{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,31]],"date-time":"2025-08-31T23:15:13Z","timestamp":1756682113308,"version":"3.37.3"},"reference-count":119,"publisher":"Institute of Electrical and Electronics Engineers (IEEE)","issue":"6","license":[{"start":{"date-parts":[[2021,12,1]],"date-time":"2021-12-01T00:00:00Z","timestamp":1638316800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/ieeexplore.ieee.org\/Xplorehelp\/downloads\/license-information\/IEEE.html"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IEEE Trans. Eng. Manage."],"published-print":{"date-parts":[[2021,12]]},"DOI":"10.1109\/tem.2019.2926643","type":"journal-article","created":{"date-parts":[[2019,7,30]],"date-time":"2019-07-30T16:14:55Z","timestamp":1564503295000},"page":"1758-1772","source":"Crossref","is-referenced-by-count":2,"title":["Effects of Surprises During Quality Improvement Projects: A Longitudinal Study on Method-Driven Learning in Behavioral Healthcare"],"prefix":"10.1109","volume":"68","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5447-3490","authenticated-orcid":false,"given":"Adrian S.","family":"Choo","sequence":"first","affiliation":[]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2078-6007","authenticated-orcid":false,"given":"Jamison V.","family":"Kovach","sequence":"additional","affiliation":[]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7127-9737","authenticated-orcid":false,"given":"Lawrence D.","family":"Fredendall","sequence":"additional","affiliation":[]}],"member":"263","reference":[{"key":"ref39","doi-asserted-by":"publisher","DOI":"10.1016\/j.jom.2015.05.001"},{"key":"ref38","doi-asserted-by":"publisher","DOI":"10.1109\/TEM.2010.2048913"},{"key":"ref33","article-title":"The effectiveness of management-by-walking-around: A randomized field study","author":"tucker","year":"2014","journal-title":"Prod Operations Manage"},{"key":"ref32","doi-asserted-by":"publisher","DOI":"10.1016\/j.jom.2009.10.003"},{"key":"ref31","doi-asserted-by":"publisher","DOI":"10.2307\/2666999"},{"key":"ref30","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.1060.0692"},{"key":"ref37","doi-asserted-by":"publisher","DOI":"10.1111\/j.1741-5446.2008.00282.x"},{"key":"ref36","article-title":"At 3M, a struggle between efficiency and creativity","author":"hindo","year":"2007","journal-title":"Business Week"},{"key":"ref35","doi-asserted-by":"publisher","DOI":"10.1177\/1077558716640415"},{"key":"ref34","doi-asserted-by":"publisher","DOI":"10.1287\/orsc.13.3.339.2780"},{"key":"ref28","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.44.11.S35"},{"key":"ref27","doi-asserted-by":"publisher","DOI":"10.1016\/j.technovation.2004.10.003"},{"key":"ref29","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.46.5.597.12049"},{"key":"ref20","doi-asserted-by":"publisher","DOI":"10.1177\/1046496414553473"},{"key":"ref22","doi-asserted-by":"publisher","DOI":"10.2307\/2393640"},{"key":"ref21","doi-asserted-by":"publisher","DOI":"10.1108\/02656710710730889"},{"key":"ref24","doi-asserted-by":"publisher","DOI":"10.1002\/ace.5"},{"key":"ref23","doi-asserted-by":"publisher","DOI":"10.1287\/orsc.1100.0570"},{"journal-title":"Econometric Analysis of Cross Section and Panel Data","year":"2010","author":"wooldridge","key":"ref101"},{"journal-title":"Design for Six Sigma for Green Belts and Champions","year":"2006","author":"gitlow","key":"ref26"},{"journal-title":"Linear Mixed Models for Longitudinal Data","year":"2009","author":"verbeke","key":"ref100"},{"key":"ref25","article-title":"Reviewing theory and research on informal and incidental learning","author":"marsick","year":"2006","journal-title":"Proc Acad Human Resour Develop Int Conf"},{"key":"ref50","doi-asserted-by":"publisher","DOI":"10.1016\/j.jom.2006.08.002"},{"key":"ref51","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.2015.2286"},{"key":"ref59","doi-asserted-by":"publisher","DOI":"10.1080\/02615479.2011.639357"},{"journal-title":"Four practical revolutions in management systems for creating unique organizational capability USA ISBN-","year":"2001","author":"shiba","key":"ref58"},{"key":"ref57","doi-asserted-by":"publisher","DOI":"10.1037\/0033-295X.93.2.136"},{"key":"ref56","first-page":"262","article-title":"The subjective experience of surprise","author":"reisenzein","year":"2000","journal-title":"The Message Within The Role of Subjective Experience in Social Cognition and Behavior"},{"key":"ref55","doi-asserted-by":"publisher","DOI":"10.1518\/001872008X375009"},{"key":"ref54","doi-asserted-by":"publisher","DOI":"10.1007\/0-306-47144-2_3"},{"key":"ref53","doi-asserted-by":"publisher","DOI":"10.1006\/obhd.2000.2891"},{"key":"ref52","doi-asserted-by":"publisher","DOI":"10.1023\/A:1024422330338"},{"key":"ref40","doi-asserted-by":"publisher","DOI":"10.1108\/09526860810900691"},{"journal-title":"Juran on Leadership for Quality","year":"1989","author":"juran","key":"ref4"},{"key":"ref3","doi-asserted-by":"publisher","DOI":"10.1287\/orsc.1090.0483"},{"key":"ref6","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijpe.2012.09.003"},{"key":"ref5","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.1060.0635"},{"key":"ref8","doi-asserted-by":"publisher","DOI":"10.1016\/j.jom.2007.06.007"},{"key":"ref49","doi-asserted-by":"publisher","DOI":"10.1111\/j.1540-5915.2010.00286.x"},{"key":"ref7","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijpe.2012.05.035"},{"key":"ref9","doi-asserted-by":"publisher","DOI":"10.1108\/IJLSS-11-2016-0069"},{"key":"ref46","doi-asserted-by":"publisher","DOI":"10.1016\/j.jom.2004.07.001"},{"key":"ref45","doi-asserted-by":"publisher","DOI":"10.1080\/10686967.1994.11918672"},{"key":"ref48","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.11.6.B136"},{"key":"ref47","doi-asserted-by":"publisher","DOI":"10.2307\/258437"},{"key":"ref42","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ps.201400384"},{"key":"ref41","article-title":"A preliminary study of continuous quality improvement in mental healthcare","author":"kovach","year":"2011","journal-title":"Proc Decis Sci Inst Annu Conf"},{"key":"ref44","doi-asserted-by":"publisher","DOI":"10.1016\/S0272-6963(01)00066-3"},{"key":"ref43","doi-asserted-by":"publisher","DOI":"10.1108\/09534810210423008"},{"key":"ref73","doi-asserted-by":"publisher","DOI":"10.1080\/02699930500262878"},{"key":"ref72","doi-asserted-by":"publisher","DOI":"10.1080\/02699939108411042"},{"key":"ref71","doi-asserted-by":"publisher","DOI":"10.1037\/0278-7393.24.5.1182"},{"key":"ref70","doi-asserted-by":"publisher","DOI":"10.5465\/ambpp.2015.12709abstract"},{"key":"ref76","doi-asserted-by":"publisher","DOI":"10.5465\/amj.2011.60263060"},{"key":"ref77","doi-asserted-by":"publisher","DOI":"10.1002\/sej.1157"},{"key":"ref74","doi-asserted-by":"publisher","DOI":"10.1007\/978-1-4419-6546-2_9"},{"key":"ref75","doi-asserted-by":"publisher","DOI":"10.1111\/tops.12312"},{"key":"ref78","doi-asserted-by":"publisher","DOI":"10.1126\/science.aaa3799"},{"key":"ref79","doi-asserted-by":"publisher","DOI":"10.1111\/apps.12076"},{"key":"ref60","first-page":"725","article-title":"Unlearning ineffective or obsolete technologies","volume":"11","author":"starbuck","year":"1996","journal-title":"Int J Technol Manage"},{"key":"ref62","doi-asserted-by":"publisher","DOI":"10.1287\/orsc.5.1.14"},{"key":"ref61","doi-asserted-by":"publisher","DOI":"10.1177\/0018726708095710"},{"key":"ref63","doi-asserted-by":"publisher","DOI":"10.2307\/258441"},{"key":"ref64","doi-asserted-by":"publisher","DOI":"10.1016\/0090-2616(93)90051-2"},{"key":"ref65","doi-asserted-by":"publisher","DOI":"10.5465\/AMR.2007.26585724"},{"key":"ref66","doi-asserted-by":"publisher","DOI":"10.1287\/orsc.1090.0435"},{"key":"ref67","doi-asserted-by":"publisher","DOI":"10.5465\/amr.1999.2202135"},{"key":"ref68","article-title":"The remedy for unproductive busyness","author":"gino","year":"2015","journal-title":"Harvard Bus Rev"},{"key":"ref2","doi-asserted-by":"publisher","DOI":"10.5465\/078559811"},{"key":"ref69","doi-asserted-by":"publisher","DOI":"10.1146\/annurev.psych.60.110707.163544"},{"key":"ref1","doi-asserted-by":"publisher","DOI":"10.1109\/TEM.2018.2889517"},{"key":"ref109","doi-asserted-by":"publisher","DOI":"10.1080\/00207540802496162"},{"journal-title":"Multilevel Statistical Models","year":"2011","author":"goldstein","key":"ref95"},{"key":"ref108","doi-asserted-by":"publisher","DOI":"10.1080\/00207543.2010.543175"},{"key":"ref94","doi-asserted-by":"publisher","DOI":"10.1108\/TPM-10-2015-0047"},{"key":"ref107","first-page":"81","article-title":"How senior managers think","volume":"62","author":"isenberg","year":"1984","journal-title":"Harvard Business Review Article"},{"key":"ref93","doi-asserted-by":"publisher","DOI":"10.1037\/0021-9010.85.5.678"},{"key":"ref106","doi-asserted-by":"publisher","DOI":"10.1080\/14739879.2017.1298405"},{"key":"ref92","doi-asserted-by":"publisher","DOI":"10.2307\/2285379"},{"key":"ref105","doi-asserted-by":"publisher","DOI":"10.1108\/eb054610"},{"key":"ref91","doi-asserted-by":"publisher","DOI":"10.4324\/9781410605337"},{"key":"ref104","doi-asserted-by":"publisher","DOI":"10.2307\/1912775"},{"key":"ref90","doi-asserted-by":"publisher","DOI":"10.1080\/14623943.2012.657795"},{"year":"2014","author":"baum","key":"ref103"},{"key":"ref102","doi-asserted-by":"publisher","DOI":"10.1080\/07350015.2012.643126"},{"key":"ref111","doi-asserted-by":"publisher","DOI":"10.1016\/j.jom.2007.11.001"},{"key":"ref112","doi-asserted-by":"publisher","DOI":"10.1111\/j.1937-5956.2009.01117.x"},{"key":"ref110","doi-asserted-by":"publisher","DOI":"10.1146\/annurev.so.14.080188.001535"},{"key":"ref98","doi-asserted-by":"publisher","DOI":"10.1177\/014920639702300303"},{"key":"ref99","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.36.2.140"},{"key":"ref96","doi-asserted-by":"publisher","DOI":"10.4324\/9781315744094"},{"key":"ref97","first-page":"349","article-title":"Within-group agreement, non-independence, and reliability: Implications for data aggregation and analysis","author":"bliese","year":"2000","journal-title":"Multilevel Theory Research and Methods in Organizations Foundations Extensions and New Directions"},{"key":"ref10","doi-asserted-by":"publisher","DOI":"10.1504\/IJPQM.2016.074462"},{"key":"ref11","doi-asserted-by":"publisher","DOI":"10.1097\/JHQ.0000000000000049"},{"key":"ref12","doi-asserted-by":"publisher","DOI":"10.5465\/19416520.2010.493286"},{"key":"ref13","doi-asserted-by":"publisher","DOI":"10.1177\/001872679104400104"},{"key":"ref14","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-8551.2005.00470.x"},{"key":"ref15","doi-asserted-by":"publisher","DOI":"10.1097\/00004010-200307000-00008"},{"key":"ref118","doi-asserted-by":"publisher","DOI":"10.1287\/msom.1060.0156"},{"journal-title":"Juran's quality Control handbook","year":"1988","author":"juran","key":"ref16"},{"article-title":"Into the big muddy and out again: Error persistence and crisis management in the operating room","year":"2003","author":"rudolph","key":"ref82"},{"key":"ref117","doi-asserted-by":"publisher","DOI":"10.1016\/j.jom.2014.09.003"},{"key":"ref17","first-page":"78","article-title":"Learning to lead at Toyota","volume":"82","author":"spear","year":"2004","journal-title":"Harvard Business Rev"},{"key":"ref81","doi-asserted-by":"publisher","DOI":"10.1186\/s13012-017-0555-2"},{"key":"ref18","doi-asserted-by":"publisher","DOI":"10.1002\/job.1784"},{"key":"ref84","doi-asserted-by":"publisher","DOI":"10.1037\/0021-9010.88.3.552"},{"key":"ref119","doi-asserted-by":"publisher","DOI":"10.2139\/ssrn.2932236"},{"key":"ref19","doi-asserted-by":"publisher","DOI":"10.1177\/0149206312441210"},{"key":"ref83","doi-asserted-by":"publisher","DOI":"10.2337\/diaspect.17.2.97"},{"key":"ref114","first-page":"305","author":"argyris","year":"1996","journal-title":"Organizational Learning II Theory Method and Practice"},{"key":"ref113","first-page":"344","author":"argyris","year":"1978","journal-title":"Organizational Learning A Theory of Action Perspective"},{"key":"ref116","doi-asserted-by":"publisher","DOI":"10.1287\/mnsc.43.4.479"},{"key":"ref80","doi-asserted-by":"publisher","DOI":"10.1177\/0021886303039001004"},{"key":"ref115","doi-asserted-by":"publisher","DOI":"10.5465\/amr.1994.9412271815"},{"key":"ref89","doi-asserted-by":"publisher","DOI":"10.1177\/001316446002000104"},{"journal-title":"Handbook of Metrics for Research in Operations Management Multi-Item Measurement Scales and Objective Items","year":"2008","author":"roth","key":"ref85"},{"key":"ref86","doi-asserted-by":"publisher","DOI":"10.1097\/00005053-198709000-00004"},{"key":"ref87","doi-asserted-by":"publisher","DOI":"10.1126\/science.1103572"},{"key":"ref88","doi-asserted-by":"publisher","DOI":"10.2189\/asqu.2005.50.3.367"}],"container-title":["IEEE Transactions on Engineering Management"],"original-title":[],"link":[{"URL":"http:\/\/xplorestaging.ieee.org\/ielx7\/17\/9520681\/08781944.pdf?arnumber=8781944","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,1,12]],"date-time":"2022-01-12T11:38:13Z","timestamp":1641987493000},"score":1,"resource":{"primary":{"URL":"https:\/\/ieeexplore.ieee.org\/document\/8781944\/"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,12]]},"references-count":119,"journal-issue":{"issue":"6"},"URL":"https:\/\/doi.org\/10.1109\/tem.2019.2926643","relation":{},"ISSN":["0018-9391","1558-0040"],"issn-type":[{"type":"print","value":"0018-9391"},{"type":"electronic","value":"1558-0040"}],"subject":[],"published":{"date-parts":[[2021,12]]}}}