with no discussion
of actions to resolve them
9 ED 2.9 1.9 33% 13/22 problems were audit items
by managers such as: Not
washing hands, leaving
cabinet unlocked
Nine solutions were to ?educate staff? No data about their solution efforts.
65 ED 4.3 2.0 53% Police bringing in dangerous
patients with only two people
on at night
Talk to police department about patients,
have security cameras, and panic buttons
You cannot fix them all, but you have to prioritize. Our patient
safety committee will end up doing that
PyxisTM is an automated medication-dispensing device used by nurses to administer medications to their patients.
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preclude taking action. Furthermore, in some of the
work areas in the bottom quartile for change in PIP
scores, such as hospital 34s OR/PACU and hospital
65s ED, identified issues had to be validated by an
external group, such as the patient safety committee,
before resolution efforts would be authorized. This
additional step substantially slowed the pace of
change. Hospital 65s CEO explained his prioritization
philosophy, ?You can?t fix them all, but you have to
prioritize. Our patient safety committee will end up
doing that.? However, the safety officer from that hospital
explained the negative effect this had on staffs?
perceptions, ?What happens is you heighten the
awareness among people and then, if they don?t see
resolutions, then it becomes a bone of contention.?
5. Discussion, Implications, and
Limitations
In this study, we investigated the effectiveness of an
MBWA-based program in randomly selected hospitals.
We found evidence that participating in this particular
program decreased performance on average.
Given that many quality-improvement initiatives
fail to achieve expected gains (Beer 2003, Nair 2006,
Repenning and Sterman 2002), it is perhaps not surprising
that our program failed to yield positive
results for all work areas. Nonetheless, this is an
important result because many hospitals throughout
the United States and United Kingdom have implemented?and
continue to implement?similar programs.
Our study provides a cautionary tale that visits
by senior managers to the front lines of the organization
to solicit improvement ideas will not necessarily
increase staffs? perceptions of performance improvement.
There may be negative repercussions if senior
managers attempt, but fail, to engage meaningfully
with frontline staff. We suspect that the negative consequences
arose from soliciting, but not sufficiently
addressing, frontline staffs? concerns (Keating et al.
1999, Morrison and Repenning 2011). Failure to meet
expectations, once raised, can frustrate employees,
negatively impact organizational climate, and dampen
employees? willingness to provide future input
(Tucker 2007). Thus, our study suggests that there is a
hidden, psychological cost of asking employees for
ideas that are subsequently disregarded.
To understand why some units had better results
than others, we examined two approaches to problem
solving. Solving a higher percentage of the highestvalued
problems was not associated with increased
PIP. This result is similar to an earlier finding in the
TQM literature that formalization could overwhelm
actual improvement efforts, leading to employee dissatisfaction
with the program (Mathews and Katel
1992). Conversely, solving a higher percentage of
easy-to-solve problems was successful, lending support
for approaches that create a bias toward action.
This signals the value in addressing ?low-hanging
fruit,? at least in the short term (Keating et al. 1999,
Morrison and Repenning 2011). Our research does
not find that a focus on surfacing and resolving only
high-value problems yields improved staff perceptions.
Senior managers can facilitate a bias for action. We
found that having senior managers assume responsibility
for ensuring that problems get resolved was
associated with increased PIP. One explanation for
this finding is that organizational change often
requires senior managers to provide financial
resources to pay for required equipment, materials, or
labor; and organizational support to get an upstream
department in the organization to change how they
do their work if benefits accrue downstream. In other
words, senior managers can help ensure that action
happens. Given the improvement literature?s emphasis
on empowering frontline employees to solve problems
(Powell 1995), our finding may be interpreted as
highlighting the importance of empowering frontline
employees to identify and solve problems while supporting
those efforts by ensuring that organizational
obstacles to improvement are removed.
5.1. Implications for Theory
Manager commitment is associated with successful
implementation of performance improvement programs
that rely on frontline employee participation
(Ahire and O?Shaughnessy 1998, Coronado and
Antony 2002, Kaynak 2003, Nair 2006, Worley and
Doolen 2006). We found that a program that stimulated
managerial involvement was productive for
some, but not all, work areas. An explanation of the
negative result of our MBWA-based program was
that asking employees for their suggestions and then
not implementing them sent the message that
employees? ideas were not valued and that the program
was symbolic. Research by Miles supports this
explanation (1965). He postulated that managers hold
one of two beliefs about the value of employee participation
programs. One belief was that frontline staff
participation was valuable because it increased morale,
though the actual ideas they contributed were
unhelpful. These managers believed in the symbolic
value of employee participation programs, such as
MBWA. Miles (1965) found that improvement programs
failed when managers held this belief. The second
belief?which was associated with success in
Miles? study?was that interactions with frontline
staff were valuable because their ideas were actually
useful. The belief in the substantive value of employees?
ideas underlies a core TPS principle: respect for
people (Liker 2004). Miles? study suggests that senior
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266 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
managers? respect for frontline employees? concerns
may have been an important but unmeasured moderator
variable for our MBWA program. An implication
is that rather than just seeking to increase manager
involvement, it may be critical first to ensure that
managers value the ideas raised by frontline staff.
An explanation for the lack of positive impact from
the high-value prioritization approach may be that
problem values in the hospital work areas in our
study had a relatively flat landscape. As a result, pursuing
a high-value prioritization approach did not
yield a substantial improvement over focusing on
easy-to-solve problems. The flat landscape may be
because the work areas had already addressed their
large-value problems or because the fragmented service
environment of health care creates a wide range
of small-scale problems. The easy-to-solve prioritization
approach may have been successful in our study,
because the work areas needed to first tackle fundamental,
lower-value problems before advancing to
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). Taking care of the basic
infrastructure and requirements is a necessary precursor
to more comprehensive organizational change
required by higher priority score problems (Keating
et al. 1999, Morrison and Repenning 2011).
There are likely circumstances under which prioritizing
high-value problems is helpful, such as when
only one idea can be fully developed, like implementation
of an enterprise-wide information system. We
also believe that organizations benefit from resolving
high-value problems, which tend to be top-down,
strategic improvements, as well as easy-to-solve problems,
which tend to be bottom-up, tactical initiatives.
Organizations should try to nurture both kinds of
problem-solving capabilities. For example, organizations
may have experts working on identifying and
solving high-value problems through six-sigma projects,
while frontline employees simultaneously work
on resolving smaller scale issues in their local work
area through lean initiatives. Furthermore, it may be
that organizations begin their improvement journey
by successfully resolving relatively easy problems,
but then need to develop new capabilities to resolve
more complex problems (Keating et al. 1999, Morrison
and Repenning 2011). For example, reducing the
time required to find vital sign monitor equipment on
a nursing unit likely requires different problem-solving
skills than reducing patients? lengths of stay in the
hospital.
5.2. Implications for Policy
Our study suggests that policy makers can play an
important role in improving safety in hospitals by
encouraging organizations to build problem-solving
capacity. Rather than requiring hospitals to participate
in a specific change program, such as MBWA,
that may not be fully validated, policy makers could
instead provide incentives for hospitals to build the
generic capacity to solve frontline problems. Given
the trend toward requiring hospital to implement
multiple quality-improvement initiatives concurrently,
we suspect that it is likely that many programs
are being implemented superficially and in ways that
lead to harmful results similar to those we observed
in this study. This could be contributing to the oftreported
failure to achieve gains through improvement
initiatives that frustrate the health-care industry
(Landrigan et al. 2010). Our study provides a warning
about mandating implementation of improvement
programs before fully understanding the conditions
required for the programs to yield successful outcomes.
The financial incentives used to encourage adoption
of electronic health records in the United States
may be instructive. Policy makers rewarded ?meaningful
use,? as demonstrated by the functionality that
was achieved, rather than rewarding implementation
of a particular software (Blumenthal 2010). Similarly,
policy makers could provide incentives for building
problem-solving capabilities that improve patientcentered
performance rather than advocate for a specific
improvement program.
5.3. Implications for Practice
Many initiatives to improve safety begin by trying to
increase employees? reports of near misses, errors,
and incidents (Bagian et al. 2001, Evans et al. 2007).
Implied assumptions are that increasing the number
of reports enables organizations to conduct trend
analysis that illuminates high-value problems which
can then be solved; and that many issues will be of
sufficiently low value that they can be ignored at low
or no cost to the organization. In contrast, our study
suggests that there may be little benefit, and some
potential harm, to this approach. Rather than increasing
reporting, organizations might be better served by
addressing known problems, which builds problemsolving
capabilities, which in turn enables actiontaking
on more problems. Our finding corroborates
prior research that highlighted the importance of
problem-solving capacity for successful improvement
programs (Adler et al. 2003, Keating et al. 1999, Morrison
and Repenning 2011). This advice is consistent
with the vision for a continuously learning health-care
system articulated by the US Institute of Medicine,
requirements for which include systematic problem
solving. Our study also resembles Kaizen, a structured
problem-solving approach involving managers
and frontline workers. However, important differences
that may make Kaizen more successful than our
program are that Kaizen occurs after managers and
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Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society 267
frontline staff have been trained on a standardized
problem-solving technique and that it emphasizes
taking action to solve as many problems as possible
within the given time period (Imai 1986). Thus, it prevents
resource depletion by limiting the time spent
identifying and solving problems rather than by
selecting among them.
5.4. Limitations
Our findings must be considered in light of study
limitations. First, our small sample size limited our
analysis. Our sample was small for several reasons.
The cost- and time-intensive nature of conducting an
experiment with hospitals over 18 months made it
challenging to conduct our field-based, interventional
program with 24 organizations, and we would
have struggled if there were more. In addition,
despite our providing a method of prioritizing problems,
many organizations chose not to assign prioritization
values and therefore work-area coded data
on problem value were not available for all treatment
work areas. Future research with larger sample sizes
could test more nuanced theory. For example, an
easy-to-solve prioritization approach may be most
successful for work areas that start from a weak
position and can benefit most from action, whereas a
high-value prioritization approach may be most
helpful for experienced work areas that can be more
selective.
A second limitation is the perceptual measure of
improvement. Hospitals were unwilling to share
actual safety incident measures with us. In addition,
publicly available clinical measures, such as mortality,
readmissions, and process of care measures,
started being reported publicly only after the initiation
of this study. Although we conducted analyses
using these ?post study? clinical outcome data, the
regressions were not significant in explaining variation.
However, for reasons detailed above, a perceptual
measure is an important indicator of the impact
of the intervention we tested. Furthermore, prior
research on an MBWA-based intervention that did
have access to clinical outcome data did not find links
between multiple clinical outcomes and the intervention
(Benning et al. 2011), corroborating our study
results.
Third, hospitals did not track resources spent on
solution efforts. Therefore, estimation was the only
way of testing the alternate explanation that spending
more money on process improvement yielded better
outcomes. Future research could contribute to
improvement theory by examining the cost of
improvement efforts compared to benefits. A fourth
limitation is that we did not randomize an easy-tosolve
prioritization approach vs. a high-value prioritization
approach among work areas. Instead, those
differences emerged naturally. A randomized assignment
of these two prioritization approaches would
provide a stronger test of the hypotheses.
5.5. Conclusions
Understanding the impact of MBWA-based programs
is helpful for organizations that may be considering
implementing them. In our study, organizations
whose managers ensured that problems were
addressed achieved better results. This suggests that
improvement programs are more likely to change
employees? perceptions when they result in action
being taken to resolve problems than when they are a
symbolic show of manager interest. On the basis of
study findings, we recommend that organizations
focus on increasing their capacity to act on improvement
suggestions rather than expending further effort
on generating more suggestions and prioritizing
them.
Acknowledgments
Funding was provided by Agency for Healthcare Research
and Quality RO1 HSO13920. Additional funding was
obtained from Fishman Davidson Center at Wharton. Jennifer
E. Hayes provided valuable data coding assistance.
Appendix A: Survey Questions for
Perceived Improvement in Performance
The quality of services I help provide is currently the
best it has ever been.
We are getting fewer complaints about our work.
Overall, the level of patient safety at this facility is
improving.
The overall quality of service at this facility is
improving.
Appendix B: Interview Questions
B.1. FrontLine Personnel Interview Protocol
I wanted to ask you some questions about the patient
safety culture at this hospital. We recognize that most
hospital personnel experience problems in the course
of their work and that these are not a reflection of
their skill level or of the quality of care provided at
their facility. My goal is to understand differences in
safety culture among organizations.
1. Do personnel on this unit talk openly about
safety issues and errors?
2. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
Tucker and Singer: The Effectiveness of MBWA
268 Production and Operations Management 24(2), pp. 253?271, ? 2014 Production and Operations Management Society
care to patients think about reporting incidents
related to patient safety.
3. Have you ever reported something? What
made you decide to report that incident? What
happened as a result of reporting? Did you
ever learn the outcome?
Can you recall a specific adverse event that
was caused by an error or series of errors?
What happened? Can you describe the investigation
process (i.e., what happened to people
involved, what changes, if any, resulted from
the investigation)?
My last question relates to a major change in a
care process at your hospital.
4. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced in your unit?
Probe: What training did you receive? Has
implementation required any workarounds of
the built-in features of the system?
B.2. Manager Interview Protocol
I wanted to ask you some questions about the
patient safety culture at this hospital. We recognize
that most hospital personnel experience problems
in the course of their work and that these are not a
reflection of their skill level or of the quality of
care provided at their facility. My goal is to understand
differences in safety culture among organizations.
1. Do you feel comfortable talking about safety
issues and errors in your manager meetings
with senior leadership?
2. Do you encourage your staff to speak up?
How?
3. Who (or what) provides impetus for patient
safety at this hospital? How do they do it?
Reporting of near miss or safety-related incidents
has received some attention lately. We
would like to better understand how healthcare
professionals that actually provide direct
care to patients think about reporting incidents
related to patient safety.
4. Can you step through a recent ?near-miss?
safety report that you addressed? Briefly (do
not need details) what was the situation and
what was the response, if any?
5. Can you recall a specific adverse event that
was caused by an error or series of errors?
Briefly, what happened? Can you describe the
investigation process (i.e., what happened to
people involved, what changes, if any, resulted
from the investigation)?
My last question relates to a major change in a
care process at your hospital.
6. Thinking about a recent major change related
to patient care processes, can you describe how
this change was introduced to a unit? Probe:
What training was provided? Has implementation
required any workarounds of the built-in
features of the system?
B.3. Hospital Administrator Interview Protocol
I wanted to ask you some questions about your daily
activities as a hospital executive and your views on
the patient safety culture at your hospital. We recognize
that leadership styles and organizational cultures
are unique at every institution and none is necessarily
better than any other. My goal is to understand the
full variation among organizations.
1. What are your primary priorities for the hospital?
[Prompt if it is not mentioned] Where does
patient safety fall in your list of priorities?
2. How do you see your role in patient safety? In
what ways do you provide leadership in this
area?
3. How would you describe the general attitude
of health-care professionals and employees
within the hospital toward patient safety?
4. It is well known that middle managers are a
key to implementation, and these people are
often extremely pressed due to budget constraints.
What is the situation with middle
managers in your hospital?
5. How do you obtain information about the hazards
present at the front lines of your organization?
6. Thinking about the most recent major organizational
change related to patient safety, can
you describe the change, your decision-making
process, and its implementation? Probe: Did
some event or new piece of information
prompt your decision to implement the
change? Did you evaluate the business case
before making the change?
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