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September 29, 2009 Vol. 2, Issue 9


The response of frontline workers to operational failures and close calls is affected by the type of incident and the managers commitment to problem solving, according to a new study by Harvard Business School.

Reporting an incident is one thing, and responding to it is another. In their working paper “Operational Failures and Problem Solving: An Empirical Study of Incident Reporting (PDF),” Harvard Business School professors Julia Adler-Milstein, Sara J. Singer, and Michael W. Toffel investigated the types of incidents that trigger problem solving, and the kinds of contexts managers can create to optimize the best response to operational failures.

The researchers hypothesized that incidents involving high liability and increased risk of cost would stimulate engagement in problem solving. They also hypothesized that a manager’s commitment to problem solving would encourage frontline workers to play a role. For the study, commitment was expressed through either a manager’s verbal campaigns or actual involvement in the problem solving efforts to set an example for others. They also observed whether these two types of commitments would be substitutes or compliments of one another.

A large Massachusetts hospital served as the study environment because the researchers sought a high-reliability organization characterized by complex, interdependent operations and serious consequences for failure. The researchers reviewed and analyzed the hospital’s internal incident reporting system, which anonymously records basic information about an incident: who was involved, the outcome, contributing factors, and the actions taken in response. Once filed, the reports are passed on to managers for follow-up. The researchers focused their study on the recorded actions following an incident.

Two students work with the Mars Spirit Rover team at JPL

Two students work with the Mars Spirit Rover team at JPL.

The study found that frontline workers were more likely to engage in problem solving for incidents that threatened legal liability rather than financial harm, while managers were more likely to use problem solving when facing financial risk than legal liability. Researchers hypothesized that this was most likely due to differences in roles and responsibilities.

The study also showed that managerial problem solving engagement and campaigning were substitutes, rather than complements, for one another. When managers verbally promoted problem solving and routinely engaged in problem solving at lower levels, frontline workers were more likely to conduct problem solving. Higher levels of engagement from managers did not produce the same positive results, a finding that the researchers wish to study in the future. The researchers also want to look at whether or not reporting systems actually reduce operational failures, as well as whether organizations actually learn from the incidents to which they respond.

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