There's a story we learned as doctoral students about six blind men and an elephant and the pitfalls of trying to fathom the great beast by taking hold of some small part of it. The story, derived originally from Indian legend and made famous by the poetry of John Godfrey Saxe in 1873, illustrates how taking too narrow a view of some phenomenon can lead to an incomplete and potentially inaccurate conclusion.

In "To Make or Buy Patient Safety Solutions: A Resource Dependence and Transaction Cost Economics Perspective," the authors examine the choice of hospital managers to innovate around the problem of patient safety and, given that choice, the decision to make or buy the solution. Applying resource dependence theory (RDT) to the former decision and transaction cost economics (TCE) theory to the latter, they speculate on the types of hospitals (e.g., larger, teaching, safety net) that are more likely to pursue patient safety solutions and suggest that those that do will innovate internally to reduce transaction costs. Although we agree that RDT and TCE may provide insight about the strategic choices that hospitals make around patient safety solutions, we believe that, like the men taking hold of the elephant, the authors may have taken too narrow a view.

Mintzberg and Lampel (1999) take a similar view of strategy research as a whole. Referring to the blind men and the elephant, they pronounced much of the writing and advising of strategy academics and consultants "decidedly dysfunctional, simply because managers have no choice but to cope with the entire beast" (p. 21). They suggest the need to move beyond the narrow insights of individual disciplines toward a more holistic, integrative view. In this spirit, we believe that there are at least four additional schools of strategic thought that provide interrelated insights to questions about patient safety innovation.

First, the entrepreneurial school pays homage to leaders' intuition, ingenuity, and prerogative (Cole, 1959; Schumpeter, 1934). This perspective suggests that creative champions and inspiring leaders influence not only what organizations choose to do but also how they do it. Choices around patient safety may therefore be as much about leadership as about the power relations, dependencies, and costs in an organization's environment.

Second, the cultural school views strategic choice as a social construct embedded in the prevailing common interests of organizational members (Schein, 1992) rather than as a function of organizational self-interest and fragmentation of power as emphasized by RDT. In this sense, the cultural perspective may be considered the opposite of power-based perspectives like RDT. For managers, this implies that choices around patient safety should consider the ease with which they can be integrated into the organization's existing beliefs, values, and norms. Moreover, success or failure may depend on the ability of managers to address cultural concerns during implementation. This perspective introduces the importance of the internal environment of the organization and its members' collective history and experience in explaining whether and how organizations approach patient safety. Although measuring and studying such characteristics are difficult, we believe that from both a theoretical and a practical perspective, examinations of patient safety are substantially improved by accounting for organizational culture.

Third, while TCE focuses on the costs of contracting, the knowledge-based theory of the firm suggests that make versus buy decisions may also be influenced by the notion that the experience, insights, skills, and tacit knowledge possessed by organizations are difficult to transfer across organizational boundaries (Conner & Prahalad, 1996). Thus, in knowledge-intensive settings like health care, a critical opportunity cost associated with buying an innovation is the potential loss of knowledge acquisition associated with internal production. The implication for health care managers is that if learning promotes patient safety (Edmondson, 2004), transaction costs might be a minor consideration. Moreover, managers should recognize that internally developed and outsourced patient safety solutions may not be productively equivalent because "there will be a difference in the knowledge that is brought to bear[horizontal ellipsis]under the two options" (Conner & Prahalad, 1996, p. 477).

Finally, and related to the knowledge-based theory of the firm, the learning school views strategies as emergent and intertwined with implementation (Levitt & March, 1988). In other words, learning begets innovation in a virtuous cycle. This school views patient safety as a process and highlights the essential role of managers in building learning capabilities that allow continuous improvement toward high performance. This perspective suggests that for practicing managers, patient safety is an ongoing rather than a static problem, the solution to which requires continuous improvement. This view of patient safety suggests that both external technology "solutions" and internally developed patient safety approaches may be necessary components of the ideal process.

Our consideration of these additional perspectives serves to emphasize three key limitations of presenting an incomplete view of strategic behavior and decision making around patient safety. First, a more holistic view introduces important internal behavioral elements into the picture, revealing a decidedly more complex and multispective "beast" with which managers must cope. Second, a narrow focus on TCE in attempting to explain make versus buy decisions assumes productive equivalence among alternatives and fails to fully consider the knowledge-based risks and benefits of patient safety solutions. Finally, viewing patient safety as a static problem-a choice between internal and external "solutions"-erroneously implies that safety can be achieved with one-time solutions that can be bought and sold on the open market.

These limitations highlight the importance of casting a wider theoretical net in considering managers' decisions about how to innovate. The schools of thought we have considered present the possibility that patient safety is not a problem amenable to solutions that can be purchased in the way that the acquisition of widgets can benefit a production process, as originally envisioned by TCE. Although it might be possible to purchase consultation, information, or technology as components designed to enhance patient safety, meaningful improvement depends on an organization's application of these products and services, not just once but consistently over time and in ways that interact positively with other elements of complex hospital systems. Such improvement requires experimentation and adaptation, the effectiveness of which depends on factors such as leadership, culture, knowledge creation, and learning, none of which can be bought.

Sara J. Singer, MBA, PhD

Jonathan R. Clark, MS, PhD

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