ISMP: Turn Short-Term Fixes Into Long-Term Remedies

Another flaw in first-order problem solving—in addition to engaging in at-risk behaviors—is that it works around problems; it does not truly solve them. While healthcare practitioners are often great at solving immediate problems, they rarely attempt to report them or alter their underlying causes (i.e., second-order problem solving) (Tucker et al., 2001). They are not necessarily trying to hide this information; they are simply pressed for time. In essence, practitioners are often forced to quickly patch problems so they can carry out their immediate responsibilities (Edmondson, 2004). We tend to encourage this aspect of independence, but it comes at the expense of system learning.

In 2015, Hewitt and Chreim described this experience as “fixing and forgetting,” meaning that practitioners faced with a problem often fix it in the moment and forget about it, rather than fixing and then reporting it. They found that “fixing and forgetting” was the predominant choice made by physicians, pharmacists, nurses, and other healthcare practitioners even when they faced recurring problems that threatened safety.

Likewise, a study involving nurses found that 92% responded to obstacles in their work with first-order problem solving, and failed to report the problem for system-wide learning and resolution (Tucker et al., 2001). The nurses in the study demonstrated a dependence on, and an addiction to, these heroics of in-the-moment problem solving. After resuming care, they did not expend further effort on the problem, rarely having time to do so or a convenient method of reporting problems. Second-order problem solving was limited to very few nurses who just communicated the problem (7%); in only one instance was the system altered to reduce problem recurrence. The research team concluded that a lack of available time, and norms that valued quick, self-sufficient solutions to problems, contributed to a pattern in which frontline practitioners rarely engaged in second-order problem solving. Tucker et al. (2001) also proposed that healthcare practitioners who would speak up and report system failures, no matter how small, ran the risk of being considered “complainers.”

Edmondson (2004) demonstrated similar results, with 93% of all nurses in a study taking the quick-fix route for system failures they encountered, concluding that neither the hospital nor other staff members, who may have contributed to the problem, were able to learn from the process failures. First-order problem solving served to isolate communication about problems, which meant that they did not surface as collective learning opportunities. Edmondson concluded that organizational cultures lacked psychological safety for speaking up about ambiguous issues of potential concern (vs. issues of obvious concern) and exhibited work designs that emphasized production pressure and quick fixes to problems above learning from failures.

Unfortunately, the true magnitude of operational failures in the system remains hidden because practitioners fail to report them. Unlike errors, the system problems faced by healthcare practitioners receive little attention, although they present a valuable source of information about ways in which the system is not working. The need for a workaround is a sign that something is wrong, and when systems are wrong, the risk of errors increases.

Safe-practice recommendations

Frontline healthcare practitioners are well positioned to help organizations learn, as they are only too aware of the problems that disrupt their work every day. Reporting these problems is critical to second-order problem solving and organizational learning for lasting improvements. To encourage organizational learning, consider the following:

Increase staff perception of risk. Coach healthcare practitioners to see the risk associated with working around the problems they encounter, and to understand that these workarounds must be reported for analysis, learning, and system-wide improvement.

Lessen autonomy. It’s ironic that current management practices typically strive to make healthcare practitioners more autonomous in problem solving and not over-burden managers with small problems (Edmondson, 2004; Hewitt & Chreim, 2015; Tucker, 2004; Tucker, 2009; Tucker et al., 2001). However, in order to uncover the root causes and prevent recurrence of daily problems that can eventually lead to patient harm, healthcare practitioners need more management support, not less. Create a work environment that empowers staff members to ask for help and to report all barriers to care. This does not imply that healthcare practitioners are not capable of creating temporary solutions to their daily problems; rather, it recognizes that failing to report those problems normalizes at-risk behaviors rather than seeking long-term organizational solutions. Instead of hoping that staff can handle issues on their own, managers need to actively seek out and be grateful for information about work challenges that their employees have experienced (Tucker, 2004).