Medical Errors

and Quality of Care

FROM CONTROL TO
COMMITMENT

Naresh Khatri
Alok Baveja
Suzanne A. Boren
Abate Mammo

"We can't solve problems by using the same kind of reasoning we used when
we created them."
Albert Einstein

W
ith its 1999 report. To Err is Human: Building a Safer Health
System, the Institute of Medicine focused the spotlight of
public opinion on errors in medical practice.' The report esti-
mated that 44,000 to 98,000 patients die annually of medical
errors, making them one of the leading causes of death in the United States,
ahead of motor vehicle crashes and breast cancer. The cost of nonfatal medical
errors is estimated to be $17 to $19 billion each year- and 2.9 to 3.7 percent of
all hospital admissions are found to result in injury from medical mismanage-
ment.^ Although the estimates of patient safety adverse events vary among
studies, the sheer magnitude and impact of every estimate suggest that medical
errors and injuries resulting from them are a serious epidemic confronting the
American health care system.
The Institute of Medicine report generated much interest and a flurry
of activities in the health care community in studying and preventing medical
errors. Consistent with the tradition in health care of investing in technology to
find solutions to clinical problems, health care organizations further intensified
investments in technological solutions and health care research has continued to
focus overwhelmingly on biomedical interventions such as drugs, devices, and
procedures."^

The authors gratefully acknowiedge the comments and suggestions of the two anonymous review-
ers that were helpful in improving both the content and presentation of this article to a great extent.

VOL 48, NO.3 SPRING 2006 I 15

 Medical Errors and Quality of Care: From Control to

Unfortunately, the 2004 study by Health Grades indicates no "big

improvement" in medical errors since 1999.^ In fact, the March 2004 MedPAC
report found that the adverse patient safety events in Medicare beneficiaries,
rather than declining, increased in the intervening years.^ Whereas there seems
to be no dearth of will or effort or capital in tackling the epidemic of medical
errors, the failure to rein it in suggests that the ways and efforts of the health
care enterprise to reduce medical errors may have been somewhat misplaced.^
Although technology is critical in improving health care delivery and
reducing medical errors, it cannot overcome adverse events arising from the
poor organization and management of health care delivery process.^ For exam-
ple, research evidence suggests that the commonly talked about technological
solutionscomputerized physician order entry system and electronic medical
recordsare not able to prevent the majority of patient safety incidents that
significantly contribute to preventable deaths and excess costs each year.^
The current bias toward innovative technological solutions over those
that require the transformation of current dysfunctional culture, management
systems, and work processes in health care must be corrected if we want to take
medical errors seriously.^*' For example, only about one-third of adverse events
are currently unpreventable in the sense that reducing them would require
advances in medical sciences." The other two-thirds of adverse events have
nothing to do with technicai advances and can be addressed only by improving
health care cultures and systems. Thus, further investments in technology
without considering subtle, pervasive, and potent behavioral factorsmay have
limited impaa on medical errors and the quality of care.'^
The causes and characteristics of major health care failures in different
countries with different ways of organizing and funding are remarkably similar,
suggesting that the problemsand their potential solutionsare deeply embed-
ded in the culture of health care organizations and the nature of clinical prac-
tice.'^ Thus, we need to understand the behavioral and cultural dynamics
underlying the clinical practice and health care professions to overcome major
failures in health care systems.
Based on a comprehensive review of clinical and health services manage-
ment literature on the linkages between organizational factors, medical errors,
and patient safety, Hoff and colleagues lament that:
almost all of the 42 articles used no systematic theoretical framework for predict-
ing or explaining the effects of their organizational variables on error or safety.
Thus, organizational variables were defined and operationalized in seemingly
random ways across studies for reasons that had nothing to do with having
to use a specific definition for a specific theory. Rather, these reasons appeared
arbitrary.*** .

The problem of patient safety can be best addressed by establishing a

comprehensive framework that directs the entire organization to understand
the rationale for a focus on patient safety.^^ Such a framework may require
developing health care systems that are capable of considering all (or most)

1 16 UNIVERSITY OF CALiFORNiA. BERKELEY V O L 48. N O ^ SPRING

 are: From Control to Commitment

of the factors affecting the quality of care.'^ In this article, we provide a frame-
work linking the overall management philosophy to medical errors and the
quality of care. Our main thesis is that overall management approach of an
organization affects its clinical outcomes via a causal chain in which managerial
assumptions determine human resource management practices. Human
resource management practices then affect medical errors and the quality of
care via their impact on employee behaviors.

Two Alternative Management Philosophies

Basic Assumptions
To grasp the impact of an overall management approach on medical
errors and quality of patient care, it is helpful to have an understanding of two
alternative management theories on human motivationcontrol-based and
commitment-based (see Table 1).'^ Each theory is founded on assumptions
(implicit or explicit) about how to manage employees more effectively. The
control-based view assumes that people are incapable of self-regulating their
behaviors and cannot be trusted. Consistent with this assumption, the natural
emphasis of control-based management is on monitoring employee behavior
closely via a variety of control mechanisms. Since the underlying assumption is
that people must be made to do what is necessary for the success of the enter-
prise, attention is directed to an elaborate machinery of direction and control.'^
The alternative view based on commitment has two underlying assump-
tions: first, people are capable of self-discipline, and given the opportunity and
developmental experiences, they would seek
responsibility and exercise initiative, and ,, , , . , . ^r
^ ^ Naresh Khatri is an Assistant Professor of Strategic
second, people work best when they are Human Resource Management in the Department
fully committed to the organization, and of Health Management and Infornnatics, School
they commit to the organization w h e n ^ Medicine, University of Missouri, Columbia.
, , ,, , - <khatrin@health.missouri.edu>
they are trusted and allowed to work
autonomously. The commitment-based f f ^aveja is an Associate Professor of
' Information and Management Sciences at the
management approach emphasizes creating school of Business of Rutgers University in
an environment that encourages commit- Camden, NJ. <baveja@rci.rutgers.edu>
ment to organizational objectives and pro- Suzanne A. Boren is an Assistant Professor of
vides opportunities for the exercise of Consumer informatics in the Department of
. .^. ,. . * J lr J- .- Health Management and Informatics, School of
mitiative, mgenuity, and self-direction in . , .- ,, *. *r,, r J ^K-.
^ Medicine, University of Missouri, Columbia.
achieving them. <borens@health.missouri.edu>
A number of scholars argue that the Abate Mammo is a Program Manager at the
attributes of the essentially control-based. Office of Health Care Quality Assessment of the
, . J ] I J ^.- u New Jersey Department of Health and Senior
bureaucratic model are maladaptive w h e n ^^^.^^^ <abate.mammo@doh.state.nj.us>
massive change, environmental dynamism,
and considerable uncertainty are the norm.^^
Self-regulating capacities of employees, shaped and normalized in large part
through the powers of expertise, have become key resources for modern forms
of organization.^" Especially, in competitive and dynamic business conditions.
VOL48. NO.3 SPRING 2006 I 17
 Medical Errors and Quairty of Care: From Control t o r

T A B L E I , Assumptions and Consequences of Control-Based and Commitment-Based

Management

Control-Based Comnnitment-Based
Management Management

Basic People are incapable of self-discipline and
Assumptions can't be trusted. Consequently, they need
to be monitored and controlled closely
and constantly to ensure that they behave
consistently with organizational objectives.
Without proper surveillance.
people/workers will shirk work and slack off.
Money is the best and perhaps the only
motivator
People do not like to take responsibility.
An implicit belief in the "mediocrity of the
masses."
The view is consistent with Taylor's scientific
management principles and prevalent
economic theories, such as principal-agent
theory and transaction cost theory (people
seek self-interest with guile).
People work best when they are fully
committed to the organization.
People commit to the organization if
they are trusted and allowed to work
autonomously.
People are capable of self-discipline.
Given the opportunity and developmental
experiences, people seek responsibility
and exercise initiative, ingenuity, and self-
direction.
Money is one of the factors, but not the
only factor people seek from their work
and organization.

Consequences Employees follow instructions/orders from
above and do just what they are told.
A sense of indifference toward work.
Employees either not engaged in their
work or"actively disengaged" from it,
Low morale and a climate of mistrust.
Feelings of helplessness and frustration.
Employee tumover and absenteeism are
high.
Utilization of human capacity is low (roughly
50 to 70%).
Employees show symptoms of deviance and
aggressive behavior.
Employees take initiative and seek
responsibility,
Employees are actively engaged and
committed to their work
High morale. Employees cooperate and
trust each other.
Energized, motivated, and empowered
employees.
Employee tumover is low.
Utilization of human capacity is 100%.
Employees take pride in the organization
and its missionThey go beyond the call of
duty.

organizations need employees who are secure enough in themselves to cope

with rapidly changing conditions and who are open and accepting of others in
order to work cooperatively in problem solving and decision making.^' Individu-
als who are committed to the aims of the organization, and who trust their man-
agers and the organization, have the potential to be self-regulating rather than
needing to be controlled by sanctions and external pressures. In essence, they
are more likely to be flexible and adaptable, both of which are crucial employee
characteristics in times of change.^- Several scholars note that a gradual shift
from control to commitment is taking place in a variety of organizations and
industries."^

I 18 UNIVERSITY' OF CALIFORNIA, BERKELEY V O L 48.

 : From Control to Commitment

Behavioral Consequences
There are behavioral consequences depending on which approach is
taken (see Table 1). The control-based approach emphasizes lower-level needs
(e.g., basic pay) and does not allow for the fulfillment of higher-level needs (e.g.,
need for independence, achievement, self-confidence, and recognition). Conse-
quently, it makes people "sick," not physically, but intellectually because it does
not offer opportunities for employees to satisfy their higher-level needs.^'^ The
employee turnover is likely to be high and morale low in such organizations.^^
The emphasis on compliance/obedience rather than on commitment does not
allow the full utilization of human capacity (knowledge and emotional energy).
Employees take initiative and are actively engaged in their work in a
commitment-based organization. They take pride in the organization and its
mission. They cooperate and trust each other, thus overcoming communication
barriers and enhancing coordination and teamwork. Employee turnover is usu-
ally low and the utilization of human capacity high. High employee morale gen-
erates a positive emotional energy.
In western economies, approximately a fifth of employees have a mental
illness in any one year and management practices resulting from control-based
management are suggested as a major source of work-induced mental illness.^^
Specifically, the following sets of practices emanating from control-based man-
agement have been reported to cause mental illness in workers:
work overload, unrealistic task performance, unrealistic deadlines, and
insufficient support staff/resources;
poor or insufficient communication;
few meetings between employees and their line manager, not permitting
frustrated employees to explain matters that are causing them stress, or
where employees are denied the opportunity to explain issues of conflict
raised by their manager;
low trust levels and use of disciplinary measures to solve issues that could
be solved via negotiation, informally;
actual lines of communication and position designations being overly
rigid and cumbersome with fair/quick decisions difficult to achieve; and
excessive repetition and lack of control over work methods."^^
The organizational behavior and human resource management scholars are to
blame at least partly for focusing too much attention on the individualistic para-
digm in management research that places too much emphasis on the individual
employee and ignores culpable organizational infiuences.^
Mental illness affects an employee's produaivity, judgment, ability to
work with others, and overall job performance. The financial costs associated
with mental illness to organizations are estimated to be very high.-^ Erom the
perspective of health care organizations, a decrease in an employee's concentra-
tion or judgment resulting from exhaustion or depression can pose safety risks
and cause costly mistakes.^ Scholars even argue that management practices

VOL 48. NO.3 SPRING 2006 119

 Medical Errors and Quality of Care: From Control to

consistent with control-based model can cause workplace deviance and

aggression^'.
The control-based management practices have taken a toll on employee
morale and well-being in several developed countries. For example, Gallup in its
national survey found that, of all U.S. workers 18 or older, 24.7 million or 19%
are actively disengaged from their work.^^ The phenomenon of active disen-
gagement from work is not limited to the United States. In fact, its extent is
significantly higher in other countries (e.g., France, Singapore, and the United
Kingdom) for which Gallup conducted the survey. More than 80% of British
workers were found to lack any real commitment to their jobs, and a quarter
of those were actively disengaged.^^
Why are so many employees disengaged? The Gallup survey cited that
workers say that their managers do not care about them as people, their jobs are
not a good fit for their talents, and their views count for very little. The survey
found that employees feel they are far more productive if their supervisor
focuses on their strengths and positive characteristics rather than their
weaknesses.

Human Resource Practices under the Two Management Approaches

The nature of human resource systems differs in the two management
approaches.^'* In a control-based organization, hierarchy is tall and communica-
tion is mostly vertical, from the top down. Labor is treated as a variable cost and
workers are hired and fired as per the convenience of the management. Tasks
are narrowly defined and standardized so that they can be properly monitored.
The focus of employee behaviors is on compliance with instructions and orders
from the top. There is much emphasis on status symbols, and the relationship
between labor and management is adversarial. In a commitment-based
approach, organization is flat, with relatively fewer layers in management.
The organizational communication is extensive and takes place in all directions,
horizontal as well as vertical; it is anemic in a control-based organization and
occurs mostly top down. A commitment-based organization stresses teams,
cooperation, and employee involvement. It invests in hiring, training, and devel-
oping of employees, and builds mutual commitment with its employees. Jobs are
broad and provide greater autonomy and empowerment. Status differences are
frowned at and the focus of employee behaviors is on commitment. The goals of
management and employees are aligned as employees and management work
together.

The Proposed Model:

Link between Management Philosophy and Clinical Outcomes
Figure 1 presents a model linking the overall management approach to
clinical outcomes. The current culture and systems in health care are those of
control-based type. The model suggests that health care organizations need a
management approach based on commitment.

120 UNIVERSITY OF CALIFORNIA, BERKELEY VOL 48,

 UUHL; ^^, Zsre: From Control to Commitment

The Model Overview

The model in Figure 1 shows that the relationship between the overall
management approach and clinical outcomes is mediated at two levels. In the
first level, the management approach affects HR management praaices. In the
second level, HR management practices affect employee behaviors that in turn
determine clinical outcomes.
The basic management philosophyimposing control on employees or
eliciting commitment from themaffects clinical outcomes significantly. It does
so in two ways: by affecting the detection and reporting of errors (the learning
effect): and by affecting the motivation, satisfaction, morale, and effort put forth
by employees (the motivational effect).
Currently, the majority of health care organizations employ a mostly con-
trol-based management philosophy. The clinical culture plays a central role in
perpetuating the industrial model of control (health care organizations treated as
factories rather than professional service organizations), creating silos, and estab-
lishing a hierarchy characterized by status differences across professional groups
in health care organizations. That is why there is not a significant improvement'
in clinical outcomes despite concerted efforts from health care institutions. Con-
trol-based management may not reduce medical errors and improve the quality
of care beyond a certain point because of its inherent weaknesses. It does not
allow any learning to take place in the health care delivery process as it sets in
motion a vicious cycle in which a greater incidence of medical errors leads to
greater control and regulation of employee behaviors, further strengthening the
blame culture and finger pointing. The culture of blame in health care organiza-
tions exists because of the lack of a supportive climate for reporting and low
perceived psychological safety.'^ In a low psychological safety environment, indi-
viduals fear that error disclosure will bring rejection, embarrassment, or punish-
ment. In the absence of any corrective action, the same medical errors keep
reoccurring.^^
Control-based management leads to low motivation and generates nega-
tive emotional energy. It constrains the initiative of health care professionals. In
its logic, the control-based model is designed to prevent undesirable actions and
behaviors from a small fraction of employees, say 5 percent.'^ An unintended
but important consequence is the constraint it imposes on the initiative, creativ-
ity, and morale of the other 95 percent of employees.
Commitment-based management may be more appropriate for the health
care context.^^ It has two beneficial effects. First, it increases learning from mis-
takes by inducing a virtuous cycle in which organizational members report all the
medical errors and search extensively for their causes in an open and trusting
environment. Second, commitment-based management generates high motiva-
tion in the workforce and harnesses the immense energy emanating from
positive emotions. Thus, it enhances the quality of care and patient safety by
improving the morale of the workforce. Self-directed and highly energized
employees do their best effort in providing care to patients.

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 Medical Errors and Quality of Care: From Control to

F I G U R E I . The Model Linking Management Philosophy to Clinical Outcomes

Current Culture and Systems in Health Care Organizations

CONTROL-BASED MANAGEMENT
Perpetuation of Industrial Model
0) p
Silos
Hierarchy/Status Differences

TRADITIONAL HRM
Low Autonomy
Narrow jobs
Tall Structure
Top-down Communication
Centralized Decision-making
Hire and Fire Policy

Culture of Blame/Finger Pointing Low Employee Morale

(frustrated, "helpless" employees)
Suppression of Reporting of
E V Medical Errors Low Commitment
UJ OQ

No Corrective Action Poor Quality of Care and

"5 Poor Patient Safety
Repetition of Errors
U 3

Low Learning Low Motivation (Negative Emotions)

The value of the proposed model is in its ability to explain the existing
health care management systems by highlighting their underlying weaknesses
and in providing a new approach based on commitment that addresses the
weaknesses in the existing system.

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 dre: From Control to Commitment

F I G U R E I . The Model Linking Management Philosophy to Clinical Outcomes (continued)

Proposed Approach for Health Care Organizations

COMMITMENT-BASED MANAGEMENT
w
E 5 Employee Involvement
DO 5 ;
Transform ati ional Leadership
c 9-
Just and Fair Practices

STRATEGIC HRM
Employees as Strategic Assets
E <^ Team-based Design
|
Flat Structure
S Extensive Information Sharing
0.
Greater Employee Discretion
X

ID
I
(A
Greater Reporting/Detection High Employee Morale
of Medical Errors (energized, empowered employees)
o. IS
E-S Extensive Search High Commitment
Best Effort

u C Lower Incidence of High Quality of Care and

= o Medical Errors Safe Patient Care
U 3

High Learning High Motivation (Positive Emotions)

The Current Culture and Management Systems in Health Care

The current culture and management systems in health care can be
thought of as a hybrid of the clinical culture and the control-based model.^^ We
view the craft culture of the pre-industrial era as the precursor of the clinical

V VOL 48. NO.3 SPRING 2006 23

 Medical Errors and Quality of Care: From Control to (

culture and the industrial model used in manufacturing organizations as a pre-

cursor of the control-based model. In the past, health care organizations lacked
management practices and systems and relied predominantly on the clinical
culture for delivering patient care. Most of them are moving toward more stan-
dardization, systematization, and formalization in their management systems
and processes. In other words, they are making a transition from a craft system
to the industrial model.'^^
Interestingly, the prevalent clinical culture in health care organizations in
itself shows no resemblance to the control-based model. In fact, it is instrumen-
tal in creating a professional commitment for delivering patient care.'*' Unfortu-
nately, through several major unintended effects, it is perhaps the single most
important factor responsible for creating and perpetuating the current culture
and systems in health care organizations. Specifically, the clinical culture has
reinforced the control-based model by resisting management innovations and
causing a major management deficit (as a result of which health care organiza-
tions remain stuck in the industrial model), by preserving status differences or
"caste structures" across professions, and by creating silos across professions and
specialties within professions.

Perpetuation of Industrial Model

An important consequence of strong clinical culture in health care
organizations is the existing management deficit or vacuum. A professional culture
enables sustained action by providing members with a similarity of approach,
outlook, and priorities. Yet these shared values, norms, and assumptions in
health care organizations have blinded health care professionals to vital manage-
ment issues affecting their performance because they lie outside the bounds of
their perceptions.'*^ Great doctors and nurses, not great organization or manage-
ment, have been seen as the means for ensuring that patients receive quality
care.'*^ Such a mindset sets in motion an important organizational and psycho-
logical dynamic that inhibits system change and creates a dysfunctional relation-
ship between management and clinical staff.'*'*
Partly as a result of strong professional cultures, the health care industry
has lagged behind other industries in management innovations.'*^ In the last ten
to fifteen years, progressive human resource practices have become common-
place in several industries. However, because of the management deficit or
vacuum, there has been little progress made in implementing strategic human
resource management practices in health care organizations. An industry criti-
cally dependent on human factor has not even begun paying attention to such
practices because of the stranglehold of professional culture."*^
Whereas nurses and physicians consider their roles as specialized and
requiring several years of technical training, they tend to assume, often implic-
itly, that managerial roles do not require any unique experience, training,
and expertise.'*'^ Nurses and physicians are placed in managerial positions for
which they are not qualified. For example, in the absence of professional man-
agers, some nurse managers oversee even highly technical human resource

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 I icun-ai LI I ui 3 ai lu v^uanty -. Care: From Control t o Commitment

management responsibilities such as designing new compensation and perfor-

mance management systems, which are too complex even for an average
human resource manager. The added burden of managerial tasks for which
they are not well-equipped may be the source of poor management as well as of
exhaustion and burnout in many health care professionals."*** Another interesting
example of the management deficit resulting from the professional culture is
that of the head of a surgery department in a university hospital overseeing
about 60 physician surgeons and associated staff in addition to carrying his nor-
mal clinical load as a surgeon. Providing leadership to such a large number of
professionals is a formidable task requiring full-time attention. Unfortunately,
the head of the surgery department in this university neither provided any lead-
ership nor felt the need to do so. Obviously, because of the lack of attention to
leadership and management issues, physicians and other professional staff in the
department were highly frustrated and demoralized, not knowing their roles and
not finding enough support. This was especially the case with new physicians
who were leaving the organization in hordes.
Some basic elements of bureaucracy are usually necessary in medium- to
large-size organizations. However, if not managed properly, bureaucratic systems
have a tendency to develop rigidity, which inhibits organizational change and
adaptation. Bureaucratic elements are pervasive in health care organizations.
There are not many studies examining their impact on clinical outcomes, how-
ever. As an exception, a study of the Veterans Administration hospitals found
a negative relationship between bureaucratic, rule-based culture and inpatient
satisfaction."*^ Certainly, in a health care setting, adherence to rules and regula-
tions is necessary to ensure quality control in the delivery of patient care. How-
ever, too much emphasis on rules may deter employees from finding new ways
of improving patient care that contribute to better patient satisfaction.
Physician autonomy, another chief characteristic of the clinical culture,
has been found to be a barrier to implementing quality improvement programs
because physicians perceive quality improvement efforts as an interference in
their practice.^^ There are other adverse consequences of strong professional
culture present in health care. The health care system offers substantial room
for structural secrecy. It is easy for one group of clinicians (one unit or one
department) to defensively encapsulate a problem or if necessary to shift the
blame to others. With weak reporting systems and even weaker mechanisms to
act constructively on reports that do come through, it is not surprising that the
same errors continue to be made even years after case reports of their first
occurrences have been distributed.^'

Hierarchy and Status Differences

Health care culture features a fairiy rigid professional hierarchy, isolation
of clinical care from institutional management, and virtually no coordinated
design of care systems around the true needs of patients.^^ As a result, health
care organizations either lack medical error reporting systems or rely on out-
moded control-based mechanisms for dealing with medical errors. Effective risk

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 Medical Errors and Quality of Carp; From Control to

management, however, depends crucially on establishing a reporting culture.

Trust is a key element of reporting culture and this, in turn, requires the exis-
tence of a just culture.^^
A number of scholars document the existence of hierarchy and its dys-
functional consequences in delivering safe and high-quality patient care. Hier-
archical relationships suppress dissent and disagreement between residents
(subordinates) and attending physicians (superiors), between nurses and doc-
tors, and between patients and medical staff, causing breakdowns in the com-
munication vital for detecting and correcting medial errors."^ Nurses and
physicians working as part of the same team face identity group boundaries that,
confounded with status differences, affect communication and collaboration in
the team.^^
A study of the cytology laboratory of a major university hospital reported
that many operations staff perceived the cytology department as a closed system
with a hierarchical structure." The rules and roles of employees in the depart-
ment were highly formalized and fixed, and many perceived that organizational
boundaries existed that made people aware of the status differences in skills and
rights.
A number of health care organizations have been reported to have a cul-
ture that tolerates a level of disrespect that is displayed by doctors and directed
toward other patient-care providers, especially nurses and aides.^^ Such a culture
blinds health care organizations to potential problems arising from culturally
supported differences between physicians (who have more status and power)
and other health care workers (who have lower status).
Hierarchy provides undue privileges to higher-ups and does not hold
them accountable. A recent study supports this point. The study found that,
whereas only 8 percent of physicians identified nurses as members of the deci-
sion-making team, a large majority of them perceived patient safety as primarily
a nursing responsibility.^^ The study demonstrates the existing imbalance
between authority and accountability. On the one hand, physicians do not con-
sider it worthwhile to involve nurses in decision making. On the other, they
think that mostly nurses, not they, should be held accountable for the outcome
of those decisions. Another study found that physicians were less aware of
patient safety efforts than nurses and recommended that more work is needed
to involve and educate physicians about patient safety efforts.^
A study of non-surgical intensive care units in teaching and non-teaching
hospitals in Houston reported that critical care physicians and nurses had dis-
crepant attitudes about the teamwork they experienced with each other.^' The
discrepancy included suboptimal conflict resolution and interpersonal communi-
cation skills. The findings were attributed to the differences in status and nursing
and physician cultures, among other factors.
Comparative studies of the aviation and health care industries concerning
management styles are particularly illuminating with regard to behaviors of
medical professionals and medical errors. The aviation and health care industries
are similar in that both are expected to function without error. A study of the

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 _ lare: From Control to Commitment

cockpit crew (captains, first officers, and second officers) and health care work-
ers (doctors, nurses, fellows, and residents) found surgeons to be most support-
ive of steep hierarchies in which junior staff do not question senior staff." Such
hierarchies, however, typically result in poor teamwork and low communica-
tion. Top-down, paternalistic style of management in health care organizations
aas as a major barrier to learning from mistakes. Thus, the reported evidence of
poor teamwork and communication across a variety of health care settings, such
as trauma resuscitation, surgical procedures, and treatment of patients in inten-
sive care units, may come as no surprise.

Silos
The phenomenon of "silos" results from health care's profession-centric,
fragmented heritage, and competing professional cultures.^^ Health care organi-
zations have been characterized as a collection of loosely coupled, self-contained
cultures or "tribes" managed by a chief executive whose idea of leadership and
oversight is to say, "You fix it."^''
Silos are symptomatic of an organizational dysfunction and have a nega-
tive effect on organizations, leading to turf wars, power struggles, and personal-
ity conflicts, all of which result in lack of cooperation and poor performance.^^ A
study on the performance improvement capability of hospitals reported striking
gaps in horizontal communication systems and few mechanisms or forums to
bring people in different units together in regular discussions and dialogue.^^
Without well-developed systems for assuring vertical and horizontal communi-
cation, it was difficult to address patient safety problems.
Silos create an environment in which the personal and departmental
interests of managers may take precedence over the well-being of the organiza-
tion. The reasons for formation of silos are all found in health care organizations
and include an organizational structure rigidly designed around functional areas,
corporate culture and traditions that do not encourage collaboration, strong
individual departmental priorities versus corporate priorities, lack of cooperation
and/or participation in cross-functional teams, poor departmental leadership,
inadequate interpersonal skills, poorly designed reward systems, and policies
and procedures that make cooperation difficult.^"^

The Need for Commitment-Based Management in Health Care

In its 2001 report, the Institute of Medicine concluded: "The higher qual-
ity of care cannot be achieved by further stressing current systems of care. The
current care systems cannot do the job. Trying harder will not work. Changing
systems of care will."^^ While the Institute needs to be commended for identify-
ing problems in health care culture and systems accurately and comprehen-
sively, most of its prescriptions to transform them do not go far enough. For
example, the Institute's emphasis on information technology, but not on people
management issues, is consistent with the old ways where health care systems
try to solve health care problems using mostly technological interventions, even

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if there is no clear relationship of using a particular technological intervention

and improvement in clinical outcomes.^^
The Institute missed a good opportunity of thrusting people issues at the
forefront. There has been a revolution both in research and practice on high-
involvement management practices in the last two decades. Surprisingly, health
care organizations appear to be insulated from it. The irony is that the health
care industry is one of those industries that relies on the skills, knowledge, abil-
ity, and effort of its workforce the most. Health care organizations are not fast-
food restaurants; the difference between committed and perfunctory
performance can literally be fatal.^
Tasks in health care are highly interdependent, requiring people from
many different disciplines and perspectives to work together to render care."
However, the central participants in health care (physicians, nurses, managers)
tend to pursue their distinctive roles with varying and often confiicting priori-
ties, organizing principles, and cultures. The lack of sufficient integration and
coordination of their activities (poor communication and teamwork) is the
major source of medical errors and poor quality of patient care.*^^ The new
process designs and technologies are not likely to improve clinical outcomes
unless they enhance integration, collaboration, communication, and teamwork
in the health care delivery process. Thus, the overall management approach
should allow and encourage people to collaborate naturally.
The fact that more than 40 percent of people with chronic conditions
have more than one such condition calls for improved mechanisms to communi-
cate and coordinate care.'^ Yet physician groups, hospitals, and other health care
organizations operate in silos, often providing care without the benefit of com-
plete information about the patient's condition, medical history, and services
provided in other settings. Improved cooperation and interdependence among
health care employees are thus critical for enhancing clinical performance.^"*
The outmoded culture and management systems in health care organiza-
tions have precipitated a crisis in the health care workplace. The quality of work
life among health care workers has deteriorated to the point where it is imped-
ing the capacity of the system to recruit and retain the staff needed to provide
effective patient care.^^ "Workers experience an increasing sense of frustration,
exhaustion and, in some cases, leave the organizationworn out by the task
of swimming upstream against an incessant tide of small, annoying problems.
Across the health care industry, this phenomenon is contributing to unaccept-
ably high levels of turnover in many organizations and to widespread nursing
shortages."^^
It is important to acknowledge that the very structure, values, cultures,
and working relationships inherent in a health care organization contribute to
the quality of work and well-being of employees. The prolonged exposure to
jobs high in demands and low in controllability,^^ typical in health care organi-
zations, leads to stress-related mental and physical problems. The adverse
effect of high-demand and low-controllability jobs is found to spill over even
to home settings.^^ Health care organizations should meet their workers' needs

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 Care: From Control to Commitment

to participate and make a contribution, provide psychological and economic

security, offer opportunities for skill development, and have the right balance
of job demands and resources for an effective and healthy workplace.*^^
The role of transformational leadership, a key component of
commitment-based management, is critical in overcoming pervasive barriers
embedded in health care's organizational systems that make learning from fail-
ures difficult.^ Leaders in health care organizations can overcome the barriers in
three ways:
by creating a compelling vision that motivates and communicates urgency
for change,
by working to create an environment of psychological safety that fosters
open reporting, active listening, and frequent sharing of insights and con-
cerns, and
by empowering and supporting team learning throughout the
organization.
Similarly, there is ample evidence and examples of companies and indus-
tries that have emphasized the importance of the other two components of the
commitment-based modelintensive employee participation in decision mak-
ing and just and fair management practices. For example. Southwest Airlines
achieves superlative flight departures, a process that requires coordination of
employees with a variety of skills and responsibilitiespilots, fiight attendants,
gate and ticket agents, mechanics, caterers, baggage and cargo handlers, and
fuelers.^' Departures have to proceed well despite uncertainty, interdependence,
and time constraints because the departure process has significant impact on
customer satisfaction, efficiency, equipment utilization, and profitability.^^ The
overall climate in Southwest is informal and egalitarian, in which people address
one another on a first name basis, dress casually, and work together to accom-
plish what needs to be done.**^ Collective rewards are given more often than
individual rewards. The company believes in empowering their employees with
information so that they are more able to act like owners and take responsibility
to make decisions. It hires employees based on their leadership skills and atti-
tude and not based on their technical skills alone.
Another good example of a commitment-based philosophy is the SAS
Institute.^'* The company seeks to create an atmosphere of fun and equality, a
place where people are treated with dignity and respect. The company believes
in the power of reciprocityif you treat your people well, they will treat the
company well by being loyal in return. It believes and relies on people's intrinsic
motivation. The company's approach to performance management entails set-
ting high expectations for conduct and performance, which then become self-
fulfilling, and giving people the freedom to do what they like to do to meet the
goals and expeaations. The company operates on the basis of trust; for example,
there is no sick leave policy. Employees stay home when they are sick or have a
sick child. Organizational structure is fiat and informal.

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 Medical Errors and Quality of Care: From Control to C

The evidence in support of the commitment-based philosophy is slowly

emerging in health care organizations as well. For example, a study of the Veter-
ans Administration hospitals found that the teamwork culture was positively
associated with inpaticnt satisfaction and the rule-based, bureaucratic culture
was negatively associated with it.^^ The positive relationship between teamwork
and inpatient satisfaction was mediated by more effective coordination and
greater cohesion among employees working toward the same goal. Similarly, a
study of 283 Canadian nursing homes found that nursing homes that had imple-
mented more "progressive" HR practices, and that reported a workplace climate
that strongly valued employee participation and accountability, performed better
on a number of clinical outcomes.^^
If the commitment-based model is more effective than the control-based
model in achieving better clinical outcomes, the natural question arises on how
to implement the commitment-based model in health care organizations.

Implementing the Commitment-Based Approach

Piecemeal, quick-fix management interventions in health care organiza-
tions are not uncommon. The majority of them fail, however, because they are
implemented without an understanding of the underlying assumptions and pos-
sible consequences of such interventions. For example, the reason why most
empowerment and involvement interventions fail is because empowerment, a
central tenet of commitment-based management, is implemented using control-
based methods. Key characteristics of the implementation process (top down
communication and bureaucratic controls) counteract any motivation on the
part of staff to break free of bureaucratic rules and regulations.^"^ To be told you
are going to be "empowered" and that you should behave in an empowered man-
ner is quite different from feeling empowered.
There are four major mechanisms to transform health care organizations
from hierarchical, industrially managed, and control-based to knowledge-based,
service-oriented, and commitment-based: breaking down of hierarchy, silos, and
"caste structure;" fostering involvement and communication; instituting just and
fair management practices; and placing transformational leaders in key positions.

Breaking Down of Hierarchy. Silos, and "Caste Structure"

Status differences, or "caste structures," that exist in health care organi-
zations at present are dysfunctional to the rendering of high-quality and safe
patient care. A lot of training and education of employees would be needed at
all levels to wipe out the prejudice that may exist based on implicit or explicit
status differences.
It is now a widely accepted fact that silos exist in the structures and
cultures of health care organizations.^^ Organizational theory literature would
predict exactly what we see. Health care organizations use predominantly func-
tional (departmental) design. The functional design by its very nature is bureau-
cratic (mechanistic) and slow to respond to changes in the environment. It also

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 . .^v...^u. ^.,-^.. ^..V. ^^..^.; *.,, Care: From Control to Commitment

generates barriers between departments that are so prevalent in health care

organizations. In its place, we need a more organic design, such as cross-func-
tional teams. A team design is ideal for health care settings.^^
The information flow in a hierarchy is vertical, top down, and is quite
anemic. The limited information flow constrains decision making and organiza-
tional adaptation in the face of environmental changes. Too much secrecy and
confidentiality of information in health care organizations exist at present. The
free flow of information is as vital to organizational health as proper circulation
of blood is to human health. Thus, the hierarchal design needs to give way to
an information-intensive, team-based design and a learning environment.^'^
Physicians, despite the fact that they are not always full-time employees,
need to lead the way in establishing mechanisms for greater reporting of errors
and their resolution. At present, the burden of reporting and fixing medical
errors falls disproportionately on nurses. The error reporting and resolution at
the level of physicians is kind of a black box; with the rest of the organization
lacking knowledge of what goes on in physician peer reviews.^'

Fostering Involvement and Communication

Employee participation or empowerment can be defined as the process of
involving employees in some or many aspects of decision making that had been
reserved for management.
It has two beneficial effects: work harder effect and work smarter effect. In
the work harder effect, empowerment acts as a motivational tool through satis-
faction, ego involvement, and commitment, and it can be achieved by participa-
tive goal setting. In the work smarter eficct, employee participation draws on
employee knowledge and information. Doing so helps in improving work
methods and processes, with the result that employees and organization end
up working smarter. By decentralizing managerial decision making, setting up
formal participation mechanisms, and providing proper training and rewards,
a commitment-based system can lead to a highly motivated and an empowered
workforce whose goals are closely aligned with those of management. Thus, the
resources needed to monitor employee compliance, such as those needed to
maintain supervision and work rules, can be reduced.^" In addition, employees
under these conditions are more likely to engage in organizational citizenship
behaviors: non-role, unrewarded behaviors that are, nonetheless, critical to
organizational success.^^ A study reported positive relationship between regis-
tered nurse participation in decision making and improvement in quality of
clinical outcomes without increasing any ^*

Instituting Just and Fair Management Practices

Fair and just management practices are central to creating a sense of
commitment in employees. Performance appraisal and reward systems are usu-
ally the source of feelings of unfairness and discontent in employees. For exam-
ple, a study of large companies from various industriesincluding the health
care industryfound variations in appraisal rating procedures, grading, and

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 Medical Errors and Quality of Cane: From Control to C

target allocation resulting in deep feelings of distrust and anger, which severely
damaged individuals' feelings about their companies.'^^ The author recom-
mended that fair and just practices play a critical role in creating a committed
workforce. Some companies implement performance-based pay systems without
specifying and communicating performance criteria clearly. Similarly, lack of
clearly communicated promotion and rewards policies are likely to create a
sense of mistrust and unfairness in employees. In addition, training opportu-
nities, transfer of employees within the organization, assigning employees to
various projects, and annual salary increases can all be a potential source of per-
ceptions of unfairness. A study of a university hospital in the mid-west provides
a good example.^^ The authors found that, while one physician had a secretary
to himself on a full-time basis, several other physicians had to share one without
any rationale. The physician in question had no more administrative work than
other physicians. Eurther, the secretary attached to the physician in question
was drawing a higher salary and received a promotion before the other secre-
tary. Such practices create a toxic work climate. The study reported that physi-
cians in the hospital were unhappy and their turnover was high. On a scale of 1
(very low) to 10 (very high), they rated their morale as zero. The reason for low
morale was attributed to unfair management practices in which the salary and
compensation of physicians were quite lop-sided, unrelated to their clinical and
research productivity. Transparent policies and practices with extensive input
from employees can go a long way in developing a fair and just workplace.
Moreover, continuous incremental changes in policies based on employee feed-
back are helpful in achieving a fair and an equitable system with attendant ben-
efits in the form of improved clinical outcomes.

Placing Transformational Leaders in Key Positions

The implementation of the commitment-based management approach is
more complex than the control-based approach and requires skillful managers
who have good leadership skills and are adept at understanding human behav-
ior. Building the new system requires transformational leaders who can raise the
level of a group's practices to its values and in doing so are able to create a com-
mon understanding and foster a willingness to change.^^ The leader's mood and
behaviors drive the moods and behaviors of everyone else. A cranky and ruth-
less boss creates a toxic organization filled with negative underachievers who
ignore opportunities; an inspirational, inclusive leader spawns acolytes for
whom any challenge is surmountable.^^ Transformational and inspirational lead-
ers are socially adept and daring and change seeking!^'^ Socially skillful managers and
leaders possess high interpersonal skills, relate well with people, are good at
building relationships, interact well at all levels in the organization, understand
the needs of others, are sensitive to the feelings of others, identify with their
subordinates, and are caring, friendly, fiexible, and open to ideas. Daring and
change-seeking leaders are driven for change, dare to be different, challenge the
tradition, and take risks. A highly significant positive relationship exists between
a socially skillful daring, and change-seeking leadership style and the motivation,
commitment, and performance of employees.^*^" Health care organizations

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 ui Care: From Control to Commitment

should recruit managers and leaders who possess such attributes and should
provide training and developmental for existing managers and leaders in order
to bring about the needed transformation.
It is not uncommon in health care organizations to promote people
(nurses or physicians) to managerial positions based on their clinical expertise.
However, a managerial job requires different skills. An excellent nurse or physi-
cian may not possess required managerial and leadership skills and may perform
poorly in a managerial position. Thus, it is essential that managers be selected
based not only on their technical competence, but on their managerial and
interpersonal competence as well.

Important Caveats in Implementing the Commitment-Based Approach

To enhance an unambiguous understanding and interpretation of the
proposed model as well as to ensure that it is implemented in the right spirit,
we would like to note the following caveats in the contrast of control-based
and commitment-based management approaches. First, our treatment of the
management approach to medical errors and patient safety in this article encom-
passes the whole organization, which is consistent with present discussions in
health services research emphasizing the adoption of a broad rather than narrow
approach in dealing comprehensively with the problem of medical errors.'^^
Other popular management practices, namely, the well-known job characteris-
tics model,*-^ high involvement work practices,^**^ empowerment, and team-
based design, are not the same as commitment-based management although
they are consistent with it and may be used to implement it.
The second important caveat is that commitment-based management
does not mean that there is no control used in the organization. Control in a com-
mitment-based approach is achieved through creating commitment in employees toward
organizational goals and objectives. The theory and practice of a control-based
approach is quite straightforward (monitoring employees closely, providing them
with minimum necessary monetary benefits to keep costs down, and reprimand-
ing them if they deviate from the norms); we all understand it well and are quite
used to it. However, the implementation of a commitment-based approach is
more complex than a control-based approach. Moreover, because it is relatively
new, individuals and organizations are less familiar with it. The successful imple-
mentation of a commitment-based approach requires skillful managers and
employees who understand human psychology and behavior at all levels in the
organization. The position of the manager or leader vis-a-vis the social sciences
becomes similar to that of the engineer vis-a-vis the physical sciences or the
doctor vis-a-vis chemistry or biology.'^^
The third caveat addresses the question of whether the control-based and
the commitment-based approaches can be implemented simultaneously. In the
short-run, their co-existence may be inevitable when an organization is tran-
siting from one approach to the other. However, in the long-run, the imple-
mentation of two approaches at the same time may not produce the intended
outcomes since they are inherently contradictory. Simultaneous implementation

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 Medical Errors and Quality of Care: From Control to (

of the two approaches may result in an unstable and inconsistent management

approach.'**' Currently, we believe that the majority of health care organizations
are stuck in a mixed approach, and, as a result, their interventions and practices
lack any coherence or consistency. The counteracting practices and interventions
are a source of confusion for both managers and employees.
The fourth caveat is that the system design and processes that are
inconsistent with broader management style are likely to be ineffective. That is,
practices consistent with control-based management may not work in a commit-
ment-based approach and vice versa. These days, we are seeing a lot of initia-
tives in health care organizations that are consistent with the commitment-based
approach (e.g., team-based work design, empowerment), but implemented in an
overall context that is highly control-based. Such interventions are not likely
to work.'*'^ If the overall management approach is control-based, monitoring
of employee behaviors closely and reprimanding them for deviations may still be
a better strategy than implementing practices consistent with the commitment-
based approach.
A final caveat concerns the cause-and-effect ordering. Do workers behave
irresponsibly and do other stupid things because it is their basic nature? Or, is it
that management praaices and systems over time have made them indolent,
passive, and averse to initiative and responsibility? It has been suggested that
employee behaviors, such as lack of initiative and motivation, low commitment,
and dislike for work are more a reflection of the management systems rather
than employees' innate desires or needs.'^ For example, the noted management
scholar, Rosabeth Moss Kanter, once commented: "It is a myth that people resist
change. People resist what other people make them do, not what they them-
selves choose to do. That's why companies that innovate successfully year after
year seek their people's ideas, let them initiate new projects and encourage more
experiments."'''^ The values and beliefs of management about human motiva-
tion necessarily permeate the design of feedback, control, and incentive systems,
and therefore become self-fulfilling.'*'^ Through supervision and control, the
organization communicates that it is responsible for controlling and determining
performance rather than the individuals who are monitored and controlled. This
makes individuals feel less responsible for their performance. In fact, the com-
mitment-based approach predicts that, when people have been controlled for
long, a sudden removal of control may result in some sort of mayhem, which
may be interpreted by "control-minded" managers as evidence supporting their
view of employee motivation.

Implications and Conclusion

Efforts to reduce medical errors and enhance quality of patient care will
not be successful unless the basic cultures and systems in the health care indus-
try are transformed. The morale of employees in health care is low because of
the "system" that poses major hurdles in letting them do what they really want
to do and do best, to serve patients. Health care professionals are looking for a

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 "are: From Control to Commitment

more open, trusting, and empowering environment. When they find themselves
in such an enabling environment, they are likely to perform beyond their capac-
ities, leading to a concomitant reduction in rates of medical errors.
Increased regulation and accreditation standards further embed control-
based management philosophy with all its ill effects. A prime example of this is
the new standard of the Joint Commission on Accreditation of Health care Orga-
nizations (JACHO) that requires a nurse to repeat to the doctor all verbal orders
and also the new standard on the correct site surgery. By treating nurses and
other employees in a mechanized manner rather than human beings, these new
measures will further strengthen the "system" that fundamentally frustrates and
demoralizes employees in health care organizations. A study of nursing homes
lends support to this view." The U.S. home nursing industry is characterized by
an extraordinary degree of government involvement and regulation. The gov-
ernment is the dominant purchaser of nursing home care via the Medicaid and
Medicare programs. The authors found a significant variation in quality across
nursing home facilities that persist over time. Specifically, they showed that both
low- and high-quality nursing home care is concentrated in certain facilities.
Based on their findings, the authors questioned the efficacy of regulation.
Health care organizations are also investing heavily in quality improve-
ment efforts. Unfortunately, most quality improvement investments and initia-
tives are implemented in a highly control-based context. As long as the old
management systems and cultures are intact, the effectiveness of quality
improvement efforts is likely to be marginal at best, if not counterproduaive.
Indeed, the major failures in health care organizations are not usually brought
to light by the systems for quality assurance or improvement, such as incident
reporting, clinical profiling, mortality and morbidity review, or the external
arrangements for regulation and accreditation.'" These systems for quality man-
agement are easily bypassed. The real barrier to disclosure and discovery is the
endemic culture of secrecy and protectionism in health care facilities.
At present, information technology, as a tool to reduce medical errors,
is also receiving a lot of attention and big investments in health care. Unfortu-
nately, several health care institutions have consumed huge amounts of money
and frustrated countless people in wasted information systems implementation
efforts.^^^ The biggest impediment to successful implementation of information
technology is not the limitations of technology but the limitations of current
culture in health care organizations."^ Developing ambitious plans at the senior
level is relatively easy when compared to changing behavior at the transaaional
level of health care. An understanding of the existing organizational culture is
the real key to effective use of information technology in health care organiza-
tions.^^** There are issues of communication and trust that need to be addressed
before a successful implementation of technology can take place. Present efforts
overlook necessary organizational transformations in favor of technology, with
the result being that technology becomes the focus of change rather than the
desired improvements in organizational cuhure. To make significant progress,
a major reengineering of health care requires changes in technical, sociological.

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 Medical Errors and Quality of Care: From Control to (

cultural, educational, financial, and other important factors of the health care
delivery system."^
The medical errors do not make sense from an economic viev^oint.
By reducing medical errors, hospitals can improve their financial performance
substantially. For example, an adverse drug event costs an extra $4,685"^ and,
depending on facility size, hospital costs for all adverse drug events are estimated
to be as much as $5.6 million per hospital.''^ The study by Health Grades esti-
mates that an additional $19 billion was spent as a direct result of the 2.5 million
patient safety incidents that occurred in U.S. hospitals from 2000 through
2002.'"^ Unfortunately, it is "not just doctors that haven't signed on to the safety
movement, however, neither have the CEOs of most hospitals and health care
systems. . . . They, too, don't see many errors, because very few are reported to
them. It is relatively easy to conclude that their hospital is above average.""^
There are a number of factors that perpetuate control-based management phi-
losophy in health care organizations. First, the education and training of health
care professionals are too narrowly focused on technical issues that develop
them into single-dimension individuals. Since most managers in health care
organizations come from clinical staff, educational institutions (medical schools
and nursing schools) can prepare health care professionals for possible manage-
ment roles by way of courses and workshops. Second, the insurance industry
can play an important role by setting up a system that rewards health care
providers for better quality and safety of patient care. At present, though, the
insurers are found wanting in this regard and, in fact, many would argue that
they are a part of the problem. Third, the lack of co-ordination between practi-
tioners, providers, and policy makers on a common approach in maximizing
patient safety is a major part of the quality improvement problem. We often see
a "cat-and-mouse game" between major players at the expense of good manage-
ment, improved patient safety, and quality of health care services. Finally, the
legal structure in the United States is an impediment to managing people accord-
ing to a commitment-based approach.'^ Laws related to employment need to be
changed such that they encourage rather than inhibit recent advances in people-
centered management practices. For example, malpractice legislation is one of
the most important barriers to creating an open error reporting culture.^"'

As Leape observed about health care in America, "Accidental medical

injuries, those caused by errors, could be reduced by 50% or more over the
next decade, if we were willing to give it the resources it needs. Health care is
so ridden with faulty systemsso many obvious targetsthat progress could be
rapid if an all-out national effort were made."'" The framework presented here
addresses the fundamental problemsclinical culture and control-based model
prevalent in health care organizationsthat lie at the core of medical errors.
Ultimately, health care organizations exist to heal people, not to make them
sicker. Given that the Americans spend the largest fraction of their GDP on
health care, they deserve the best quality of health care. Health care organiza-
tions and professionals must rise to the occasion, or they risk losing their credi-
bility and reputation.

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 . .^-,^-. ^,. ^, ^ .o ><uuMv <^' Care: From Control to Commitment

Notes
1. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds.. Committee on Quality of Health Care
in America, Institute of Medicine, To Err is Human: Building a Safer Health System (Washing-
ton, DC: National Academy Press, 1999).
2. J. Rovner, "Washington Wakes up to Medical Mistakes," Business and Health. 18/1 (2000): 19.
3. G.C. Benjamin, "Addressing Medical Errors: The Key to a Safer Health Care System." Physi-
cian Executive. 26/2 (2000): 66-67.
4. L.L. Leape, "Making Health Care Safe: Are We Up to It?" Joumal ofPediatric Surgery, 39/3
(2004): 258-266.
5. Health Grades, Inc., "Patient Safety in American Hospitals," Health Grades Quality Study,
2004)
6. MedPAC, "Quality of Care for Medicare Beneficiaries," Report to the Congress, Medicare
Payment Policy, March 2004.
7. The noted patient safety scholar. Professor L.L. Leape, M.D., once commented: "We lose
more lives each year from medical errors than NIH's scientific and technological advances
save. We should spend as much trying to do something about it." He thinks that changing
the culture of medicine is just as important as funding new research. See L.L. Leape, "Learn-
ing from Mistakes: Toward Error-Free Medicine," Research in Profile. 11/1 (August 2004),
Investigator Awards in Health Policy Research, The Robert Wood Johnson Foundation.
8. B. Zhao and F. Olivera, "Understanding Individuals' Error Reporting in Organizations,"
Academy of Management Annual Meeting, New Orleans, LA, 2004.
9. Health Grades, op. cit.; Leape (2004), op. cit.
10. Several scholars have looked at organizational and management issues affecting medical
errors. Clearly, more work is needed. Some notable studies examining management issues
and their impact on medical errors include PS. Adler, P Riley, S.K. Kwon, J. Signer, B. Lee,
and R. Satrasala, "Performance Improvement Capability: Keys to Accelerating Performance
Improvement in Hospitals," California Management Review. 45/2 (Winter 2003): 12-33; A.C.
Edmondson, "Learning from Mistakes Is Easier Said than Done: Group and Organizational
Inlluences on the Detection and Correction of Human Errors," Journal of Applied Behavioral
Science. 32 (1996): 5-28; D.M. Gaba, "Structural and Organizational Issues in Patient Safety:
A Comparison of Health Care to Other High-Hazard Industries," California Management
Review. 43/1 (Fall 2000): 83-102; J.B. Sexton, E.J. Thomas, and R.L. Hehnreich, "Errors,
Stress, and Teamwork in Medicine and Aviation: Cross-Sectional Surveys," British Medical
Journal. 320/7237 (2000): 745-749; A.L. Tucker and A.C. Edmondson, "Why Hospitals Don't
Learn from Failures: Organizational and Psychological Dynamics that Inhibit System
Change," California Management Review. 45/2 (Winter 2003): 55-71; K. Walshe and S.M.
Shorten, "When Things Go Wrong: How Health Care Organizations Deal with Major Fail-
ures," Health Affairs. 2111 (2004): 103-111; K.E. Weick and K.M. Sutcliffe. "Hospitals as
Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary," California Management
Review, 45/2 (Winter 2003): 73-84.
11. L.L. Leape, D.M. Berwick, and D.W. Bates, "What Praaices Will Most Improve Safety?
Evidence-Based Medicine Meets Patient Safety," JAMA. 288/4 (2002): 501-507.
12. B.D. Gifford, R.F. Zammuto, and E.A. Goodman, "The Relationship between Hospital Unit
Culture and Nurses' Quality of Work Life," Joumal of Health Care Management, 47/1 (2002):
13-25; R.M. Goldberg, G. Kuhn, L.B. Andrew, and H.A. Thomas, "Coping with Medical
Mistakes and Errors in Judgment," Annals of Emergency Medicine, 39/3 (2002): 287-292.
13. Walshe and Shortell, op. cit.
14. T. Hoff, L. Jameson, E. Hannan, and E. Flink, "A Review of the Literature Examining Link-
ages between Organizational Faaors, Medical Errors, and Patient Safety," Medical Care
Research and Review. 61/1 (2004): 3-37. The quote appears on page 21.
15. A.F. Al-Assaf, L.J. Bumpus, D. Carter, and S.B. Dixon, "Preventing Errors in Health Care:
A Call for Action," Hospital Topics: Research and Perspectives on Health Care, 81/3 (2003): 5-12.
16. M. Koehoom, G.S. Lowe, K.V. Rondeau, G. Schellenberg, and T.H. Wagar, "Creating High-
Quality Health Care Workplaces," Work Network Discussion Paper. W/14 2002, Canadian Policy
Research Networks, Inc., Ottawa, Canada.
17. See D. McGregor, The Human Side of Enterprise. 25th Armiversary Printing (New York, NY:
McGraw-Hill, 1985). Also, see Truss's arguments on "soft" and "hard" models of manage-
ment. C. Truss, "Soft and Hard Models of Human Resource Management," in L. Gratton, V.
Hope Hailey, R Stiies, and C. Truss, eds.. Strategic Human Resource Management: Corporate

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Rhetoric and Human Reality {New York, N\: Oxford University Press, 1999), pp. 79-100. She
uses the terms "soft" and "hard" to denote commitment-based and control-based manage-
ment, respectively. She suggests that "control" in the soft model is accomplished through
commitment and that trust and self-regulated behavior lie at ihe core of the soft modeL In
the hard model, on the other hand, individuals are managed on an instrumental basis, with
their activities monitored ciosely. R.E. Walton, "From Control to Commitment in the Work-
place," Harvard Business Review, 63/2 (March/April 1985): 77-84.
18. McGregor, op. cit.
19. A. Baveja and G. Porter, "Creating an Environment for Personal Growth: The Challenge of
Leading Teams," Advances in Interdisciplinary Studies of Work Teams. 3 (1996): 127-143; L.
Gratton, "People Processes as a Source of Competitive Advantage," in L. Gratton, V. Hope
Hailey, P. Stiles, and C. Ttuss, eds.. Strategic Human Resource Management: Corporate Rhetoric
and Human Reality (Oxford University Press: New York, 1999), pp. 170-198; P Miller and
N. Rose, Governing Economic Life (London: Routledge, 1993); H. Mintzberg, The Rise and Fall
of Strategic Planning (New York, NY: The Free Press, 1993).
20. Miller and Rose, op. cit.
21. Baveja and Pnrter, op. cit.
22. Gratton, op. cit.
23. N. Khatri and P Budhwar, "A Study of Strategic HR Issues in an Asian Context," Personnel
Review. 31/2 (2002): 166-188; J. Pfeffer, Competitive Advantage Through People (Boston, MA:
Harvard Business School Press. 1994); Walton, op. cit.
24. M.S. De Lorenzo, "Absenteeism: Work-induced Stress Illnesses, and Hidden Mental
Illnesses," Ph.D. Thesis, Faculty of Business and Economics, Monash University, Melbourne,
Australia, 2003; McGregor, op. cit.
25. N. KJiatri, The Human Dimension of Organizations (London: Spiro Press, 2003).
26. De Lorenzo, op. cit.
27. Ibid.
28. Ibid.
29. Ibid.
30. Health Grades, op. cit.; F. Williams, "ILO Warns of Epidemic of Stress," Financial Times Octo-
ber 10, 2000.
31. F. Herzberg, The Managerial Choice: To be Efficient and to be Human (Homewood, IL: Dow Jones-
Irwin, 1976).
32. Gallup Management Jouma!, "What Your Disaffected Workers Cost,"
<www.gallupjournai.com/GMJarchive/issuel/2001315g.asp>. Dated March 15, 2001.
According to the Gallup estimate, actively disengaged workers cost the U.S. economy about
$300 billion, the British Economy about $65 billion, and the Singaporean economy about
$4.9 billion a year.
33. Gallup Management Journal, "Great Britain's Workforce Lacks Inspiration,"
<http://gmj.gallup.com>. Dated December 11, 2003.
34. Walton, op. cit.
35. M.D. Cannon and A.C. Edmondson, "Confronting Failure: Antecedents and Consequences
of Shared Beliefs about Failure in Organizational Work Groups," Journal of Organizational
Behavior. 22 (2001): 161-177, T.J. Hoff, H. Pohl, and J. Bartfield, "Creating a Learning Envi-
ronment to Produce Competent Residents: The Role of Culture and Context," Acad Med. 79
(2004): 532-539; B. Zhao and F. Olivera, "Understanding Individuals' Error Reporting in
Organizations," Academy of Management Annual Meeting, New Orleans, LA, 2004.
36. Adier et al., op. cit.
37. McGregor, op. cit.; T.J. Peters and R.H. Waterman, In Search of Excellence: Lessons from Amer-
ica's Best-run Companies (New York, NY: Harper and Row, 1982); Walton, op. cit.
38. N. Khatri, L.L., Hicks, and G.D. Brown, "HR and IT Capabilities and Complementarities in
Health Care Organizations," Health Care Division, Academy of Management Conference,
Hawaii 2005. The authors argue that health care organizations are service-oriented and
knowledge-based and thai managing people using a commitment-based approach is funda-
mental to effective management of such organizations. The service logic of health care
organizations (more complex processes and employees coming in direct contaa with cus-
tomers) dictates that HR practices play a central rather than supportive role in managing
them.
39. We have begun seeing health care organizations that are breaking the typical mold and
embracing the latest management innovations and practices. This trend is likely to get

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stronger in the years to come. See also M.D. Merry, "21st Century Health Care," Trustee
Leadership Forum, MHA Annual Convention and Trade Show, Billings, Montana, 2003.
40. Although the proper implementation of the control-based model does not maximize the uti-
lization of human capacity in organizations, it does produce reliable level of performance
through formal, systematic, and standardized work processes. There are a number of health
care organizations that use control-based model but have not implemented it well. These
organizations may be able to improve iheir clinical outcomes by improving their control-
based design. We would, however, suggest that health care organizations, rather than
strengthening the control-based practices, should move in the direction of commitment-
based management, because changing from a control-based model to a commitment-based
model later would be a difficult, long process.
41. D.E. Detmer, "A New Health System and Its Quaiity Agenda," Frontiers of Health Sen'ices
Management, lS/I (2001): 3-52.
42. Weick and Sutdiffe, op. cit.
43. A. Hornhlow, "New Zealand's Health Reforms: A Clash of Cultures," British Medical Journal,
314/7098 (1997): 1892; M.Laurence. L. V^right. P. Barnett. and C. Hendry, "Building a
Successful Partnership between Management and Clinical Leadership: Experience from New
Zealand," British MedicalJournal, 326/7390 (2003): 653-654; Tucker and Edmondson, op. cit.
44. Hornblow, op. cit.; Merry, op. cit.; Tucker and Edmondson, op. cit.
45. Adier et al., op. cit.
46. S. Bach, "HR and New Approaches to Public Sector Management: Improving HRM Capac-
ity," Department of Organization of Health Services Delivery, World Health Organization,
Geneva, Switzerland, 2001; J. Buchan, "Wlial Difference Does ("Good") HRM Make?"
Human Resources for Health, 2/6 (Juno 2004): 1-7.
47. Adler et al., op. cit.; N. Khatri and J. Kauk, "The Relationship between Management
Approach and Medical Errors: A Qualitative Study," Academy of Health Services Research.
Annual Research Meeting, San Diego, CA, 2004.
48. Tucker and Edmondson, op. dt.
49. M. Meterko, D.C. Mohr, and G.J. Young, "Teamwork Culture and Patient Satisfaction in
Hospitals," Medical Care, 42/5 (2004): 492-498.
50. A. Kaissi, J. Kralewski, A. Curoe, B. Dowd, and J. Silversmith, "How Does the Culture of
Medical Group Praaices Influence the Types of Programs Used to Assure Quality of Care?"
Health Care Management Revie^v. 2912 (2004): 129-138.
51. Gaba, op. cit.
52. Merry, op. cit.
53. J. Reason, "Human Error: Models and Management," British MedicalJournal, 320 (2000):
768-770.
54. Edmondson, op. cit.; J.A. Valentine and R. Behara, "A Sociotechnical Approach to Patient
Safety: Quality Improvement in Hospital Laboratories." Hospital Topics: Research and Perspective
on Health care, 79/2 (2001): 21-26; H.H. Cook, K. Guttmannova, and J.C. Joyner, "An Error
by Any Other Name," American Journal of Nursing 104/6 (2004): 32-43; S.M. Crow and
SJ. Hartman, "Organizational Culture: Its Impact on Employee Relations and Discipline in
Health Care Organizations," Health Care Manager, 21/2 (2002); P.J. Pronovost, B. Weast, C.G.
Holzmueller, B.J. Rosenstein, R.P. Kidwell, K.B. Haller. E.R. Peroli. J.B. Sexton, and H.R.
Rubin, "Evaluation of the Culture of Safety': Survey of Clinidans and Managers in an Acade-
mic Medical Center," Qual Saf Health Care. 12 (2003): 405-410.
55. SJ. Spear and M. Schmidhofer, "Ambiguity and Workarounds as Contributors to Medical
Error," Annals of Internal Medicine, 142/8 (2003): 627-630.
56. Sexton et al., op. dt.
57. Valentine and Behara, op. dt.
58. Crow and Hartman, op. cit.
59. Cook et al., op. dt.
60. Pronovost et aL, op. dt.
61. E.J. Thomas, B.J. Sexton, and R.L. Helmreich, "Discrepant Attitudes about Teamwork
among Critical Care Nurses and Physidans," Critical Care Medicine, 31/3 (2003): 956-959.
62. Sexton et al., op. dt.
63. Merry, op. cit.
64. Weick and SutcUffe, op. dt.
65. P. Stone, "Deconstructing Silos atid Supporting Collaboration," Employment Relations Today.
Spring (2004): 11-18.

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 Medical Errors and Quality of Care: From Control to

66. Adicr el al., op. cit.

67. Stone, op. cit.
68. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century
{Washington, D.C.: The National Academies Press, 2001).
69. Adler et al., op. cit.; Leape et al. (2002), op. dt.
70. Adler et aL, op. cit.
71. AJ-Assaf et al., op. cit.
72. Gifford et ai., op. cit.; McGregor, op. cit.; H. Mintzberg, The Rise and Fall of Strategic Planning
(New York, NY: The Free Press, 1994).
73. The Institute for Health and Aging, University of California, San Francisco, Chronic Care in
America: A 21" Century Challenge (Princeton, NJ: The Robert Wood Johnson Foundation,
1996).
74. Weick and Suicliffe, op. cit.
75. Koehoorn et aL, op. cit.
76. Tucker and Fdmondson, op. cit., p. 66.
77. Jobs wilh high demands and low controllability are typical of control-based organizations.
The expectations from employees tend to be greater than resources provided to them by the
organization to perform the required tasks.
78. M.L. Fox, D.J. Dwyer, and D.C. Ganster, "Effects of Stressful Job Demands and Control on
Physiological and Auitudinal Outcomes in a Hospital Setting," Academy of Management Jour-
nal. 36/2 (1993): 289-318.
79. Koehoorn et al., op. cil.
80. A.C. Edmondson, "Learning from Failure in Health Care: Frequent Opportunities, Pervasive
Barriers," Qual Saf Health Care. 13 (2004): ii3-ii9.
81. See J.H. Gittell, The Southwest Airlines Way: Using the Power of Relationships to Achieve High
Performance (McGraw-Hill, 2002); J.H. Gittell, "Paradox of Coordination and Control," Cali-
fornia Management Review. 42/3 (Spring 2000): 117-134.
82. Health care industry professionals seem to think that their industry is too complex (more
complex than other industries) and as a result more difficult to manage than other indus-
tries. We believe that there are several other industries that are far more difficult and chal-
lenging to manage than health care (e.g., the airline industry, retail industry', and computer
manufacturing, to cite a few). As compared to these industries, health care may be a rela-
tively benign, munificent environment.
83. C.A. O'Reilly III and J. Pfeffer, Hidden Value (Boston, MA: Harvard Business School Press,
2000).
84. Ibid.
85. M. Meterko, D.C. Mohr, and G.J. Young, "Teamwork Culture and Patient Satisfaction in
Hospitals," Medical Care, 42/5 (2004): 492-498.
86. K.V. Rondeau and T.H. Wagar, "Impact of Human Resource Management Practices on l<inxs-
ing Home FerioTmancc," Health Services Management Research, 14/3 (2001): 192-202.
87. Truss, op. cit.
88. Adler et aL, op. cit.
89. Management scholars and consultants have studied teams and team-based performance
fairly intensely for the past two decades. Consequently, there is a large body of literature on
the subject and substantial consensus on the properties of effeaive teams. The book Creating
Teams with an Edge: The Complete Skill Set to Build Powerful and Influential Teams (Harvard Busi-
ness School Press, Boston, 2004) s^Tithesize the literature on teams and describe the differ-
ent tiTX-'s of teams used by organizations, ihe costs and benefits of team-based work, and
what every team must have to be successful Tbe qualities of effective teams suggested in the
book include competence (collective talent, knowledge, experience, and organizational clout
of team members), a clear goal, committed and contributing members, an enabling struc-
ture, a supponive organizational environment, and alignment of team goals and rewards
with organizational goals.
90. See the above note and also Detmer, op. cit.
91. Cook et al., op. cit.; Pronovost et al., op. cit.
92. Empowerment, another term used for employee participation, is an intrinsic task motivation
manifested in a set of cognitions reflecting an individual's orientations to his or her work
role in which an individual wishes or feels able to shape his or work role and context. The
control-based approach and empowerment are inconsistent with each other. According to
McGregor [op. cit.], participation works only when it grows out of a commitment-based

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approach in which managers have a genuine confidence in the potcniialiiics of subordi-

nates. The involvement of employees in decisions can vary from a little to a lot, dictated
entirely hy the situation and the suhordinate at hand. A vast amount of literature on
employee participation or high-involvement practices has emerged in the last 20 to 25 years.
93. J.B. Arthur, "Effects of Human Resource Systems on Manufacturing Performance and
Turnover," Academy of Management Journal. 37/3 (1994): 670-687.
94. R.N. Anderson and R.R. McDaniel, Jr., "RN Participation in Organizational Decision Making
and Improvements in Resident Outcomes," Health Care Management Review, 24/1 (1999):
7-16.
95. Gratton, op. cit.
96. R.A. Kalgi, K. Rangnekar, P. Singh, and R. Wadhawan, "Development of Objeaive Indicators
of Employee Morale/' Executive Management Study, Department of Health Management
and Informatics, University of Missouri, Columhia, MO, 2004.
97. Detmer, op. cit.; Edmondson (2004), op. cit.; Merry, op. cit.
98. D. Goleman, R. Boyatzis, and A. McKee, "Primal Leadership, the Hidden Driver of Great
Performance," Hansard Business Rei'ie^v. 191 \ 1 {December 2001): 42-51.
99. N. Khatri, P.S. Budhwar, K.J. Templet, H.S. Lee, S.N. Lim, and L.R Lim, "Measurement of
Charisma and Vision," Academy of Management, Annual Meeting, August 12-14, Denver,
CO, 2002.
100. N. Khatri and A. Felker, "Impact of Transformational Leadership on Employee Motivation,
Satisfaaion, and Performance in Health Care Organizations," The Academy of Health Ser-
vices Research, Annual Research Meeting, San Diego, 2004.
101. Hoff etal., op. cit.
102. J.R. Hackman and G.R. Oldham, Work Redesign (Reading, MA: Addis on-Wesley, 1980).
103. E.E. Lawler, S.A. Mohrman, and G.E. Ledford, Strategies for High Performance Organizations.
The CEO Report: Employee Involvement. TQM. and Rcengineering Programs in Fortune WOO Corpo-
rations (San Francisco, CA: Jossey-Bass, 1998).
104. McGregor, op. cil.
105. Gratton, op. cit.
106. Baveja and Porter, op. cit.
107. McGregor, op. cit.
108. R.M. Kanter, "Lasting Leadership Lessons," Sales and Marketing Management, 149/13 (1997):
22-23, at 22.
109. Pfeffer, op. cit.
110. D.C. Grabowski and N.G. Castle, "Nursing Homes with Persistent High and Low Quality,"
Medical Care Research and Review. 61/1 (2003): 89-115.
111. Walsheand Shoriell, op. cit.
112. G. Pare, "Implementing Clinical Information Systems: A Multiple-Case Study within a U.S.
Hospital," Health Ser\'ices Management Research, 15 (2002): 71-92.
113. I.R. Lazarus, "Developing Internet Strategies is a Top Priority for Hospital Systems," Health
Care Strategic Management. 12 (2001): 12-13.
114. L.A. Malato, "Nurses, Pharmacists and Information Technology in Public Heahh Care/'
Master of Public Administration Thesis, Graduate College, University of Nevada, Las Vegas,
NV, 2001.
115. E. Ortiz and CM. Clancy, "Use of Information Technology to Improve the Quality of Health
Care in the United States/' Health Serx'ices Research. 3S/2 (2003): xi-xxi.
116. D.W. Bates, N. Spell, D.J. Cullen, E., Burdick, N. Laird, L.A. Peterson, S.D. Small, B.Z.,
Sweitzer, and L.L. Lcape, "The Costs of Adverse Drug Events in Hospitalized Patients.
Adverse Drug Events Prevention Study Group," JAMA, 277/4 (1997): 307-311; Leape
(2004), op. cit.
117. Agency for Health Care Research and Quality, "Reducing and Preventing Adverse Drug
Events to Decrease Hospitals Costs," Research in Action. Issue 1, AHRQ Publication Number
01-0020, (March 2001).
118. Health Grades, op. cit.
119. Leape (2004), op. cit. page 264.
120. Pfeffer, op. cit.
121. W.B. Runciman, A.F. Merr^', and F. Tito, "Error, Blame, and the Law in Health CareAn
Antipodean Perspective," Annals of Intenml Medicine. 138/12 (2003): 974-980.
122. Leape (2004), op. cit., p. 264.

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