Manager Visibility No Guarantee of Fixing Problems

Observing and understanding the tasks and challenges that workers face every day is important. But managers who merely put in time "walking the floor" are not doing enough; in fact, it can make employees feel worse about their situation.

In their working paper "Going Through the Motions: An Empirical Test of Management Involvement in Process Improvement ," HBS professor Anita L. Tucker and Harvard School of Public Health professor Sara J. Singer show that communicating with frontline workers can backfire if managers make only a token effort to resolve issues their staff is encountering.

Drawn from the health-care industry, the research is based on a sample of 69 randomly selected hospitals, 20 of which participated in a three-part cycle of process improvement activities. Focusing on one area of the hospital at a time, the hospital's top administrative and medical officers spent 30 to 60 minutes with frontline workers involved in the processes of a particular unit. In addition, they held open communication forums related to patient safety. After generating a list of issues from these two activities, the group decided which ones to solve, and senior leaders communicated to workers what actions had been taken.

The 20 hospitals identified 1,732 safety-related problems in areas such as facility design and maintenance, equipment and supplies, communication, staffing, and medication issues. On average, hospitals identified 86 problems, took action on 67 percent, and provided feedback to frontline workers on 24.5 percent.

The researchers reviewed surveys taken before and after process improvement activities, supplementing them with in-person interviews with frontline staff, department managers, and the CEO.

Following the findings
Some of the findings supported what Tucker and Singer had already hypothesized. For example, when the hospital took action on a higher percentage of problems, it had a positive effect on organizational climate. The researchers also confirmed their belief that identifying those problems more negatively affected senior managers' perceptions of the organizational climate for improvement than the frontline workers who observed and lived those problems every day.

However, there were surprises, too. Identifying many problems to correct had a somewhat negative impact overall. Most significantly, Tucker and Singer found that senior managers' communications with frontline workers regarding their corrective actions had a clear negative impact on frontline workers' perceptions of the organizational climate for improvement—quite the opposite of what they had anticipated.

"When we went into this study, I really believed the common theory behind improvement thinking, which is that you first go out and find a lot of issues," Tucker says. "You obviously can't address everything, so you pick one or two, fix them, and then explain why you weren't able to get to the others. In fact, identifying all these issues dredged up negative sentiment, fixing only one or two amplified that feeling, and then telling frontline workers what had been done made it even worse."

Ironically, the process improvement approach used in the study mirrors that of the incident reporting systems employed in many hospitals. Tucker notes that these systems have their place, as they provide the opportunity for workers to anonymously report safety violations being made by physicians and other health-care workers. But her research shows that they can also be counterproductive on many levels when used as a vast collection vehicle.

"It's a bit of a Pandora's box," she says. "Identifying more is not necessarily better if the organization then ignores the majority of the concerns."
A Pareto problem

The philosophy behind incident reporting systems is similar to that seen in a Pareto chart, Tucker adds.

"Pareto's theory was that 80 percent of the cost is caused by 20 percent of the problems, so you find lots of issues, identify patterns, and select the one or two most highly leveraged problems to solve to get the biggest results. Instead, our findings suggest that solving issues as they arise with intense and substantive actions is much more productive in creating a climate where it's clear that the manager is concerned enough to improve the systems."

Of the 20 hospitals that participated in the program, 9 registered greater improvement in organizational climate and performance. Some of the negatively performing hospitals engaged in low levels of activity, but one poorly performing hospital in particular caught Tucker's eye.

This institution had high levels of activity when it came to gathering information and acting on problems, reporting 66 safety-related problems, taking action on a well above average 91 percent, and providing feedback on 83 percent. So why wasn't this organization rewarded with a better organizational climate and performance? Tucker and Singer went back to the interviews and observational data.

The answer, they say, is because management was auditing workers by catching them on technical mistakes and telling them how to do something the right way.

"You can see how that would erode the staff's trust in management," Tucker says. "A worker might think, 'Leadership just doesn't get it. I'm not doing these things because I don't know any better. Look at this environment and the complexity of issues I have to deal with. Instead of helping, they're basically slapping me on the wrist.' "

In contrast, hospitals that were able to improve their safety climate took action on the issues raised, and conducted site visits "in the spirit of being truly curious about the problems they observed and how they could help people do their job better," Tucker says.

The same findings can be applied to any industry or organization. "What we're finding is more related to human psychology than anything health-care specific," Tucker says.

It's helpful for managers to be reminded that their symbolic physical presence on the frontlines does not necessarily have a positive impact.

"Yes, it's important to interact with employees, but understand that the most effective question to ask is, 'What can I do to make your job easier?' " she adds. "It's all about working with the unit manager to help people be more effective, not just looking for positive or negative actions."
Long tail problems

Tucker hopes to focus future research on figuring out how organizations can successfully attack what she calls the "long tail" of problems.

While it's highly visible mistakes such as medication errors that make the headlines, health-care managers need also be concerned about less dramatic infrastructure-type problems—such as insufficient supplies of pumps or intravenous poles—that are easily ignored but eventually add up to real trouble.

"In complex services like health care, there are many opportunities for systems to fail because of the multiple interactions and hand-offs between people of different disciplines. It is more like 50 percent of the problems cause 80 percent of the issues, rather than there being just a handful of highly significant problems," she says.

"People get discouraged because they fix something and don't see the needle move in a big way. It's my belief that management and frontline workers in the health-care industry are going to need to address many issues on multiple dimensions, and figure out how to do so in a cost-effective manner.

Julia Hanna is associate editor of the HBS Alumni Bulletin.