Anita L. Tucker

Associate Professor of Business Administration

Dr. Anita L. Tucker is an Associate Professor at the Harvard Business School.  She uses operations management and organizational learning theory to understand how to increase integration among the different departments that comprise an organization’s internal supply chain.  She has found that a lack of integration can create small-scale operational problems that individually can be worked around, but collectively waste up to 10% of an employees’ time and compromise quality. She uses a variety of methods to study this phenomenon, including ethnographic observations, surveys, and field and laboratory experiments. Dr. Tucker has received numerous awards including a 2013 “Wyss Mentoring Award” for excellence in mentoring doctoral students, 2006 Sloan Industry Studies Fellowship, 2004 AcademyHealth Dissertation award, the 2004 Accenture Award for her article with Amy C. Edmondson in California Management Review, and three best paper awards from Academy of Management conferences. Professor Tucker has a BSc. in Industrial Engineering from University of Massachusetts, Amherst, a master’s degree in Industrial Engineering and Operations Research from Purdue University, and a doctorate in business administration from Harvard University.

Journal Articles

  1. Designed for Workarounds: A Qualitative Study of the Causes of Operational Failures in Hospitals

    Frontline care providers in hospitals spend at least 10% of their time working around operational failures, which are situations where information, supplies, or equipment needed for patient care are insufficient. However, little is known about underlying causes of operational failures and what hospitals can do to reduce their occurrence. To address this gap, we examined the internal supply chains at two hospitals with the aim of discovering organizational factors that contribute to operational failures. We conducted in-depth qualitative research, including observations and interviews of over 80 individuals from 4 nursing units and the ancillary support departments that provide equipment and supplies needed for patient care. We found that a lack of interconnectedness among interdependent departments' routines was a major source of operational failures. The low levels of interconnectedness occurred because of how the internal supply chains were designed and managed rather than because of employee error or a shortfall in training. Thus, we propose that the time that hospital staff spend on workarounds can be reduced through deliberate efforts to increase interconnectedness among hospitals' internal supply departments. Four dimensions of interconnectedness include (1) hospital-level—rather than department-level—performance measures; (2) internal supply department routines that respond to specific patients' needs rather than to predetermined stocking routines; (3) knowledge that is necessary for efficient handoffs of materials is translated across departmental boundaries; and (4) cross-departmental collaboration mechanisms that enable improvement in the flow of materials across departmental boundaries.

    Keywords: Supply Chain; Health Care and Treatment; Failure; Business Processes; Health Industry;

    Citation:

    Tucker, Anita L., W. Scott Heisler, and Laura D. Janisse. "Designed for Workarounds: A Qualitative Study of the Causes of Operational Failures in Hospitals." Permanente Journal (forthcoming).
  2. The Effectiveness of Management-By-Walking-Around: A Randomized Field Study

    Management-By-Walking-Around (MBWA) is a widely adopted technique in hospitals that involves senior managers directly observing frontline work. However, few studies have rigorously examined its impact on organizational outcomes. This paper examines an improvement program based on MBWA in which senior managers observe frontline employees, solicit ideas about improvement opportunities, and work with staff to resolve the issues. We randomly selected 19 hospitals to implement the 18-month long MBWA-based improvement program; 56 work areas participated. We find that the program, on average, had a negative impact on performance. To explain this surprising finding, we use mixed methods to examine the impact of the work area's problem-solving approach. Results suggest that prioritizing easy-to-solve problems was associated with improved performance. We believe this was because it resulted in greater action taking. A different approach was characterized by prioritizing high-value problems, which was not successful in our study. We also find that assigning to senior managers responsibility for ensuring that identified problems get resolved resulted in better performance. Overall, our study suggests that senior managers' physical presence on their organizations' frontlines was not helpful unless it enabled active problem solving.

    Keywords: quality improvement; patient safety; culture; implementation research; Management Practices and Processes; Organizational Culture; Performance Improvement; Health Care and Treatment; Health Industry;

    Citation:

    Tucker, Anita L., and Sara J. Singer. "The Effectiveness of Management-By-Walking-Around: A Randomized Field Study." Production and Operations Management (forthcoming). (Revised September 2013.)
  3. Deliberate Learning to Improve Performance in Dynamic Service Settings: Evidence from Hospital Intensive Care Units

    Dynamic service settings-characterized by workers who interact with customers to deliver services in a rapidly changing, uncertain, and complex environment (e.g., hospitals)-play an important role in the economy. Organizational learning studies in these settings have largely investigated autonomous learning via cumulative experience as a strategy for performance improvement. Whether induced learning through the use of deliberate learning activities provides additional performance benefits has been neglected. We argue that the use of deliberate learning activities offers performance benefits beyond those of cumulative experience because these activities counter the learning challenges presented by rapid knowledge growth, uncertainty, and complexity in dynamic settings. We test whether there are additional performance benefits to using deliberate learning activities and whether the effectiveness of these activities depends on interdisciplinary collaboration in the workgroup. We test our hypotheses in a study of 23 hospital neonatal intensive care units (NICUs) involved in a quality improvement collaborative. We find that using deliberate learning activities is associated with better workgroup performance, as measured by NICUs' risk-adjusted mortality rates for 2,159 infant patients, but only after two years. In the shorter term, using these activities is associated with worse performance. By the third year, the positive impact of using deliberate learning activities is similar to the benefit of cumulative experience (18% and 20% reduction in odds of mortality, respectively). Contrary to prediction, interdisciplinary collaboration mediates, rather than moderates, the relationship between using deliberate learning activities and workgroup performance. Thus, our data suggest that using deliberate learning activities fosters interdisciplinary collaboration.

    Keywords: Experience and Expertise; Customer Focus and Relationships; Learning; Health Care and Treatment; Service Delivery; Performance Improvement; Quality; Groups and Teams; Cooperation; Health Industry;

    Citation:

    Nembhard, I. M., and A. L. Tucker. "Deliberate Learning to Improve Performance in Dynamic Service Settings: Evidence from Hospital Intensive Care Units." Organization Science 22, no. 4 (July–August 2011): 907–922.
  4. Front-line Staff Perspectives on Opportunities for Improving the Safety and Efficiency of Hospital Work Systems

    Objective To link safety-related concerns raised by frontline staff about hospital work systems (operational failures) to the safety and efficiency of hospitals, and to contrast these concerns with national patient safety initiatives.

    Data Sources Primary data include semi-structured interviews with frontline staff and 1732 staff identified operational failures at 20 U.S. hospitals from 2004-2006.

    Study Design Senior-level managers observed frontline staff work with particular attention to patient safety issues and facilitated open-discussion meetings with employees about their safety related concerns.

    Data Collection Hospitals submitted data on the operational failures they identified through their interactions with frontline workers. Data were analyzed for type of failure and frequency of occurrence. Interviews were conducted with frontline staff.

    Principal Findings The two most frequent categories of operational failures, equipment/supplies and facility issues, posed safety risks and diminished staff efficiency, but have not been priorities in national initiatives.

    Conclusions Our study suggests an underutilized strategy for improving patient safety and staff efficiency: leveraging frontline staff experiences with work systems to identify and remove operational failures. In contrast to the perceived tradeoff between safety and efficiency, fixing operational failures can yield benefits for both. Thus, prioritizing improvement of work systems in general, rather than focusing more narrowly on specific clinical conditions, can increase safety and efficiency of hospitals.

    Keywords: Perspective; Opportunities; Safety; Performance Efficiency; System; Failure; Conferences; Employees; Management Analysis, Tools, and Techniques; Experience and Expertise; Health Care and Treatment; Health Industry; United States;

    Citation:

    Tucker, Anita L., Sara J. Singer, Jennifer E. Hayes, and Alyson Falwell. "Front-line Staff Perspectives on Opportunities for Improving the Safety and Efficiency of Hospital Work Systems." Health Services Research (June 2008).
  5. An Empirical Study of System Improvement by Frontline Employees in Hospital Units

    Keywords: Information; System; Employees; Health; Health Industry;

    Citation:

    Tucker, A. L. "An Empirical Study of System Improvement by Frontline Employees in Hospital Units." Manufacturing & Service Operations Management 9, no. 4 (fall 2007): 492–505.
  6. Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units

    Keywords: Practice; Organizations; Learning; Health; Information; Health Industry;

    Citation:

    Tucker, A. L., I. Nembhard, and A. C. Edmondson. "Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units." Management Science 53, no. 6 (June 2007): 894–907.
  7. Operational Failures and Interruptions in Hospital Nursing

    Keywords: Operations; Failure; Health; Health Industry;

    Citation:

    Tucker, A. L., and S. Spear. "Operational Failures and Interruptions in Hospital Nursing." Health Services Research 41, no. 3 (June 2006): 643–662.
  8. The Impact of Operational Failures on Hospital Nurses and Their Patients

    Keywords: Operations; Failure; Health;

    Citation:

    Tucker, A. L. "The Impact of Operational Failures on Hospital Nurses and Their Patients." Journal of Operations Management 22, no. 2 (April 2004).
  9. A Case Study of Operational Failures in Home Healthcare

    Keywords: Operations; Failure; Health; Information;

    Citation:

    Tucker, A. L. "A Case Study of Operational Failures in Home Healthcare." Journal for Healthcare Quality 26, no. 3 (2004): 42–48. (Special Issue featuring papers presented at the 2003 National Policy Meeting of Home Health Care Quality.)
  10. Why Hospitals Don't Learnfrom Failures: Organizational and Psychological Dynamics That InhibitSystem Change

    Keywords: Health Care and Treatment; Health Industry;

    Citation:

    Tucker, A., and A. Edmondson. "Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change." California Management Review 45, no. 2 (winter 2003). (Winner of Accenture Award For the article published in the California Management Review that has made the most important contribution to improving the practice of management.)
  11. When Problem Solving Prevents Organizational Learning

    Keywords: Problems and Challenges; Organizations; Learning;

    Citation:

    Tucker, Anita L., Amy C. Edmondson, and Steven Spear. "When Problem Solving Prevents Organizational Learning." Journal of Organizational Change Management 15, no. 2 (2002). (Best paper proceedings, Academy of Management Conference, Healthcare Management Division.)
  12. Managing Routine Exceptions: A Model of Nurse Problem Solving Behavior

    Keywords: Management; Health; Problems and Challenges; Behavior;

    Citation:

    Tucker, A. L., and Amy C. Edmondson. "Managing Routine Exceptions: A Model of Nurse Problem Solving Behavior." Advances in Health Care Management 3 (2002): 87–113.

Working Papers

  1. The Diseconomies of Queue Pooling: An Empirical Investigation of Emergency Department Length of Stay

    We conduct an empirical investigation of the impact of two different queue management systems on throughput times. Using an Emergency Department's (ED) patient-level data (N = 231,081) from 2007 to 2010, we find that patients' lengths of stay (LOS) were longer when physicians were assigned patients under a pooled queuing system, compared to when each physician operated under a dedicated queuing system. The dedicated queuing system resulted in a 10 percent decrease in LOS—a 32-minute reduction in LOS for an average patient of medium severity in this ED. We propose that the dedicated queuing system yielded shorter throughput times because it provided physicians with greater ability and incentive to manage their patients' flow through the ED from arrival to discharge. Consistent with social loafing theory, our analysis shows that patients were treated and discharged at a faster rate in the dedicated queuing system than in the pooled queuing system. We conduct additional analyses to rule out alternate explanations, such as stinting on care and decreased quality of care. Our paper has implications for health care organizations and others seeking to reduce throughput time, resource utilization, and costs.

    Keywords: pooling; queue management; strategic servers; social loafing; empirical operations; health care; Management Practices and Processes; Service Delivery; Health Care and Treatment; Health Industry;

    Citation:

    Song, Hummy, Anita L. Tucker, and Karen L. Murrell. "The Diseconomies of Queue Pooling: An Empirical Investigation of Emergency Department Length of Stay." Harvard Business School Working Paper, No. 14-050, December 2013.
  2. Increased Speed Equals Increased Wait: The Impact of a Reduction in Emergency Department Ultrasound Order Processing Time

    We exploit an exogenous process change at two emergency departments (EDs) within a health system to test the theory that increasing capacity in a discretionary work setting increases wait times due to additional services being provided to customers as a consequence of reduced marginal costs for a task. We find that an increase in physicians' capacity for ordering ultrasounds (U/S) resulted in an 11.5 percentage point increase in the probability of an U/S being ordered, confirming that resource availability induces demand. Furthermore, we find that the additional U/S demand increased the time to return other radiological tests due to the higher demand placed on radiologists from the additional U/S. Consequently, the average length of stay (LOS) for patients with an abdominal complaint increased by nearly 30 minutes, and the waiting time to enter the ED increased by 26 minutes. We do not find any indications of improved performance on clinical metrics, with no statistical change in the number of admissions to the hospital or readmissions to the ED within 72 hours. Our study highlights an important lesson for process improvement in interdependent service settings: increasing process capacity at one step in the process can increase demand at that step, as well as for a subsequent shared service, and both can result in an overall negative impact on performance.

    Keywords: Technology; Demand and Consumers; Service Delivery; Health Care and Treatment; Business Processes; Health Industry;

    Citation:

    Berry Jaeker, Jillian, Anita L. Tucker, and Michael H. Lee. "Increased Speed Equals Increased Wait: The Impact of a Reduction in Emergency Department Ultrasound Order Processing Time." Harvard Business School Working Paper, No. 14-033, October 2013.
  3. The Impact of Conformance and Experiential Quality on Healthcare Cost and Clinical Performance

    The quality of operational processes is an important driver of performance in hospitals. In particular, processes that reliably deliver both evidence-based and patient-centered care, which we call conformance and experiential quality, respectively, have been argued to result in better clinical outcomes. However, hospitals, in general, struggle to perform well on these quality dimensions. Operations management theory suggests that this may be due to the cost involved in combining these dimensions. In other words, there may be a tradeoff between clinical and financial performance. To investigate this issue in detail, we use longitudinal data from 3458 U.S. acute care hospitals and examine the relationships between conformance and experiential quality and two important dimensions of hospital performance: cost efficiency and clinical outcomes. We find that hospitals with high levels of both conformance and experiential quality demonstrate better clinical outcomes as measured by length of stay and readmissions, but have worse performance with regard to cost efficiency. This may result in hospitals' inability to invest in both conformance and experiential quality due to the greater financial burden. We conclude by highlighting that although hospitals may need to persevere through a short term financial hardship to achieve high levels of both conformance and experiential quality, financial performance benefits are likely to emerge in the longer term. Our results have implications for researchers and policy makers investigating the operational processes, clinical outcomes, and financial performance of hospitals.

    Keywords: healthcare; experiential quality; conformance quality; clinical outcomes; cost efficiency; Quality; Service Operations; Health Care and Treatment; Performance; Outcome or Result; Health Industry;

    Citation:

    Senot, Claire, Aravind Chandrasekaran, Peter T. Ward, and Anita L. Tucker. "The Impact of Conformance and Experiential Quality on Healthcare Cost and Clinical Performance." Harvard Business School Working Paper, No. 14-024, September 2013.
  4. An Empirical Study of the Spillover Effects of Workload on Patient Length of Stay

    We use two years of inpatient data from 243 California hospitals to quantify the relationship between hospital-level workload and patient length of stay (LOS), and its "spillover" effects across patient types. Patients are categorized as medical or surgical, and the effects of same type patient workload (occupancy) on LOS are analyzed. The analysis is repeated with workload replaced by other type patient occupancy, providing a "spillover" effect. We find that the effects of inpatient workload on LOS spillover across patient types, which we theorize results from most inpatients, regardless of type, utilizing the same shared resources (e.g. pharmacy and laboratory). These spillover effects remain even while we find that the effects of workload vary at different time points during a patient's stay: LOS increases as inpatient workload on the day of admission increases, while inpatient workload at the end of the stay has a U-shaped effect on LOS.

    Keywords: Workload; Processing times; healthcare; Working Conditions; Performance Productivity; Time Management; Health Care and Treatment; Health Industry; California;

    Citation:

    Berry Jaeker, Jillian, and Anita Tucker. "An Empirical Study of the Spillover Effects of Workload on Patient Length of Stay." Harvard Business School Working Paper, No. 13-052, December 2012. (Revised July 2013.)
  5. Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration

    Operational failures persist in hospitals, in part because employees work around them rather than attempt to prevent recurrence. Drawing on a process improvement tool—the Andon cord—we examine three work design components that may foster improvement-oriented behaviors: 1) blockages to prevent workarounds; 2) a support person to assist with problem-solving; and 3) education portraying operational failures as "waste" to be removed from the system. Using laboratory experiments, we test each component's impact on whether hospital nurses speak up about medication administration problems and contribute improvement ideas. We find that each component provides its own contribution to organizational performance. Blockages encourage people to suggest improvement ideas, while education sparks improvement suggestions even when there are no blockages. Blockages can backfire, however, if they are difficult to work around in a policy-compliant manner and problem-solving support is unavailable. Under these conditions, blockages led to a risky workaround associated with a 10X overdose of insulin. Risky workarounds can be mitigated with a readily-available support person, whose presence also elicits higher levels of speaking up about operational failures.

    Keywords: health care; process improvement; organizational learning; behavioral operations; prosocial behavior; experiments; Organizational Change and Adaptation; Behavior; Performance Improvement; Health Care and Treatment; Business Processes; Health Industry;

    Citation:

    Tucker, Anita L. "Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration." Harvard Business School Working Paper, No. 13-044, November 2012. (Revised September 2013.)

Cases and Teaching Materials

  1. Dignity Health: Prevention of Retained Sponges

    Citation:

    Tucker, Anita L., and Lydia Ypsse Kim. "Dignity Health: Prevention of Retained Sponges." Harvard Business School Case 613-092, April 2013. (Revised March 2014.)
  2. Cincinnati Children's Hospital Medical Center, Video Supplement 2012

    Keywords: process improvement; leadership succession; healthcare; quality and safety; transparency; Organizational Change and Adaptation; Management Succession; Health Care and Treatment; Performance Improvement; Business Processes; Health Industry; Ohio;

    Citation:

    Tucker, Anita, and Amy Edmondson. "Cincinnati Children's Hospital Medical Center, Video Supplement 2012." Harvard Business School Video Supplement 613-710, February 2013.
  3. Learning About Reducing Hospital Mortality at Kaiser Permanente

    In 2011, Kaiser Permanente Northern California (KPNC) region's efforts to reduce mortality in their 21 hospitals is showing promise. They developed and launched a region-wide initiative to improve the treatment of sepsis, a serious and often deadly medical condition. The case illustrates the challenges of spreading change in a complex, highly interdependent organization, and presents an alternative framework to traditional management models for addressing such situations. It also asks students to consider how change should be made under conditions of uncertainty, in which best performances remain unknown.

    Keywords: Change Management; Health Care and Treatment; Performance Improvement; Health Industry; California;

    Citation:

    Tucker, Anita. "Learning About Reducing Hospital Mortality at Kaiser Permanente ." Harvard Business School Case 612-093, April 2012. (Revised February 2013.)
  4. Learning About Reducing Hospital Mortality at Kaiser Permanente

    Keywords: patient safety; process improvement; standardization; organizational learning; knowledge development;

    Citation:

    Tucker, Anita Carson. "Learning About Reducing Hospital Mortality at Kaiser Permanente." Harvard Business School Teaching Note 612-098, May 2012. (Revised February 2014.)
  5. Cleveland Clinic: Improving the Patient Experience

    Healthcare has traditionally focused on medical outcomes and financial performance. The big question is always, "How much is it going to cost?" What would happen, though, if healthcare also considered the question of "How does the patient feel?" This case looks at the Cleveland Clinic's attempt to answer the latter question by attempting to institutionalize empathy as part of its delivery of care.

    Keywords: Health Care and Treatment; Customer Satisfaction; Performance Improvement; Service Delivery; Value Creation; Personal Characteristics; Human Needs;

    Citation:

    Raman, Ananth, and Anita L. Tucker. "Cleveland Clinic: Improving the Patient Experience." Harvard Business School Case 612-031, September 2011. (Revised February 2013.)
  6. The Cleveland Clinic: Improving the Patient Experience (Abridged)

    Healthcare has traditionally focused on medical outcomes and financial performance. The big question is always, "How much is it going to cost?" What would happen though if healthcare also considered question of "How does the patient feel?" This case looks at the Cleveland Clinic's attempt to answer the latter question by attempting to institutionalize empathy as part of its delivery of care.

    Keywords: Customer Satisfaction; Ethics; Health Care and Treatment; Six Sigma; Performance Improvement; Safety; Value Creation;

    Citation:

    Raman, Ananth, Anita L. Tucker, and Rachel Gordon. "The Cleveland Clinic: Improving the Patient Experience (Abridged)." Harvard Business School Case 611-015, October 2010.
  7. Cincinnati Children's Hospital Medical Center

    The case describes an organization's use of the science of improvement to transform their process quality from below average to the top 10% in their industry. The case outlines the protagonist's strategy of developing internal experts who are trained in a common methodology for making improvement and spreading these ideas in their work units.

    Keywords: Change Management; Experience and Expertise; Leading Change; Measurement and Metrics; Service Delivery; Performance Improvement; Health Industry; Ohio;

    Citation:

    Tucker, Anita L., and Amy C. Edmondson. "Cincinnati Children's Hospital Medical Center." Harvard Business School Case 609-109, June 2009. (Revised April 2011.)
  8. Cincinnati Children's Hospital Medical Center (TN)

    Teaching Note for 609109.

    Keywords: Quality; Performance Improvement; Management Practices and Processes; Strategy; Business Units; Science; Health Industry;

    Citation:

    Tucker, Anita L. "Cincinnati Children's Hospital Medical Center (TN)." Harvard Business School Teaching Note 610-106, June 2010.
  9. Patient Flow at Brigham and Women's Hospital (A)

    Brigham and Women's Hospital challenged a team of physicians to improve patient flow from the Emergency Department to Intensive Care Units (ICUs). One of the team members, Selwyn Rogers, Director of the Surgical Intensive Care Unit (SICU) at Brigham and Women's Hospital, encountered workarounds by two physicians attempting to transfer their patients to the SICU because the other ICUs were full. Reflecting on the wasted effort and confusion caused by the workarounds, Rogers sent an email outlining the situation to the team. His email generated a negative backlash and chain of defensive emails from involved staff who felt criticized.

    Keywords: Change Management; Health Care and Treatment; Service Operations; Business Processes; Performance Productivity; Conflict and Resolution; Health Industry; Massachusetts;

    Citation:

    Tucker, Anita L., and Jillian Alexandra Berry. "Patient Flow at Brigham and Women's Hospital (A)." Harvard Business School Case 608-171, June 2008. (Revised October 2010.)
  10. Patient Flow at Brigham and Women's Hospital (B)

    The B Case is an email from the ED Director. He clarifies where the process deviations occurred.

    Keywords: Change Management; Health Care and Treatment; Service Operations; Business Processes; Performance Productivity; Conflict and Resolution; Health Industry; Massachusetts;

    Citation:

    Tucker, Anita L., and Jillian Alexandra Berry. "Patient Flow at Brigham and Women's Hospital (B)." Harvard Business School Supplement 608-172, June 2008. (Revised November 2010.)
  11. Patient Flow at Brigham and Women's Hospital (TN) (A) and (B)

    Teaching Note for 608171 and 608172.

    Keywords: Business Processes; Change; Employees; Emotions; Health Care and Treatment; Health Industry;

    Citation:

    Tucker, Anita L. "Patient Flow at Brigham and Women's Hospital (TN) (A) and (B)." Harvard Business School Teaching Note 610-107, June 2010. (Revised September 2012.)
  12. Children's Hospital and Clinics (A)

    Describes the major phases of an initiative designed to transform the organization and enhance patient safety. Raises interesting questions about how to encourage candid discussion about failures while continuing to hold people accountable for their performance.

    Keywords: Health Care and Treatment; Leading Change; Business Processes; Organizational Change and Adaptation; Organizational Culture; Performance Improvement; Safety; Health Industry;

    Citation:

    Edmondson, Amy C., Michael Roberto, and Anita L. Tucker. "Children's Hospital and Clinics (A)." Harvard Business School Case 302-050, November 2001. (Revised September 2007.)