Disrupted routines: Team learning and new technology implementation in hospitals

Administrative Science Quarterly,  Dec, 2001  by Amy C. Edmondson,  Richard M. Bohmer,  Gary P. Pisano

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Step 3: Trials. After learning before doing, teams shifted into learning by doing (Pisano, 1996) in trials of MICS with real patients. As in Steps 1 and 2, leaders' actions continued to provide a signaling function; remaining consistent with their emphasis on teamwork and not sanctioning the efforts of other team members was critical. As part of Step 3, team leaders actively coached the team. For example, at Janus, Betty reported, "[Dr. J] talks everyone through it. He says things like 'Can you see it?' and so on," helping them learn new technical skills. At the same time, he also encouraged new ways of communicating, and as a result, as reported by a perfusionist, "It is no longer surgeon outward; everyone has to talk to each other both ways. And so I have to say to the anesthesiologist, 'Don't do that until the balloon is up.'" Sophia echoed, "For [MICS] everyone is involved in the communication....I always take the initiative [to look at vital pressures] because the surgeon is very busy [stitching vessels] ." At Mountain, the team leader often wore a head camera, as a nurse explained, "so others can see what's going on and ask 'Why did you do this then?'"

Data from all seven high (and only one of seven low) implementers showed active team leader coaching. This was associated with psychological safety, assessed in analysis of interview data through evidence that lower-status team members were willing to speak up with observations without being asked directly by the surgeon. For example at Janus, Betty explained, "I am very comfortable speaking up....You have to talk. I have no qualms about it. In a regular case, you can clam up, but in MICS it's too late. There is no chance for recovery." In equating no qualms about speaking up with no chance for recovery, she takes for granted a frame in which the potential value of an observation itself enables one to feel comfortable speaking up against status barriers and historical precedent, a frame that clearly was not shared across the entire sample. Team members at Mountain similarly noted that communication was "much more intensive" and that the "hierarchy [has] changed" so that "there's a free and open environment wi th input from everybody." An interesting illustration of shifts in hierarchical roles came from Urban Hospital, where a scrub nurse, a position senior to a circulating nurse, volunteered a story about her own error and how it was pointed out to her by the junior nurse:

We all have to share the knowledge. For example, in the last case, we needed to reinsert a guidewire and I grabbed the wrong wire and I didn't recognize it at first. And my circulating nurse said, "Sue, you grabbed the wrong wire." This shows how much the different roles don't matter. We all have to know about everything. You have to work as a team.

The comment that "the different roles don't matter" depicts a profoundly different interpersonal context than in conventional surgery, in which the well-defined roles matter greatly.