Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change
通过对九家医院护士应对流程失败的实地研究，揭示了小流程失败如何侵蚀组织效能而非推动学习，并提出了三个管理杠杆来改善医院从失败中学习的能力。
The importance of hospitals learning from their failures hardly needs to be stated. Not only are matters of life and death at stake on a daily basis, but also an increasing number of U.S. hospitals are operating in the red. This article reports on in-depth qualitative field research of nurses' responses to process failures in nine hospitals. It identifies two types of process failures—errors and problems—and discusses implications of each for process improvement. A dynamic model of the system in which front-line workers operate reveals an illusory equilibrium in which small process failures actually erode organizational effectiveness rather than driving learning and change in hospitals. Three managerial levers for change are identified, suggesting a new strategy for improving hospitals' and other service organizations' ability to learn from failure.