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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Similarly, a nurse told us that it was difficult to speak up openly when she suspected that something might be wrong, such as a possible migration of the balloon clamp (also life-threatening):

I'd tell the adjunct. Or, I might whisper to the anesthesiologist, "Does it look like it migrated?" In fact I've seen that happen. It drives me crazy. They are talking about it--the adjunct is whispering to the anesthesiologist, "It looks like it moved" or "There is a leak in the ASD" or something, and I'm saying, "You've got to tell him! Why don't you tell him?" But they're not used to saying anything. They are afraid to speak out. But for this procedure you have to say stuff.

To understand this description fully, it is useful to visualize the constrained quarters of an operating room and realize that speaking up such that everyone hears you is virtually a default option. It requires effort to whisper to only one person, hoping to have the information passed along. This nurse's belief that team members "are afraid to speak out" epitomizes an absence of psychological safety. This absence was typical of sites in which the team leader did not explicitly signal a change by framing MICS as a team endeavor and encouraging others to speak up. Some surgeons were not prepared to make these kinds of changes. As a Decorum nurse explained, "[The surgeon] is a creature of habit." Another nurse described his leadership style as follows: "Dr. D is very regimented. Proper decorum in the room is his big thing." We were told in two different interviews that the surgeon was the "captain of the ship" and, in one, that "he's the chairman and that's how he runs the show." In all seven high (and only two low) implementers, trials were characterized by psychological safety and reports of profound changes in OR team communication.

Step 4: Reflection. After, between, and during trials, some teams engaged in reflective practices, including reviewing data, discussing past cases, planning next cases, and suggesting technical process changes. These practices informed subsequent trials. The reflection step was characterized by collective processing of the team experience--including full-team debrief sessions at two sites and partial-team informal but frequent conversations at other sites--grabbing whatever time was available rather than scheduling formal meetings. In all cases, reflection involved an explicit effort to learn from past cases. This characterized five of the seven high implementers and two of seven low implementers. Although some of the other low implementers did collect data and periodically analyze them for academic reports, they were not used as feedback to inform subsequent practice.

The reflection step provides a group-level analog to Schon's (1983) notion of the reflective practitioner, who engages in an ongoing private dialogue with his or her work. Group-level reflection, however, occurs publicly or out loud (Edmondson, 1999). Reflective teams explicitly asked themselves, through formal meeting, informal conversation, and shared review of relevant data, "What are we learning? What can we do better? What should we change?" In four sites--three successful and one not--these discussions led to process changes, including uses of the technology to carry out operations previously considered impossible, changes in patient eligibility criteria, and slight modifications of the equipment. Illustrating the latter at Janus, Betty reported, "[MISA] has been great at R&D. They take our suggestions and they come through with new changes... [For instance, they] put markers on the balloon--that makes it easier. Within nursing we've shared ideas and we keep making changes." Likewise, a perfusionist at Mountain mentioned another process change, in which the team "developed a special perfusion pack for MISA's 3/8th-inch line. We had [another medical equipment supplier] manufacture it for us." Combined with Step 3, engaging in Step 4 created a meta-routine of learning from experience, within which the daily task routines sit. The implementation journey involved multiple iterations of Steps 3 and 4.