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

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. Working closely with healthcare providers, we developed a survey to measure workaround 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.