I was reading an article in the Financial Times this morning that referred to an old proverb that I have not heard in a while - "a camel is a horse designed by committee." I think the proverb is trying to say that a committee isn't very effective at making decisions and coming up with unique and innovative ideas. Committees, by virtue of the fact that they are made up of several members, each with different perspectives, viewpoints, and preferences, have a difficult time reaching consensus. Their logic is fragmented, flawed, and prone to failure. So, as the saying goes, if a committee set off to design a four-legged animal that was strong enough to pull a heavy load (for example, a wagon), smart enough to follow directions, and fast enough to carry a rider from one village to another in a reasonable amount of time, they would come up with something that looks like a camel, as opposed to a horse.
In this particular case, the proverb is actually a quote (supposedly) by Sir Alec Issigonis. Issigonis was a highly innovative automobile designer who is known for the design and development of the Mini. Clearly, Issigonis felt that most committees, at least in regards to innovation and design, were completely useless.
What can we say about the camel, though? Is a camel really that useless? Actually, the camel is perfectly designed for the harsh desert climate of the Sahara Desert. When I was young, I was led to believe that camels stored water in their humps - this is actually not true. The hump is actually where the camel stores its fat. This particular adaptation allows the camel to withstand the hot temperatures of the desert climate. Fat is a perfect insulator - if the camel's fat stores were distributed evenly all over its body, they would not be able to withstand the hot desert temperatures for very long. The camel's thick coat of hair protects it from the intense sun in the desert. The camel's intestines are able to absorb water much better than most mammals, and similarly, the camel's kidneys are able to conserve water and excrete a concentrated urine. The camel's long eyelashes and ear hair prevents sand from irritating the eyes and ears. Camels also apparently have a transparent third eyelid to further protect the eyes from blowing sand. Finally, camels do not sweat. In other words, a camel is perfectly designed for its primary purpose, just like a horse is perfectly designed for its primary purpose.
So, are committees good at innovation or not? I happen to believe that the diverse membership of most committees is an asset, not a liability. Different backgrounds, viewpoints, opinions, and perspectives create environments that foster innovation. Moreover, team diversity is much less susceptible to something known as "groupthink" (more about groupthink in a later post), where members of the committee come to a consensus too early on a solution or design that is not necessarily the best.
Different personalities and experiences can, at times, be challenging to manage. However, in the long run, if a team or committee is led by someone who creates an environment that encourages different viewpoints while at the same time pushing the team to come to a consensus, we end up with the best of both worlds - a highly innovative group that forms a consensus in a reasonable amount of time. In other words, we end up with a committee or team that is perfectly designed for its primary purpose - we get a camel if we are in a desert and a horse if we are anywhere else!
Friday, December 30, 2016
Sunday, December 25, 2016
Peace on Earth, Good will to all.
I have been reading the Horatio Hornblower series by C.S. Forester. There are eleven books which tell the story of Horatio Hornblower, a fictional Royal Navy officer during the Napoleonic Wars. The Hornblower series is actually the second book series that I have enjoyed about the British Navy during that era - I have also read Patrick O'Brian's Aubrey-Maturin series (the 2003 movie, Master and Commander: The Far Side of the World, starring Russell Crowe and Paul Bettany was partially based on three of the Aubrey-Maturin novels). What has impressed me about both of these book series is the fact that whenever an opposing ship is captured, the officers hand over their swords to the victors and pledge not to fight or try to escape. In many cases, the captured officers are left free to wander around either the ship (if still at sea) or the countryside (if captured near shore). War was apparently vastly different during the Napoleonic Wars compared to today, and perhaps "honor" was more meaningful and more significant.
I am reminded of an event that I first learned about while watching a Paul McCartney video for his song, called Pipes of Peace. The setting of the video is the Western Front, 1914 (World War I). On December 25, 1914, French, German, and British soldiers crawled out of their trenches, crossed "No Man's Land," and joined together to celebrate Christmas. They exchanged food and souvenirs, sang carols, played football (soccer), and drank a toast to peace. Christmas brought out the best of humankind on that day. After several months of grueling, hand-to-hand combat, in the middle of the "War to End All Wars," there was peace. Men who merely hours earlier were killing one another, joined hands, broke bread together, and enjoyed a few quiet moments on Christmas. On that Christmas night, the guns were silent, bringing special meaning to the Christmas carol, "Silent Night" that they sang.
How beautiful would it be to have a peace like that on this Christmas Day? It is difficult, if not impossible, to imagine a similar scenario occurring in these times. But I still have a hope and belief that peace on Earth is within our reach. World peace must start with peace here at home. World peace must start with compassion and good will to all, no matter what gender, sexual orientation, race, ethnicity, or religious background. World peace must start with all of us, here and now, joining together as a community in the common bonds of humankind. "And now these three remain: Faith, hope, and love. But the greatest of these is love." (1 Corinthians 13:13)
World peace will only come if we open our hearts to everyone. Merry Christmas. Peace on Earth and Good will to All.
I am reminded of an event that I first learned about while watching a Paul McCartney video for his song, called Pipes of Peace. The setting of the video is the Western Front, 1914 (World War I). On December 25, 1914, French, German, and British soldiers crawled out of their trenches, crossed "No Man's Land," and joined together to celebrate Christmas. They exchanged food and souvenirs, sang carols, played football (soccer), and drank a toast to peace. Christmas brought out the best of humankind on that day. After several months of grueling, hand-to-hand combat, in the middle of the "War to End All Wars," there was peace. Men who merely hours earlier were killing one another, joined hands, broke bread together, and enjoyed a few quiet moments on Christmas. On that Christmas night, the guns were silent, bringing special meaning to the Christmas carol, "Silent Night" that they sang.
How beautiful would it be to have a peace like that on this Christmas Day? It is difficult, if not impossible, to imagine a similar scenario occurring in these times. But I still have a hope and belief that peace on Earth is within our reach. World peace must start with peace here at home. World peace must start with compassion and good will to all, no matter what gender, sexual orientation, race, ethnicity, or religious background. World peace must start with all of us, here and now, joining together as a community in the common bonds of humankind. "And now these three remain: Faith, hope, and love. But the greatest of these is love." (1 Corinthians 13:13)
World peace will only come if we open our hearts to everyone. Merry Christmas. Peace on Earth and Good will to All.
Thursday, December 22, 2016
Do women make better physicians?
My oldest daughter tells a story that she remembers when she was younger. Her sisters and brother were playing with their cousins at my parents' house over summer vacation - the boys all wanted to play "army." They had built a fort in the basement, complete with an army field hospital! The "field hospital" was a small tent, complete with one of my old toy doctor's kit mixed with some of my old medical instruments. My oldest nephew (who happens to be the oldest cousin) told my daughter and her sisters to go into the tent, "You can't be soldiers. You are the nurses." My daughter responded that she wanted to be the doctor!
I am old enough to remember that male nurses were once exceedingly uncommon. Thankfully, that has changed. While I still think that female nurses outnumber male nurses, my impression is that the gap is closing. I am also old enough to remember when female physicians were not very common either. Thankfully, that has changed. In fact, nearly half of all medical students starting medical school this year will be female. In my own field of pediatrics, there are more female pediatricians graduating from residency training programs than there are male pediatricians. Even in the traditionally male-dominated field of surgery, there are more females becoming surgeons (even though males still outnumber females). It is a trend that is long overdue.
Why is this important? Well for one, I think that medical profession should reflect the greater society as a whole. Patients generally want to be treated by physicians who are like them. More interesting to me are the studies showing that female physicians spend more time listening to their patients, ask more questions about their patients' overall well-being (focusing on healing the mind, body, AND spirit), and encourage more shared decisionmaking. Female physicians are also more likely to follow clinical guidelines and order preventive tests compared to their male counterparts. All of this is very interesting. However, just last week, a large retrospective study of over 1.5 million Medicare beneficiaries over age 65 years admitted to the hospital over a three year period from 2011-2014, showed that patients treated by female physicians had a significantly lower 30-day mortality rate compared to those treated by male physicians. These differences persisted even after controlling for 8 specific medical conditions and adjusting for severity of illness. While this is a retrospective study, it is the first study of its kind to show that some of the differences in care between female and male physicians discussed above appear to matter!
There are probably two major lessons here. First, we should NEVER discount the ability of our female colleagues to practice excellent medicine. Female physicians are not only good doctors, they may even be better doctors than males! Second, we should try to learn what things that female physicians are doing to provide better care - and then model that behavior! I think many physicians entered the profession of medicine to take care of patients. Most physicians would like to spend more time with their patients. The data discussed here potentially suggests that we, as health care administrators, should figure out how to foster these behaviors and how to provide ample time for physicians to actually listen to their patients.
I mentioned this study to my daughter just the other night. It turns out that she had already heard of the study. I think she was going to call her cousin and let him know about it as well!
I am old enough to remember that male nurses were once exceedingly uncommon. Thankfully, that has changed. While I still think that female nurses outnumber male nurses, my impression is that the gap is closing. I am also old enough to remember when female physicians were not very common either. Thankfully, that has changed. In fact, nearly half of all medical students starting medical school this year will be female. In my own field of pediatrics, there are more female pediatricians graduating from residency training programs than there are male pediatricians. Even in the traditionally male-dominated field of surgery, there are more females becoming surgeons (even though males still outnumber females). It is a trend that is long overdue.
Why is this important? Well for one, I think that medical profession should reflect the greater society as a whole. Patients generally want to be treated by physicians who are like them. More interesting to me are the studies showing that female physicians spend more time listening to their patients, ask more questions about their patients' overall well-being (focusing on healing the mind, body, AND spirit), and encourage more shared decisionmaking. Female physicians are also more likely to follow clinical guidelines and order preventive tests compared to their male counterparts. All of this is very interesting. However, just last week, a large retrospective study of over 1.5 million Medicare beneficiaries over age 65 years admitted to the hospital over a three year period from 2011-2014, showed that patients treated by female physicians had a significantly lower 30-day mortality rate compared to those treated by male physicians. These differences persisted even after controlling for 8 specific medical conditions and adjusting for severity of illness. While this is a retrospective study, it is the first study of its kind to show that some of the differences in care between female and male physicians discussed above appear to matter!
There are probably two major lessons here. First, we should NEVER discount the ability of our female colleagues to practice excellent medicine. Female physicians are not only good doctors, they may even be better doctors than males! Second, we should try to learn what things that female physicians are doing to provide better care - and then model that behavior! I think many physicians entered the profession of medicine to take care of patients. Most physicians would like to spend more time with their patients. The data discussed here potentially suggests that we, as health care administrators, should figure out how to foster these behaviors and how to provide ample time for physicians to actually listen to their patients.
I mentioned this study to my daughter just the other night. It turns out that she had already heard of the study. I think she was going to call her cousin and let him know about it as well!
Monday, December 19, 2016
Stop. Point, and Cross
A few months ago, I had the opportunity to tour the Toyota Motor Manufacturing Kentucky, Inc. (TMMK) plant in Georgetown, Kentucky. Toyota builds the Lexus ES350, Avalon, and Camry at this plant. TMMK is Toyota's largest automobile manufacturing plant in North America - the plant itself covers over 7.5 million square feet (that's about 156 football fields, according to the website) and is staffed by over 7,000 employees. The Toyota team builds nearly 2,000 vehicles every day! The tour is completely free to the public - it is a popular field trip destination for local schools.
I was very impressed with the amount of traffic inside the plant! Employees and managers were either walking around or riding on bicycles, golf carts, or forklifts. Our tour was riding around on a long tram. The intersections were as busy as any intersection in America! As the tour guide stated in his introduction to the plant, safety is the main priority at this plant. He specifically asked us to look out for employees when they came to an intersection. Look for the employee to "Stop, Point, and Cross." Every time a worker came to an intersection, he or she would stop, look both ways, point in the direction that he or she was going to move, and then cross the intersection. What impressed me the most was that the workers did this each and every time. Every time I looked, they did it! It was so in-grained that they didn't stop to think about NOT doing it.
I started thinking to myself - health care is so very different. We can never quite reach above 90% on our handwashing compliance - at either our hospital or even throughout our industry. What is Toyota doing that every worker universally and without fail, "stops, points, and crosses"? Why can't we get this same level of compliance in health care when it comes to handwashing? Several of us on the tour noticed this level of compliance and asked the same question. My only response is that the culture is very different, perhaps, at TMMK. I later found out that workers are incentivized (or in some cases, penalized) for complying with this particular safety initiative. However, I don't think that is quite sufficient. There is something deeper there. Several hospitals that I know use employee incentives to encourage compliance with handwashing - yet, compliance is never quite 100% (and in some cases, it is actually far lower than 100%). It has to be the culture at Toyota! It has simply become an expectation of everyone who works at the plant.
How do we build this kind of culture in healthcare? I suspect that Toyota started by being relentless about their "Stop, Point, and Cross" initiative. Employees were accountable not only to themselves, but also for their fellow employees (something that has been called "200% accountability"). Whenever someone forgot to "stop, point, and cross" - they were called out for not doing so. How many times in the hospital does a physician get "called out" by another physician or a bedside nurse for not washing his or her hands? We simply need to do better. We need to make handwashing automatic, just as TMMK did for "Stop, Point, and Cross." But it all starts with culture.
I was very impressed with the amount of traffic inside the plant! Employees and managers were either walking around or riding on bicycles, golf carts, or forklifts. Our tour was riding around on a long tram. The intersections were as busy as any intersection in America! As the tour guide stated in his introduction to the plant, safety is the main priority at this plant. He specifically asked us to look out for employees when they came to an intersection. Look for the employee to "Stop, Point, and Cross." Every time a worker came to an intersection, he or she would stop, look both ways, point in the direction that he or she was going to move, and then cross the intersection. What impressed me the most was that the workers did this each and every time. Every time I looked, they did it! It was so in-grained that they didn't stop to think about NOT doing it.
I started thinking to myself - health care is so very different. We can never quite reach above 90% on our handwashing compliance - at either our hospital or even throughout our industry. What is Toyota doing that every worker universally and without fail, "stops, points, and crosses"? Why can't we get this same level of compliance in health care when it comes to handwashing? Several of us on the tour noticed this level of compliance and asked the same question. My only response is that the culture is very different, perhaps, at TMMK. I later found out that workers are incentivized (or in some cases, penalized) for complying with this particular safety initiative. However, I don't think that is quite sufficient. There is something deeper there. Several hospitals that I know use employee incentives to encourage compliance with handwashing - yet, compliance is never quite 100% (and in some cases, it is actually far lower than 100%). It has to be the culture at Toyota! It has simply become an expectation of everyone who works at the plant.
How do we build this kind of culture in healthcare? I suspect that Toyota started by being relentless about their "Stop, Point, and Cross" initiative. Employees were accountable not only to themselves, but also for their fellow employees (something that has been called "200% accountability"). Whenever someone forgot to "stop, point, and cross" - they were called out for not doing so. How many times in the hospital does a physician get "called out" by another physician or a bedside nurse for not washing his or her hands? We simply need to do better. We need to make handwashing automatic, just as TMMK did for "Stop, Point, and Cross." But it all starts with culture.
Thursday, December 15, 2016
Successful Successions (or not)
There has been a lot of talk about transitions lately. The peaceful turnover of power from one President to the next is one of the hallmarks of our democracy, and regardless of which side of the political fence you spend your time on, this time should be no different. Coincidentally, I happened to have a meeting just yesterday with some members from Human Resources about succession planning. Succession planning happened to start the day I first stepped into my new administrative role about 18 months ago. Was I nervous? After all, here I was just starting in a new position, and I was already being asked to identify a few individuals who could replace me and under what circumstances they could do so. In full disclosure, I wasn't nervous at all - in fact, I view succession planning as a key part of what leaders should be doing. Why wouldn't you want to assure that the work that you started and the culture that you have helped build on your team continue after you are no longer in the position? Succession planning is not only the right thing to do, even on day one of your job, but it is also a key part of talent management, which every leader should view as his or her responsibility.
So all of this talk about leadership transitions and succession planning got me thinking. Has their ever been an example of a "good" transition of Presidential leadership in which the previous President hands off to one of his (unfortunately, we have still yet to have a "her" as President) hand-picked successor, one that he has played a major role in developing and placing in a position to be successful? Well.... I started with our first President, George Washington. He certainly handed off power to another member of his party (the Federalist Party), but even if you believe that John Adams was a successful President (and I do believe that), one could certainly argue that he wasn't necessarily "developed" or mentored by President Washington. In fact, John Adams was famously said to have described the Vice Presidency as "the most insignificant office that ever the invention of man contrived or his imagination conceived." Okay, strike one. How about one of Franklin D. Roosevelt's (FDR) Vice Presidents? John Nance Gardner, who served as FDR's Vice President from 1933 to 1941 was once quoted as saying, "The vice-presidency isn't worth a pitcher of warm piss." Ouch. Not really what I would call a ringing endorsement. Strike two. What about Harry Truman? He was FDR's Vice President in 1945, but he only became President of the United States after FDR died in office (actually, he only was Vice President for 82 days!), so he doesn't really count. But we could say that Truman was fairly successful. Let's skip ahead a few Presidents to George H.W. Bush. He served as Vice President for two full terms under President Ronald Reagan, but as much as I hate to admit it (when I was in the Navy, all I heard was what an incredibly nice, friendly man President Bush was), Bush 41's presidency was not all that successful either. Strike three.
So, it would seem that succession planning plays no major role in arguably the most important office in the world! Very disappointing. How about in the sports world? I like sports analogies, and I think there is a lot that we can learn from successful sports teams. The quarterback position is one of the most important positions on any football team - we often hear of NFL teams drafting quarterbacks out of college and then having them sit on the bench to learn from the coaches and be mentored by the veteran quarterback. Once the younger quarterback has had time to develop, the veteran quarterback steps aside and continues to mentor and coach the quarterback from the sideline. Sounds great, right? Succession planning at its finest! But again, as I think about some of the great quarterbacks, even if they "mentored" younger quarterbacks for a few years (think Joe Montana and Steve Young, or Brett Favre and Aaron Rogers), the veteran quarterback usually leaves the team to go play somewhere else, rather than sitting on the bench to watch the younger quarterback play.
But absolutely my all-time favorite succession story (in this case, perhaps not altogether successful, but certainly not a failure either) from the sports world comes from the Tour de France! Greg LeMond was the first, and after the last two Americans - Floyd Landis and Lance Armstrong were declared ineligible due to doping violations - the only American to ever win this grueling bicycling race. Greg LeMond was a promising cyclist, finishing first in the 1983 World Road Racing Championships and third in the 1984 Tour de France, recruited by Bernard Hinault ("The Badger") to race for his Team La Vie Claire in the 1985 Tour. Hinault was chasing history by trying to win his fifth Tour de France (only three other men have won five Tours - Jacques Anquetil, Eddy Merckx, and Miguel Indurain) and needed strong riders on his team to help him win (in bicycle road racing, there is usually one rider who is the designated team leader - everyone else on the team rides to help the leader win). Hinault convinced LeMond to join him, partly by promising that he would work just as hard for LeMond the following year as a member of his team (they would, in essence, switch roles). Again, succession planning perhaps as it is designed to work!
During the 1985 Tour, Hinault had trouble and fell behind. At one point (I remember watching this live on television), LeMond found himself in a position where he could easily have taken the race lead and worn the vaunted Yellow Jersey for one day. The Team Director told him that he must not do this - he was riding for Hinault and not for himself. LeMond agreed (very reluctantly, I might add) and Hinault eventually won his fifth Tour. Hinault again publicly promised that he would ride as hard for LeMond the following year as LeMond had done for him at the 1985 Tour. Well, to make a long blog post a little shorter, I will summarize the 1986 Tour. LeMond won his first Tour de France and the Badger came in second. Hinault had challenged LeMond throughout the race, and to many it seemed as if he was actually trying to win the race. Hinault later claimed that he was only pushing LeMond so that he would win. So, maybe this example still meets our definition of successful succession planning?
Unfortunately, I don't have a lot of great examples of successful successions from either the sporting world or from our nation's Presidential history (at least today - maybe in a future blog post!). Suffice it to say that I still think succession planning is absolutely vital to an organization's success. Succession planning is an important aspect of talent management, and it assures a safe, effective transition of leadership for the future.
So all of this talk about leadership transitions and succession planning got me thinking. Has their ever been an example of a "good" transition of Presidential leadership in which the previous President hands off to one of his (unfortunately, we have still yet to have a "her" as President) hand-picked successor, one that he has played a major role in developing and placing in a position to be successful? Well.... I started with our first President, George Washington. He certainly handed off power to another member of his party (the Federalist Party), but even if you believe that John Adams was a successful President (and I do believe that), one could certainly argue that he wasn't necessarily "developed" or mentored by President Washington. In fact, John Adams was famously said to have described the Vice Presidency as "the most insignificant office that ever the invention of man contrived or his imagination conceived." Okay, strike one. How about one of Franklin D. Roosevelt's (FDR) Vice Presidents? John Nance Gardner, who served as FDR's Vice President from 1933 to 1941 was once quoted as saying, "The vice-presidency isn't worth a pitcher of warm piss." Ouch. Not really what I would call a ringing endorsement. Strike two. What about Harry Truman? He was FDR's Vice President in 1945, but he only became President of the United States after FDR died in office (actually, he only was Vice President for 82 days!), so he doesn't really count. But we could say that Truman was fairly successful. Let's skip ahead a few Presidents to George H.W. Bush. He served as Vice President for two full terms under President Ronald Reagan, but as much as I hate to admit it (when I was in the Navy, all I heard was what an incredibly nice, friendly man President Bush was), Bush 41's presidency was not all that successful either. Strike three.
So, it would seem that succession planning plays no major role in arguably the most important office in the world! Very disappointing. How about in the sports world? I like sports analogies, and I think there is a lot that we can learn from successful sports teams. The quarterback position is one of the most important positions on any football team - we often hear of NFL teams drafting quarterbacks out of college and then having them sit on the bench to learn from the coaches and be mentored by the veteran quarterback. Once the younger quarterback has had time to develop, the veteran quarterback steps aside and continues to mentor and coach the quarterback from the sideline. Sounds great, right? Succession planning at its finest! But again, as I think about some of the great quarterbacks, even if they "mentored" younger quarterbacks for a few years (think Joe Montana and Steve Young, or Brett Favre and Aaron Rogers), the veteran quarterback usually leaves the team to go play somewhere else, rather than sitting on the bench to watch the younger quarterback play.
But absolutely my all-time favorite succession story (in this case, perhaps not altogether successful, but certainly not a failure either) from the sports world comes from the Tour de France! Greg LeMond was the first, and after the last two Americans - Floyd Landis and Lance Armstrong were declared ineligible due to doping violations - the only American to ever win this grueling bicycling race. Greg LeMond was a promising cyclist, finishing first in the 1983 World Road Racing Championships and third in the 1984 Tour de France, recruited by Bernard Hinault ("The Badger") to race for his Team La Vie Claire in the 1985 Tour. Hinault was chasing history by trying to win his fifth Tour de France (only three other men have won five Tours - Jacques Anquetil, Eddy Merckx, and Miguel Indurain) and needed strong riders on his team to help him win (in bicycle road racing, there is usually one rider who is the designated team leader - everyone else on the team rides to help the leader win). Hinault convinced LeMond to join him, partly by promising that he would work just as hard for LeMond the following year as a member of his team (they would, in essence, switch roles). Again, succession planning perhaps as it is designed to work!
During the 1985 Tour, Hinault had trouble and fell behind. At one point (I remember watching this live on television), LeMond found himself in a position where he could easily have taken the race lead and worn the vaunted Yellow Jersey for one day. The Team Director told him that he must not do this - he was riding for Hinault and not for himself. LeMond agreed (very reluctantly, I might add) and Hinault eventually won his fifth Tour. Hinault again publicly promised that he would ride as hard for LeMond the following year as LeMond had done for him at the 1985 Tour. Well, to make a long blog post a little shorter, I will summarize the 1986 Tour. LeMond won his first Tour de France and the Badger came in second. Hinault had challenged LeMond throughout the race, and to many it seemed as if he was actually trying to win the race. Hinault later claimed that he was only pushing LeMond so that he would win. So, maybe this example still meets our definition of successful succession planning?
Unfortunately, I don't have a lot of great examples of successful successions from either the sporting world or from our nation's Presidential history (at least today - maybe in a future blog post!). Suffice it to say that I still think succession planning is absolutely vital to an organization's success. Succession planning is an important aspect of talent management, and it assures a safe, effective transition of leadership for the future.
Sunday, December 11, 2016
Peeling away the layers of the onion - "first principles thinking"
I like metaphors and similes. When I was younger, some of my favorite stories were myths, fables, legends, and folk tales. The common thread in all of these stories was the so-called "moral of the story" - lessons that we, the readers, could learn from the characters in the stories on how to act, how to respond to challenges in life, how to relate to others, and what to do in certain situations. I am still a big believer in the power of stories to teach and to learn. We often learn in this manner - cognitive psychologists would call this method of instruction, "analogous learning."
A recent blog post from Michael Roberto called my attention to a completely different way of thinking. As it turns out, the great innovator and entrepreneur, Elon Musk (of PayPal, Space X, Tesla Motors, and SolarCity fame), believes that we should spend more time learning from a method called first principles thinking as opposed to analogous learning. First principles are basic, foundational, and self-evident ideas, propositions, or assumptions that cannot be deduced from other ideas or principles. In mathematics and physics, first principles are known as axioms or postulates. Conceptually, first principles come from the writings and teachings of the Greek philosopher, Aristotle. Aristotle defined a "first principle" as "the first basis from which a thing is known." In philosophy, first principles are "a priori" rather than "a posteriori" (they are simply assumed to exist, without question).
First principles thinking involves de-constructing an idea to its simplest elements or the fundamental truths. Once you are there, you can develop your ideas more fully and reach an entirely different plane of understanding. "First principles" thinking forces us to "think outside the box" and develop new and different ways to attack a particular problem. There is a famous quote by Henry Ford (whether he actually said it or not is not known for certain) that I believe illustrates what happens when we get stuck in traditional modes of thinking. Ford said, "If I had asked people what they wanted, they would have said faster horses." Ford was a "first principles" kind of thinker, which allowed him to step "outside the box" and improve upon the design of the early automobile.
All good - but it is difficult to get away from analogous learning. I even found an online article that uses an analogy to explain first principles thinking! The article described the process of de-constructing an idea down to its first principles as if you were peeling away the layers of an onion. The heart of the onion is the first principle. The first question you ask peels away the outermost layer of the onion - and you keep asking "why?" (i.e. peeling away another layer) until you reach the inner core of the onion. Only then have you found the first principle!
A recent blog post from Michael Roberto called my attention to a completely different way of thinking. As it turns out, the great innovator and entrepreneur, Elon Musk (of PayPal, Space X, Tesla Motors, and SolarCity fame), believes that we should spend more time learning from a method called first principles thinking as opposed to analogous learning. First principles are basic, foundational, and self-evident ideas, propositions, or assumptions that cannot be deduced from other ideas or principles. In mathematics and physics, first principles are known as axioms or postulates. Conceptually, first principles come from the writings and teachings of the Greek philosopher, Aristotle. Aristotle defined a "first principle" as "the first basis from which a thing is known." In philosophy, first principles are "a priori" rather than "a posteriori" (they are simply assumed to exist, without question).
First principles thinking involves de-constructing an idea to its simplest elements or the fundamental truths. Once you are there, you can develop your ideas more fully and reach an entirely different plane of understanding. "First principles" thinking forces us to "think outside the box" and develop new and different ways to attack a particular problem. There is a famous quote by Henry Ford (whether he actually said it or not is not known for certain) that I believe illustrates what happens when we get stuck in traditional modes of thinking. Ford said, "If I had asked people what they wanted, they would have said faster horses." Ford was a "first principles" kind of thinker, which allowed him to step "outside the box" and improve upon the design of the early automobile.
All good - but it is difficult to get away from analogous learning. I even found an online article that uses an analogy to explain first principles thinking! The article described the process of de-constructing an idea down to its first principles as if you were peeling away the layers of an onion. The heart of the onion is the first principle. The first question you ask peels away the outermost layer of the onion - and you keep asking "why?" (i.e. peeling away another layer) until you reach the inner core of the onion. Only then have you found the first principle!
Wednesday, December 7, 2016
FDR's "Day of Infamy" Speech
Today is the 75th Anniversary of the surprise attack on Pearl Harbor. On December 8, President Franklin D. Roosevelt stood before a joint session of the United States Congress and requested a formal declaration of war. We remember all of those who gave their lives on that fateful day 75 years ago and during all of the days of war that followed thereafter.
Below is the text of the speech that President Roosevelt gave, now known as the "Day of Infamy" speech. During times of crisis, leaders lead.
Vice President, and Mr. Speaker, and Members of the Senate and House of Representatives:
Yesterday, December 7, 1941—a date which will live in infamy—the United States of America was suddenly and deliberately attacked by naval and air forces of the Empire of Japan.
The United States was at peace with that Nation and, at the solicitation of Japan, was still in conversation with its Government and its Emperor looking toward the maintenance of peace in the Pacific. Indeed, one hour after Japanese air squadrons had commenced bombing in the American Island of Oahu, the Japanese Ambassador to the United States and his colleague delivered to our Secretary of State a formal reply to a recent American message. And while this reply stated that it seemed useless to continue the existing diplomatic negotiations, it contained no threat or hint of war or of armed attack.
It will be recorded that the distance of Hawaii from Japan makes it obvious that the attack was deliberately planned many days or even weeks ago. During the intervening time the Japanese Government has deliberately sought to deceive the United States by false statements and expressions of hope for continued peace.
The attack yesterday on the Hawaiian Islands has caused severe damage to American naval and military forces. I regret to tell you that very many American lives have been lost. In addition American ships have been reported torpedoed on the high seas between San Francisco and Honolulu.
Yesterday the Japanese Government also launched an attack against Malaya.
Last night Japanese forces attacked Hong Kong.
Last night Japanese forces attacked Guam.
Last night Japanese forces attacked the Philippine Islands.
Last night the Japanese attacked Wake Island. And this morning the Japanese attacked Midway Island.
Japan has, therefore, undertaken a surprise offensive extending throughout the Pacific area. The facts of yesterday and today speak for themselves. The people of the United States have already formed their opinions and well understand the implications to the very life and safety of our Nation.
As Commander in Chief of the Army and Navy I have directed that all measures be taken for our defense.
But always will our whole Nation remember the character of the onslaught against us.
No matter how long it may take us to overcome this premeditated invasion, the American people in their righteous might will win through to absolute victory. I believe that I interpret the will of the Congress and of the people when I assert that we will not only defend ourselves to the uttermost but will make it very certain that this form of treachery shall never again endanger us.
Hostilities exist. There is no blinking at the fact that our people, our territory, and our interests are in grave danger.
With confidence in our armed forces—with the unbounding determination of our people—we will gain the inevitable triumph- so help us God.
I ask that the Congress declare that since the unprovoked and dastardly attack by Japan on Sunday, December 7, 1941, a state of war has existed between the United States and the Japanese Empire.
Monday, December 5, 2016
HRO: Deference to Expertise
I recently picked up an old book about the game of chess the other day. I never really was all that good at chess, but I have always wanted to be better. It really is an amazing game and is much more complex than most people think. I was talking to my son (who is a much better player than me) who suggested that I learn about some of the classic opening moves. Standardization has been on my mind a lot lately, and I thought perhaps I could develop a few "standard opening move" sequences, depending upon the moves that the other player made in response. Perhaps I could even develop a playbook of sorts - if my opponent does this, then I should do this in response. So I actually started to right down some possibilities in a small notebook. This was going to be great! I was finally going to be able to play chess like the pro's! However, while I was doing some research on the Internet (looking for tips and pointers), I came across an article that stated there are 20 possible opening chess moves (16 possible pawn moves plus 4 possible knight moves - the rest of the pieces can't be moved until one of the pawns has moved out of the way) for the first player, the White player. Similarly, White's opponent (the Black player) also has 20 possible opening moves. Once Black has moved, White is now faced with 400 possible moves. Once White has moved a second time, the Black player has 5,362 possible moves. After that, the numbers get really out of hand (see the calculation here). In other words, even if I did want to write down all the possible moves, I would need more than just one notebook! I would probably need an entire library of notebooks. There is just simply no way to be able to follow a specific kind of algorithm that takes into account every possible contingency. As much as I would like to plan out all my possible moves in a "chess playbook," it is just not possible.
High reliability organizations (HROs) have already figured this out. It would be really great if the leadership team of a HRO could script out the desired response for every single contingency that the rest of the organization could face in the future. Unfortunately, just like in my game of chess, it is just not possible to cover every possible contingency. The very nature of the environments that HROs exist in precludes any kind of script, checklist, or playbook that covers every possible issue. So how do HROs deal with this issue? They push decision making, especially in times of crisis, as much as possible to the frontline leaders and managers. The true experts - the individuals who know their systems the best - are found on the frontlines and not in the board room! Moreover, there is no way that an executive leader can have a full understanding of all the information that is at the frontline. Even with the best communication plans and systems, the individuals who will have the most up-to-date and most accurate information will be the ones on the frontline. The military has a term for the rapidly evolving, chaotic, confusing, and unpredictable nature of combat known as the "fog of war." I think this concept applies to what most HROs deal with on a daily basis! As a famous Marine Corps general once said, "Once the shooting starts, all plans fall apart."
The military has developed a variation on the "deference to expertise" theme known as "commander's intent" (based upon an earlier concept developed by the German military during the early days of World War II, called "auftragstaktik"). Frontline leaders (who are usually far removed from their commanding officers) are provided with a set of orders and instructions that describe the overall goals and objectives of a particular mission, the tactics and strategy that will be used, and the resources that will be immediately available. In other words, the frontline leaders are given a rough blueprint of the battle plan and are then told to go and complete the mission. "Commander's intent" is a really beautiful example of the last defining characteristic of a high reliability organization - "deference to expertise."
I am not against standardization in health care - in fact, I think we need to standardize, as much as possible, as many key processes that lend themselves to standardization. Used in such a manner, standardization can and will improve outcomes and reduce costs. However, I do think that we need to be careful not to over-script and over-plan for every possibility - there is just no feasible way to do that. We would be much better off taking a cue from the military ("commander's intent") and other HROs, who leverage their frontline experts as much as possible. Do these frontline leaders have specific and detailed instructions? Yes - absolutely. Do these frontline leaders have guidelines and guardrails within which they are free to make decisions? They sure do. Developing these concepts will require education and training - over and over and over again. It is the right kind of investment to make though, and it will make a significant difference for our patients. For now, I guess I better go back to learning more about the different kinds of chess moves and practice, practice, practice!
High reliability organizations (HROs) have already figured this out. It would be really great if the leadership team of a HRO could script out the desired response for every single contingency that the rest of the organization could face in the future. Unfortunately, just like in my game of chess, it is just not possible to cover every possible contingency. The very nature of the environments that HROs exist in precludes any kind of script, checklist, or playbook that covers every possible issue. So how do HROs deal with this issue? They push decision making, especially in times of crisis, as much as possible to the frontline leaders and managers. The true experts - the individuals who know their systems the best - are found on the frontlines and not in the board room! Moreover, there is no way that an executive leader can have a full understanding of all the information that is at the frontline. Even with the best communication plans and systems, the individuals who will have the most up-to-date and most accurate information will be the ones on the frontline. The military has a term for the rapidly evolving, chaotic, confusing, and unpredictable nature of combat known as the "fog of war." I think this concept applies to what most HROs deal with on a daily basis! As a famous Marine Corps general once said, "Once the shooting starts, all plans fall apart."
The military has developed a variation on the "deference to expertise" theme known as "commander's intent" (based upon an earlier concept developed by the German military during the early days of World War II, called "auftragstaktik"). Frontline leaders (who are usually far removed from their commanding officers) are provided with a set of orders and instructions that describe the overall goals and objectives of a particular mission, the tactics and strategy that will be used, and the resources that will be immediately available. In other words, the frontline leaders are given a rough blueprint of the battle plan and are then told to go and complete the mission. "Commander's intent" is a really beautiful example of the last defining characteristic of a high reliability organization - "deference to expertise."
I am not against standardization in health care - in fact, I think we need to standardize, as much as possible, as many key processes that lend themselves to standardization. Used in such a manner, standardization can and will improve outcomes and reduce costs. However, I do think that we need to be careful not to over-script and over-plan for every possibility - there is just no feasible way to do that. We would be much better off taking a cue from the military ("commander's intent") and other HROs, who leverage their frontline experts as much as possible. Do these frontline leaders have specific and detailed instructions? Yes - absolutely. Do these frontline leaders have guidelines and guardrails within which they are free to make decisions? They sure do. Developing these concepts will require education and training - over and over and over again. It is the right kind of investment to make though, and it will make a significant difference for our patients. For now, I guess I better go back to learning more about the different kinds of chess moves and practice, practice, practice!
Wednesday, November 30, 2016
Did he really say, "Shut up and listen"?
I came across a good TED talk the other day by an Italian developmental economist named Ernesto Sirolli. Oddly enough, I heard about this particular TED talk at our church this summer. I can't remember what exactly the priest was talking about, but he did recommend Sirolli's book, Ripples from Zambezi: Passion, Entrepreneurship, and the Rebirth of Local Economies as well as the TED talk, "Want to help someone? Shut up and Listen!" Sirolli tells of one of his early experiences with an Italian non-governmental organization (NGO) - every one of the projects that the NGO attempted in Africa had failed. He tells one particularly poignant story of an early project that involved teaching the local African population how to grow food. The NGO brought Italian seeds to southern Zambia in order to teach the locals how to grow Italian tomatoes and zucchini. The area was located along the Zambezi River, and Sirolli tells how the tomatoes grew to two or three times the size of even the best tomatoes in Italy. He goes on to say how the locals really weren't that interested in learning how to grow tomatoes and zucchini. They tried paying them, which did work for some, at least on occasion. Sirolli and his team were obviously very frustrated with the Zambians, but "instead of asking them how come they were not growing anything, we simply said Thank God we're here!" The Italian aid workers were really proud of how well the tomatoes and zucchini were growing - "just think what we can accomplish here! We will save the Zambian people from starvation." But then, overnight, 200 hippos came out from the river and ate all the tomatoes and zucchini. "And we said to the Zambians, My God, the hippos! And the Zambians said, Yes, that's why we don't try to grow things along the river." The Italians asked why the Zambians didn't warn them of the hippos. "And the Zambians said, You never asked!"
Sirolli's message really struck home with me. How many times do we experience a similar phenomenon with any kind of change initiative? The most successful projects or initiatives that I have observed (in fact, nearly all of them) usually have two elements in common. Number one - the project team is super-engaged and passionate about the work. Number two - the project team takes complete ownership of the project - the planning and design of the project, as well as the implementation and execution of the work. On the other hand, the projects that are 100% led in a top-down fashion almost invariably end in failure. So, I guess it really does pay to "shut up and listen." Incidentally, Sirolli's advice is a really great example of the High Reliability Organization principle of "deference to expertise," which we will discuss next.
Sirolli's message really struck home with me. How many times do we experience a similar phenomenon with any kind of change initiative? The most successful projects or initiatives that I have observed (in fact, nearly all of them) usually have two elements in common. Number one - the project team is super-engaged and passionate about the work. Number two - the project team takes complete ownership of the project - the planning and design of the project, as well as the implementation and execution of the work. On the other hand, the projects that are 100% led in a top-down fashion almost invariably end in failure. So, I guess it really does pay to "shut up and listen." Incidentally, Sirolli's advice is a really great example of the High Reliability Organization principle of "deference to expertise," which we will discuss next.
Sunday, November 27, 2016
A night at the theatre
Last night, I let my daughter talk me into taking the family to go see "Phantom of the Opera." My youngest daughter has seen the movie, listened to the soundtrack countless times, and read the book (Le Fantôme de l'Opéra by Gaston Leroux), I think (I can't remember exactly - my response "It was a book!?!?!?"). She had always wanted to see the musical on stage, but until last night she had not been able to do so. Therefore, our family (minus a daughter who had returned to college) all saw the musical for the first time together. It was really quite an enjoyable experience.
I actually used to go see musicals fairly often as a child - my parents took my sister and I to see Oklahoma!, Camelot, The Music Man, The Sound of Music, Show Boat, Seven Brides for Seven Brothers, The Stephen Foster Story, South Pacific, and many more at a place called "Starlight Musicals"in Indianapolis, Indiana. I mention this as I reflect that for the past several years, I have heard concerns about how children in the United States lag behind children from other countries in science and mathematics. I fully understand and agree that in order to be competitive in today's global environment, we as a nation need to narrow the gap in the so-called STEM subjects (Science, Technology, Engineering, and Mathematics). Our educational system needs to do better. However, I am also reminded (yet again - please see my previous blog post, September 7, 2016) that subjects such as Literature, Art, Music, Drama, History, and Philosophy matter too.
The Abbe Faria, one of the characters in one of my favorite novels, "The Count of Monte Cristo" by Alexandre Dumas, teaches the main character, Edmond Dantes, "everything he knows" during their imprisonment. He teaches Dantes mathematics, economics, physics, but also history, philosophy, and "three or four modern languages." The Abbe tells Dantes, "...to learn is not to know; there are the learners and the learned. Memory makes the one, philosophy the other." He seems to paraphrase the Greek philosopher, Socrates here, who defined wisdom as knowing what you don't know rather than knowing everything ("The only true wisdom is knowing you know nothing.").
I believe that leaders need to broaden their horizon. I see nothing wrong with being a "Jack of all trades, but the Master of none" here - some leadership gurus have referred to this as a "T-shaped" leaders, i.e. leaders who are deep in knowledge and skills for one particular area of focus (usually the discipline in which they lead) but well-versed in a broad range of knowledge and skills (expert in one area, highly competent in a number of areas). Leaders should be well read in a variety of subjects - a broad knowledge base acquired through a professional reading program (focusing on subjects outside the leader's traditional area of expertise) has been scientifically proven to improve memory, increase creativity, reduce stress, develop verbal and non-verbal skills, and increase compassion.
We, as leaders, need more exposure to the arts and humanities - my visit to the theatre last night once again emphasized that to me, and for that, I guess I owe my daughter a simple, "Thank you."
I actually used to go see musicals fairly often as a child - my parents took my sister and I to see Oklahoma!, Camelot, The Music Man, The Sound of Music, Show Boat, Seven Brides for Seven Brothers, The Stephen Foster Story, South Pacific, and many more at a place called "Starlight Musicals"in Indianapolis, Indiana. I mention this as I reflect that for the past several years, I have heard concerns about how children in the United States lag behind children from other countries in science and mathematics. I fully understand and agree that in order to be competitive in today's global environment, we as a nation need to narrow the gap in the so-called STEM subjects (Science, Technology, Engineering, and Mathematics). Our educational system needs to do better. However, I am also reminded (yet again - please see my previous blog post, September 7, 2016) that subjects such as Literature, Art, Music, Drama, History, and Philosophy matter too.
The Abbe Faria, one of the characters in one of my favorite novels, "The Count of Monte Cristo" by Alexandre Dumas, teaches the main character, Edmond Dantes, "everything he knows" during their imprisonment. He teaches Dantes mathematics, economics, physics, but also history, philosophy, and "three or four modern languages." The Abbe tells Dantes, "...to learn is not to know; there are the learners and the learned. Memory makes the one, philosophy the other." He seems to paraphrase the Greek philosopher, Socrates here, who defined wisdom as knowing what you don't know rather than knowing everything ("The only true wisdom is knowing you know nothing.").
I believe that leaders need to broaden their horizon. I see nothing wrong with being a "Jack of all trades, but the Master of none" here - some leadership gurus have referred to this as a "T-shaped" leaders, i.e. leaders who are deep in knowledge and skills for one particular area of focus (usually the discipline in which they lead) but well-versed in a broad range of knowledge and skills (expert in one area, highly competent in a number of areas). Leaders should be well read in a variety of subjects - a broad knowledge base acquired through a professional reading program (focusing on subjects outside the leader's traditional area of expertise) has been scientifically proven to improve memory, increase creativity, reduce stress, develop verbal and non-verbal skills, and increase compassion.
We, as leaders, need more exposure to the arts and humanities - my visit to the theatre last night once again emphasized that to me, and for that, I guess I owe my daughter a simple, "Thank you."
Tuesday, November 22, 2016
HRO: Commitment to Resilience
High reliability organizations (HROs) are 100% fully committed to resilience. Resilience is defined as the capacity to quickly recover or "bounce back" from difficulties. By their very nature, HROs are highly complex and tightly coupled. In other words, these organizations are highly interdependent - a small error in one part of the organization can impact a completely separate part of the organization. Furthermore, these small errors are often compounded and magnified. HROs also exist in unforgiving environments where learning by experimentation is often neither feasible or safe. In reality, by developing resilient systems with multiple back-ups and mitigation plans, HROs have made themselves even more complex and more tightly coupled!
When I think of resilience, I am drawn to a particular quote by the martial artist, television and movie celebrity, and philosopher, Bruce Lee. Lee used the analogy of water in one of his most famous quotes ("Be like water my friend"). The quote actually comes from a very short-lived TV series, "Longstreet" in which Lee explained one of the tenets of his philosophy of Gung Fu. He explains how he came to this analogy:
After spending many hours meditating and practicing, I gave up and went sailing alone in a junk. On the sea I thought of all my past training and got mad at myself and punched the water! Right then — at that moment — a thought suddenly struck me; was not this water the very essence of gung fu? Hadn’t this water just now illustrated to me the principle of gung fu? I struck it but it did not suffer hurt. Again I struck it with all of my might — yet it was not wounded! I then tried to grasp a handful of it but this proved impossible. This water, the softest substance in the world, which could be contained in the smallest jar, only seemed weak. In reality, it could penetrate the hardest substance in the world. That was it! I wanted to be like the nature of water.
Suddenly a bird flew by and cast its reflection on the water. Right then I was absorbing myself with the lesson of the water, another mystic sense of hidden meaning revealed itself to me; should not the thoughts and emotions I had when in front of an opponent pass like the reflection of the birds flying over the water? This was exactly what Professor Yip meant by being detached — not being without emotion or feeling, but being one in whom feeling was not sticky or blocked. Therefore in order to control myself I must first accept myself by going with and not against my nature.
Professor Yip was Lee's martial arts instructor before he became famous. Yip taught Lee the Chinese philosophy Wing Chun, which he adapted into his own philosophy of Gung Fu. It really is a beautiful metaphor for resilience:
Be like water making its way through cracks. Do not be assertive, but adjust to the object, and you shall find a way around or through it. If nothing within you stays rigid, outward things will disclose themselves.
Empty your mind, be formless. Shapeless, like water. If you put water into a cup, it becomes the cup. You put water into a bottle and it becomes the bottle. You put it in a teapot, it becomes the teapot. Now, water can flow or it can crash. Be water, my friend.
High reliability organizations are like that. They adapt to their circumstances. They roll with the punches, so to speak. They can be anything at anytime, as circumstances dictate. "Be water, my friend."
When I think of resilience, I am drawn to a particular quote by the martial artist, television and movie celebrity, and philosopher, Bruce Lee. Lee used the analogy of water in one of his most famous quotes ("Be like water my friend"). The quote actually comes from a very short-lived TV series, "Longstreet" in which Lee explained one of the tenets of his philosophy of Gung Fu. He explains how he came to this analogy:
After spending many hours meditating and practicing, I gave up and went sailing alone in a junk. On the sea I thought of all my past training and got mad at myself and punched the water! Right then — at that moment — a thought suddenly struck me; was not this water the very essence of gung fu? Hadn’t this water just now illustrated to me the principle of gung fu? I struck it but it did not suffer hurt. Again I struck it with all of my might — yet it was not wounded! I then tried to grasp a handful of it but this proved impossible. This water, the softest substance in the world, which could be contained in the smallest jar, only seemed weak. In reality, it could penetrate the hardest substance in the world. That was it! I wanted to be like the nature of water.
Suddenly a bird flew by and cast its reflection on the water. Right then I was absorbing myself with the lesson of the water, another mystic sense of hidden meaning revealed itself to me; should not the thoughts and emotions I had when in front of an opponent pass like the reflection of the birds flying over the water? This was exactly what Professor Yip meant by being detached — not being without emotion or feeling, but being one in whom feeling was not sticky or blocked. Therefore in order to control myself I must first accept myself by going with and not against my nature.
Professor Yip was Lee's martial arts instructor before he became famous. Yip taught Lee the Chinese philosophy Wing Chun, which he adapted into his own philosophy of Gung Fu. It really is a beautiful metaphor for resilience:
Be like water making its way through cracks. Do not be assertive, but adjust to the object, and you shall find a way around or through it. If nothing within you stays rigid, outward things will disclose themselves.
Empty your mind, be formless. Shapeless, like water. If you put water into a cup, it becomes the cup. You put water into a bottle and it becomes the bottle. You put it in a teapot, it becomes the teapot. Now, water can flow or it can crash. Be water, my friend.
High reliability organizations are like that. They adapt to their circumstances. They roll with the punches, so to speak. They can be anything at anytime, as circumstances dictate. "Be water, my friend."
Sunday, November 20, 2016
"A few appropriate remarks..."
When I was in eighth grade, our Social Studies teacher gave us an assignment - recite from memory Lincoln's Gettysburg Address. In hindsight, it really wasn't that difficult of an assignment, given the fact that there are only 272 words of text to memorize. Unfortunately, even though I had memorized the speech, I never fully appreciated (at least until many years later) the significance of the text itself. These words are powerful, and they are packed with symbolism.
The speech was delivered on November 19, 1863 (yesterday marks the 153rd anniversary of the speech) at the dedication of the Soldier's National Cemetery in Gettysburg, Pennsylvania. Gettysburg had been the site of an epic battle between the Union's Army of the Potomac and the Confederate's Army of Northern Virginia only four and a half months prior to the dedication ceremony. The battle marked a turning point in the Civil War and was at the time (and until the Battle of the Argonne Forest in World War I) the deadliest battle, in terms of lives lost, in our nation's history.
The dedication ceremony's program started with a two-hour long speech by Edward Everett (who served as a U.S. Representative, U.S. Senator, Governor of Massachusetts, Minister to Great Britain, U.S. Secretary of State, and President of Harvard University). The quality of a speech at that time was measured largely by its length - so by all measures of the day, Everett's speech was a great one! Lincoln stood up at the end of Everett's speech to give "a few appropriate remarks." In just 10 sentences and in a speech lasting just over 2 minutes, Lincoln was able to re-iterate the principles of liberty and equality originally stated in the Declaration of Independence. In these 272 words, Lincoln redefined the Civil War not just as a struggle to maintain the Union (keeping all Confederate states as part of the United States of America), but also as a fight to preserve the individual rights of freedom and equality:
Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal. Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived and so dedicated, can long endure. We are met on a great battlefield of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.
But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
Everett himself wrote Lincoln the following day, stating, "I should be glad if I could flatter myself that I came as near to the central idea of the occasion, in two hours, as you did in two minutes."
It is a great speech - perhaps one of the greatest speeches ever delivered by a U.S. President. Lincoln was a gifted orator, but the beauty and the power of his Gettysburg Address rests in its simplicity and its brevity. I think the speech demonstrates the power of just a few simple words.
With many of the struggles that we are going through as a country today, it is my hope that we will all rediscover Lincoln's Gettysburg Address and re-dedicate our lives to the principles espoused in the Declaration of Independence, that we are all equal and that "government of the people, by the people, for the people" will endure forever.
The speech was delivered on November 19, 1863 (yesterday marks the 153rd anniversary of the speech) at the dedication of the Soldier's National Cemetery in Gettysburg, Pennsylvania. Gettysburg had been the site of an epic battle between the Union's Army of the Potomac and the Confederate's Army of Northern Virginia only four and a half months prior to the dedication ceremony. The battle marked a turning point in the Civil War and was at the time (and until the Battle of the Argonne Forest in World War I) the deadliest battle, in terms of lives lost, in our nation's history.
The dedication ceremony's program started with a two-hour long speech by Edward Everett (who served as a U.S. Representative, U.S. Senator, Governor of Massachusetts, Minister to Great Britain, U.S. Secretary of State, and President of Harvard University). The quality of a speech at that time was measured largely by its length - so by all measures of the day, Everett's speech was a great one! Lincoln stood up at the end of Everett's speech to give "a few appropriate remarks." In just 10 sentences and in a speech lasting just over 2 minutes, Lincoln was able to re-iterate the principles of liberty and equality originally stated in the Declaration of Independence. In these 272 words, Lincoln redefined the Civil War not just as a struggle to maintain the Union (keeping all Confederate states as part of the United States of America), but also as a fight to preserve the individual rights of freedom and equality:
Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal. Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived and so dedicated, can long endure. We are met on a great battlefield of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.
But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
Everett himself wrote Lincoln the following day, stating, "I should be glad if I could flatter myself that I came as near to the central idea of the occasion, in two hours, as you did in two minutes."
It is a great speech - perhaps one of the greatest speeches ever delivered by a U.S. President. Lincoln was a gifted orator, but the beauty and the power of his Gettysburg Address rests in its simplicity and its brevity. I think the speech demonstrates the power of just a few simple words.
With many of the struggles that we are going through as a country today, it is my hope that we will all rediscover Lincoln's Gettysburg Address and re-dedicate our lives to the principles espoused in the Declaration of Independence, that we are all equal and that "government of the people, by the people, for the people" will endure forever.
Wednesday, November 16, 2016
"Five Things"
Last night, I had the honor and privilege of attending a special ceremony in Columbus, Ohio - my mentor, colleague, and friend, Richard J. Brilli, MD, MCCM received the John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality & Safety. Rich has taught me so much and has done so much for my career over the years, that I would not have missed this ceremony for the world.
Those of you who have worked with Rich in the Pediatric Intensive Care Unit (PICU) will remember that he always taught about "five things." For example, there are "5 causes of arterial hypoxemia," "5 reasons that children get admitted to the PICU following spinal fusion surgery" (at least in the old days), and at least "5 bugs that can kill you." I used to joke with Rich about this when I was a PICU fellow - however, the joke was always on me. I had to laugh (inwardly, of course) on my first day of clinical service as an attending when all of the residents were waiting for me to say something half-way intelligent. I quickly reverted to the "five things" method of bedside teaching!
As I was thinking last night, there are at least "five things" that Rich has taught me about leadership. Specifically, there are "5 leadership values" that Rich taught me - these remain personal values for me to this day.
1. Honor: Rich said it best last night during his acceptance speech. "It is a blessing. It is a gift. It is a privilege to do what we do every day. Honor it." Above all else, honor the patient in front of you.
2. Courage: Rich always taught me to have the courage to stick to your core principles and your core values. Everything else flows from your core values. Stand up for what you believe in. Stand up for those who can't.
3. Commitment: Making clinical decisions about someone else's critically ill child is frightening. But you owe it to the patient to make that decision, and once you do make the decision, be strong and stay committed to it. I think the same is true in health care administration. If you honor the patients your organization is taking care of (#1) and stick to your core principles (#2), the decision you make is more than likely the correct one. Stay committed to that decision and course of action, until the information tells you it is time to make a new one.
4. Humility: Working in the PICU is difficult - on any given patient, there are probably at least 100 different ways that you can make a mistake or error and cause harm to the patient. Be humble. We work in a difficult field in healthcare - there is no place for haughtiness and ego here.
5. Patience: Rich joked last night that he had some "idiosyncracies" - he does! But he was always patient, especially with the residents and fellows. Have patience with those who work for you. Give them breathing room. Give them enough autonomy to develop (some of the best ways to learn is by making a mistake) without placing the patient in harm's way. Again, there is something here for those of us in health care administration as well. Leadership is a learned skill - it takes time and practice. Be patient with new and emerging leaders.
Again, thank you Rich for everything you have done - for your patients and their families, for all of the medical students, residents, fellows, and junior attendings that have worked with you, and for me personally. We owe you a lot more than you will ever know. Congratulations! Here's to the almighty Fick equation and "five things"!
Those of you who have worked with Rich in the Pediatric Intensive Care Unit (PICU) will remember that he always taught about "five things." For example, there are "5 causes of arterial hypoxemia," "5 reasons that children get admitted to the PICU following spinal fusion surgery" (at least in the old days), and at least "5 bugs that can kill you." I used to joke with Rich about this when I was a PICU fellow - however, the joke was always on me. I had to laugh (inwardly, of course) on my first day of clinical service as an attending when all of the residents were waiting for me to say something half-way intelligent. I quickly reverted to the "five things" method of bedside teaching!
As I was thinking last night, there are at least "five things" that Rich has taught me about leadership. Specifically, there are "5 leadership values" that Rich taught me - these remain personal values for me to this day.
1. Honor: Rich said it best last night during his acceptance speech. "It is a blessing. It is a gift. It is a privilege to do what we do every day. Honor it." Above all else, honor the patient in front of you.
2. Courage: Rich always taught me to have the courage to stick to your core principles and your core values. Everything else flows from your core values. Stand up for what you believe in. Stand up for those who can't.
3. Commitment: Making clinical decisions about someone else's critically ill child is frightening. But you owe it to the patient to make that decision, and once you do make the decision, be strong and stay committed to it. I think the same is true in health care administration. If you honor the patients your organization is taking care of (#1) and stick to your core principles (#2), the decision you make is more than likely the correct one. Stay committed to that decision and course of action, until the information tells you it is time to make a new one.
4. Humility: Working in the PICU is difficult - on any given patient, there are probably at least 100 different ways that you can make a mistake or error and cause harm to the patient. Be humble. We work in a difficult field in healthcare - there is no place for haughtiness and ego here.
5. Patience: Rich joked last night that he had some "idiosyncracies" - he does! But he was always patient, especially with the residents and fellows. Have patience with those who work for you. Give them breathing room. Give them enough autonomy to develop (some of the best ways to learn is by making a mistake) without placing the patient in harm's way. Again, there is something here for those of us in health care administration as well. Leadership is a learned skill - it takes time and practice. Be patient with new and emerging leaders.
Again, thank you Rich for everything you have done - for your patients and their families, for all of the medical students, residents, fellows, and junior attendings that have worked with you, and for me personally. We owe you a lot more than you will ever know. Congratulations! Here's to the almighty Fick equation and "five things"!
Sunday, November 13, 2016
It's "gut check" time!
It has been an interesting week! The results of the recent U.S. Presidential election came as quite a shock (and dare I say, quite a disappointment) to many of us in the United States. Just about every major poll in the days and weeks prior to last Tuesday had predicted that Hillary Clinton would win a very tight race. Several political pundits had even predicted that she would win the Electoral College but lose the popular vote. The exact opposite happened - Donald Trump won the Electoral College (fairly easily) but will likely lose the popular vote by about 200,000 votes (there are still absentee votes to be counted). What happened with the predictions? How could the pollsters have been so wrong? There are a number of theories that have been put forth - for example, some experts have suggested that some of the individuals who were polled before the election were not completely honest with who they were going to support in the election. Regardless, I think that many of us will look at polls and predictions in the future with a healthy dose of skepticism.
I have talked about a number of studies that show that statistical analyses and computer algorithms are more accurate than humans in decision making in a variety of circumstances (see "Humans versus computers in decision making" from one of my earlier blog posts). I would like to suggest, however, that there is a time and place for so-called "gut feelings" - even in health care. Narayan Kandasamy and colleagues recently published a very interesting study on "gut instinct" and "gut feelings" ("Interoceptive ability predicts survival on a London trading floor"). The investigators in this study analyzed whether interoceptive ability (the ability to detect and respond to somatic signals, such as quickening heart rate, breathlessness, "butterflies in the stomach", or sweating - basically everything that a lie detector test measures) could predict whether a high-frequency trader is successful making profitable investments. High frequency trading requires quick thinking - these traders have to make a decision in a matter of seconds on whether to buy or sell a particular stock investment. Their individual livelihoods depend upon their ability to predict the right stock. Kandasamy's team of investigators theorized that successful traders used "gut instinct" to make their decisions. Those traders who could "detect" (unconsciously, of course) an increase in their heart rate would be more attuned to their gut-level instincts - these investigators, would in turn, be more likely to make the correct (i.e. profitable) decisions on their investments. The results of this study suggested the following:
1. High-frequency traders had a better interoceptive ability (i.e. they could tell the investigators their heart rate without measuring their own pulse) compared to age- and gender-matched control subjects (graduate students).
2. Interoceptive ability predicted which high-frequency traders were the most successful (as determined by their individual profit-loss statements).
3. Experienced (in terms of the number of years on the job) high-frequency traders had a better interoceptive ability than less experienced traders.
4. The traders were asked how confident they were in determining their individual heart rates - unfortunately, there was no relationship between their degree of confidence in their heart rate predictions and the accuracy of these predictions, or in the accuracy of their decision making.
This is a great study that raises a number of interesting points to ponder further. It is clear that "gut instinct" can play a role in making accurate decisions. The dilemma here is that we really can't know whose "gut feeling" is accurate. The study suggested that the traders with a lower body mass index, lower resting heart rate, and lower beat-to-beat variability had a greater degree of interoceptive ability than the rest of the traders. I am not sure what this means, but I would surmise that those traders with a lower, more consistent heart rate would be more likely to "pick up" even a subtle increase in their heart rate when trying to make a decision (the lower resting heart rate and beat-to-beat variability, in effect, improves the signal-to-noise ratio). This would suggest that we could potentially "train" an individual to respond to "gut feelings." This is, in effect, what we are doing when we perform drills and simulations (e.g. mock codes and mass casualty exercises in health care, flight simulations in aviation, and war games in the military).
We have learned to pay attention to "gut feelings" in health care. For example, Beth Crandall published a study several years ago that suggested that nurses in the neonatal ICU respond to "gut feelings" to diagnose infants with life-threatening sepsis, often before more obvious signs and symptoms manifest. We have operationalized "gut feelings" in our hospital by teaching bedside providers to verbalize their concerns about particular patients who may get sicker and require transfer to the ICU using the term "watcher" (we published this work in the journal, Pediatrics).
So, which is better - gut instinct or computerized algorithms? The answer is probably both. I think we need to work with both cognitive psychologists and human factors engineers to develop techniques and methods to fully utilize all of the information available to the bedside provider to provide the best care to our patients - both the "Big Data" available in the electronic medical record, published literature, and Internet, as well as the information provided by so-called hunches and gut feelings. We need to identify the best way to reduce the signal-to-noise ratio of our "gut feelings" through repetitive simulation training (the more realistic the better). We also need to train providers to pay attention to their "gut feelings." And perhaps most importantly, we need to identify useful indicators of whose "gut feeling" is accurate and whose is not. Humans will never be able to pull together all of the information available as rapidly (and as accurately) as a computer can do, but computers will never be able to completely replace the human providers at the bedside. For this reason, there will always be a place for "gut feelings" and "gut instincts".
I have talked about a number of studies that show that statistical analyses and computer algorithms are more accurate than humans in decision making in a variety of circumstances (see "Humans versus computers in decision making" from one of my earlier blog posts). I would like to suggest, however, that there is a time and place for so-called "gut feelings" - even in health care. Narayan Kandasamy and colleagues recently published a very interesting study on "gut instinct" and "gut feelings" ("Interoceptive ability predicts survival on a London trading floor"). The investigators in this study analyzed whether interoceptive ability (the ability to detect and respond to somatic signals, such as quickening heart rate, breathlessness, "butterflies in the stomach", or sweating - basically everything that a lie detector test measures) could predict whether a high-frequency trader is successful making profitable investments. High frequency trading requires quick thinking - these traders have to make a decision in a matter of seconds on whether to buy or sell a particular stock investment. Their individual livelihoods depend upon their ability to predict the right stock. Kandasamy's team of investigators theorized that successful traders used "gut instinct" to make their decisions. Those traders who could "detect" (unconsciously, of course) an increase in their heart rate would be more attuned to their gut-level instincts - these investigators, would in turn, be more likely to make the correct (i.e. profitable) decisions on their investments. The results of this study suggested the following:
1. High-frequency traders had a better interoceptive ability (i.e. they could tell the investigators their heart rate without measuring their own pulse) compared to age- and gender-matched control subjects (graduate students).
2. Interoceptive ability predicted which high-frequency traders were the most successful (as determined by their individual profit-loss statements).
3. Experienced (in terms of the number of years on the job) high-frequency traders had a better interoceptive ability than less experienced traders.
4. The traders were asked how confident they were in determining their individual heart rates - unfortunately, there was no relationship between their degree of confidence in their heart rate predictions and the accuracy of these predictions, or in the accuracy of their decision making.
This is a great study that raises a number of interesting points to ponder further. It is clear that "gut instinct" can play a role in making accurate decisions. The dilemma here is that we really can't know whose "gut feeling" is accurate. The study suggested that the traders with a lower body mass index, lower resting heart rate, and lower beat-to-beat variability had a greater degree of interoceptive ability than the rest of the traders. I am not sure what this means, but I would surmise that those traders with a lower, more consistent heart rate would be more likely to "pick up" even a subtle increase in their heart rate when trying to make a decision (the lower resting heart rate and beat-to-beat variability, in effect, improves the signal-to-noise ratio). This would suggest that we could potentially "train" an individual to respond to "gut feelings." This is, in effect, what we are doing when we perform drills and simulations (e.g. mock codes and mass casualty exercises in health care, flight simulations in aviation, and war games in the military).
We have learned to pay attention to "gut feelings" in health care. For example, Beth Crandall published a study several years ago that suggested that nurses in the neonatal ICU respond to "gut feelings" to diagnose infants with life-threatening sepsis, often before more obvious signs and symptoms manifest. We have operationalized "gut feelings" in our hospital by teaching bedside providers to verbalize their concerns about particular patients who may get sicker and require transfer to the ICU using the term "watcher" (we published this work in the journal, Pediatrics).
So, which is better - gut instinct or computerized algorithms? The answer is probably both. I think we need to work with both cognitive psychologists and human factors engineers to develop techniques and methods to fully utilize all of the information available to the bedside provider to provide the best care to our patients - both the "Big Data" available in the electronic medical record, published literature, and Internet, as well as the information provided by so-called hunches and gut feelings. We need to identify the best way to reduce the signal-to-noise ratio of our "gut feelings" through repetitive simulation training (the more realistic the better). We also need to train providers to pay attention to their "gut feelings." And perhaps most importantly, we need to identify useful indicators of whose "gut feeling" is accurate and whose is not. Humans will never be able to pull together all of the information available as rapidly (and as accurately) as a computer can do, but computers will never be able to completely replace the human providers at the bedside. For this reason, there will always be a place for "gut feelings" and "gut instincts".
Tuesday, November 8, 2016
HRO: Sensitivity to Operations
Okay, I confess. I have seen the movie, "Top Gun" more times than I would like to admit. The movie is a bit cheesy in parts and totally unrealistic, but it is classic 1980's. The movie does have unique appeal - in fact, the United States Library of Congress placed the film in the National Film Registry in 2015, calling the movie "culturally significant." There is a quote towards the beginning of the movie - in the infamous bar scene ("You've lost that loving feeling!"). The two protagonists of the movie, Maverick (an F-14 pilot, played by Tom Cruise in one of the roles that made him famous) and Goose (the Radar Intercept Officer, played by Anthony Edwards, who later starred in the TV series, "ER") are talking about one of the other F-14 pilots, following up on an earlier question in which Maverick had wondered who was the best pilot among all the other pilots at Top Gun. The quote goes something like this:
Goose: Mav, you want to know who's the best? That's him. Iceman. It's the way he flies - Ice cold. No mistakes. Wears you down. After enough time, you just get bored and frustrated, you do something stupid, and he's got you.
Iceman (played by the actor, Val Kilmer) is Maverick's nemesis throughout the movie (spoiler alert: they, of course, become the best of friends at the end of the movie) and does everything "by the book." One could argue that his flying is highly standardized with little variation from the textbook (if such a book on F-14 combat tactics existed) and little variation from minute-to-minute. In other words, Iceman focuses on "operational excellence", what High Reliability Organizations would call "sensitivity to operations."
Operational excellence is characterized by standardization of best practices and elimination of waste, through continuous process improvement. It is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement. Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and W. Edwards Deming.
Practically, operational excellence in a nuclear power plant (to use a different example of HRO) means that the technicians follow standard operating procedures, each and every time. The nuclear power plant technicians use checklists and other cues to help them follow highly technical procedures in the exact same sequence from shift to shift, day to day, year to year. Performance is monitored closely (monitoring is also standardized) - any deviations from normal are quickly recognized and corrected, again according to a defined, standardized protocol. The nuclear power plant technicians understand measurement and statistical process control. These technicians use measurement and statistical process control charts in order to understand what is happening in their work environment.
Operational excellence has a role to play in today's health care environment. I whole-heartedly agree that "patients are not widgets" and that "we shouldn't practice cookbook medicine." Standardization, one of the key elements in operational excellence, is NOT "cookbook medicine." There is simply no justification for why we should not standardize the care of common conditions (e.g. management of diabetic ketoacidosis, acute chest pain, or acute asthma exacerbation) or processes (e.g. care and maintenance of central lines, urinary catheters, surgical time-outs) - these are the kinds of conditions and processes that should be managed the same way, every day, by each and every member of the health care team. With the care of common conditions, there is some room to maneuver, so to speak. For example, if a patient deviates from the expected clinical course, then and only then should we deviate from a standardized treatment protocol. However, there is no reason why we should deviate from standardized protocols for surgical time-outs, shift hand-offs, or maintenance of central lines.
If hospitals are to become high reliability organizations, we must embrace the core tenets of operational excellence. We must be sensitive to operations - what is happening on the front lines of health care. The good news is that many health care organizations have demonstrated that standardization of best practices and elimination of waste through operational excellence can lead to sustained improvement in outcomes and lower costs.
Goose: Mav, you want to know who's the best? That's him. Iceman. It's the way he flies - Ice cold. No mistakes. Wears you down. After enough time, you just get bored and frustrated, you do something stupid, and he's got you.
Iceman (played by the actor, Val Kilmer) is Maverick's nemesis throughout the movie (spoiler alert: they, of course, become the best of friends at the end of the movie) and does everything "by the book." One could argue that his flying is highly standardized with little variation from the textbook (if such a book on F-14 combat tactics existed) and little variation from minute-to-minute. In other words, Iceman focuses on "operational excellence", what High Reliability Organizations would call "sensitivity to operations."
Operational excellence is characterized by standardization of best practices and elimination of waste, through continuous process improvement. It is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement. Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and W. Edwards Deming.
Practically, operational excellence in a nuclear power plant (to use a different example of HRO) means that the technicians follow standard operating procedures, each and every time. The nuclear power plant technicians use checklists and other cues to help them follow highly technical procedures in the exact same sequence from shift to shift, day to day, year to year. Performance is monitored closely (monitoring is also standardized) - any deviations from normal are quickly recognized and corrected, again according to a defined, standardized protocol. The nuclear power plant technicians understand measurement and statistical process control. These technicians use measurement and statistical process control charts in order to understand what is happening in their work environment.
Operational excellence has a role to play in today's health care environment. I whole-heartedly agree that "patients are not widgets" and that "we shouldn't practice cookbook medicine." Standardization, one of the key elements in operational excellence, is NOT "cookbook medicine." There is simply no justification for why we should not standardize the care of common conditions (e.g. management of diabetic ketoacidosis, acute chest pain, or acute asthma exacerbation) or processes (e.g. care and maintenance of central lines, urinary catheters, surgical time-outs) - these are the kinds of conditions and processes that should be managed the same way, every day, by each and every member of the health care team. With the care of common conditions, there is some room to maneuver, so to speak. For example, if a patient deviates from the expected clinical course, then and only then should we deviate from a standardized treatment protocol. However, there is no reason why we should deviate from standardized protocols for surgical time-outs, shift hand-offs, or maintenance of central lines.
If hospitals are to become high reliability organizations, we must embrace the core tenets of operational excellence. We must be sensitive to operations - what is happening on the front lines of health care. The good news is that many health care organizations have demonstrated that standardization of best practices and elimination of waste through operational excellence can lead to sustained improvement in outcomes and lower costs.
Sunday, November 6, 2016
Happy Guy Fawkes Day!
I was texting my son last night while watching college football on the television. When I asked him what he had been doing, he told me that he had just finished watching the movie, "V for Vendetta". I have never seen this movie, but I have seen enough trailers to know that the movie's protagonist wears a "Guy Fawkes" mask. "Ahhh - today is November 5, Guy Fawkes Day," I texted. I have to admit, I thought I was being particularly clever here and didn't think he would make the connection. To my surprise, my son texted back, "Yes, I know. Ever since we watched 'V for Vendetta' in my high school religion class on November 5th, I have made it an annual tradition." In other words, not only was I not being clever, my son apparently knew more about Guy Fawkes than I thought.
Guy Fawkes was one of the English Catholics who helped plan and (unsuccessfully) orchestrate the infamous Gunpowder Plot of 1605 (also known as the Jesuit Treason). The plan was to blow up the House of Lords and assassinate King James I of England, and in so doing, install James' daughter, Elizabeth (a Catholic) as the new head of state. The plot failed, and the perpetrators (including Guy Fawkes) were hanged, drawn, and quartered. Apparently, Fawkes fell from the scaffolding where he was to be hanged, breaking his neck and dying before being drawn and quartered. His name has become synonymous with the annual celebration of the failure of the Gunpowder Plot on November 5, now known as "Guy Fawkes Day." Apparently, the movie, "V for Vendetta" is an allegory for oppressive government, but that is a discussion for another day!
What struck me about this entire conversation was the importance of annual traditions - the English celebrate "Guy Fawkes Day" every year on November 5th. My son watches the movie, "V for Vendetta" every year on November 5th, remembering fondly one of his favorite high school teachers. Conceptually, we use traditions to share our common links with the past. The word tradition comes from the Latin noun, traditio which is based on the Latin verb, tradere, meaning to transmit, to hand over, to give for safekeeping. Traditions are beliefs and customs that originated in the past that are passed down from one generation to the next, more or less in the same form in which they originated.
I frequently talk about "high reliability organizations" and use the United States Navy's aircraft carrier flight operations as an example of a "high reliability organization." One of the most common criticisms that I hear is how health care is completely different than the military. "In the Navy, if you aren't compliant with the rules, you get in big trouble!" The mistaken belief is that the Navy uses strict hierarchy and authoritarian leadership to enforce strict discipline and compliance with policies, rules, and regulations. Nothing could be further from the truth. While there are certain elements of hierarchical and authoritarian leadership in the military, the most important unifying element that keeps daily operations running exactly (more or less) the same way from ship to ship across the fleet, year after year, are the traditions and customs that are handed down from past generations of sailors. Traditions are the glue that holds the Navy together.
I am not saying that all traditions are good. Some of the traditions in the Navy are no longer appropriate (perhaps they never were) - as one example, the "crossing the line" ceremony" is not quite as violent as it was in the distant past. However, for the most part, traditions are how the right "culture" is instilled in new sailors and how "culture" is maintained throughout the ship.
Most health care organizations have some important traditions. However, I would suggest that traditions are not used nearly enough. Traditions can and should be an important way to set the proper tone, encourage the proper attitudes, and build the culture that is necessary for a high-performing health care delivery organization.
Guy Fawkes was one of the English Catholics who helped plan and (unsuccessfully) orchestrate the infamous Gunpowder Plot of 1605 (also known as the Jesuit Treason). The plan was to blow up the House of Lords and assassinate King James I of England, and in so doing, install James' daughter, Elizabeth (a Catholic) as the new head of state. The plot failed, and the perpetrators (including Guy Fawkes) were hanged, drawn, and quartered. Apparently, Fawkes fell from the scaffolding where he was to be hanged, breaking his neck and dying before being drawn and quartered. His name has become synonymous with the annual celebration of the failure of the Gunpowder Plot on November 5, now known as "Guy Fawkes Day." Apparently, the movie, "V for Vendetta" is an allegory for oppressive government, but that is a discussion for another day!
What struck me about this entire conversation was the importance of annual traditions - the English celebrate "Guy Fawkes Day" every year on November 5th. My son watches the movie, "V for Vendetta" every year on November 5th, remembering fondly one of his favorite high school teachers. Conceptually, we use traditions to share our common links with the past. The word tradition comes from the Latin noun, traditio which is based on the Latin verb, tradere, meaning to transmit, to hand over, to give for safekeeping. Traditions are beliefs and customs that originated in the past that are passed down from one generation to the next, more or less in the same form in which they originated.
I frequently talk about "high reliability organizations" and use the United States Navy's aircraft carrier flight operations as an example of a "high reliability organization." One of the most common criticisms that I hear is how health care is completely different than the military. "In the Navy, if you aren't compliant with the rules, you get in big trouble!" The mistaken belief is that the Navy uses strict hierarchy and authoritarian leadership to enforce strict discipline and compliance with policies, rules, and regulations. Nothing could be further from the truth. While there are certain elements of hierarchical and authoritarian leadership in the military, the most important unifying element that keeps daily operations running exactly (more or less) the same way from ship to ship across the fleet, year after year, are the traditions and customs that are handed down from past generations of sailors. Traditions are the glue that holds the Navy together.
I am not saying that all traditions are good. Some of the traditions in the Navy are no longer appropriate (perhaps they never were) - as one example, the "crossing the line" ceremony" is not quite as violent as it was in the distant past. However, for the most part, traditions are how the right "culture" is instilled in new sailors and how "culture" is maintained throughout the ship.
Most health care organizations have some important traditions. However, I would suggest that traditions are not used nearly enough. Traditions can and should be an important way to set the proper tone, encourage the proper attitudes, and build the culture that is necessary for a high-performing health care delivery organization.
Thursday, November 3, 2016
The world has changed ("Fly the W")
I woke up this morning to a brand new world. Things changed overnight. The sun still rose up in the East. The sky was blue. The grass was green. I started the day with a cup of coffee and the morning newspaper. But things were different. On this morning, my beloved Chicago Cubs were no longer the "Loveable Losers" of the North side. Chicago Cubs - 2016 World Series Champions. It has a nice ring, don't you think?
Without a doubt, game 7 last night was the best baseball game that I have ever seen - period. It had everything. Two teams fighting for their first World Series title in many, many years. An untouchable pitcher from the Cleveland Indians became touchable. An untouchable pitcher from the Chicago Cubs also became touchable. A blown save. Extra innings. A rain delay. Every pitch seemed like it would make one team a champion and one team a runner-up. Epic. It was simply unbelievable.
For this long-suffering Cubs fan, last night was truly magical. Even now, I wonder if it was all just a dream. Cubs fans just think that way. But this team just never gave up. They didn't quit. Even down three games to one with their backs to the wall. They found a way to win. Even after blowing a three run lead in the 8th inning of game 7, they found a way to win. What a game! What a team!
But this post isn't really about the Cubs. My hat goes off to the Cleveland Indians. They never gave up. They never quit. They fought until the bitter end. Unfortunately, there had to be a winner and there had to be a loser. But the Cleveland Indians didn't lose this game. The Chicago Cubs won it. As much as I was inspired by my Cubs, I was even more inspired by the Cleveland Indians' manager, Terry Francona. He gave a truly remarkable, inspirational, humble, honorable post-game interview. What a class act. Here is some of what he said:
"You know, we ask our players to play the game with respect and to leave it on the field. That was it. They gave everything they had. And I kind of talked about it before the game, what an honor it was, but it really was. To go through that with this group and these people, it was an honor."
Well, Mr. Terry Francona, the honor was ours. You showed us everything that we could ever ask of a leader last night. You are a great manager, and you deserve your place in the Hall of Fame. I will never forget how you led your team throughout the play-offs and throughout the World Series. I will never forget your humility, your pain in losing, and your respect for this great game.
It is an unfortunate truth that even great leaders fail at times. But I think that what makes these leaders really great is how they fail. They fail with class. They fail with humility. They fail with respect. They fail with honor.
So close to Election Day, I am also reminded of another great leader who failed with class. President George H.W. Bush left a letter for the incoming President Bill Clinton on his last day of office. He said:
Dear Bill,
When I walked into this office just now I felt the same sense of wonder and respect that I felt four years ago. I know you will feel that, too.
I wish you great happiness here. I never felt the loneliness some Presidents have described.
There will be very tough times, made even more difficult by criticism you may not think is fair. I’m not a very good one to give advice; but just don’t let the critics discourage you or push you off course.
You will be our President when you read this note. I wish you well. I wish your family well.
Your success now is our country’s success. I am rooting hard for you.
Good luck – George
Respect. Honor. Humility. Class. These are the characteristics that separate the great leaders from the good leaders.
Without a doubt, game 7 last night was the best baseball game that I have ever seen - period. It had everything. Two teams fighting for their first World Series title in many, many years. An untouchable pitcher from the Cleveland Indians became touchable. An untouchable pitcher from the Chicago Cubs also became touchable. A blown save. Extra innings. A rain delay. Every pitch seemed like it would make one team a champion and one team a runner-up. Epic. It was simply unbelievable.
For this long-suffering Cubs fan, last night was truly magical. Even now, I wonder if it was all just a dream. Cubs fans just think that way. But this team just never gave up. They didn't quit. Even down three games to one with their backs to the wall. They found a way to win. Even after blowing a three run lead in the 8th inning of game 7, they found a way to win. What a game! What a team!
But this post isn't really about the Cubs. My hat goes off to the Cleveland Indians. They never gave up. They never quit. They fought until the bitter end. Unfortunately, there had to be a winner and there had to be a loser. But the Cleveland Indians didn't lose this game. The Chicago Cubs won it. As much as I was inspired by my Cubs, I was even more inspired by the Cleveland Indians' manager, Terry Francona. He gave a truly remarkable, inspirational, humble, honorable post-game interview. What a class act. Here is some of what he said:
"You know, we ask our players to play the game with respect and to leave it on the field. That was it. They gave everything they had. And I kind of talked about it before the game, what an honor it was, but it really was. To go through that with this group and these people, it was an honor."
Well, Mr. Terry Francona, the honor was ours. You showed us everything that we could ever ask of a leader last night. You are a great manager, and you deserve your place in the Hall of Fame. I will never forget how you led your team throughout the play-offs and throughout the World Series. I will never forget your humility, your pain in losing, and your respect for this great game.
It is an unfortunate truth that even great leaders fail at times. But I think that what makes these leaders really great is how they fail. They fail with class. They fail with humility. They fail with respect. They fail with honor.
So close to Election Day, I am also reminded of another great leader who failed with class. President George H.W. Bush left a letter for the incoming President Bill Clinton on his last day of office. He said:
Dear Bill,
When I walked into this office just now I felt the same sense of wonder and respect that I felt four years ago. I know you will feel that, too.
I wish you great happiness here. I never felt the loneliness some Presidents have described.
There will be very tough times, made even more difficult by criticism you may not think is fair. I’m not a very good one to give advice; but just don’t let the critics discourage you or push you off course.
You will be our President when you read this note. I wish you well. I wish your family well.
Your success now is our country’s success. I am rooting hard for you.
Good luck – George
Respect. Honor. Humility. Class. These are the characteristics that separate the great leaders from the good leaders.
Sunday, October 30, 2016
HRO: Reluctance to simplify
There's an old Hindu parable about an elephant and five blind men (the number of blind men varies in different versions of the story). In the story, each blind man touches the elephant in order to describe to the others what an elephant is like. As each blind man touches a different part of the elephant, the description varies significantly, and not one description is exactly correct.
The American poet John Godfrey Saxe immortalized the story in the American lexicon with his version, which can be found here. In Saxe's version, there are six blind men. The first blind man touches the elephant's side and states that the elephant is like a wall. The second blind man touches the elephant's tusk and states that the elephant is like a spear. The third blind man touches the elephant's trunk and states that the elephant is like a snake. The fourth blind man touches the elephant's leg and states that the elephant is like a tree. The fifth blind man touches the elephant's ear and states that the elephant is like a fan. The sixth blind man touches the elephant's tail and states that the elephant is like a rope.
The "Blind Men and the Elephant" is a perfect example of how different perspectives can provide vastly different explanations of a particular event. I am reminded of a great movie, called Vantage Point, starring Dennis Quaid, Forest Whitaker, Sigourney Weaver, and William Hurt. Dennis Quaid plays a U.S. Secret Service agent trying to protect the President of the United States (played by William Hurt). The movie is unique in that it tells the same story eight different times - each from the vantage point of a different character in the movie. There was a similar movie in 1950 called Rashomon, which has given rise to the phenomenon known as the "Rashomon Effect" in cognitive psychology.
Collectively, this Hindu parable and these two movies describe the situation in which multiple perspectives can lead to multiple explanations (some of which may be completely wrong) of an event. We see examples of the "Rashomon effect" in health care today. Consider the case of a physician who commits a 10-fold dosing error with a particular medication order (note that in pediatrics, medication dosing is based on body weight, so that medications are administered on a mg medication per kg body weight basis). Why did this dosing error occur? The simplest explanation is that the physician had a momentary lapse in judgment and made a decimal point error in the calculation. Upon further review, however, the physician was in the last hour of a 36 hour shift (this particular case occurred prior to the implementation of duty-hour restrictions for residents). Moreover, the bedside nurse was relatively new to the hospital and didn't want to question the physician's authority. Finally, the medication was a verbal order (i.e. not written down - again, before the days of computerized physician order entry) and was administered in an emergency to a critically ill infant in the Pediatric Intensive Care Unit. For this reason, the pharmacist, who would have normally reviewed and filled the medication order, was not involved in the case. Multiple checkpoints for medication safety were bypassed. Had we talked to each individual - the physician, the nurse, and the pharmacist - we likely would have heard vastly different stories. Only by putting all three versions of the event together could we learn the true root cause of the medication error.
High reliability organizations (HROs) are characterized by a reluctance to simplify interpretation of events. HROs understand that we live in a complex, unpredictable world and that the easiest explanation (often the first explanation) is usually not the complete story. HROs do not fall victim to either the Rashomon effect or to the related phenomenon of "groupthink" (more on groupthink in a future post). HROs conduct thorough, in-depth investigations of adverse events, usually interviewing multiple individuals to get different perspectives, in order to get to the root-cause of the event.
We can easily see that if we relied simply on only one of the blind men's explanations, we would never fully understand what an elephant looks like. It is only by putting together all six explanations that we come close to knowing the truth. The simplest explanation (often the easiest explanation) is rarely the correct one. Dig deeper for the truth and do not simplify.
The American poet John Godfrey Saxe immortalized the story in the American lexicon with his version, which can be found here. In Saxe's version, there are six blind men. The first blind man touches the elephant's side and states that the elephant is like a wall. The second blind man touches the elephant's tusk and states that the elephant is like a spear. The third blind man touches the elephant's trunk and states that the elephant is like a snake. The fourth blind man touches the elephant's leg and states that the elephant is like a tree. The fifth blind man touches the elephant's ear and states that the elephant is like a fan. The sixth blind man touches the elephant's tail and states that the elephant is like a rope.
The "Blind Men and the Elephant" is a perfect example of how different perspectives can provide vastly different explanations of a particular event. I am reminded of a great movie, called Vantage Point, starring Dennis Quaid, Forest Whitaker, Sigourney Weaver, and William Hurt. Dennis Quaid plays a U.S. Secret Service agent trying to protect the President of the United States (played by William Hurt). The movie is unique in that it tells the same story eight different times - each from the vantage point of a different character in the movie. There was a similar movie in 1950 called Rashomon, which has given rise to the phenomenon known as the "Rashomon Effect" in cognitive psychology.
Collectively, this Hindu parable and these two movies describe the situation in which multiple perspectives can lead to multiple explanations (some of which may be completely wrong) of an event. We see examples of the "Rashomon effect" in health care today. Consider the case of a physician who commits a 10-fold dosing error with a particular medication order (note that in pediatrics, medication dosing is based on body weight, so that medications are administered on a mg medication per kg body weight basis). Why did this dosing error occur? The simplest explanation is that the physician had a momentary lapse in judgment and made a decimal point error in the calculation. Upon further review, however, the physician was in the last hour of a 36 hour shift (this particular case occurred prior to the implementation of duty-hour restrictions for residents). Moreover, the bedside nurse was relatively new to the hospital and didn't want to question the physician's authority. Finally, the medication was a verbal order (i.e. not written down - again, before the days of computerized physician order entry) and was administered in an emergency to a critically ill infant in the Pediatric Intensive Care Unit. For this reason, the pharmacist, who would have normally reviewed and filled the medication order, was not involved in the case. Multiple checkpoints for medication safety were bypassed. Had we talked to each individual - the physician, the nurse, and the pharmacist - we likely would have heard vastly different stories. Only by putting all three versions of the event together could we learn the true root cause of the medication error.
High reliability organizations (HROs) are characterized by a reluctance to simplify interpretation of events. HROs understand that we live in a complex, unpredictable world and that the easiest explanation (often the first explanation) is usually not the complete story. HROs do not fall victim to either the Rashomon effect or to the related phenomenon of "groupthink" (more on groupthink in a future post). HROs conduct thorough, in-depth investigations of adverse events, usually interviewing multiple individuals to get different perspectives, in order to get to the root-cause of the event.
We can easily see that if we relied simply on only one of the blind men's explanations, we would never fully understand what an elephant looks like. It is only by putting together all six explanations that we come close to knowing the truth. The simplest explanation (often the easiest explanation) is rarely the correct one. Dig deeper for the truth and do not simplify.
Wednesday, October 26, 2016
HRO: Preoccupation with Failure
The first defining characteristic of high reliability organizations (HROs) is a preoccupation with failure. High reliability organizations do not consider failures as things to avoid at all cost. Rather, HROs believe that failures represent opportunities to learn and improve their systems. As Thomas Watson, founder of International Business Machines (IBM) once said,"If you want to increase your success rate, double your failure rate." Individuals in HROs report their mistakes, even when nobody else is looking! HROs do not punish individuals who make mistakes. On the contrary, in many cases, individuals who report their mistakes are often rewarded!
A couple of examples from US Navy aircraft carrier flight operations are illustrative of the kind of preoccupation of failure that is necessary to become a HRO. Debris and other loose objects can be very dangerous on the flight deck - if a foreign object or piece of debris (or on rare occasions, one of the aircraft mechanics) is sucked up into the aircraft engine, the plane can no longer fly. For this reason, each and every day while the aircraft carrier is at sea, every single individual on the flight deck, regardless of rank, lines up at the back of the flight deck and walks slowly to the other end, picking up any piece of debris or foreign object along the way (foreign object damage, or FOD walk). There is a popular story of an aircraft mechanic who once lost a screwdriver while working on one of the planes. He notified his supervisor, who then notified his supervisor (and so on through the chain of command). The incident triggered a FOD walk, and the screwdriver was found. Was the mechanic punished? Absolutely not. He was recognized by the commanding officer in a ceremony later that same cruise. The last example of "preoccupation with failure" involves the pilots. In the early days of naval aviation, pilots were guided back to the flight deck by the landing signal officer (LSO), affectionately known as "paddles". The LSO was also an experienced pilot. Today, pilots use advanced technology to assist the landing. However, the LSO remains as an important part of the landing process. Each and every landing is graded by the LSO. Pilots who do not pass muster receive additional training and instruction, and if they continue to have problems, they may be permanently grounded. The LSO provides the ultimate "peer review" for all the pilots in the squadron. These landings are also videotaped and broadcast throughout the ship - every one on the ship can watch these landings (PBS once broadcast a special segment on flight deck operations aboard the USS Nimitz - there is an excellent video showing an example of several pilots landing on a rolling, pitching flight deck at night!).
So what would "preoccupation with failure" look like in a hospital? A hospital on its way to becoming a HRO usually has a "reporting culture" where slips, lapses, mistakes, and errors are reported without fear of punishment. These hospitals view errors as opportunities to learn and get better. HRO-like hospitals fully embrace training through simulation - simulation provides a safe, nonstressful environment in which processes can be learned and tested, often using real world scenarios. Finally, these hospitals fully leverage peer review as a way to identify problems early, so that they can be corrected. I know of some hospitals that videotape record all of the trauma resuscitations in the emergency department - these videotaped resuscitations are later watched and critiqued in a safe, blame-free environment by all members of the team. The videotape recording is used as a teaching tool to improve and learn. The HRO experts Karl Weick and Kathleen Sutcliffe published a short list of questions that hospitals can use to assess whether they are "preoccupied with failure"
There are some experts who feel that "preoccupation with failure" is too pessimistic and focuses too much on events in the past. These experts suggest that hospitals should be preoccupied with success by focusing on what they need to do in the future in order to be successful. While I can certainly appreciate this sentiment, I think this view misses the point. A preoccupation with failure doesn't have to be pessimistic at all. I think the key (and perhaps Weick and Sutcliffe should have used a different terminology here) is that HROs are focused on LEARNING.
A couple of examples from US Navy aircraft carrier flight operations are illustrative of the kind of preoccupation of failure that is necessary to become a HRO. Debris and other loose objects can be very dangerous on the flight deck - if a foreign object or piece of debris (or on rare occasions, one of the aircraft mechanics) is sucked up into the aircraft engine, the plane can no longer fly. For this reason, each and every day while the aircraft carrier is at sea, every single individual on the flight deck, regardless of rank, lines up at the back of the flight deck and walks slowly to the other end, picking up any piece of debris or foreign object along the way (foreign object damage, or FOD walk). There is a popular story of an aircraft mechanic who once lost a screwdriver while working on one of the planes. He notified his supervisor, who then notified his supervisor (and so on through the chain of command). The incident triggered a FOD walk, and the screwdriver was found. Was the mechanic punished? Absolutely not. He was recognized by the commanding officer in a ceremony later that same cruise. The last example of "preoccupation with failure" involves the pilots. In the early days of naval aviation, pilots were guided back to the flight deck by the landing signal officer (LSO), affectionately known as "paddles". The LSO was also an experienced pilot. Today, pilots use advanced technology to assist the landing. However, the LSO remains as an important part of the landing process. Each and every landing is graded by the LSO. Pilots who do not pass muster receive additional training and instruction, and if they continue to have problems, they may be permanently grounded. The LSO provides the ultimate "peer review" for all the pilots in the squadron. These landings are also videotaped and broadcast throughout the ship - every one on the ship can watch these landings (PBS once broadcast a special segment on flight deck operations aboard the USS Nimitz - there is an excellent video showing an example of several pilots landing on a rolling, pitching flight deck at night!).
So what would "preoccupation with failure" look like in a hospital? A hospital on its way to becoming a HRO usually has a "reporting culture" where slips, lapses, mistakes, and errors are reported without fear of punishment. These hospitals view errors as opportunities to learn and get better. HRO-like hospitals fully embrace training through simulation - simulation provides a safe, nonstressful environment in which processes can be learned and tested, often using real world scenarios. Finally, these hospitals fully leverage peer review as a way to identify problems early, so that they can be corrected. I know of some hospitals that videotape record all of the trauma resuscitations in the emergency department - these videotaped resuscitations are later watched and critiqued in a safe, blame-free environment by all members of the team. The videotape recording is used as a teaching tool to improve and learn. The HRO experts Karl Weick and Kathleen Sutcliffe published a short list of questions that hospitals can use to assess whether they are "preoccupied with failure"
There are some experts who feel that "preoccupation with failure" is too pessimistic and focuses too much on events in the past. These experts suggest that hospitals should be preoccupied with success by focusing on what they need to do in the future in order to be successful. While I can certainly appreciate this sentiment, I think this view misses the point. A preoccupation with failure doesn't have to be pessimistic at all. I think the key (and perhaps Weick and Sutcliffe should have used a different terminology here) is that HROs are focused on LEARNING.
Monday, October 24, 2016
High Reliability Organizations - A Very Brief Introduction
We hear a lot about so-called high reliability organizations (HROs) these days. Regulatory agencies such as the Center for Medicare and Medicaid (CMS), the Joint Commission, and the Leapfrog Group have all embraced the concept that health care delivery organizations should aspire to become HRO's. HRO theory started with the analysis of three vastly different organizations - the US Navy nuclear-powered aircraft carrier, the USS Carl Vinson, the Federal Aviation Administration's Air Traffic Control system, and Pacific Gas and Electric's nuclear power plant at Diablo Canyon by an eclectic group of investigators - Rear Admiral (retired) Tom Mercer, Todd LaPorte, Gene Rochlin, and Karlene Roberts (all at the University of California at Berkeley). Additional contributions to the HRO literature have been provided by Karl Weick, Paul Schulman, and Kathleen Sutcliffe. But what exactly is a "high reliability organization"? HROs are usually defined as organizations that somehow avoid catastrophic accidents, even though they normally exist in an environment where normal accidents can be expected to occur by virtue of the complexity of the organization and by the nature of the industry. Examples of HROs have included flight deck operations on US Navy aircraft carriers, nuclear power plants, commercial aviation, NASA, and forest fire fighting operations.
Interestingly enough, every single HRO has, at one time or another, experienced catastrophic accidents. For example, NASA has had the space shuttle Challenger and Columbia accidents, while the nuclear power industry has experienced the Three Mile Island and, more recently, the Fukushima Daiichi disasters. Even the highly acclaimed Toyota Production System (many experts have claimed that Toyota has been one of the more recent examples of a HRO) has experienced difficulties. As such, there are certainly lessons that we, in health care, can learn from HRO's past successes and failures (I wrote a recent article on this topic, available here). Karl Weick and Kathleen Sutcliffe have written extensively on HRO principles in their excellent book entitled "Managing the Unexpected". Weick and Sutcliffe explain that all HROs have five key organizational characteristics in common:
1. Preoccupation with failure
2. Reluctance to simplify interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise
In the next few blog posts, I plan to discuss in greater detail each specific characteristic. Whether hospitals can become HROs is debatable - some experts even suggest that hospitals can NEVER become HROs (for example, see the article here). I would argue that most HROs will never admit that they are, in fact, highly reliable organizations. In other words, the first characteristic - "preoccupation with failure" suggests (in my opinion) that most prototypical HROs are so focused on failure that they will never claim that they are HROs. So, beware the hospital that claims to be a HRO!
Interestingly enough, every single HRO has, at one time or another, experienced catastrophic accidents. For example, NASA has had the space shuttle Challenger and Columbia accidents, while the nuclear power industry has experienced the Three Mile Island and, more recently, the Fukushima Daiichi disasters. Even the highly acclaimed Toyota Production System (many experts have claimed that Toyota has been one of the more recent examples of a HRO) has experienced difficulties. As such, there are certainly lessons that we, in health care, can learn from HRO's past successes and failures (I wrote a recent article on this topic, available here). Karl Weick and Kathleen Sutcliffe have written extensively on HRO principles in their excellent book entitled "Managing the Unexpected". Weick and Sutcliffe explain that all HROs have five key organizational characteristics in common:
1. Preoccupation with failure
2. Reluctance to simplify interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise
In the next few blog posts, I plan to discuss in greater detail each specific characteristic. Whether hospitals can become HROs is debatable - some experts even suggest that hospitals can NEVER become HROs (for example, see the article here). I would argue that most HROs will never admit that they are, in fact, highly reliable organizations. In other words, the first characteristic - "preoccupation with failure" suggests (in my opinion) that most prototypical HROs are so focused on failure that they will never claim that they are HROs. So, beware the hospital that claims to be a HRO!
Tuesday, October 18, 2016
The Sorcerer's Apprentice
One of my favorite Disney scenes was the short sketch adapted from Goethe's poem, The Sorcerer's Apprentice in the 1940 movie, Fantasia. In the movie, Mickey Mouse plays the part of the apprentice to the great wizard, "Yen Sid" (note - Disney spelled backwards). I actually never realized that the movie was based on a Goethe poem until relatively recently, and I was quite surprised to see that the movie (except for the fact that the main character is a mouse) follows the poem almost exactly! Here is the text of the poem:
That old sorcerer has vanished
And for once has gone away!
Spirits called by him, now banished,
My commands shall soon obey.
Every step and saying
That he used, I know,
And with sprites obeying
My arts I will show.
Flow, flow onward
Stretches many
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
Come, old broomstick, you are needed,
Take these rags and wrap them round you!
Long my orders you have heeded,
By my wishes now I've bound you.
Have two legs and stand,
And a head for you.
Run, and in your hand
Hold a bucket too.
Flow, flow onward
Stretches many,
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
See him, toward the shore he's racing
There, he's at the stream already,
Back like lightning he is chasing,
Pouring water fast and steady.
Once again he hastens!
How the water spills,
How the water basins
Brimming full he fills!
Stop now, hear me!
Ample measure
Of your treasure
We have gotten!
Ah, I see it, dear me, dear me.
Master's word I have forgotten!
Ah, the word with which the master
Makes the broom a broom once more!
Ah, he runs and fetches faster!
Be a broomstick as before!
Ever new the torrents
That by him are fed,
Ah, a hundred currents
Pour upon my head!
No, no longer
Can I please him,
I will seize him!
That is spiteful!
My misgivings grow the stronger.
What a mien, his eyes how frightful!
Brood of hell, you're not a mortal!
Shall the entire house go under?
Over threshold over portal
Streams of water rush and thunder.
Broom accurst and mean,
Who will have his will,
Stick that you have been,
Once again stand still!
Can I never, Broom, appease you?
I will seize you,
Hold and whack you,
And your ancient wood
I'll sever,
With a whetted axe I'll crack you.
He returns, more water dragging!
Now I'll throw myself upon you!
Soon, O goblin, you'll be sagging.
Crash! The sharp axe has undone you.
What a good blow, truly!
There, he's split, I see.
Hope now rises newly,
And my breathing's free.
Woe betide me!
Both halves scurry
In a hurry,
Rise like towers
There beside me.
Help me, help, eternal powers!
Off they run, till wet and wetter
Hall and steps immersed are Iying.
What a flood that naught can fetter!
Lord and master, hear me crying! -
Ah, he comes excited.
Sir, my need is sore.
Spirits that I've cited
My commands ignore.
"To the lonely
Corner, broom!
Hear your doom.
As a spirit
When he wills, your master only
Calls you, then 'tis time to hear it."
So what does this poem have to do with leadership? In my opinion, quite a lot. In the poem (and in the movie), the sorcerer's apprentice tries to cut corners by casting a spell on the broomsticks. Unfortunately, while he remembers the spell needed to enchant the broomsticks, he has forgotten the spell that turns the broomsticks back to normal. In other words, he has set something in motion that he is quite powerless to stop. Luckily, the sorcerer returns in the end to cast the proper spell, and everything returns back to normal. In the movie, Fantasia, the sorcerer scolds Mickey Mouse and sends him on his way. It's almost as if he is saying, "Go back to your chores and don't mess with magic until you are ready!"
I think that Goethe is telling us something more. One of the best ways to learn is through failure. Thomas Edison reportedly failed so many times before he was successful in creating the light bulb that he claimed, "I didn't fail. I found 10,000 ways how NOT to build a light bulb." As the author, J.K. Rowling said, "It is impossible to live without failing at something, unless you live so cautiously that you might as well not have lived at all, in which case you have failed by default." Nike had a fantastic commercial when I was growing up, in which Michael Jordan kept talking about how many times he had failed. At the end of the commercial (right before the Nike swoosh appears with the famous "Just Do It"), Michael Jordan says, "I have failed over and over and over again. And that is why I succeed." In other words, FAILURE is how WE LEARN. It is one of the best ways that we do learn - and more often than not, the lessons we learn through failure are the ones that stick in our minds. FOREVER. I still remember, to this day, the word I missed to win my school Spelling Bee in 6th grade ("aggravate") - as my PE teacher told me as I walked slowly off the stage, "You will never ever misspell that word again." And I haven't (incidentally, I also remember my losing word in the 7th grade Spelling Bee, "masonry").
As leaders, one of the greatest things that we can do is to give the members of our team the chance to fail. More likely than not, in the majority of circumstances, there is enough slack in the system to allow our team members to experiment and learn. If they do fail, more often than not, we can rescue them, as in the "Sorcerer's Apprentice" story. Give folks a chance - more often than not, they will surprise us and succeed. However, even if they do fail, they will learn a lesson that they will never forget.
That old sorcerer has vanished
And for once has gone away!
Spirits called by him, now banished,
My commands shall soon obey.
Every step and saying
That he used, I know,
And with sprites obeying
My arts I will show.
Flow, flow onward
Stretches many
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
Come, old broomstick, you are needed,
Take these rags and wrap them round you!
Long my orders you have heeded,
By my wishes now I've bound you.
Have two legs and stand,
And a head for you.
Run, and in your hand
Hold a bucket too.
Flow, flow onward
Stretches many,
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
See him, toward the shore he's racing
There, he's at the stream already,
Back like lightning he is chasing,
Pouring water fast and steady.
Once again he hastens!
How the water spills,
How the water basins
Brimming full he fills!
Stop now, hear me!
Ample measure
Of your treasure
We have gotten!
Ah, I see it, dear me, dear me.
Master's word I have forgotten!
Ah, the word with which the master
Makes the broom a broom once more!
Ah, he runs and fetches faster!
Be a broomstick as before!
Ever new the torrents
That by him are fed,
Ah, a hundred currents
Pour upon my head!
No, no longer
Can I please him,
I will seize him!
That is spiteful!
My misgivings grow the stronger.
What a mien, his eyes how frightful!
Brood of hell, you're not a mortal!
Shall the entire house go under?
Over threshold over portal
Streams of water rush and thunder.
Broom accurst and mean,
Who will have his will,
Stick that you have been,
Once again stand still!
Can I never, Broom, appease you?
I will seize you,
Hold and whack you,
And your ancient wood
I'll sever,
With a whetted axe I'll crack you.
He returns, more water dragging!
Now I'll throw myself upon you!
Soon, O goblin, you'll be sagging.
Crash! The sharp axe has undone you.
What a good blow, truly!
There, he's split, I see.
Hope now rises newly,
And my breathing's free.
Woe betide me!
Both halves scurry
In a hurry,
Rise like towers
There beside me.
Help me, help, eternal powers!
Off they run, till wet and wetter
Hall and steps immersed are Iying.
What a flood that naught can fetter!
Lord and master, hear me crying! -
Ah, he comes excited.
Sir, my need is sore.
Spirits that I've cited
My commands ignore.
"To the lonely
Corner, broom!
Hear your doom.
As a spirit
When he wills, your master only
Calls you, then 'tis time to hear it."
So what does this poem have to do with leadership? In my opinion, quite a lot. In the poem (and in the movie), the sorcerer's apprentice tries to cut corners by casting a spell on the broomsticks. Unfortunately, while he remembers the spell needed to enchant the broomsticks, he has forgotten the spell that turns the broomsticks back to normal. In other words, he has set something in motion that he is quite powerless to stop. Luckily, the sorcerer returns in the end to cast the proper spell, and everything returns back to normal. In the movie, Fantasia, the sorcerer scolds Mickey Mouse and sends him on his way. It's almost as if he is saying, "Go back to your chores and don't mess with magic until you are ready!"
I think that Goethe is telling us something more. One of the best ways to learn is through failure. Thomas Edison reportedly failed so many times before he was successful in creating the light bulb that he claimed, "I didn't fail. I found 10,000 ways how NOT to build a light bulb." As the author, J.K. Rowling said, "It is impossible to live without failing at something, unless you live so cautiously that you might as well not have lived at all, in which case you have failed by default." Nike had a fantastic commercial when I was growing up, in which Michael Jordan kept talking about how many times he had failed. At the end of the commercial (right before the Nike swoosh appears with the famous "Just Do It"), Michael Jordan says, "I have failed over and over and over again. And that is why I succeed." In other words, FAILURE is how WE LEARN. It is one of the best ways that we do learn - and more often than not, the lessons we learn through failure are the ones that stick in our minds. FOREVER. I still remember, to this day, the word I missed to win my school Spelling Bee in 6th grade ("aggravate") - as my PE teacher told me as I walked slowly off the stage, "You will never ever misspell that word again." And I haven't (incidentally, I also remember my losing word in the 7th grade Spelling Bee, "masonry").
As leaders, one of the greatest things that we can do is to give the members of our team the chance to fail. More likely than not, in the majority of circumstances, there is enough slack in the system to allow our team members to experiment and learn. If they do fail, more often than not, we can rescue them, as in the "Sorcerer's Apprentice" story. Give folks a chance - more often than not, they will surprise us and succeed. However, even if they do fail, they will learn a lesson that they will never forget.
Sunday, October 16, 2016
"Every one of my patients is a VIP"
Several years ago, I was approached by a grandparent of one of my patients in the ICU who told me, "Treat this girl as if you were treating the President of the United States." Luckily, this kind of request has been relatively rare during my career. However, I am proud of my response - "Sir, I treat every patient that I have as if he or she was the President of the United States. My ICU is full of "very important patients" tonight."
There seems to be a belief that health care providers can adjust up or down their ability to treat the patients that are in front of them. It's almost like some would have you believe that doctors and nurses are saying to themselves, "You know what, I am kind of tired tonight. Maybe I will take the night off and just give 50% effort tonight." Alternatively, when confronted with a patient who happens to be related (or as more commonly the case, the relative of a friend of a friend of a friend) to someone important, these same health care providers say, "Wow. I better be on my 'A game' tonight." Really?!?!? Come on. I am absolutely, 100% confident that in the vast majority of circumstances, everyone working in health care today are giving their absolute best effort for every single patient, every single time.
VIP ("very important patient") care is not the best care. First, place yourself in the shoes of the healthcare worker in front of you. Knowing that the patient you are caring for is someone important (or at least knows someone that is important) can be intimidating and anxiety-provoking. Second, at times the VIP demands to be cared for by the senior most physician (frequently one of the physicians in the C suite) - never mind that in many cases, these senior physicians infrequently provide care and don't have the requisite volume of patients to maintain the skills that got them to their station in life. As an example, on the night that President Abraham Lincoln was shot, a young physician named Charles Leale happened to be at Ford's Theatre watching the same play. Dr. Leale immediately responded by conducting what would now be described as a primary survey - noting no pulse, he opened Lincoln's airway by repositioning his head and neck and depressed his tongue by placing two fingers in the President's mouth (note - this is not how we do this now!). Lincoln started breathing again and his pulse returned. Leale was later joined by more senior physicians (the Army Surgeon General, Dr. Joseph K. Barnes, for one). While Leale was only 23 years old, he was familiar with all of the latest theories on the care of battlefield injuries. He disagreed with the care being provided by the senior physicians but was overruled due to his "inexperience." Significantly, two modern-day neurosurgeons reviewed Lincoln's care and suggested that if Leale's instructions had been followed, Lincoln may have survived the assassination attempt, albeit with significant neurological sequelae! There are several additional cases in the more recent literature, especially when care is provided to Hollywood celebrities, such as Michael Jackson, Joan Rivers, and Prince.
We can do better - and we should. We need to recognize "VIP syndrome" and do our best to avoid it. Drs. Jorge Guzman, Madhu Sasidhar, and James Stoller recently published an article on the VIP syndrome, suggesting nine different things that health care administers should do to guard against it:
1. Don't bend the rules.
2. Work as a team, not in silos.
3. Communicate, communicate, communicate.
4. Carefully manage communications with the media
5. Resist "chairperson's syndrome"
6. Care should occur where it is most appropriate
7. Protect the patient's security
8. Be careful about accepting or declining gifts
9. Be careful about working with the patient's personal physician
To these guiding principles, I would add another. Sending a senior member of the hospital to "check in on the patient" may or may not be appropriate (I happen to believe that it is not). However, at a minimum, these kinds of visits need to be conducted tactfully, respectfully, and carefully (in terms of the providers at the bedside and NOT the VIP). Visitation guidelines and HIPAA laws should still apply here. Finally, and perhaps most importantly, please don't insult the integrity of the caregiver at the bedside by informing her or him that the patient is a VIP. To all providers at the bedside, every patient is a VIP!
There seems to be a belief that health care providers can adjust up or down their ability to treat the patients that are in front of them. It's almost like some would have you believe that doctors and nurses are saying to themselves, "You know what, I am kind of tired tonight. Maybe I will take the night off and just give 50% effort tonight." Alternatively, when confronted with a patient who happens to be related (or as more commonly the case, the relative of a friend of a friend of a friend) to someone important, these same health care providers say, "Wow. I better be on my 'A game' tonight." Really?!?!? Come on. I am absolutely, 100% confident that in the vast majority of circumstances, everyone working in health care today are giving their absolute best effort for every single patient, every single time.
VIP ("very important patient") care is not the best care. First, place yourself in the shoes of the healthcare worker in front of you. Knowing that the patient you are caring for is someone important (or at least knows someone that is important) can be intimidating and anxiety-provoking. Second, at times the VIP demands to be cared for by the senior most physician (frequently one of the physicians in the C suite) - never mind that in many cases, these senior physicians infrequently provide care and don't have the requisite volume of patients to maintain the skills that got them to their station in life. As an example, on the night that President Abraham Lincoln was shot, a young physician named Charles Leale happened to be at Ford's Theatre watching the same play. Dr. Leale immediately responded by conducting what would now be described as a primary survey - noting no pulse, he opened Lincoln's airway by repositioning his head and neck and depressed his tongue by placing two fingers in the President's mouth (note - this is not how we do this now!). Lincoln started breathing again and his pulse returned. Leale was later joined by more senior physicians (the Army Surgeon General, Dr. Joseph K. Barnes, for one). While Leale was only 23 years old, he was familiar with all of the latest theories on the care of battlefield injuries. He disagreed with the care being provided by the senior physicians but was overruled due to his "inexperience." Significantly, two modern-day neurosurgeons reviewed Lincoln's care and suggested that if Leale's instructions had been followed, Lincoln may have survived the assassination attempt, albeit with significant neurological sequelae! There are several additional cases in the more recent literature, especially when care is provided to Hollywood celebrities, such as Michael Jackson, Joan Rivers, and Prince.
We can do better - and we should. We need to recognize "VIP syndrome" and do our best to avoid it. Drs. Jorge Guzman, Madhu Sasidhar, and James Stoller recently published an article on the VIP syndrome, suggesting nine different things that health care administers should do to guard against it:
1. Don't bend the rules.
2. Work as a team, not in silos.
3. Communicate, communicate, communicate.
4. Carefully manage communications with the media
5. Resist "chairperson's syndrome"
6. Care should occur where it is most appropriate
7. Protect the patient's security
8. Be careful about accepting or declining gifts
9. Be careful about working with the patient's personal physician
To these guiding principles, I would add another. Sending a senior member of the hospital to "check in on the patient" may or may not be appropriate (I happen to believe that it is not). However, at a minimum, these kinds of visits need to be conducted tactfully, respectfully, and carefully (in terms of the providers at the bedside and NOT the VIP). Visitation guidelines and HIPAA laws should still apply here. Finally, and perhaps most importantly, please don't insult the integrity of the caregiver at the bedside by informing her or him that the patient is a VIP. To all providers at the bedside, every patient is a VIP!
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