The performance gap between hospital spending and outcomes is indicative of inefficient care delivery. Operational failures—breakdowns in internal supply chains that prevent work from being completed—contribute to inefficiency by consuming 10% of nurses’ time (Hendrich et al. 2008, Tucker 2004). This paper seeks to identify organizational factors associated with operational failures, with a goal of providing insight into effective strategies for removal. We observed nurses on medical/ surgical units at two hospitals, shadowed support staff who provided materials, and interviewed employees about their internal supply chain’s performance. These activities created a database of 120 operational failures and the organizational factors that contributed to them. We found that employees believed their department’s performance was satisfactory, but poorly trained employees in other departments caused the failures. However, only 14% of the operational failures arose from errors or training. They stemmed instead from multiple organizationally-driven factors: insufficient workspace (29%), poor process design (23%), and a lack of integration in the internal supply chains (23%). Our findings thus suggest that employees are unlikely to discern the role that their department’s routines play in operational failures, which hinders solution efforts. Furthermore, in contrast to the “Pareto Principle” which advocates addressing “large” problems that contribute a disproportionate share of the cumulative negative impact of problems, the failures and causes were dispersed over a wide range of factors. Thus, removing failures will require deliberate cross-functional efforts to redesign workspaces and processes so they are better integrated with patients’ needs
