How do we define "reliability"?

I wanted to build upon the theme from last month on High Reliability Organizations.  How do we know when an organization may be legitimately called "highly reliable"?  Is there an objective measure of performance that organizations must achieve to become classified as High Reliability Organizations?  By extension then, can these same organizations "lose" their classification as a High Reliability Organization if they experience a catastrophic accident?  Alternatively, does the term High Reliability Organization represent some theoretically possible but realistically unattainable performance that organizations can only aspire to achieve?  As the legendary Hall of Fame Green Bay Packers coach Vince Lombardi, once said "Perfection is not attainable, but if we chase perfection we can catch excellence."

It seems like a good time to quickly go back and re-visit the history of the concept of a highly reliable organization, which was first described by an eclectic group of interdisciplinary researchers from the University of California, Berkley in 1984.  Todd LaPorte (a political scientist), Gene Rochlin (a physicist-turned-political scientist), and Karlene Roberts (a business school professor with an expertise in organization management) analyzed three vastly different organizations - the US Navy nuclear-powered aircraft carrier USS Carl Vinson (in partnership with retired Rear Admiral Tom Mercer), the Federal Aviation Administration's Air Traffic Control system, and Pacific Gas and Electric's nuclear power plant at Diablo Canyon.  Importantly, these three organizations were selected out of convenience, not because of any randomization or pre-defined criteria (basically, they used what is called a "convenience sample").  These investigators identified a number of key characteristics that the three prototypical HRO's shared, which included "engaging in considerable delegation of decision making and responsibility; structuring themselves to quickly move from completely centralized decision making and hierarchy during periods of relative calm, to completely decentralized and flat decision structures during 'hot times'; engaging in constant training and developing strong cultures of safety orientation and simultaneously embracing a complicated mix of very old and very new technologies according to what is most appropriate to the task at hand" (see "Learning how organizations mitigate risk" in the Journal of Contingencies and Crisis Management).

Importantly, most descriptions of so-called High Reliability Organizations fail to provide a definition of reliability in exact terms, i.e. the degree of reliability that is required in order for an organization to be classified as highly reliable.  For example, one article suggested that High Reliability Organizations could be identified by asking the following question: "How many times could this organization have failed, resulting in catastrophic consequences, that it did not?"  If the answer to the question was on the order of tens of thousands of times, then that organization could be classified as highly reliable (see "Some characteristics of one type of high reliability organisation" in the journal Organization Science).  While that definition makes sense, it is far from satisfactory.  As a matter of fact, Gene Rochlin himself said in 1993 (see "Defining high reliability organisations in practice: A taxonomic prologue" in Karlene Roberts' book, New Challenges to Understanding Organisations) that "no truly objective measure is possible" and "what distinguishes reliability enhancing organizations is not their absolute error or accident rate, but their effective management of innately risky technologies..."  Again, not very satisfying.  In the end, we are left with definitions that are both highly subjective and mostly descriptive in nature (see a great article by Andrew Hopkins "The Problem of Defining High Reliability Organisations").  

While I hesitate to add to the confusion here, I do think that it's important to quickly review some of the commonly used definitions of reliability (importantly - not necessarily high reliability).  For example, an error (or defect) rate is calculated by the number of errors that occur in a certain number of opportunities, typically expressed as the number of errors in 1,000 opportunities (or in some cases, per 1,000,000 opportunities).  Error rates can also be expressed as a percentage.  Finally, one commonly used method is to express the error rate on a logarithmic scale (10 raised to the negative power of X, where X denotes the denominator of the equation for error rates), as shown in the Table below.

For example, central line infections in a hospital's Intensive Care Unit (ICU) are often expressed as the number of infections per 1,000 central line days (where the denominator is the number of opportunities for infection due to the presence of a central line).  Most ICU's have central line infection rates less than 1 infection per 1,000 line days, which would equate to Level 3 reliability (10 raised to the -3 power).  Notably, most airlines operate at around this same level of reliability when it comes to baggage handling (i.e., they lose 1 bag per 1,000 opportunities).  

I recently came across the mathematician Terrence Tao's system of classifying reliability based upon a concept that he calls the "Nines of Safety".  For example, if a process is reliable 90% of the time, Tao would say that the process has "one nine of safety".  Similarly, if a process is 99.9% reliable, Tao would say that the process has "three nines of safety" (which equates to Level 3 Reliability discussed above).  It's an interesting way of expressing reliability.

Note that I am avoiding a discussion on Six Sigma reliability (a topic for another, future post), which is similar yet distinct to the methods described above.  I think that all of these ways to classify reliability can be helpful, and I suspect that most so-called High Reliability Organizations operate at a reliability level of 4 or greater (1 error per 10,000 - 1,000,000 opportunities).  David Ikkersheim and Marc Berg have suggested (see "How reliable is your hospital?" in the journal BMJ Quality and Safety) that most hospitals operate at a reliability level of 1 or 2, which is consistent with my own experience and observations.  In other words, most hospitals are not at a point where we would consider them to be High Reliability Organizations.  Regardless, high reliability is certainly an important and attainable goal, so the journey to become a High Reliability Organization continues.

The Swing Route

My wife and I watched the new Netflix movie Lonely Planet, starring Laura Dern and Liam Hemsworth the other night.  Dern plays a novelist, Katherine, who is struggling to write her next book, so she travels overseas to Morocco to a writer's retreat to "get away" and move past her writer's block.  Hemsworth's character, Owen, happens to be attending with his girlfriend, who is an up and coming novelist in her own right.  Katherine and Owen end up spending a day together on a sightseeing tour, and they end up falling in love.  As my father-in-law used to say, "It's a classic love story.  Boy meets girl.  Boy and girl fall in love.  Boy and girl break up.  Boy and girl fall back in love."

Katherine ends up with a new book and a new partner.  She names her book after something that Owen had related to her from his high school football days, which essentially describes their relationship.  He mentions the swing route in a conversation at the beach, stating that it is a route that football teams use when things aren't going their way.  He goes on to say that the play depends heavily upon the quarterback's ability to trust his instincts, make a quick decision, and follow through.  As Owen puts it, the swing route is all about "finding hope in a big mess" (which again, describes what the two have been going through in their personal lives).

Of course my wife noticed that I was looking up "swing route" on the Internet during the movie.  She asked, "Is this going to find it's way into an upcoming blog post?"  Yes it will and yes it has!  As luck would have it, someone else beat me to the punch (see Aval Sethi's LinkedIn post, "The swing route in football and leadership: Trusting your instincts amid chaos").

If you aren't familiar with it, the swing route is exactly as the character Owen described it in the movie.  It's one of the most effective ways to turn a broken play with a potential loss of yardage into a big gain.  During the swing route, the running back moves out of the backfield and toward the sideline, catches a short pass, and quickly turns upfield (check out a video describing the swing route here).  It's a great option for the quarterback when all the other potential receivers aren't open.

The swing route is a perfect analogy to describe the kind of leadership that is required to thrive in today's VUCA environment.  The leadership "swing route" is necessary when things aren't progressing according to plan, or even worse the carefully laid-out plan is falling apart.  Leaders can and should use the "swing route" when they need to pivot and re-establish momentum.  Going back to the football analogy, leaders use the "swing route" to make something out of nothing or generate small wins (i.e., turn a loss into a gain).  And just as in football, there are a couple of keys to achieving success with the "swing route".  First, leaders need to learn to trust their instinct and make quick decisions, even with imperfect information.  Second, leaders need to trust their teams (the football equivalent of trusting that the running back will be in the flat to catch the ball when it's thrown).  Third, and perhaps most importantly, the "swing route" requires flexibility, adaptability, and a little creativity.

No risk, no leadership

I read a great article by Darren Walker, who is soon to be the retired President of the Ford Foundation, in The New York Times, "There is no leadership without risk".  His opening statement is profound in both its truth and its implication: "There has never been a more difficult time to lead anything..."  As I have stated in a number of recent posts, we live in a world characterized by the acronym VUCA, i.e. one that is volatile, uncertain, complex, and ambiguous.  Walker suggests that at a time when leadership is needed the most, individuals are asking legitimate questions such as "Why would I even want to be a leader?"  He calls it a "gathering crisis of leadership" and further suggests that the societal and cultural norms today often "discourage the courage that is essential to effective leadership."

Walker further states that "courageous, moral leadership...challenges us to recognize that bringing light is often worth enduring the heat, especially in moments of profound challenge" like what exists today in our VUCA world.  We need leaders who are not afraid to embrace complexity, leaders who are not afraid to take risks.  Leadership in our VUCA world requires courage, and as Walker ends his article, "No courage? No leadership.  We cannot move forward, however unevenly, without courageous visionaries blazing new paths that illuminate the way for all of us to follow."

"It is not necessary to change..."

I have stated over and over again in this blog that leading and managing change is perhaps one of the most difficult, but also the important jobs for leaders.  To this end, W. Edwards Deming said that "It is not necessary to change.  Survival is not mandatory."  Winston Churchill said, "To improve is to change; to be perfect is to change often."  Unfortunately, most organization-wide change initiatives fail.  Countless numbers of books, articles, white papers, and blogs have been written on how to effectively lead and manage change.  Perhaps the volume of literature on change management is a reflection of the fact that nobody really knows how to do it effectively and successfully.

The management consulting firm Bain & Company surveyed transformation initiatives of 300 large companies worldwide in 2013 and 2023.  They defined "failure" as achieving less than half of what the leaders of the transformation initiative were targeting.  While just over 1/3 (38%) of all transformation initiatives failed in 2013, the percentage of organizational transformation initiatives that failed in 2023 improved to thirteen percent.  While this is certainly an improvement, Bain & Company also noted that the percentage of transformation initiatives with only marginal outcomes (defined as achieving more than 50% but less than 100% of the results that were targeted) increased from 50% in 2013 to 75% in 2023.  As Michael Mankins and Patrick Litre write in their Harvard Business Review article "Transformations That Work", "Instead of pushing their organizations to deliver more, many senior leaders seem to settle for improved but still unexceptional performance."  

Mediocre results tend to signal to employees that the latest organizational change initiative is just the "flavor of the month" and that if they just wait long enough, the status quo will be restored.  Bain & Company found that only 12% of change initiatives produce lasting results!  And, settling for less only breeds the kind of cynicism that will undermine future efforts at organizational transformation.

So how can organizations do better?  What is the "secret sauce" for successful organizational transformation initiatives?  Bain & Company found six practices that are common to organizations that seemed to have figured this all out:

1. Treating transformation as a continuous process.  While most transformation initiatives are structured as a discrete project with a defined beginning and end, the successful organizations are in a constant state of transformation.  Rather than the "flavor of the month", these organizations focus on continuous improvement and perpetual change!  These organizations are in it for the long haul.

2. Building transformation into the company's operating rhythm.  Building on the first practice, the most successful organizations recognize that transformational change is an important part of everyone's normal workflow.  Improvement is embedded in the daily work.  

3. Explicitly managing organizational energy.  The leaders of successful transformation initiatives recognize that organization-wide change tends to fizzle out when it consumes more energy than it creates.  They identify which group(s) of stakeholders will be most impacted by the change and sequence the change so that no one group is expected to alter multiple routines or workflows at the same time.  These leaders also use rewards and recognition to help build energy and enthusiasm for the transformation initiative along the way.

4. Using aspirations, not just targets, to stretch management's thinking.  As Mankins and Litre write, "Relying on benchmarks tends to confine the art of the possible to what others have already achieved, effectively setting the bar too low.  True transformation calls for breakthrough thinking and pushing beyond current practices."  

5. Driving change from the middle out.  Most transformation initiatives are top-down.  The most successful ones utilize a "middle out" approach emphasizing leadership by the mid-level leaders.

6. Accessing substantial external capital from the start.  Transforming an organization can be expensive, and unfortunately in the Bain & Company study, nearly all of the failed transformations were underfunded and under-resourced.  While most health care organizations won't have access to capital markets, it's important that they provide adequate funding and resources to the transformation efforts.  Relying upon the potential cost savings from the transformation to fund itself is neither realistic nor likely to be successful.  

While this article was likely written for large, multinational, for profit corporations, I do think that the six key practices to success may be applied to all organizations.  We've learned a lot about transformation initiatives in the last 10 years, and it will be interesting to see where we are 10 years from now.  

The memory of a goldfish

It's commonly believed that goldfish have a memory that lasts only three seconds, even though recent research suggests that may not be true.  For example, laboratory studies have shown that goldfish can recognize human faces and even drive a miniaturized robotic car.  Perhaps Albert Einstein said it best when he suggested, "Everybody is a genius.  But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid."

Building on what is perhaps admittedly an urban myth, I love the quote from the television show Ted Lasso.  Ted was talking to one of his players who had just made a mistake and said, "You know what the happiest animal in the world is?  It's a goldfish.  It's got a 10 second memory.  Be a goldfish."  In other words, learn from your mistake.  Put the past behind you.  Move on.

It's actually great advice.  Just consider what happened on Sunday Night Football on NBC this past weekend.  The Detroit Lions were losing to the Houston Texans 23-7 at the start of the second half.  By the start of the fourth and final quarter, the Lions were still losing 23-13 and their quarterback, Jared Goff had already thrown five interceptions (he had only thrown four interceptions in the entire NFL season up to that point).  Rather than giving up what by that point had been a horrible outing, Goff would lead his team to score 13 points and win the game 26-23.  

It was an ugly performance, but the Lions, who were the NFL's hottest team up to that point, still found a way to win.  In the post-game press conference, Goff said, "Honestly I didn't feel like I was playing all that bad, and I was seeing things well and I was throwing it well...I had some unfortunate things happen early, but I've been through a whole lot worse in that I've been to the bottom mentally.  Some unlucky plays aren't going to throw me off my game."

Talk about a goldfish memory!  If you make a mistake (or commit whatever version of throwing five interceptions at your place of work), learn from it.  Put the past behind you.  Trust what got you to this point.  Move on. 

Just as important is a team or organizational culture that embraces psychological safety, what Harvard Business School professor Amy Edmondson defines as "the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes, and the team is safe for interpersonal risk taking."  Goff knew that his coaches and teammates had his back.  He knew that they trusted him and had faith in him, which ultimately allowed him to persevere and stay resilient despite what had been an ugly performance up to the fourth quarter.  If you are a leader in an organization, it's important that the members of your team know and understand that it's okay to make a mistake or to take risks.  Without a culture of psychological safety, there is just no way that the Lions win that game.  The same can be said for organizations...

Happy Veterans Day 2024

Today is Veterans Day, when those of us in the United States of America celebrate all the men and women who have served in the United States Navy, Army, Air Force, Coast Guard, Marine Corps, and Space Force. 

Veterans Day was originally known as Armistice Day to mark the end of World War I (remember being taught that World War I ended at the 11th hour of the 11th day of the 11th month?). President Woodrow Wilson issued a message to the people of the United States on that very first Armistice Day, in which he expressed what he felt the day meant to Americans:

“To us in America the reflections of Armistice Day will be filled with solemn pride in the heroism of those who died in the country’s service, and with gratitude for the victory, both because of the thing from which it has freed us and because of the opportunity it has given America to show her sympathy with peace and justice in the council of nations.”

Congress passed a law on May 13, 1938 which officially made November 11th a legal holiday, “a day to be dedicated to the cause of world peace and to be thereafter celebrated and known as ‘Armistice Day’.”

Unfortunately, World War I wasn’t the “war to end all wars” as everyone had believed. World War II veteran Raymond Weeks had the idea to celebrate all veterans on Armistice Day, not just those who died in World War I. Weeks led the first celebration in his hometown of Birmingham, Alabama, a tradition that he continued until his death in 1985. It was President Dwight Eisenhower who signed a bill on May 26, 1954 to recognize November 11th as Veterans Day, a national holiday. President Ronald Reagan awarded Weeks the Presidential Citizenship Medal in 1982 as the driving force for the national holiday.

Importantly, while the holiday is commonly printed as “Veteran’s Day” (with an apostrophe before the letter ‘s’), the official spelling is “Veterans Day” (without the apostrophe), as the holiday is not a day that belongs to veterans, but rather a day to honor all veterans. Also, the term “veteran” is defined as “a person who served in the active military, naval, or air service and who was discharged or released therefrom under conditions other than dishonorable.” In other words, even if you only served in peace time and never war time, you are still a veteran.

For those of you who’ve followed my posts in the past, you know that I like quotes.  I looked for a few that I thought were particularly relevant for this year's Veterans Day.  General Douglas MacArthur said, "The soldier above all others prays for peace, for it is the soldier who must suffer and bear the deepest wounds and scars of war."  The tennis player Arthur Ashe said, "True heroism is remarkably sober, very undramatic.  It is not the urge to surpass all others at whatever cost, but the urge to serve others at whatever cost."  The writer Tom Clancy said, "The U.S. military is us.  There is no truer representation of a country than the people that it sends into the field to fight for it.  The people who wear our uniform and carry our rifles into combat are our kids, and our job is to support them, because they're protecting us."

Lastly, I want to end today's post with a poem by the English poet Alfred Noyes.  It's one of his most famous poems, and the words are hauntingly poignant for a day to celebrate veterans.  The poem was written either during or shortly after World War I.  The narrator is a survivor of that war, and he is visiting a battlefield littered with the dead from both sides.  It's called "On the Western Front" and its message is important:

I found a dreadful acre of the dead,

  Marked with the only sign on earth that saves.

The wings of death were hurrying overhead,

  The loose earth shook on those unquiet graves;

For the deep gun-pits, with quick stabs of flame,

  Made their own thunders of the sunlit air;

Yet, as I read the crosses, name by name,

  Rank after rank, it seemed that peace was there;

Sunlight and peace, a peace too deep for thought,

  The peace of tides that underlie our strife,

The peace with which the moving heavens are fraught,

  The peace that is our everlasting life.

The loose earth shook. The very hills were stirred.

The silence of the dead was all I heard.

We, who lie here, have nothing more to pray.

  To all your praises we are deaf and blind.

We may not ever know if you betray

  Our hope, to make earth better for mankind.

Only our silence, in the night, shall grow

  More silent, as the stars grow in the sky;

And, while you deck our graves, you shall not know

  How many scornful legions pass you by.

For we have heard you say (when we were living)

  That some small dream of good would “cost too much.”

But when the foe struck, we have watched you giving,

  And seen you move the mountains with one touch.

What can be done, we know. But, have no fear!

If you fail now, we shall not see or hear.

In honor of all those who have served, the living and the dead, we owe them our gratitude.  We owe them our praise.  We owe them our love.  But most of all, we owe it to them not to fail in the task to which they gave up their lives.  We owe it to them to keep pushing for a better world.  We owe it to them to keep pushing for peace.

Happy Veterans Day to all!

Bad Systems Beat Good People

W. Edwards Deming said, "A bad system will beat a good person every time."  He was right.  Three executive leaders from the Institute for Healthcare Improvement (IHI) (Kedar Mate, Josh Clark, and Jeff Salvon-Harman) recently wrote a digital article for the Harvard Business Review ("To Improve Health Care, Focus on Fixing Systems - Not People") that emphasizes this exact point.  While a number of health care organizations have adopted management strategies such as the Toyota Production System, Lean/Six Sigma, and High Reliability Organization principles, most of these efforts have unfortunately met with either limited or temporary success.  Mate, Clark, and Salvon-Harman studied a number of industries outside of health care, including not only the prototypical High Reliability Organizations in the nuclear power industry, commercial aviation, and U.S. Navy, but also highly performing organizations such as Amazon, Ritz Carlton, and the Cheesecake Factory.  They found that all of these organizations have "focused less on trying to get more from their workforce and more on trying to maximize what they can get from the system."  Importantly, improvement work is considered part of everyone's daily work.  

Maureen Bisognano, a senior fellow at IHI said, "Everyone in health care has two jobs: the job that they were hired to do and the job of making it better."  Mate, Clark, and Salvon-Harman argue that these are the same job as part of a culture of continuous learning and improvement.  A critical component of this kind of culture, however, is having leaders within the organization working to eliminate roadblocks and overcoming organizational inertia.

Leaders in these highly performing organizations spend time on the front lines seeking feedback on how they can redesign daily operations to make their workers' jobs easier and more efficient, which invariably also leads to improved output from the system.  While leaders within these organizations have customized what Mate, Clark, and Salvon-Harman refer to as the operating system to the needs of their customers and workforce, all of these organizations share a few key features.  First, they deeply value both the commitment and passion of their workforce to achieving the mission of the organization.  Second, they understand that organizations can be highly complex and that complex organizations require a system that supports its workforce.  Third, they recognize that efforts to improve culture are meaningless unless there are strong systems that enable the kind of culture that they are trying to build.  As Mate, Clark, and Salvon-Harman suggest, "Seeking a transformed culture without building the systems that enable it is like trying to create music without instruments."  Fourth, and this is particularly important in my mind, they recognize that a "silo mentality" is not conducive to a highly performing organization.  For health care organizations in particular (which were the focus of the article), safety, quality, equity, efficiency, and experience are viewed as important components of a single, integrated, and highly coordinated operating system.  Lastly, the leaders of these organizations believe in true transparency, reporting their outcomes not only internally but also externally as well. 

Soon

I've been a fan of the progressive rock group Yes since my early days in high school.  The band was originally formed in 1968 and has undergone a number of line-up changes throughout its history (they are still playing).  The band is known for its complex musical arrangements and lyrics, with some of their songs lasting up to 20 minutes (far too long for radio).  One of the band's most beautiful songs is actually a part of another, much longer song called "The Gates of Delirium" from their seventh studio album, Relayer.  "The Gates of Delirium" is almost 22 minutes in length, and its lyrics are loosely based upon Leo Tolstoy's classic novel War and Peace.  The final section of the song is called "Soon", which was actually released on radio as a separate single in the United Kingdom and was played live in concert by itself.   The lyrics carry a message of hope and transformation for a better future, where darkness is replaced by light.  The song was released in 1974, which was a difficult time in America and the world.    

Regardless of what you think about the recent U.S. election, I think it's fair to say that we are again going through a difficult time in our nation's history.  I still believe in America.  I still believe that there is a bright future ahead, and I can't think of a better moment to send out a message of peace and hope:

Soon oh soon the light

Pass within and soothe the endless night

And wait here for you

Our reason to be here

Soon oh soon the time

All we move to gain will reach and calm

Our heart is open

Our reason to be here

Long ago, set into rhyme

Soon oh soon the light

Ours to shape for all time, ours the right

The sun will lead us

Our reason to be here

The sun will lead us

Our reason to be here

Check out a version of "Soon" from the band's 1975 World Tour here.

"We are Family"

The 1979 Pittsburgh Pirates were loaded with talent, but by June 1st of that year, they were sitting in fourth place in the NL East Division with a Win-Loss record of 23-21, six games behind the Division leading Montreal Expos.  Their game against the San Diego Padres was delayed due to rain, and the clubhouse was rather morose and disengaged.  Nobody really wanted to be there on that night.  Willie Stargell, the Pirates' team leader (and future Hall of Famer) decided that the team needed a wake-up call.  During rain delays, the Three Rivers Stadium staff usually played the newest episode of "This Week in Baseball" on the scoreboard or played hit songs over the public address system.  On this night, they were playing music.

Pirates reliever Kent Tekulve tells what happened next, "Willie happens to be sitting at the far end of the dugout where the phones were at.  There was one phone for the bullpen. And there was one phone for the press box. Well, Willie just reaches up and grabs the press box telephone."  

Stargell tells the Pirates PR Director, Joe Safety, "Joe, when this song is done, I want you to make the announcement that this is the official Pirates clubhouse song."  The song was the pop music hit "We are Family" by Sister Sledge.  And that's what Safety did - once the song came over the public address system, the scoreboard announces, "We are Family, The Official Song of the 1979 Pirates."  Stargell originally thought of it as a joke, but the team responded and ended up winning the game.  The Pirates ended up finishing the season with a Win-Loss record of 98-64, winning the NL East by two games over the Expos. They beat the Cincinnati Reds to win their ninth National League pennant, and then they came back from a 3-1 deficit to defeat the Baltimore Orioles to win their fifth World Series title.  They were World Champions, and "We are Family" had become their theme song.

Stargell, at the age of 39 years, became the first (and so far only) player to win the National League's Most Valuable Player (MVP), the National League Championship Series MVP, and the World Series MVP in a single season.  Stargell said of the "We are Family Pirates", "There's really no words to put into the way I feel. We had to scratch, we had to crawl, and we did it together because we are family.  We didn't mean to be sassy or fancy, but we felt the song typified our ballclub."

The 1979 "We are Family Pirates" is a great story.  But can we really say that the team was really a family?  I see and hear both organizations and employees within organizations describing their culture like a family ("Welcome to the [insert company name] family").  Several years ago at a previous organization, I heard employees talking about how the organization had become too corporate and lamenting the fact that the older culture was more like a family.

If you look at how much time we spend at work (I've seen statistics suggesting that approximately 1/3 of our life is spent at work), it's tempting to want to feel like we can be ourselves at work and that we can rely upon the emotional support from our co-workers, just like we would do from the members of our family.  Unfortunately, most experts suggest that comparing an organization to a family is neither appropriate nor realistic.  As Joshua Luna writes in the Harvard Business Review (see his article, "The Toxic Effects of Branding Your Workplace a Family"), "While some aspects of a family culture, like respect, empathy, caring, a sense of belonging can add value, ultimately trying to sell your organization's culture as family-like can be more harmful than psychologically satisfying."  

Luna goes on to suggest that when we try to describe an organization's culture like that of a family, the personal and professional lines begin to blur.  Not everyone wants to feel a deeper family-like connection with their fellow employees.  There are things that we would probably share with our family members in confidence that we would never share with colleagues at work.  In addition, making a comparison between an organization and a family assumes that family life is always positive and nurturing, and that's unfortunately not always the case.  Some families are dysfunctional, so why would we want that kind of environment at work?  

We wouldn't think twice about bending over backwards to help a family member out, and that may be true when it comes to some of our colleagues at work too.  Loyalty and teamwork are certainly positive aspects of an organization's culture, though too much loyalty can have negative aspects too.  For example, blogger Johnny Handsome suggests that a family-like organizational culture brings with it unspoken expectations and pressure to behave in ways that encroach upon our personal lives. He writes, "While these expectations are rarely articulated, they are palpably present, creating an environment where declining to participate can lead to feelings of guilt and fear of being perceived as not a team player."  Joe Pinsker, writing for The Atlantic magazine (see "The Dark Side of Saying Work is Like a Family"), adds, "When I hear something like We're like a family here, I silently complete the analogy: We’ll foist obligations upon you, expect your unconditional devotion, disrespect your boundaries, and be bitter if you prioritize something above us."

We know that diverse teams are stronger and more productive (see my previous posts, "How groups can make better decisions..." and "What's good for the hive is good for the bee").  Pinsker writes, "Families can be unwelcoming to outsiders, especially when it comes to differences in class, race, or sexuality."  Tessa West, author of Jerks at Work: Toxic Coworkers and What to Do About Them, suggest, "Family implies a degree of similarity, of being a good culture fit."  We all have biases and opinions, and we often share those with our family members.  The lack of diversity of thought within an organizational "family" can be counterproductive.

It can be difficult at times to hold a family member accountable.  Family members tend to overlook negative or even harmful comments from other family members.  Cynthia Pong, a New York-based career coach says, "I have seen that happen in the workplace, excusing people who've maybe been around the company for some time, and really not holding them to account for the highly problematic things they may be saying or doing."  Luna emphasizes, "You don't fire a family member, nor do you put them through performance improvement plans."  Similarly, studies have shown that employees who work in a family-like culture are less likely to report any wrongdoing.  Luna adds, "Numerous examples and research show that overly loyal people are more likely to participate in unethical acts to keep their jobs and are also more likely to be exploited by their employer."  

I think that organizations should focus on creating a culture that focuses on empathy, a sense of belonging, and a shared purpose.  Luna suggests that organizations should be more like a sports team and less like a family, writing that "in doing so, you retain a culture of empathy, collectiveness, belonging, and shared values and goals, while outlining a performance-driven culture that respects the transactional nature of this relationship."  In order to take advantage of all the positive aspects of a family culture and avoid all of the negative ones, organizations should:

1. Define high performance and focus on purpose.  Organizations should shift from the family-like culture of "We're all in this together" to the sports team-like culture of "We share the same purpose."

2. Set clear boundaries.  As Luna writes, "The grayer the policy, the more opportunities for misunderstanding.  Make sure employees understand what's expected when it comes to work hours and what lies beyond standard work hours."

3. Mutually accept the temporary and professional nature.  Luna makes an important point here.  He suggests, "We have to be realistic about the relationships employees build with their employers and remember that it is transactional.  Most won't stay at the same company for their entire career, and that's completely okay."

I want to close with some final thoughts from the blogger Candace Coleman ("The Pitfalls of Projecting a Family Culture at Work"), who writes, "Organizations that want to convey a family-like dynamic may have good intentions. However, doing so can open the door for blurred professional and personal boundaries, limit professional growth, and lead to excessive conformity. All of this can be detrimental to employee wellbeing and job satisfaction, which can undermine the company’s success.  Instead, leaders should focus on developing organizational culture that promotes collaboration and a shared purpose and provides a wellspring of support and respect that employees need to thrive."

"Everything else is just sand..."

I came across an online video (courtesy of one of my LinkedIn connections) that I thought was great, so I wanted to share it here.  In the video, a teacher is using a glass jar filled with golf balls (among other things) to make an important point to his students.  Here's the link to the video: A Valuable Lesson For a Happier Life.  I think the original story comes from Stephen Covey, but I am not 100% sure.

The teacher starts with an empty glass jar, to which he adds several golf balls.  He then turns to the students and asks, "Is this jar full?"  Some students nod, others answer "Yes".  Not every one agrees though.

Next, the teacher adds a smaller jar full of pebbles.  He asks again, "Is the jar full now?"  More students nod and say "Yes" this time.

The teacher then reaches into his bag and pulls out a small jar filled with sand.  He then pours the sand into the jar with the golf balls and pebbles.  He asks one last time, "Is the jar full?"  Everyone answers in the affirmative this time.

At least in the version of the video I watched, he next pulls out two bottles of beer, opens one, and pours the contents into the jar, which by this time, is obviously full.

The teacher then turns to the students and offers a simple, yet powerful explanation.  The golf balls represent the most important things in our life, such as family, friends, health, and our hobbies.  The pebbles represent other important things (but not quite as important as the golf ball things) in our life, such as our job, our home, or our car.  The sand represents everything else.  The small stuff that is just not that important (sorry, sand).

The metaphor is that if you spend all of your time and energy focusing on the small things, you won't have time in your life for the most important things.  If the teacher had started by filling the large empty jar with sand, he wouldn't have had any room left over for the golf balls or the pebbles.  So it is true for life.

At the very end, one of the students raises his hand and asks the teacher, "What does the beer represent?"  The teacher replies, "I'm glad you asked.  It goes to show you that no matter how full your life may seem to be, there is always room for a couple of beers with a friend."

Making lists and checking them twice...

I can't believe that I missed that October 30th was National Checklist Day!  One of our superb facilities project managers reminded me in his daily e-mail update.  Actually, to be 100% honest, I didn't even know there was such a day of recognition until he told me.  I've posted at least a couple of times in the past on checklists (see "Aviation checklists - an interesting observation" and "Today, I was a doofus...maybe I should use a checklist?").  They are an important tool utilized by most High Reliability Organizations.  

If any of you have ever read the excellent book, The Checklist Manifesto  by Atul Gawande, you will at least have read about the significance of October 30th in the history of checklists.  On October 30, 1935, Boeing was set to debut the most technologically advanced aircraft ever made, the Model 299 (also known as the B-17 Flying Fortress) at Wright Field in Dayton, Ohio.  The large, shiny aircraft raced down the runway in front of an anxious and excited audience.  It lifted off the ground, started its climb, and then promptly crashed after making it to just 300 feet.  Two of the country's top test pilots (Army Air Corps Major Ployer Peter Hill and Boeing's Leslie Tower) died in the crash.  The audience, which consisted of several top military generals, were stunned.  A subsequent investigation revealed the cause - the test pilot Major Hill had forgotten to release the gust lock, a device that keeps the rudder, elevators, and ailerons from moving due to excessive wind while the airplane is parked on the ground. Hill had tried to unlock it shortly after take-off, but it was too late.

Importantly, the Army Air Corps wanted to make the Model 299 its principal bomber aircraft.  However, the generals came under intense pressure from critics who thought Model 299 was too complex to be flown - there were at least 30 steps that had to be completed in sequence just to make the plane ready to fly!  The Army Air Corps had to think of something to change that if the Model 299 was going to ever fly again.  

According to Gawande, the Army Air Corps leaders asked their own test pilots for potential solutions ("Deference to Expertise").  The test pilots came up with an incredibly simple yet ingenious solution - a checklist.  He writes, "They created a pilot’s checklist.  Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert."

The test pilots' plan called for them to check off each item listed on a piece of paper that included all the major steps to prepared the plane for take-off.  Using the checklist would ensure that nothing was overlooked and every step was completed.  The new procedure worked great, and it was soon adopted for use on all the rest of the Army Air Corps' airplanes.  More importantly, the checklist saved the Model 299, which did, in fact, become the principal bomber used during World War II, primarily in Europe.  In fact, the B-17 Flying Fortress dropped more bombs than any other aircraft during World War II.

The checklist has since been adopted as an important safety tool in just about every industry out there.  If you want to learn more about the events of October 30, 1935, check out David Kindy's article in the Smithsonian's Air and Space Quarterly, "On. Set. Checked."  If you want to read more about how checklists are used in health care, check out either Atul Gawande's book The Checklist Manifesto or Safe Patients, Smart Hospitals by Peter Pronovost.  Next year, I will be sure not to forget National Checklist Day!

Trick or Treat!

Trick or Treat!  I wanted to re-post one of my older posts from October 31, 2018 and wish everyone a Happy Halloween.  One of the many great things about working in a children's hospital is that you get to wear your Halloween costume to work - and it's completely acceptable!  In the spirit of Halloween, I want to talk about one of my all-time favorite television shows growing up - the cartoon series, "Scooby Doo, Where Are You!", which was produced by Hanna-Barbera Productions from 1969 to 1970 (surprisingly, this now iconic series aired for only two seasons before going into syndication and generating a number of spin-offs).  The show featured the adventures of Scooby Doo and Mystery, Inc., a group of four teenagers who solved mysteries which frequently involved ghosts, monsters, and the supernatural.  Shaggy Rogers (I bet you didn't know his last name was Rogers!) and his best pal, Scooby Doo, once gave some really great advice:

Hold on, man.  We don't go anywhere with 'scary,' 'spooky', 'haunted,' or 'forbidden' in the title.

It seems fairly intuitive and simple, but the advice is really great.  Unfortunately, most of the mysteries that Scooby Doo and his friends were trying to solve involved going to places with the words 'scary,' 'spooky,' 'haunted,' and 'forbidden' in the title!  That happens a lot of times in the real world too.   Despite our best intentions, the world can be a dangerous place.  And no matter how hard we try, there are times when we are going to have to choose to take risks.

I like to read and write a lot about so-called High Reliability Organizations.  High Reliability Organizations (HROs) are usually defined as organizations that have succeeded in avoiding serious accidents or catastrophes in dangerous environments - the kind of environments where accidents are not only likely to occur, they are expected to occur.  The important point to realize, however, is that these same HROs don't seek to avoid risk - indeed, they could not exist if they did.  Rather, these organizations manage that risk in such a way that when (because it's always a matter of "when" and not "if") accidents occur, the adverse impact on the organization is significantly attenuated. 

Shaggy and Scooby Doo tried hard every episode to avoid taking a risk.  However, the whole purpose of Mystery, Inc. was to solve the mystery, and solving the mystery required taking a risk.  Scooby and his friends usually did a good job of managing risk - I wouldn't say that Mystery, Inc. was a great example of a High Reliability Organization, but they usually did pretty well in the end.  There was always the line from the villain in the end, "I would have gotten away with it too, if it weren't for those meddling kids."

So, in the spirit of Halloween, take a leadership cue from the gang at Mystery, Inc.  Manage your risks.  Solve the mystery.  And have fun.

Michael Jordan, Chocolate, Coffee, and the Nobel Prize

The famous mathematician Paul Erdös (perhaps best known to non-mathematicians for the eponymous Erdös number - see my post "Six degrees of Kevin Bacon") reportedly once said, "A mathematician is a device for turning coffee into theorems."  I had to laugh at that, because I can totally relate.  However, I can't imagine that there is any true, cause-and-effect relationship between coffee consumption and academic productivity.  As any scientist (or mathematician) knows, causation and correlation are two completely different concepts.  Confuse these two concepts at your own peril.

There is a famous study published in the New England Journal of Medicine that demonstrated a statistically significant correlation between a country's per capita chocolate consumption and the number of Nobel laureates (winners) in that country.  The study's investigator, Franz Messerli, found a correlation coefficient of +0.791 (with positive 1 being perfect correlation, so +0.791 is actually quite good) between the number of Nobel laureates per 10 million inhabitants and the chocolate consumption in kilogram per year among 22 countries.  He then suggested a potential reason, stating the potential (and still theoretical) benefits of dietary flavonoids found in chocolate on learning and memory.  

Incidentally, another investigator found a similar correlation between chocolate consumption and Nobel laureates even after controlling for other factors, though he also found that per capita coffee consumption did not correlate with the number of Nobel laureates.  It's an interesting idea, but one that demonstrates yet again that studies of this kind (analyzing large data sets) should only be used to generate new hypotheses, not prove them.  I don't think anyone would use the results of this study to suggest that a government should encourage (or even mandate) its citizens to eat more chocolate!  

I don't necessarily need data to convince me that Michael Jordan was the greatest basketball player that I've ever seen play in my lifetime.  Jordan made everyone around him better.  Actually, that's an understatement.  He made everyone around him great!  And it seemed like he could take over any game that he was playing in and exercise his will to win.  Jordan's Chicago Bulls drafted power forward Stacey King out of the University of Oklahoma with the 6th overall pick in the 1989 NBA Draft.  King averaged 8.9 points per game (PPG) in his first season with the Bulls and was named to the NBA All-Rookie Second Team that same year.  However, it was his performance on March 28, 1990 that stands out for me.  King and Jordan together combined for 70 points in the Bulls' win against the Cleveland Cavaliers.  King was quoted in the L.A. Times and said, "I'll always remember this as the night that Michael Jordan and I combined to score 70 points."

That sounds great, but there's a catch.  The stat sheet for the game on March 28, 1990 shows that Jordan scored 69 points, while King scored just 1 point.  So, to be 100% honest, they both combined to score 70 points.  But that doesn't come anywhere close to telling the real story.  For the real story, you have to dive a little deeper into the data.  It's almost always a good idea to have someone with content expertise review the data and the conclusions that are trying to be made.

When it comes to data analytics then, remember these important points.  First, correlation is not causation.  Second, analyzing large data sets should only be used to generate new hypotheses, not prove them.  Third, don't jump to conclusions until someone with content expertise has reviewed the data and the conclusions that are trying to be made.

Containment: Deference to Expertise

The very nature of the environments that high reliability organizations (HROs) exist in precludes any kind of script, checklist, or playbook that covers every possible issue.  So how do HROs deal with this drawback?  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.

Here is a list of all the posts in which the main (or at least a major) theme is "Deference to Expertise":

1.   "Brace for Impact" (September 18, 2016)
2. "Did he really say Shut up and listen?" (November 30, 2016)
3. "HRO: Deference to Expertise" (December 5, 2016)
4. "You know what to do..." (January 29, 2017)
5. "...plans are useless, but planning is indispensable" (August 9, 2017)
6. "Sua Sponte" (November 7, 2018)
7. "Biblical Org Charts" (November 14, 2018)
8. "The goal of all leaders should be to work themselves out of a job" (September 29, 2019)
9. "Taming the chaos" (February 23, 2020)
10. "Study the past" (March 11, 2020)
11. "Hungry, hungry hippos" (May 27, 2020)
12. "We rely upon your ability...you know what to do" (August 16, 2020)
13. "The bureaucracy paradox" (February 21, 2022)
14. "The definition of power is the transfer of energy" (May 7, 2022)
15. "Serve and thou shall be served" (July 23, 2022)
16. "We were soldiers once..." (July 30, 2022)
17. "The six thousand mile screwdriver" (October 22, 2022)
18. "Why Ted Lasso is the perfect HRO leader" (May 22, 2023)
19. "Player, Manager, Coach" (May 24, 2023)
20. "The few and the proud" (September 7, 2023)
21. "White elephants and wheelwrights" (November 3, 2023)
22. "The power of empowerment" (November 14, 2023)
23. "The Nelson Touch" (February 19, 2024)
24. "Leadership is not about solving problems??" (March 28, 2024)
25. "Turning around the ship..." (May 5, 2024)
26. "Better, stronger, faster, and flatter?" (August 28, 2024)
27. "Empowering employees doesn't mean leaving them alone..." (September 7, 2024)
28. "Improvise, Overcome, Adapt" (September 13, 2024)
29. "Fix the environment, not the people..." (September 27, 2024)

Containment: 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!  But that is okay, especially if it means that mistakes and errors can be contained.  Errors will happen, but HROs are not paralyzed by them.

Here is a list of all the posts in which the main (or at least a major) theme is "Commitment to Resilience" (focusing on organizational resilience, not personal resilience):

1. "HRO: Commitment to Resilience" (November 22, 2016)
2. "Still I Rise" (February 12, 2017)
3. "Be like Young" (June 14, 2017)
4. "Enter the Dragon" (April 28, 2019)
5. "Failure is not an option!" (April 17, 2020)
6. "For want of a nail..." (April 14, 2021)
7. "The grit in the oyster" (April 11, 2021)
8. "The Oak and the Reeds" (April 9, 2022)
9. "Disappointed but not defeated" (February 13, 2023)
10. "Be like water" (September 1, 2023)
11. "The Legend of the Spider" (March 22, 2024)
12. "Resilience and grit" (October 1, 2024)

Anticipation: Sensitivity to Operations

High reliability organizations are sensitive to operations, i.e. what is happening on the front lines of their operations.  They use standardization of best practices and elimination of waste to increase efficiency, lower cost, and minimize errors as much as possible.  

Here is a list of all the posts in which the main (or at least a major) theme is "Sensitivity to Operations":

1. "HRO: Sensitivity to Operations" (November 8, 2016)
2. "Failure is not an option" (April 17, 2020)
3. "For want of a nail..." (April 14, 2021)
4. "The bureaucracy paradox" (February 21, 2022)
5. "The law of continuous improvement" (March 17, 2022)
6. "Leaders adjust the sails" (July 5, 2022)
7. "Practice makes perfect" (December 1, 2023)
8. "A science of uncertainty and an art of probability..." (April 13, 2024)
9. "Turning around the ship..." (May 5, 2024)

Anticipation: Reluctance to Simplify

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 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. 

Here is a list of all the posts in which the main (or at least a major) theme is "Reluctance to Simplify":

1. "HRO: Reluctance to Simplify" (October 30, 2016)
2. "The curious case of the missing dollar" (September 27, 2017)
3. "The Alabama Paradox" (January 16, 2019)
4. "Einstellung" (June 22, 2021)
5. "Wicked" (September 18, 2022)
6. "...like a stand of trees" (September 22, 2022)
7. "My car is allergic to vanilla ice cream..." (November 29, 2023)
8. "Why is a raven like a writing desk?" (April 3, 2024)
9. "The SAT problem" (April 11, 2024)
10. "1+2+3+4+...= ?" (May 24, 2024)
11. "Things aren't always what they seem" (September 25, 2024)

Anticipation: 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!

Here is a list of all the posts in which the main (or at least a major) theme is "Preoccupation with Failure":

1. "HRO: Preoccupation with Failure" (October 26, 2016)
2. "Always try to keep the number of landings you make equal to the number of take-offs you've made..." (February 6, 2019)
3. "Murphy's Law, the U.S. Navy SEALS, and High Reliability Organizations" (March 10, 2022)
4. "The soul becomes dyed with the color of its thoughts..." (April 5, 2022)
5. "The failure of foresight" (October 6, 2022)
6. "Imagine the worst" (October 10, 2022)
7. "10Xers" (October 29, 2022)
8. "Six blind men from Indostan" (January 13, 2023)
9. "Is it really a surprise if there were plenty of warnings?" (May 17, 2023)
10. "Practice makes perfect" (December 1, 2023)
11. "L2M" (May 9, 2024)

Once again...High Reliability Organizations

It's been a couple of years since I first posted about High Reliability Organizations (HROs).  I wanted to re-visit the topic again in today's post.  HRO theory started with the analysis of three vastly different organizations - an US Navy nuclear-powered aircraft carrier (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 over the years by Karl Weick, Paul Schulman, and Kathleen Sutcliffe.  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, has 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.  Commercial aviation has become incredibly safe over the last few decades, but occasionally there are accidents that result in significant loss of life.  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 (see also my article "Organization-wide approaches to patient safety" published several years ago).  

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
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise

Three of these organizational characteristics have been called "Principles of Anticipation" as they have more to do with prevention of errors.  These include (1) Preoccupation with failure, (2) Reluctance to simplify, and (3) sensitivity to operations.  The last two organizational characteristics are known as "Principles of Containment" as they involve minimizing the impact of an error once it has already occurred.  These include, (4) Commitment to resilience and (5) Deference to expertise. 

I have written a number of posts over the years, highlighting at one time or another each of these five organizational characteristics.  I wanted to make it easier to search this blog for older posts on what separates HROs from the rest of us.  So, in my next five posts, I will collect all of these older posts and list them in a post on each of the five characteristics listed above.

Are smart phones making us dumb?

There was a time several years ago when I subscribed to both the Wall Street Journal and the Financial Times newspapers.  I enjoyed reading both, but it just got to be too much.  I soon found myself just throwing the daily edition of each newspaper unread (or partially read) into the recycle bin.  I have to be 100% honest though, while I thought the writing was slightly better in the WSJ (and more focused on current events in the US), the articles were shorter and easier to digest in the FT.  I've posted in the past about how much I like to read, but more recently I've found myself enjoying shorter books, magazine articles, and newspaper articles.  So, I started wondering if something was going on with my reading habits.  Have they changed?  As it turns out, there may be a very logical answer and explanation.

The American writer and journalist, Nicholas Carr, wrote an article for The Atlantic in 2008 entitled, "Is Google Making Us Stupid?"  He expands on this theme in his excellent book, The Shallows: What the Internet Is Doing to Our Brains. He suggests (and provides convincing evidence) that our online reading habits have changed not only how we read, but also how we think.  Consider this - studies show that when we read online, we skim over information and bounce around the Internet using either the embedded hypertext links or by starting a completely new search.  Just like my preference for the shorter articles of the Financial Times compared to the Wall Street Journal, we've all lost our ability to read lengthy passages of text.  Our brains have become permanently accustomed to the 280 character count of Twitter or the short messages with all the emoji's that we send and receive in a text!  As Maggie Jackson writes in her book Distracted, the Internet, social media, and email are all set up to distract us and keep us distracted.  Carr describes the changes in his reading habits by stating, "Once I was a scuba diver in a sea of words.  Now I zip along the surface like a guy on a Jet Ski."  Case in point, in his book Carr references an article that appeared in New York magazine in 2009 written by Sam Anderson, entitled "In Defense of Distraction."  I took a look, but when I saw how long it was, I quickly skimmed through it!

Even traditional forms of media have been forced to adapt to our new reading habits.  Television programs add text crawls at the bottom of the screen, while magazines and newspapers (if they are even around) have shortened their articles (see my point on the Financial Times above) or provided abstracts or summaries of the longer articles.  I've even heard of e-books that have started to look more like the Internet, complete with hypertext links, pop-up advertisements, and rolling text crawls.  

What if the Internet has changed more than just our reading habits?  What if it has fundamentally changed the way we think?  Carr starts and ends both the Atlantic article and his book with a famous scene from Stanley Kubrick's 1968 movie, 2001: A Space Odyssey.  Astronaut Dave Bowman is slowly turning off the computer HAL-9000, which had tried to kill him earlier in the film (and actually did kill his fellow astronauts).  At first, HAL-9000 admonishes, "Dave, stop. Stop, will you? Stop, Dave. Will you stop?"  As the astronaut continues to shut off HAL's circuits, one at a time, the computer responds with "I can feel it. I can feel it. I'm afraid."  Carr ends the article (and the book) with, "That's the essence of Kubrick's dark prophecy: as we come to rely on computers to mediate our understanding of the world, it is our own intelligence that flattens into artificial intelligence."  It's a haunting prediction, but one that doesn't seem all that far off.  

Carr writes, "The Net grants us instant access to a library of information unprecedented in its size and scope, and it makes it easy for us to sort through that library - to find, if not exactly what we are looking for, at least something sufficient for our immediate purposes.  What the Net diminishes is...the ability to know, in depth, a subject for ourselves, to construct within our own minds the rich and idiosyncratic set of connections that give rise to a singular intelligence."  To be blunt, the Internet is driving our brain into the shadows!

There is evidence to suggest that "how" we read helps to shape the neural circuits inside our brains (called neuroplasticity - for another example of neuroplasticity, see my post "London Hackney" on the neuroplasticity found in London taxi drivers).  For example, experiments have shown that readers of written language that uses symbols (e.g., Chinese characters, called Hanzi, that are among the oldest writing systems in the world) develop different neural circuitry compared to those whose written language uses an alphabet.  Similarly, studies have shown that our online reading habits ("power browsing" to use a term by another author) form different neural circuits in our brain compared to our traditional way of reading, where we become deeply engrossed in an article or book.

As it turns out, people have been worrying about how advances in technology can change us in dramatic ways since the time of the ancient Greeks.  In Plato's Phaedrus, Socrates laments how writing has made people forget how to think.  Socrates argues that the written word is "a recipe not for memory, but for reminder."  And as people use the written word as a substitute for the knowledge that they used to carry around in their heads and recite by memory, they will "cease to exercise their memory and become forgetful."

Maybe Nicholas Carr is right.  Maybe our smart phones have made us less intelligent.  Technological progress has become, to use Socrates' analogy, a crutch that in the long run will only make us less intelligent, less resilient, and less independent.  Carr carries on this theme with his book on the dangers of automation, The Glass Cage: How Computers Are Changing Us, but that is a topic for another post.

Royal Pains Part Two

I ended my last post ("Royal Pains") with a promise to revisit and further explain my statement that the lack of alignment between physicians on a hospital's medical staff and the hospital administration is well known.  Some experts refer to this lack of alignment as "Blue Suits versus White Coats", referencing that administrators frequently wear blue or black suits, while physicians frequently wear white lab coats.  Unfortunately, negative stereotypes only make this lack of alignment worse.  As Deane Waldman and Kenneth H. Cohn write in The Business of Healthcare, "The manager sees a doctor who has no understanding of, or interest in, resource constraints or proper organizational behavior, even if the doctor has an MBA and manages a successful multimillion-dollar division. The doctor sees a heartless bean counter who cares nothing for patients, despite the CEO spending seven hours before a state oversight committee aggressively seeking support for the doctors’ medical programs."

The management expert Henry Mintzberg suggested that there are four different "worlds" or subcultures that exist in hospitals today (see his article, "Toward healthier hospitals"): the hospital trustees (or Board of Directors), the physicians, the managers (i.e. the hospital administrators), and the nurses.  Mintzberg also noted that these four worlds rarely talk to each other, nor do they attempt to solve problems by collaborating together.  Each world has its own language, which makes it even harder for the "citizens" of each of the four worlds to collaborate and communicate with each other.  Mintzberg wrote his article in the late 1990's, and while the communication and collaboration between the four different worlds has certainly improved, I will admit that there are still four distinctly different subcultures in most hospitals today.

The divide (some would call it a chasm) between physicians and administrators is compounded by the fact that the growth in the number of healthcare administrators has far outpaced the growth in the number of physicians.  Between 1975 and 2010, the number of physicians in the U.S. increased by 150%, roughly proportional to the growth of the U.S. population as a whole.  In contrast, the number of healthcare administrators increased by 3,200% (see the graph that is frequently shown on social media below):

Most experts defend the tremendous growth in healthcare administrators by citing the tremendous growth in complexity of the U.S. healthcare system due to advances in technology in general (and in information technology in particular), as well as the greater scrutiny from regulatory agencies and payors.  Unfortunately, the imbalance in growth between physicians and administrators has only further escalated the tensions between the two groups.  As Pooja Chandrashekar and Sachin Jain write (see "Understanding and fixing the growing divide between physicians and healthcare administrators"), "Physicians blame managers for creating administrative hurdles that diminish autonomy and increase workload.  Administrators blame physicians for failing to comply with resource complaints."

Some of the reasons for this growing divide between physicians and administrators is historical.  It was not all that long ago that most physicians were independently employed (rather than being employed by hospitals), working mostly in a private practice setting and rounding occasionally at the hospital whenever one of their patients was admitted.  There was very little regulatory or administrative oversight of physicians, which has largely changed in recent years.  While both physicians and administrators are often following a call to serve, they differ in how they approach that calling.  For example, while physicians focus on improving the health of their individual patient, administrators focus on improving the health of the population.  While an individual physician may feel justified in expending all the available resources for one patient, an administrator often has to balance resource expenditures to serve the needs of all the patients who seek care in their organization.  

One potential solution to this issue is to develop physician executives who can bridge the divide between their colleagues and the hospital management team.  There has been a virtual explosion of physician leadership programs in the last several years, including dual-degree (MD/MBA) programs, postgraduate certificates, and graduate (e.g., MHA, MBA, MMM) programs tailored specifically for physicians. Hospitals and health systems have developed specific executive-level leadership roles for physicians, with a number of different titles (Chief Medical Officer, Physician-in-Chief, Chief Clinical Officer, etc).  These physician executives must balance reading the New England Journal of Medicine with the Wall Street Journal, speaking both the "language" of their physician and administrator colleagues. What frequently happens (based on surveys of physicians in executive positions), however, is that the physician executive is never fully embraced by the administrators ("You're still a physician!") and can find themselves alienated by their physician colleagues ("You've gone to the dark side!").  It can be difficult to balance this reality that they may no longer be viewed as physicians by their colleagues, while at the same time never be fully trusted by the hospital management team.

There are certainly other ways to bridge the divide between physicians and administrators.  There are countless articles and books written on this very subject.  Admittedly, however, despite the growing literature on this subject, the divide between physicians and administrators remains.  What has worked well in one organization may not necessarily translate to another organization, as a lot depends on the history, culture, and leaders of an organization.  Regardless, here are some high-level, general themes (from the Chandrashekar and Jain article, as well as the Institute for Healthcare Improvement's (IHI) white paper, "Engaging Physicians in a Shared Quality Agenda"):

1. Unite around a common, patient-centered vision. What's generally not very controversial, even between physicians and administrators, is that the care that is provided in an organization should be of the highest quality.  I've found that physicians and administrators can and often do unite around the common goal of providing safe, effective, timely, efficient, equitable, and patient-centered care.  

2. Improve mutual understanding of roles.  Administrators need to understand the physician experience, but just as important, physicians can benefit from looking at a problem through the lens of an administrator.  Executive rounding (using Lean/Six Sigma concepts, "going to the gemba", a Japanese term for "the place where value is created") and clinical shadowing programs are two commonly used techniques to help administrators gain a better understanding and appreciation of what physicians do.  Conversely, leadership training and teaching physicians "the business side of medicine" can help physicians better appreciate and understand what administrators do.

3. Increase transparency and provide opportunities to collaborate.  To increase trust between physicians and administrators, organizations should increase transparency around how and why certain decisions are made.  Better yet, having members of the medical staff participate in those decisions helps to increase trust and collaboration.  Importantly, these physicians shouldn't be viewed as the token physician representative, but rather as active participants in the decision-making process.  A number of organizations have adopted so-called leadership dyads (physician/nurse, physician/administrator) or triads (physician/nurse/administrator), whether for service line leadership or leadership of organization-wide change initiatives.  Importantly, make physician involvement in these initiatives clearly visible to the rest of the medical staff.  

4. Remember that respect is as important as autonomy.  Administrators can preserve both autonomy and respect by engaging physicians in "active problem-solving, rather than passive rule-following".  Administrators should take physicians' concerns about administrative burden, workplace culture, and burnout seriously.  Initiatives that are co-led by physicians and administrators (see the "dyad model" above) and that focus on reducing hassles and wasted time can go a long way.  The IHI white paper "Engaging Physicians in a Shared Quality Agenda" recommends changing the narrative by making physicians partners, not customers.  Having administrators treat physicians as partners, collaborators, and colleagues will go a long way towards building trust and collaboration.

The leading healthcare organizations have figured out how to narrow the divide between senior management and physicians.  It's not easy.  But it's important for physicians and administrators to be on the same page when it comes to the goals of the organization.