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Anita Tucker
DBA in Technology and Operations Management

Dissertation Chair: Prof. K. Bowen

Organizational Learning from Operational Failures

This dissertation examines employee response to operational failures to understand mechanisms through which organizations learn and fail to learn. In four related papers, the dissertation builds on theory from the organizational learning and quality improvement literatures. Multiple methods were used to gather data, starting with hypothesis-generating observation of 26 nurses at 9 hospitals, followed by thirteen interviews. Inductive analyses of these data combined with literature reviews suggested hypotheses, which were tested using survey data from 907 nurses.

The findings shed new light onto the nature of operational failures and employee responses, with important implications for organizational learning efforts. My research challenges two key assumptions underpinning improvement techniques. First, quality experts propose that improvement comes from addressing the "vital few" problems and the "trivial many" can safely be ignored (Deming, 1986; Juran, Godfrey, Hoogstoel, & Schilling, 1999). In contrast, I found that myriad daily failures, although seemingly small, collectively erode employee effectiveness and create opportunities for similar failures to recur, potentially with worse consequences. Limiting employee and managerial attention to large failures precludes significant improvement and suggests a new explanation for why many improvement programs do not achieve expected performance gains. Second, error reduction programs often assume that front line employees will document failures and rely on this information to select improvement projects. My analyses suggest that employees rarely communicate about failures, even in situations presenting potentially serious consequences. In addition, managers and others did not always perceive failure-related communication to be valuable data, adding to the difficulty of learning from failures and eroding employee motivation to speak up.

Industries with unusually high task variability and interdependence face operational failures on a routine basis, making learning of vital concern. Given the increasing complexity of service and manufacturing environments, these findings are relevant to many organizations, and thus to the future of operations management.

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