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An Empirical Study of System Improvement by Frontline

Employees in Hospital Units
Anita L. Tucker,

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Service Operations Management 9(4):492-505. http://dx.doi.org/10.1287/msom.1060.0156

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 MANUFACTURING & SERVICE
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Vol. 9, No. 4, Fall 2007, pp. 492505 doi 10.1287/msom.1060.0156

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An Empirical Study of System Improvement by

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Frontline Employees in Hospital Units

Anita L. Tucker
The Wharton School of Business, University of Pennsylvania, 545 Huntsman Hall, 3730 Walnut Street,
Philadelphia, Pennsylvania 17104-6340, tuckera@wharton.upenn.edu

T his paper investigates the conditions under which frontline employees take initiative to improve their work
systems to prevent operational failures. Drawing on the system improvement and team learning literatures,
we develop a framework of frontline system improvement and test it using survey data from 37 workgroups.
We nd that psychological safetythe belief that one can talk about errors without risk of punishment
and problem-solving efcacythe belief that the organization will support employees system improvement
effortswere positively correlated with frontline system improvement (FLSI). Surprisingly, felt responsibil-
ity was negatively associated with FLSI. These ndings suggest that rather than relying on hiring motivated
individuals, managers need to support employees efforts to improve their work systems by creating a work
environment where it is safe to talk about operational failures and responding to employee communication
about operational failures. Doing this may result in higher levels of FLSI efforts and ultimately improve work
processes.
Key words: health care; system improvement; problem solving; survey research
History: Received: April 14, 2005; accepted: December 14, 2006.

1. Introduction about prior equipment and processes failures, which

1
Grace Fletcher, a medical/surgical nurse on a 37-bed
unit, was unable to administer prescribed medications
for four of her ve patients during 30 minutes
of observation. Three patients medication drawers
lacked required medications, and had she adminis-
tered the fourth patients medication as prescribed,
it would have exceeded the recommended daily
amount. Such disruptions and errors in materi-
als, information, and equipment used by frontline
employees can decrease productivity and perfor-
mance quality. These disruptions, which we refer to
as operational failures, range from minor but time-
wasting incidents, such as a searching for a piece
of equipment, to major incidents, such as a medica-
tion error that could cause death. Operational failures,
therefore, can act as signals to frontline employees
about opportunities for work system improvement
(Victor et al. 2000).
Quality improvement experts advocate engaging
those closest to the work in system improvement
efforts. Frontline employees have in-depth knowledge
1
A pseudonym.
492
makes their input valuable in deciding which prob-
lems should be selected for resolution efforts (Banker
et al. 2001, Field and Sinha 2005, Tyre and von Hippel
1997). For example, Field and Sinhas (2005) study
of four production-line improvement teams found
that teams improved process yield by soliciting and
implementing ideas from production workers. Simi-
larly, Spear and Bowens (1999) study of Toyota found
that effective frontline system improvement efforts
involved employees collectively and systematically,
addressing many small but important problems that
managers might not have addressed. In addition,
their detailed knowledge about work systems enables
them to suggest potential solutions to reduce opera-
tional failures (Bagian et al. 2001, Bowen and Lawler
1995, Deming 1986, Feigenbaum 1991, Gaba 2000).
Employees system improvement efforts can provide
a competitive advantage to organizations able to har-
ness this resource (Victor et al. 2000).
Unfortunately, engaging frontline employees in
a system improvement effort remains challenging
(Hackman and Wageman 1995). Prior research found
that when operational failures occur, time-pressured
frontline employees favor quick xes over genuine
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
improvements that prevent recurrence (Tucker and
Edmondson 2003). The resulting loss of information
about operational failures hampers system improve-
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ment. In addition, frontline employees struggle with
switching between their regular jobs and system
improvement efforts (Victor et al. 2000). Finally, man-
agers emphasize technical or clinical improvements
over work system improvements, further attenuating
frontline efforts (Roth et al. 1996).
Therefore, in this paper, we investigate the con-
ditions under which frontline employees engage in
system improvement to prevent recurrence of oper-
ational failures. Tucker and Edmondson (2003) refer
to this behavior as second-order problem solving.
In this paper, to highlight our focus on frontline
employeesas opposed to managers or other sup-
port staffsefforts to improve their work systems,
we refer to this behavior as frontline, second-order
system improvement, or frontline system improve-
ment (FLSI) for short. Examples of FLSI include com-
municating about operational failures to people in
positions to x the systems (Tucker and Edmondson
2002), suggesting potential solutions to common fail-
ures to managers, and experimenting systematically
with solutions (Thompson et al. 2003, Uhlig et al.
2002).
We rst introduce a model of FLSI. Second, we test
three hypotheses using survey data from nurses from
37 hospital units. Although the focus of this paper is
on hospital nurses, we believe that our framework can
have important implications for other service employ-
ees who rely on complex work systems where they
are likely to encounter operational failures.
2. A Model of FLSI
Our research question was, What factors support
system improvement efforts by frontline employees?
Our unit of analysis was the workgroup, which is
a set of employees set under an administrative unit
manager (i.e., the maternity ward nurses at a hos-
pital). In turn, these workgroups were nested in
broader organizations, creating a hierarchy of individ-
uals nested in workgroups nested in organizations, as
described by Sinha and van de Ven (2005). Hargadon
and Bechky (2006) found that when problems were
discussed among the workgroup, benecial problem
reframing and solution generation often occurred.
493
Workgroups are similar to teams, and therefore the
team learning literature provides important insights
into the phenomenon we studied. For example, Field
and her colleagues (Banker et al. 2001, Field and Sinha
2005) and Lapre and his colleagues (Lapre et al. 2000,
Lapre and Van Wassenhove 2001, Mukherjee et al.
1998) studied teams convened for the purpose of sys-
tem improvement. At the workgroup level of analysis,
we propose that higher levels of employee psycholog-
ical safety, problem-solving efcacy, and felt responsi-
bility for improving work systems will correlate with
higher levels of FLSI.
Theories about human cognition assert that employ-
ees choose to engage in costly behaviors only when
they believe that potential benets outweigh costs
(Vroom 1995). Similarly, when employees encounter
operational failures, they will decide to remove
underlying causes only when they believe that their
problem-solving efforts will result in more reliable
work systems and that the potential benets will be
greater than the lost time, effort, and interpersonal
risk of communicating failure (Fine 1986, Marcellus
and Dada 1991, Morrison and Phelps 1999). This
paper considers three belief variablespsychological
safety (PS), problem-solving efcacy (PSE), and felt
responsibility (FR). Prior research suggests that these
three variables were meaningful at the team level and
could inuence whether employees collectively try to
resolve operational failures as a workgroup.
2.1. Psychological Safety
PS is a shared belief created when managers value
communication about errors and pardon employ-
ees who admit to making unintentional mistakes
(Edmondson 1999). Edmondson (1996) found that
teams reported more of the errors they made
when they had higher levels of PS. FLSIespecially
in healthcare settingsinvolves interpersonal risk
because operational failures can stem from errors
or oversights committed by powerful others (Tucker
2004). In addition, FLSI involves communicating
about system shortcomings and discussing potential
solutions (Hargadon and Bechky 2006). We therefore
predict that PS at the unit level can encourage FLSI
by the workgroup.
Hypothesis 1. A collective sense of PS by the work-
group is positively related to FLSI by the workgroup.
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
494 Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
2.2. Problem-Solving Efcacy
Group efcacy, dened as a groups general belief
that it can achieve what it sets out to accomplish,
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is an important predictor of workgroup performance
(Gibson 1999). Studies have shown that group ef-
cacy can be measured and that it varies among
workgroupseven those with seemingly identical
skills and resources (Campion et al. 1993). The-
ory on group efcacy states that more condent
groups will put forth more effort toward accomplish-
ing their goals. Building on this notion, we predict
that groups condent of their ability to success-
fully remove causes of operational failures will be
more willing to engage in FLSI (Kasouf et al. 2006).
Following prior research, we anticipate that group
problem-solving efcacy (PSE) varies at the group
level because problem-solving success depends on
several key group-level variables, such as the support-
iveness of the manager, the groups history of resolv-
ing failures, and their hierarchical status (Banker et al.
2001).
Hypothesis 2. Group PSE is positively related to FLSI
behaviors by the workgroup.
2.3. Felt Responsibility
FLSI effort lies outside the scope of routine job
responsibilities (Victor et al. 2000). Thus, FLSI can be
considered a benecial, but discretionary, employee
behavior. Researchers have studied such behaviors to
better understand the conditions under which they
occur (Frese et al. 1996, McNeely and Meglino 1994,
Organ 1988). Prior research suggests that personal
characteristics can inuence employees willingness
to engage in system improvement, including self-
efcacy (Morrison and Phelps 1999), locus of control
(Lefcourt 1991), and felt responsibility (Hackman and
Oldham 1976, Morrison and Phelps 1999, Pearce and
Gregersen 1991).
We chose to include felt responsibility in our study
because it is conceptually different from problem-
solving efcacy (unlike self-efcacy and locus of con-
trol) and the established scale items align better with
system improvement behaviors than do the other
constructs. In particular, we draw on Morrison and
Phelps (1999, p. 407) denition of felt responsibility
as an individuals belief that he or she is personally
obligated to bring about constructive change. This
Figure 1 Model of Frontline System Improvement
Psychological safety (PS) H1
H2 Manager rating of
Problem solving efficacy (PSE) frontline system improvement
(FLSI)
H3
Felt responsibility (FR)
construct implies that people with high levels of felt
responsibility will take more initiative to resolve oper-
ational failures. Prior research has not examined the
link between felt responsibility of individuals and the
average felt responsibility within workgroups. There-
fore, this study makes a contribution by examining
felt responsibility at the workgroup level. We propose
that the average level of felt responsibility within the
workgroup should be positively related to FLSI by the
workgroup.
Hypothesis 3. The average felt responsibility within
the workgroup is positively related to FLSI behaviors by
the workgroup.
See Figure 1 for the detailed model and hypotheses.
3. Methods
3.1. Research Sample
We studied FLSI of hospital nursing units for sev-
eral reasons. Nursing occurs at the center of com-
plex patient care systems, increasing the likelihood
that nurses will encounter operational failures. Sec-
ond, nurses are highly skilled professionals who use
a problem-solving process to treat patients; therefore,
these workers should be capable of engaging in FLSI.
Finally, human lives are at stake, raising the impor-
tance of smoothly functioning work systems, and
hence the motivation to resolve operational failures.
This survey study was informed by prior research,
which involved primary, observational data of opera-
tional failures on nursing units.
In 2002, letters were sent to head nursing execu-
tives at 64 hospitals, requesting permission to sur-
vey their nursing staff (both registered nurses and
licensed practical nurses) regarding operational issues
that interrupted patient care. These hospitals included
all 58 Massachusetts hospitals listed in the Ameri-
can Hospital Directory, in addition to six other hos-
pitals dispersed throughout the United States and
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS 495

Table 1 Characteristics of Hospitals Included in Exploratory and Conrmatory Factor Analyses
N = 21

Number of units in Teaching Response

ID nal data Union Location State hospital Beds FTE RN rate (%)
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2 1 Non Rural MA None 27 126 42

10 3 Union Rural MA Limited 214 558 14
11 5 Union Suburban MA None 185 222 28
12 1 Union Suburban MA Major 329 433 24
15 0 Union Urban MN Limited 163 488 40
19 0 Non Rural MA Limited 41 56 10
21 4 Union Rural MA None 46 43 52
22 3 Union Rural MA None 83 100 23
23 8 Union Urban MA None 120 148 25
25 2 Non Rural MA None 113 94 23
28 4 Non Rural MA Limited 249 238 36
31 5 Union Rural MA None 138 184 23
32 0 Non Suburban MA None 50 74 6
33 3 Non Suburban MA Limited 248 515 32
35 2 Non Urban UT Major 441 504 34
36 3 Non Urban MA None 231 208 42
38 0 Union Rural MA None 25 42 55
46 0 Non Urban RI Major 216 395 23
58 1 Non Urban MA None 150 327 11
59 0 Union Rural Ontario None 333 Unknown 34
66 3 Union Urban MA None 662 445 14
Total 48
Ave. 26

Hospitals removed from hypotheses testing analyses because no manager survey received or fewer than four surveys received
from nurses on a uniquely identiable unit.

Canada in which the author had previously con-
ducted observations. Survey data were collected
between February and September 2002 from nurses
at 21 hospitals (33% hospital participation rate). We
surveyed multiple units at each hospital and asked
respondents to indicate the type of nursing unit on
which they worked, enabling us to control for dif-
ferences between types of nursing units. At 16 hos-
pitals, surveys were distributed only to those nurses
who worked on medical/surgical (med/surg), mater-
nity, hematology/oncology, or intensive care units. To
increase the total number of surveys returned, ve
hospitals distributed surveys to all their nurses, which
included units such as emergency departments and
telemetry/cardiac care.
There were 3,621 survey packets distributed; these
contained a survey booklet, a stamped return enve-
lope addressed to the principal investigator, and a
cover letter from the hospital nursing executive. Of
the distributed packets, 42 were not delivered because
of address changes. We received 932 completed sur-
veys from this one wave of distribution, of which 907
were usable, from 100 units from 21 hospitals. Inter-
nal review board regulations prevented the use of
individual identiers other than the hospital and the
type of nursing oor; therefore it was not possible to
send multiple survey waves to nonrespondents. The
overall response rate was 26%, which was comparable
to other single-wave, multiple-hospital surveys con-
ducted by external researchers (i.e., Sorra and Nieva
2004). See Table 1 for details on the characteristics of
the 21 hospitals in the sample, including number of
beds and surveys distributed and received.
In 2003, the unit managers were surveyed and
asked to report on their units level of FLSI as
well other control variables, such as the number of
salaried positions on the unit in 2002. Collecting data
from multiple sources helped mitigate methodologi-
cal weaknesses inherent in cross-sectional, self-report
research (Spector 1994). To test the hypotheses, only
those units from which surveys from the manager and
at least four nurses were received were used. Because
of listwise deletion of missing data, the nal sample
size was 37 units from 14 hospitals.
We conducted sample selection tests to ensure that
the data were representative of the larger population
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
496 Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS

Table 2 Respondent Demographics

Respondents from units

with more than four
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All respondents surveys/unit and mgr

Demographic (N = 907 surveys, survey (N = 389 surveys, HRSA May 2000
variable Ranges 100 units, 21 hospitals) (%) 37 units, 14 hospitals) (%) U.S. survey (%)

Gender Female 94 93 94
Union Union 54 66 Not avail.
Education Diploma 21 20 18
Associate 29 30 38
Bachelor 43 43 36
Master 5 5 75
Doctorate 03 0.5 01
Nursing unit Med/surg 41 28 324
Intensive care 23 29 17
Maternity 11 16 82
Experience <5 yrs 17 14 15
510 years 14 14 146
1015 years 11 13 (1015 yrs) 12.7
15 years 58 59 >15 yrs 57.4
Tenure <1 year 15 39 Not avail.
15 years 28 10 Not avail.
510 years 105 14 Not avail.
1020 years 255 37 Not avail.
20 yrs 21 39 Not avail.
Job satisfaction Extremely satised 106 10 18
Moderately satised 548 56 48
Neither 85 9 12
Moderately dissatised 218 20 17
Extremely dissatised 42 5 5

of U.S. nurses. Table 2 presents a comparison of demo-
graphic data for this sample as well as comparison
data from the 2000 U.S. survey of nurses conducted
by the department of Health Resources and Services
Administration (Spratley et al. 2002). The rst col-
umn presents data from the complete survey sample
(N = 907 surveys). The second column reports on the
manager-matched subset of data that was used to test
the hypotheses (N = 37 units, 389 nurses). The third
column presents the 2000 HRSA sample. A robustness
test involved comparing the N = 389 sample scores
on reported job satisfaction with a similar item on the
2000 U.S. national survey. The comparison in Table
2 shows identical percentages of extremely dissatis-
ed nurses (5%) and extremely or moderately satis-
ed nurses (66%), suggesting that this sample does not
contain a disproportionate number of either satised
or dissatised nurses. In alignment with the national
sample, 93% of the respondents were women, and
roughly 60% of the sample had worked as nurses for
more than 15 years. The mean number of years as
a nurse was 18, and the mean tenure at the hospital
was 11 years. The education level of our sample had a
slightly higher percentage of nurses who held bachelor
degrees (43%) than did the national sample (36%) and
slightly lower percentage of associate degree nurses
(30% versus 38%). This difference may be attributable
to the fact that this sample had a higher percentage
of intensive care unit nurses (29%) than the national
survey in 2000 (17%). Overall, this sample has negli-
gible differences from the 2000 U.S. national survey.
Furthermore, there was substantial variation between
hospital units measures of problem-solving efcacy
and felt responsibility. This suggests that the result-
ing sample of hospital units contained a variety of
perspectives, which provided sufcient variation for
hypotheses testing.
3.2. Survey Measures
We designed the survey to enhance our qualitative
study of operational failures at nine hospitals. The
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
items measure the constructs shown in the model of
Figure 1. We used existing scales and items when pos-
sible and developed new items as needed. Final sur-
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vey items are shown in the appendix.
3.2.1. Survey Development. After formulating
the initial survey, we conducted four iterations of
cognitive interviews with staff nurses who read, an-
swered, verbally shared comments for each question,
and actively revised ambiguous questions after each
interview (Sheatsley 1983). Next, we piloted the sur-
vey at three hospitals where we had conducted our
observations. Forty-seven pilot surveys (35% response
rate) were received. Based on psychometric analy-
sis of the pilot data, we added problem-solving ef-
cacy questions and dropped one of the PS items. We
excluded pilot data from further analyses.
3.2.2. Factor Analysis. Psychometric analyses
measured discriminant and internal validity. We rst
used SPSS to conduct exploratory factor analysis
(EFA) with varimax rotation to verify that the survey
items formed the intended scales. The criteria for
selection were eigenvalues of 1.0 or higher for factors
to be selected and loading of 0.45 or greater for items
to be part of a factor, and we removed items that
loaded on multiple factors (Tabachnick and Fidell
2001). The EFA replicated our scales, indicative of
both convergent and divergent validity. In addition,
the emergence of multiple factors suggested that
common method bias did not pose a signicant
threat to the surveys validity (Podsakoff and Organ
1986).
Preliminary psychometric analysis on the rst 16
hospitals revealed that the PS items were loading on
the problem-solving efcacy construct. As problem-
solving efcacy was central to our examination, we
attempted to separate these two constructs by modify-
ing the psychological safety items for the last ve hos-
pitals. Therefore, we used this smaller data set (N =
334) for conducting EFA and conrmatory factor anal-
ysis (CFA) on the three belief constructs. EFA results
suggested that the belief items did form these three
distinct factors, which accounted for 58.5% of the vari-
ance, a percentage comparable to other factor analyses
published in leading journals (e.g., Leatt and Schneck
1981, MacCrimmon and Wehrung 1990, Mukherjee
et al. 1998). The items loaded strongly on the expected
497
factors (all loadings 0.61 or greater), and there were no
crossloadings greater than 0.32. The three constructs
were (1) PS (11.4% of the variance, eigenvalue = 114);
(2) PSE (31.8% of the variance, eigenvalue = 318); and
(3) FR pressure (15.3%, eigenvalue = 153).
After EFA, we conducted CFA using LISREL 8.72.
All model estimations were based on the covari-
ance matrix, and missing data were handled with
full-information maximum likelihood. We randomly
divided the data set (n = 334) into two halves, stan-
dardized the data in both halves, and used one half to
develop the measurement model with CFA. We used
the second half to conrm the measurement model
obtained with the rst half (Froehle and Roth 2004).
The resulting path diagram is shown in Figure 1 of
the online supplement.2 The initial model had an ade-
quate t (standardized root mean squared residual =
0051, 90% condence interval for root mean square
error of approximation = 000 to 0.076,  2 = 4064, p-
value = 014; and goodness-of-t index = 095). We
then tested the original measurement model with the
second sample and also achieved an adequate t.
Finally, we compared the three-factor model against
a rival two-factor model with PS and PSE items
assigned to one factor and FR items assigned to the
second factor. The two-factor model had a worse t
than the three-factor model. For detailed factor anal-
ysis results, please see Tables 1 and 2 in the online
supplement. The measures are outlined below.
3.2.3. Survey Items. For all items, respondents
were asked to use a seven-point scale (1 = very inac-
curate, 7 = very accurate) to describe how accurately
the survey items described their current manager,
unit, or hospital. With the exception of workload,
for which higher scores represent heavier workloads,
negative items were reverse scored so that higher
scores reected positive environments.
As stated earlier, we modied the PS items for the
last ve hospitals because the PS items were loading
together with PSE items. Only one PS item, Work-
ing with members of this unit, my unique skills and
talents are valued, remained consistent for all the
hospitals in our study. In addition, the three PS items
2
The online supplement to this paper is available on the Manu-
facturing & Service Operations Management website (http://msom.
informs.org/ecompanion.html).
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
498 Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
that formed a distinct construct had moderate relia-
bility ( = 058). Therefore, to test hypotheses related
to PS, we used the one unchanged item, which also
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was the highest-loading item on the scale. Other stud-
ies have used single-item scales when the construct
has been well established in the literature and the
item has a high correlation with the overall construct
(Edmondson 1999, McNeely and Meglino 1994, Scott
and Bruce 1994). The PS item meets both conditions.
We developed three new items to measure PSE
( = 079), including, It is worth my time to com-
municate about work system problems. We aver-
aged four items from Morrison and Phelps (1999) to
measure FR ( = 070). A sample item for FR was,
Correcting problems is not really my responsibil-
ity (reverse scored). To compute an overall score for
each construct, we averaged items measuring the same
construct.
3.2.4. System Improvement. We asked unit man-
agers to rate how frequently nurses on the unit
take initiative to improve the hospitals work sys-
tems. The selections were: (0) never, (1) rarely,
(2) sometimes, (3) often, and (4) always. This mea-
sure taps into activities that resemble true improve-
ment efforts aimed at removing underlying causes of
failures. In contrast, the measures do not ask about
work-around activities that leave the work sys-
tems unchanged, such as quick xes or patches to
the immediate situation. This distinction is impor-
tant because elsewhere researchers have noted that
frontline employees typically engage in work-arounds
instead of true improvement activities (Tucker and
Edmondson 2003). However, work-arounds are less
desirable because they do not change the underlying
performance of work systems.
3.2.5. Number of Operational Failures on the
Prior Shift. On the survey, we asked nurses to report
whether they had encountered seven types of opera-
tional failures during the last shift they worked. Our
prior observational data informed the selection of fail-
ure types. The seven types of failures included miss-
ing medication, missing supplies, difculty getting
a required order from a doctor, missing equipment,
inability to do a task because a necessary person was
missing (i.e., the patient, an aide, physical therapist),
insufcient stafng, or having to correct someone
elses mistakes. If the nurses experienced a type of
failure (e.g., missing medication), we asked them to
report the number of times they had encountered that
type of failure during the prior shift. On average,
nurses reported experiencing an operational failure
every 76 minutes.
3.3. Statistical Analysis
3.3.1. Data Aggregation. To justify aggregating
individual-level survey data to the unit level, we
calculated three measures of intergroup agreement:
Interrater agreement score, rwg ; and intraclass corre-
lations, ICC[1] and ICC[2] (Bliese 2000, James et al.
1993). First, we calculated rwg for each units mea-
sures of each composite variable, using the method
outlined by James and colleagues (James et al. 1993).
The mean rwg s were 0.54 for PSE, 0.69 for FR, and
0.68 for PS (n = 15 units). These ndings showed sat-
isfactory agreement for aggregation to the unit level
for FR and PS and marginally acceptable values for
PSE. In addition, we calculated intraclass correlations
(ICC[1] and ICC[2]) to test convergence within units
(Bliese 2000, Klein and Kozlowski 2000). All ICC[1]
values, shown in the online supplement Table 3, were
signicant and greater than zero (ranging from 0.08
to 0.40, with the F -test for the analysis of variance
signicant at least at the 0.05 level), indicating that
aggregation to the unit level was appropriate (Kenny
and LaVoie 1985). Finally, ICC[2] values ranged from
0.43 to 0.83, also in strong support of data aggregation
(Klein and Kozlowski 2000). Collectively, these mea-
sures supported averaging responses to create unit-
level variables.
3.3.2. Statistical Analysis. We tested our hypothe-
ses at the unit level because our dependent variable
of interestmanagers ratings of the units frontline
system improvement activitywas at the unit level.
In addition, the aggregation statistic suggested that
aggregation to the unit level was appropriate. There-
fore, we used the average employee ratings by unit
as our independent variables. Testing the hypotheses
at the individual level yielded the same results.
Although our results could provide valuable in-
sights by linking employee beliefs (PSE) with bene-
cial behaviors (problem solving), some readers might
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS 499

be concerned about potential endogenous relation- Table 3 Unit-Level Means, Standard Deviations, and Intercorrelations
ships between our dependent and independent vari- Between Components (N = 37 Units)
ables. For example, we hypothesize that PSE fosters Variable Mean S.D. Scale 1 2 3 4 5
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frontline engagement in systems improvement. How- 1. Org support 4.48 0.87 1 to 7

ever, a plausible reverse-causality argument exists: As
a result of successful system improvement initiatives,
frontline employees come to believe that it is worth
their while to engage in such behaviors. Hence, one
could argue that high levels of FLSI lead to high lev-
els of PSE. In addition, there might be unobserved
features of the hospitals or units that result in higher
(or lower) levels of both dependent and independent
variablesand therefore we erroneously attribute the
correlation to be causal. For example, a hospitals
nancial stability might result in both (a) employees
believing that the unit has money to x operational
failures (PSE) and (b) the unit addressing operational
failures (e.g., purchasing additional equipment, which
would be FLSI).
Therefore, because of potential reverse causality as
well as the limitations of our single-item measure for
PS, we used instrumental variables for PS and PSE
with a two-stage (2SLS) analysis approach (Weiner
et al. 2006). We used the STATA instrumental vari-
able regression procedure ivreg with the cluster
option to account for correlation between responses
from the same hospital. We regressed the dependent
variable on the predicted values of the instrumented
variables, other independent variables, and the con-
trol variables.
Control variables helped account for potential
unobserved variables. Control variables from the
manager surveys included a measure of team size
(budgeted number of full-time equivalent nurses),
team communication (whether the unit engaged in
face-to-face change-of-shift reports), and level of tech-
nology (whether the unit had automated dispensing
units for medications). Control variables from the staff
nurse surveys included years of experience as a nurse,
a dummy variable for intensive care units, aver-
age hours worked per week, organizational support,
and perceived workload. Organizational support was
measured using three items ( = 081). A sample item
was, This hospital has an explicit goal to improve
the reliability of work systems. To measure workload
(WL), we used two items from Weinberg (2000). One
WL item was, Nurses do not have time to attend
2. Workload 4.80 1.07 1 to 7 045
3. Psychological
safety 5.12 0.70 1 to 7 057 035
4. Problem-solving
efcacy 3.98 0.72 1 to 7 075 032 061
5. Felt responsibility 4.82 0.55 1 to 7 041 026 059 056
6. Manager rating
of FLSI 2.35 0.85 0 to 4 029 036 036 025 0.05
p < 010; p < 005; p < 001;
p < 0001 (two-tailed).
to patients emotional needs ( = 078). Other con-
trol variables, such as education level (bachelors or
greater = 1, otherwise, 0) and union status, were not
signicant, which led to their exclusion in the models.
4. Results
Table 3 displays the means, standard deviations, and
Pearson correlation coefcients for all the indepen-
dent and dependent variables using unit-level data
(n = 37). Triangulating data from nurse and man-
ager surveys resulted in signicantand theoreti-
cally consistentcorrelations, lending credibility to
our measures. There were signicant and meaning-
ful correlations between manager ratings of FLSI and
staff nurse ratings of (a) their own WL (r = 036;
p < 005); (b) organizational support for FLSI (r = 029;
p < 01); (c) PS (r = 036; p < 005); and (d) PSE (r =
025; p < 01).
Table 4 in the online supplement shows results
from the rst-stage models for instrumenting PS and
PSE. These rst-stage models consisted of theoreti-
cal instruments for the variables, as well as the inde-
pendent variables from the second-stage regression
equation. Both rst-stage regression equations were
signicant at the 0.05 level with adjusted R2 values
of 0.41 and 0.62. PS was instrumented by the per-
cent of encountered operational failures for which the
frontline staff reported telling their manager (told%)
and sharing their resolution ideas (share%). PSE was
instrumented by whether the unit manager was read-
ily available on the unit during the last shift worked,
and the number of salaried staff on the unit.
Model 1 in Table 4 presents the results of the 2SLS
model for testing our hypotheses. The level of analy-
sis was at the nursing unit, and data were clustered
by hospital. Our results provided marginal support
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
500
Table 4 Unit-Level Regression Results Clustered by Hospital (Robust
Standard Errors in Parentheses)
Model
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Method
Outcome variable
Control variables
Medication technology
Dummy for ICU unit
Budgeted FTE
Hrs worked/week
Workload
Org. support
Independent variables
Psychological safety [PS]
Problem-solving efcacy [PSE]
Felt responsibility [FR]
Constant
Observations
R-squared
F 23.44
Sig
df
13 rately perceived that improving work systems was the
Notes. Model 1: STATA procedure ivreg with cluster option. Boldface denotes
instrumented variables. p < 010; p < 005; p < 001.
for Hypothesis 1, which predicted that PS would be
positively associated with higher levels of FLSI ( =
083, p < 010). Hypothesis 2, which predicted a posi-
tive association between PSE and FLSI, was supported
by our data ( = 14, p < 005). Hypothesis 3 predicted
a positive association between FR for improving the
units work systems and FLSI. Hypothesis 3 was not
supported, however, because our data showed a sig-
nicant but negative relationship between FR and
FLSI ( = 15, p < 005). Model 1 in the online sup-
plement Table 5 shows the noninstrumented ordered
logistic regression results for comparison.
5. Discussion and Conclusions
Our study supports research that found that health-
care providers routinely encounter operational fail-
uresincluding missing equipment, medications,
supplies, and information (Beaudoin and Edgar
2003, Tillman et al. 1997, Tucker and Spear 2006,
Uhlig et al. 2002). Nurses responding to our sur-
vey reported having experienced an operational fail-
ure every 76 minutes during the last shift that they
worked. Operational failures vary in severity from
major to minor (de Leval et al. 2000). However,
a single major failure or multiple minor failures can
Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
have negative consequences for patients and staff
(Beaudoin and Edgar 2003, de Leval et al. 2000,
1 Tillman et al. 1997). Therefore, this paper makes
an important contribution by formally testing fac-
2SLS
FLSI tors that prior research suggests inuences frontline
employees system improvement efforts. Specically,
039 (0.44) we built on Tucker and Edmondson (2002, 2003) by
008 (0.38)
quantitatively testing the impact of PS on FLSI. This
000 (0.01)
012 (0.04) paper makes an additional contribution by introduc-
021 (0.15) ing PSE and FR as important constructs for explain-
066 (0.30) ing FLSI by workgroups. We found that workgroups
efforts to improve their work systems were positively
083 (0.47)
140 (0.50)
associated with PS and PSE. Surprisingly, lower lev-
153 (0.53) els of average FR within the units were associated
009 (2.94) with higher levels of unit FLSI. One explanation is
37 that nurses who worked together to improve their
0.28
work systems did not feel individually responsible
<0000 for improving their work systems, but instead accu-
9
responsibility of the entire unit.
Our results imply that, in contrast to research em-
phasizing individual commitment (McNeese-Smith
2001), hiring and empowering highly motivated
employees may not ensure that encounters with fail-
ures will spark process improvement efforts. Instead,
managers must consciously provide an environ-
ment that facilitates employees collective efforts to
improve their work systems. In sum, a units abil-
ity to prevent operational failures through systems
improvement can be cultivated by conscious manage-
rial effort.
5.1. Implications for Research
This paper provides empirical support for the notion
that facilitating FLSI requires two distinct conditions
(Tucker and Edmondson 2003). First, employees must
collectively feel that they will not be punished for
reporting operational failures or suggesting changes
to reduce their recurrence. This result builds on prior
research that found that team PS was an important
condition for reporting medical errors and engaging
in team learning behaviors (Edmondson 1996, 1999).
Second, employees must also collectively believe that
workgroup efforts to improve organizational systems
will receive sufcient organizational response to merit
the extra time and energy. The need for PSE was not
explicitly tested in Edmondsons (1996) study of med-
ical errors and was not signicant in her 1999 study of
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
team learning behaviors, such as asking customers for
feedback on performance (Edmondson 1999). Thus,
in comparison to reporting errors that might harm
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patients or strategically soliciting valuable customer
feedback, our research suggests a higher hurdle for
engaging frontline employees in system improvement
efforts related to operational failures. Not only must
employees have PS, but they also need a shared belief
that the organization will respond to their communi-
cation. For example, a nurse from Hospital 33 wrote,
I feel management listens to us, but there is little
or no follow through and therefore no resolution to
problems. Further survey comments suggested that
PSE was earned through bona de attempts to resolve
system failures. Employees evaluate whether they
should take the extra minute to communicate about
a failure, based on past experiences with attempts to
motivate organizational change. This was illustrated
by an employee from Hospital 28 who wrote at the
end of her survey, One can make so many sugges-
tions until they get fed up when it doesnt seem like
anything gets done. Why keep trying?
5.2. Implications for Managers
Our ndings also provide insights to managers seek-
ing to implement a strategy of continuous improve-
ment on their units. Managers must provide visible
support of their frontline employees efforts to im-
prove their work systems. First, managers can model
FLSI themselves by seeking to nd and eliminate
underlying causes of failures to prevent recurrence.
For example, at one hospital we observed an oper-
ational failure result in a lengthy delay in provid-
ing a patient with a necessary blood transfusion. The
salaried support person contacted phlebotomy and
asked, What can we do so that this doesnt happen
again? Second, an overall organizational focus on
improving work systems helps. For example, focusing
on improving patient safety can align units and sup-
port departments toward a common goal of reducing
operational failures. At the unit level, active efforts to
improve work systems as a result of operational fail-
ures can be a powerful catalyst for change (Banker
et al. 2001, Field and Sinha 2005, Thompson et al.
2003). Such proactive behavior can engender PSE,
which we found to be critical for successful FLSI. At
Hospital 46, the oncology unit manager made a point
501
of responding in writing to the nurses who commu-
nicated about failureseven if she just acknowledged
receipt of the information and explained why nothing
could be done to remedy the situation. A nurse from
that unit commented,
If I mention it [the operational failure] to the nurse
manager or the assistant manager, they follow up on
the issue. She [the nurse manager] leaves notes for us
in our box on what she does for problems. The prob-
lems will get solved, but it is not overnight and I dont
expect it to be. The problems dont get lost under a
pile somewhere.
What else can managers do to increase their staffs
efforts toward continuous improvement? First, imple-
menting a structured improvement program might
help. The Toyota Production System (TPS) provides
one example of a structured improvement program
that has been used successfully in hospitals (Insti-
tute of Medicine 2004, Spear and Schmidhofer 2005,
Thompson et al. 2003). TPS designs work to increase
the visibility of operational failures. It also educates
frontline staff to expect to have the materials and in-
formation they need to do their work on time and
correctlyand what to do if the work system fails
(Spear 1999). The inability to complete tasks on time
and correctly would be considered an operational fail-
ure, and instead of blaming those involved, man-
agers and staff focus on using the scientic method
(plan-do-check-act) to improve work systems to pre-
vent future recurrence (Institute of Medicine 2004).
Furthermore, TPS provides a clear process and man-
agerial support for resolving failures (Institute of
Medicine 2004, Spear 1999).
Our paper highlights the importance of two by-
products of TPSPS and PSEthat occur when hos-
pitals adopt a structured improvement process such
as TPS. First, having a crisp denition of what is an
operational failure enables frontline employees to rec-
ognize them when they occur. The reduced ambiguity
surrounding when to call for help (Spear and Bowen
1999) would create PS to communicate about fail-
ures to managers. Second, managerial commitment to
resolving operational failures and unitwide training
on problem-solving techniques provide PSE.
Unfortunately, PS seemed to be lacking in many of
the hospitals we observed. The unit manager and sup-
port departments sometimes did not perceive com-
munication about operational failures as a valuable
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
502 Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
signal for systems improvement. For example, recall
Nurse Grace Fletcher, who encountered several miss-
ing medications. These operational failures violate
TPS, which dictates that employees should be able
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to execute their tasks at the time specied. When
Nurse Fletcher called the pharmacy about the third
missing medication, she had to convince the techni-
cian that the physician-ordered medication was really
missing. She resorted to banging the empty medica-
tion drawer on the cart so the technician could hear
that the drawer was indeed empty.
Instead, if the hospital had embraced the TPS
principals, it would have provided a template for
(a) identifying the missing medication as an opera-
tional failure, (b) contacting the source about the fail-
ure, (c) investigating why it occurred, and (d) taking
action to prevent future recurrence. Thus, over time,
the nurse would have PS in notifying the manager
and the pharmacythat she had encountered an
operational failure. Both the manager and the phar-
macy would value the communication as a signal that
the system was not working as designed and would
investigate to understand what could be changed to
prevent future recurrence. This would create PSE.
Finally, not all operational failures have the same
level of severity (Field and Sinha 2005). Therefore,
to avoid spreading limited problem-solving resources
too thin, managers and employees can select a
class of operational failures for resolution, such
as medication-related failures. Unit problem-solving
efforts can then focus on addressing those types of
operational failures when they occur (Thompson et al.
2003).
5.3. Limitations
The study has several limitations. First, cross-sectional
data cannot answer questions about causality (Spector
1994). Untangling the causality issue would require
longitudinal or experimental data. Future longitudi-
nal research of workgroups engaged in improvement
initiatives could bring insight into the dynamic rela-
tionship among the occurrence of operational failures,
employee response to these failures, and subsequent
work system improvements.
Second, although our survey measure of PSE had
moderate reliability and validity ratings, additional
research could further develop and extend this con-
struct. The items for PSE could be improved so that
they are more distinct from the general concept of
organizational supportiveness. We also had difculty
creating a scale for PS that remained distinct from
PSE. As a result, we had to modify the PS items,
weakening the validity of conclusions regarding that
construct. However, given the strength of previous
research examining PS (i.e., Edmondson 1999), our
papers similar ndings lend credibility to the results.
Nevertheless, strengthening of the PS scale would be
benecial.
Third, our measure of FLSI was a single survey item
that asked the unit managers to rate how frequently
nurses took initiative to improve their hospitals work
systems. We worded the question this way because
prior research suggested that the types of operational
failures nurses were likely to encounter stemmed
from hospital systemssuch as medications, supplies,
and physician ordersrather than unit-level systems
(Tucker 2004). Nonetheless, future research might
ask about nurses willingness to improve their units
systems, rather than their hospitals. Future studies
might instead use a richer measure for FLSI, such
as documenting actions taken in response to medi-
cation or laboratory failures. Furthermore, an objec-
tive outcome measure, such as medication returns for
wrong medication or turnaround time for laboratory
test results, would provide a powerful test for the
value of FLSI. In addition, the severity of operational
failures could serve as a moderator for FLSI, so future
research could attempt to measure this variable.
Finally, our study was conducted on a sample of
hospital nurses, primarily from the state of Mas-
sachusetts. Consequently, it is unclear whether these
ndings apply to other types of medical professionals,
nurses in other states or countries, or nonmedical ser-
vice workers. Scott and Bruces (1994) study, for exam-
ple, found that managers role expectations inuenced
the innovative behavior of technicians, but not that
of scientists. Similarly, physicians problem-solving
behaviors may differ from nurses, which in turn
may differ from unlicensed support staffs. Also, the
healthcare setting may have inuenced employees
FLSI because of the notorious time pressure faced by
nurses and the potential for operational failures to
impact human life. Other service industries with a less
urgent frontline environment, such as hotels, restau-
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS 503

rants, technical support desks, and banks, may have
different dynamics that inuence both the nature of
operational failures and employee responses to them.
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deliberate actions to support communication about
failures. In contrast, employee selection strategies
appear to be less successful. It is our belief that devel-
oping an organizational capability for FLSI will yield

5.4. Conclusions benets for organizations, customers, and employees.

This paper focused on the collective response of front-
line employees to operational failures. Customers and
government regulators expect organizations to learn
from failuresespecially in high-risk industries such
as chemicals, oil renement, aviation, and healthcare.
Given the reality that operational failures happen, it
is imperative to understand how managers can cre-
ate positive outcomes from these negative situations.
Organizations can suffer losses from being unpre-
pared to coordinate improvement efforts in response
to failures. They waste opportunities to improve per-
formance and exacerbate employee turnover because
of frustration with repeated system difculties. How-
ever, managers can induce second-order FLSI through
Acknowledgments
The author is grateful to the nurses and nurse man-
agers who participated in this research. Jennifer Hayes,
Trent Hudson, Sandra Grifn, and Bryce LaPierre pro-
vided research assistance. Rogelio Oliva, Frances Frei, Amy
Edmondson, Kent Bowen, and Steven Spear provided assis-
tance with survey development. Enno Siemsen and Rachna
Shah provided assistance with LISREL. Lorin Hitt provided
assistance with STATA. Rachel Croson, Amy Edmondson,
Sandra Grifn, Jennifer Hayes, Serguei Netessine, and Julie
Sochalski provided valuable feedback on earlier drafts of
this paper. Any errors are the authors. Financial assistance
was provided by Fishman-Davison Center for Service and
Operations Management at The Wharton School, Univer-
sity of Pennsylvania, and the doctoral program at Harvard
Business School.

Appendix. Survey Constructs (Scales 1 to 7 Unless Otherwise Stated)

Construct Item code Survey item Source Mean S.D. N

Organizational Goal1 This hospital has an explicit goal to improve the quality of patient care. New 5.29 1.49 873
support ( = 081) Goal2 This hospital has an explicit goal to improve the reliability of our work New 4.56 1.70 875
systems. (For example, medication delivery, supplies, handling
exceptions, etc.)
Norm5 This hospital is open and responsive to change. Scott and 3.90 1.72 873
Bruce (1994)
Workload ( = 078) WL1 Nurses on this unit have to rush to meet patient care responsibilities. Weinberg (2000) 5.20 1.65 903
WL3 Nurses on this unit do not have time to attend to patients emotional needs. Weinberg (2000) 4.46 1.85 905
Psychological SAFE1 Working with members of this unit, I believe my unique skills and talents Edmondson (1999) 5.14 1.56 333
safety ( = 058) are valued.
SAFE3 Nurses on this unit are comfortable checking with each other if they have New 6.33 1.07 334
questions about the right way to do something.
RS_SAFE4 If you make a mistake in this unit, it is often held against you. Edmondson (1999) 4.62 1.67 333
Problem-solving EXP1 It is worth my time to communicate about work system problems. New 4.20 1.75 875
efcacy ( = 079) EXP2 Bringing a problem to managements attention usually results in the New 3.73 1.72 877
problem being resolved.
EXP3 It is worth my effort to try to resolve problems that disrupt my New 3.94 1.74 874
nursing care, but originate in other departments.
Felt responsibility FR1 I feel a personal sense of responsibility to bring about Morrison and 4.67 1.60 898
( = 070) change at this hospital. Phelps (1999)
FR3 I feel responsible to try to introduce new work procedures (nonclinical) Morrison and 4.61 1.49 862
where appropriate. Phelps (1999)
FR4_INV Correcting problems is not really my responsibility. (Reverse scored) Morrison and 4.85 1.60 896
Phelps (1999)
FR5_INV I feel little responsibility to challenge or change the status quo (RS). Morrison and 4.84 1.63 866
Phelps (1999)
Manager rating: NM_FLSI How frequently do nurses on this unit take initiative to improve New 2.35 0.85 46
FLSI [FLSI] the hospitals work systems? (0 = Never, 1 = Rarely, 2 = Sometimes,
3 = Often, 4 = Always)
 Tucker: An Empirical Study of System Improvement by Frontline Employees in Hospital Units
504 Manufacturing & Service Operations Management 9(4), pp. 492505, 2007 INFORMS
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