When do workarounds help or hurt patient outcomes? The moderating role of operational failures

• Published date: 01 January 2020
• Author: John W. Gardner,Sarah Zheng,Anita L. Tucker,Roger E. Bohn
• DOI: http://doi.org/10.1002/joom.1015
• Date: 01 January 2020

RESEARCH ARTICLE

When do workarounds help or hurt patient outcomes?

The moderating role of operational failures

Anita L. Tucker

1

| Sarah Zheng

2

| John W. Gardner

3

| Roger E. Bohn

4

1

Operations and Technology Management,

Boston University Questrom School of

Business, Boston, Massachusetts

2

Peter B. Gustavson School of Business,

University of Victoria, Victoria BC Canada

3

Marriott School of Business, Brigham

Young University, Provo, Utah

4

School of Global Policy and Strategy,

University of California San Diego, La Jolla,

California

Correspondence

Anita L. Tucker, Boston University

Questrom School of Business,

595 Commonwealth Avenue, Boston,

MA 02215.

Email: altucker@bu.edu

Handling Editor: Lawrence Fredendall,

Anand Nair, Jeffery Smith

Funding information

Gordon and Betty Moore Foundation

Abstract

Hospital providers often use workarounds to circumvent processes so that patients

can receive care. Workarounds in response to operational failures enable care to

continue and therefore may be indicative of workers' commitment. On the other

hand, workarounds in the absence of operational failures may signal an ineffective

approach associated with lower quality of care and worse patient outcomes. Work-

ing closely with healthcare providers, we developed a survey to measure work-

around behaviors and operational failures on medical/surgical units. The lead

author surveyed over 4,000 nurses from 63 hospitals throughout the United States.

We matched this data with audit data on the incidence of pressure injuries among

over 21,000 patients on 262 nursing units in 56 survey hospitals. Hospital-acquired

pressure injuries are a significant risk to patient health and hospital costs. We do

not find support for our hypothesis that workarounds are associated with a higher

rate of hospital-acquired pressure injuries. However, when we take into account the

moderating role of operational failures on the relationship between workarounds

and pressure injuries, we find significant results. When nursing units have lower

levels of operational failures, workarounds are associated with higher rates of

hospital-acquired pressure injuries. Our results provide evidence that workarounds

may be associated with negative patient outcomes, if they stem from a process-

avoiding approach. The best results can be achieved by reducing both operational

failures and workarounds via instilling a process-focused approach.

KEYWORDS

healthcare cost, medical error, operational failures, survey, workarounds

1|INTRODUCTION

Even when there are established procedures for how work

should be done, workers do not necessarily follow them.

Noncompliance to set procedures can be a deliberate attempt

to improve a local performance measure. This insight dates

back at least to the 1980s, when studies of complex informa-

tion technology systems found that users often “worked

around”information technology systems in order to accom-

plish their own work goals (Gasser, 1986). Computerized

material requirements planning systems of that era, for

example, were notorious for having inaccurate information

about manufacturing status and for inflexibility in adjusting

to complex or rapidly changing situations. Users coped by

creating their own unapproved techniques, such as systemat-

ically altering inputs or creating manual systems to work

parallel to the formal system.

The concept of workarounds also appears in literature on

healthcare services and service quality. Workarounds are

actions taken by an individual or a group to accomplish a

Received: 3 October 2017 Revised: 1 September 2018 Accepted: 1 December 2018

DOI: 10.1002/joom.1015

J Oper Manag. 2020;66:67–90. wileyonlinelibrary.com/journal/joom © 2019 Association for Supply Chain Management, Inc. 67

work goal when existing processes make it difficult to

accomplish that goal (Halbesleben, Wakefield, & Wakefield,

2008). Workarounds may be used to address limitations or

failures in work processes, to get by when workers lack

knowledge of correct procedures, to bypass standards to

meet alternative objectives, to save time, or to accomplish

various other purposes. Although workarounds are often

deviations from approved methods, workers' intentions in

using them are usually to improve performance in some

way. In nursing units, the intent is often to conduct a patient

care task faster than the formal procedures allow, enabling

clinicians to provide more care (Lalley, 2014).

One reason that workarounds are receiving research

attention in healthcare settings is their seeming conflict with

the important goals of improving patient safety and reducing

mortality and morbidity caused by the healthcare system

itself (McFadden, Henagan, & Gowen III, 2009). When a

particular task, such as administering medication, has a high

error rate, a common solution is to surround it with a formal

procedure that checks for errors (Mazur & Chen, 2008).

Another approach is mistake proofing (Grout, 2006), such as

completely segregating medication-related activities for each

patient and using barcode scanning to ensure that the correct

patient receives the correct medications. In both cases,

nurses may perceive the additional steps as nonvalue-added

and time-consuming, and when rushed, they may bypass

or work around the mistake-proofing activities (Koppel,

Wetterneck, Telles, & Karsh, 2008).

However, the net effect of workarounds on performance is

not straightforward. Workarounds can have mixed effects on

health outcomes, on costs, and on measures of servicequality.

The presumption of the literature on process standardization is

that workarounds have net negative effects. When safety pro-

cedures are bypassed in an effort to save time, workarounds

can contribute to errors (Koppel et al., 2008; Tucker, 2016),

safety risks (Brown, Willis, & Prussia, 2000), and poor patient

outcomes. By reducing process standardization, workarounds

increase process variation (Bendoly & Cotteleer, 2008). Pro-

cess variation can decrease performance and stifle organiza-

tional learning (Mazur & Chen, 2008; Naveh & Marcus,

2005; Spear & Schmidhofer, 2005). But on the other hand,

workarounds add flexibility and innovation to a system,

enabling staff to respond to situations that were not consid-

ered when a procedure was created (Lalley, 2014; Morrison,

2015; Petrides, McClelland, & Nodine, 2004; Sarnecky,

2007). In the context of our study, workarounds may be logi-

cal and expedient responses to problems.

The overall effect of workarounds on outcomes of inter-

est, especially patient health, can therefore only be resolved

by research, which measures health outcomes. To our

knowledge, there are a few if any tests of the impact of

workarounds on actual health outcomes. We address this

gap by measuring the incidence of a serious and relatively

common complication in medical and surgical nursing units.

Examining the effects of workarounds on an important

health outcome pressure injuries. This also serves as a test of

the theory of work standardization and quality. Deviations

from process standards, which are not directly quality related

harm nonquality measures of process performance but do

they also actually harm final patient outcomes?

The theoretically mixed effects of workarounds suggest

that why they are done may determine their impact. In this

article, we examine workarounds as related to the frequency

of operational failures. Operational failures include break-

downs in the supply of materials, equipment, and internal ser-

vices needed to complete tasks (Tucker, 2004). Our premise

is that to the extent that workarounds are responses to opera-

tional failures, they might be useful. When service providers

encounter operational failures, they can choose to work

around the failures. For example, taking supplies from other

units (Survey question WA1) may be a response to out-of-

stock supplies (Survey question OF1). Such workarounds in

response to operational failures may be beneficial for patients

because they enable service to continue more quickly than if

the providers followed the official response. Units that have

high levels of both operational failures and workarounds are

using a fire-fighting approach to solving problems (Bohn,

2000). But when there is a high level of operational failures

providers may choose not work around them. These decisions

may signal an apathetic problem-solving approach that results

in patients not getting thecare they need in a timely fashion.

A third approach occurs on units where operational fail-

ures are rare but providers nonetheless decide to engage in

workarounds for other reasons. Workarounds performed in

the absence of operational failures might reflect an approach

overly driven by corner-cutting (Oliva & Sterman, 2001),

where employees either lack clear processes or ignore

known policies and standard procedures (Mazur & Chen,

2008; Oliva & Sterman, 2001). Such a process-avoiding

approach might result in lower service quality because of

weak design of work processes and variability in their exe-

cution. Finally, a fourth approach occurs in contexts where

there are few operational failures and providers abstain from

using workarounds, signaling a process-focused approach

that may result in higher service quality.

Many previous studies have looked at the causes of work-

arounds in healthcare processes, such as the blocks encoun-

tered after the introduction of new medication administration

technology (Ash, Berg, & Coiera, 2004; Halbesleben, Savage,

Wakefield, & Wakefield, 2010; Holden, Rivera-Rodriguez,

Faye, Scanlon, & Karsh, 2013; Koppel et al., 2008). How-

ever, to the best of our knowledge, there are few tests of the

impact of workarounds on actual health outcomes. We

address this gap by examining the effects of workarounds

68 TUCKER ET AL.