Thursday, October 13, 2016

The Disastrous Product Recall Hall of Fame (or is it Shame?)

One of the many summer jobs I had growing up was working in a small factory that manufactured underwater lighting and photography equipment.  I spent two summer and two winter breaks during college working at the factory, assembling parts for underwater flashlights.  During one of those summers, there was an issue with one of the parts in the flashlight that caused the light beam to scatter in all directions.  The company issued a recall and spent several days going back and forth with the design engineers to try to determine the root-cause of the problem.  Eventually, the problem was identified and we were able to replace the defective part to address the problem.  Why am I bringing this up now?  I guess reading all about the issues with the Samsung Galaxy Note 7 triggered my memory. 




The Galaxy Note 7 smartphone was Samsung's answer to the new iPhone.  The Galaxy note 7 was officially released on August 19, 2016 as the successor to the Galaxy Note 5 (it was branded as the Note 7 in order to distinguish it from Samsung's Galaxy S7 smartphone) and was supposed to be technologically superior to any other smartphone on the market.  Demand was incredibly high, and Samsung's stock value soared.  However, shortly after release, there was a number of reports of the smartphone literally exploding into flames due to the battery generating excessive heat.  Samsung issued a product recall and tried to come up with a fix, but continued reports of battery fires, even after the initial product recall and replacement product release, led to Samsung finally pulling the plug on the Note 7 for good on October 11, 2016.  The Samsung stock price has taken an absolute beating, and the company expects to lose over $2.3 billion in lost earnings as a result of the recall.  Earlier today, the company announced that it will offer a $100 rebate to any customer who exchanges his or her Galaxy Note 6 for another Samsung smartphone.  I guess $100 is the price of customer loyalty these days!




It turns out that disastrous product recalls are not that uncommon - there is even a frequently cited list of the "top 10" most disastrous product recalls of all time.  The list is old (Samsung is not even on there) but includes Toyota's faulty gas pedal recall in 2010, the Ford Pinto in 1978, and the Firestone tire recall in 2000, just to name a few.  Importantly, the list was published before General Motor's ignition switch fiasco that resulted in over 124 fatalities and 274 injuries over a several year timespan.  Also listed is Johnson & Johnson's Tylenol recall of 1982.  This last case is notable for two reasons.  First, while the previously cited product recalls involved manufacturing defects, the 1982 Tylenol recall occurred after 7 people in the Chicago area died after taking cyanide-laced Tylenol.  In this particular case, the root-cause of the problem was completely out of the company's control - someone had obviously  tampered with the medication (although no one was ever charged or convicted).  The case is also notable for how Johnson  & Johnson dealt with the issue - the case is used in many business schools as a demonstration for how to effectively manage a corporate crisis.  Johnson & Johnson removed over 30 million units from the market.  Prior to introducing the product back to the public, Johnson & Johnson issued a formal apology, introduced triple-seal tamper resistant packaging (the company was, in fact, the first company to do so), switched to caplets (instead of capsules, which could be easily tampered with), and offered a significant rebate ($2.50 off coupon on all bottles sold, obtained through a number of newspaper ads or through a toll-free number).  While the company's market share decreased from 35% to 8% shortly after these deaths were publicized, Johnson & Johnson recovered in less than 12 months and Tylenol soon became the number one over-the-counter analgesic sold in the United States.


What does all of this have to do with health care?  As I posted last week, "Sometimes, sorry is the best thing to say".  Medical errors are quite common in health care - in fact, one study estimated that medical errors are the third leading cause of death in the United States.  When a medical error is made, the natural inclination is to want to hide the error or not to disclose that the error is made for fear of malpractice litigation.  On the contrary, several studies have found that when health care institutions are completely open and transparent (so-called open disclosure programs), the risk of malpractice litigation is decreased, especially if disclosure of the error is coupled with a formal apology.  Additional studies are certainly required, and there should be formal policies (and perhaps legal protection) to encourage full transparency and open disclosure.  However, being honest and telling a patient or family that a mistake has been made, combined with a simple apology, is absolutely the right thing to do!  In other words, health care institutions should take a cue from Johnson & Johnson's playbook (at least the one that they followed in 1982) and not Toyota, Ford, or General Motors. 

Monday, October 10, 2016

Can you "mandate" culture change?

I read an interesting tweet yesterday.  Apparently, the Canadian Nuclear Safety Commission (CNSC) recently released a new regulatory document (REGDOC-2.1.2) that details new requirements and recommendations for "fostering a healthy safety culture" for nuclear facilities and uranium mines.  To be fair, the document that was released is actually a draft that is open for public comment.  These kinds of regulatory requirements are actually not new.  The United States Nuclear Regulatory Commission released a similar guideline (NRC-2010-0282) that requires "individuals and organizations performing or overseeing regulated activities establish and maintain a positive safety culture commensurate with the safety and security significance of their activities and the nature and complexity of their organizations and functions."  The tweet I received regarding the CNSC guideline questioned whether it was appropriate, indeed whether it was possible, to mandate a safety culture.

The NRC defines "safety culture" as "the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment."  Culture is frequently described as "the way we do things around here."  There are a number of high-profile accidents that detailed investigations implicated the lack of an adequate safety culture , including the accidents at Three Mile Island, Chernobyl, and Fukushima Daiichi nuclear power plant, as well as the space shuttle Challenger and Columbia disasters, Piper Alpha oil production platform accident, and Deepwater Horizon accident.  Given the role that culture (specifically, the absence of a healthy, robust safety culture) played in the genesis of these catastrophic events, several industries have tried to identify ways to foster a safety culture.  Health care organizations such as the Agency for Healthcare Research and Quality (AHRQ) have recommended certain practices aimed at safety culture that hospitals can use to improve patient safety. 

So back to the original question posed in the tweet.  If certain practices are believed to foster a healthy, robust safety culture, then why not mandate these practices?  Unfortunately, I don't think that it is quite that easy.  As Shawn Galloway stated in a blog post in 2013, "Cultures are not a program; they are the interconnectedness that explains why efforts work, don't work, succeed, and fail."  He further calls on organizations to "stop trying to create a safety culture."  In many cases, as Galloway suggests, the basic elements are already there and just need to be developed further.   

Safety culture encompasses both visible, directly observable elements, such as policies, procedures, and behaviors, as well as invisible, hidden elements, such as beliefs, values, perceptions, and attitudes (see the Iceberg model of culture for a great description of this concept).  Culture change takes time - in some reports, experts suggest that culture change may take an organization several years.  Leadership engagement is absolutely essential, but it is not even close to being enough.  While "top-down" leadership can set an organization on the proper course towards establishing a safety culture, true culture change needs to occur from the "bottom-up."  Leaders need to "walk the walk" and "talk the talk," but front-line engagement is critical to the success of any culture change initiative.  The CNSC suggests that safety culture is dependent upon the following:

1.  Safety is a clearly recognized value in the organization.
2.  Accountability for safety in the organization is clear.
3.  Safety is integrated into all activities in the organization.
4.  A safety leadership process exists in the organization.
5.  Safety culture is learning-driven in the organization. 

In my opinion, it is hard, if not impossible, to establish any of these 5 core elements without leadership at the highest level of the organization AND 100% engagement by front-line employees. While organizational leaders can and should set the tone and provide the necessary resources for any safety culture change effort, the kind of organizational change that is required to foster the kind of safety culture envisioned by both the NRC and CNSC (in other words, the kind of safety culture that will prevent accidents such as Three Mile Island, Chernobyl, and Fukushima Daiichi catastrophes) MUST develop from the "bottom-up."  For this simple reason, I agree with my friends on Twitter that you cannot (and should not) try to "mandate" safety culture.

Thursday, October 6, 2016

Sometimes, sorry is the best thing to say

Just the other night, my wife and I decided to go back to a restaurant that we had been to only just once in the past.  The last time we went there, the food (Thai food), service, and atmosphere were all pretty good.  I made reservations for 7:30 pm, and we arrived right on time.  The maĆ®tre d' informed us that they were running a little behind schedule due to a large party and asked us to sit and wait for about 10 minutes.  Once we sat down at our table (around 7:45 pm), we ordered drinks, an appetizer, and our main course.  The drinks and appetizer came fairly quickly, but we waited quite a long time for our main course.  Two couples sat down at the table next to us, and we overheard them asking each other whether or not they were hungry enough to order appetizers (we told them, "You definitely should!").  Finally, around 9:00 pm, our main course arrived.  The food was good, we paid our bill, and left for home.

On the way to our car, both my wife commented on how it would have been nice if our server had kept us informed about the delays, perhaps even giving us an approximate time that we could expect our food.  We also thought it would have been nice to have received an apology for the long delay.  While we certainly understood that there was not a lot that our server could personally do about the delay in the kitchen, he could have done a better job of keeping us well-informed.  An apology would have been even nicer.  Perhaps if we had put himself in our place, he would have provided better service.

How often in health care do we hear of patients complaining of long delays in the waiting room?  Delays at the doctor's office are so common, they are almost completely expected, perhaps even assumed.  How much nicer would it be if we placed ourselves in our patients' shoes and treated them how we ourselves would want to be treated - telling us sorry, giving us an explanation for the delay, and providing us with an estimate of when we can expect to be seen?  There are now multiple studies and books on improving the patient and family experience in health care.  Most of the recommendations in these studies and books boil down to two simple rules - (1) treat the patient how you would want to be treated and (2) when the experience is not optimal, tell the patient that you are sorry.

Sorry is such a wonderful word.  And sometimes, sorry is the best thing to say.

Sunday, October 2, 2016

Aviation checklists - an interesting observation.

My wife and I flew to Boston over the weekend to visit our daughter for college parent's weekend.  While we were sitting on the tarmac awaiting take-off, I noticed something that I hadn't considered before in the past.  Shortly before take-off, our flight attendant asked us to "pay attention for a brief safety message."  He then proceeded to repeat a memorized speech on how to put on and take-off your seat belt, how to use your seat cushion for a flotation device, how to find your way out of the plane in case of an accident, and how to put on your oxygen mask in the event of a loss in cabin pressure.  It was all very important information, but I was particularly impressed by the fact that he had memorized the entire speech - though if you consider that he had probably given that speech at least a thousand times, maybe it wasn't such an impressive feat after all!

What struck me as interesting was the fact that so many of the passengers weren't paying attention to the flight attendant's "important safety brief."  Several passengers continued reading, while several more were punching away on their smartphones or laptops.  As I thought more about it, this was one of the few times that I actually paid attention to the flight attendant's well-rehearsed speech.  I had just happened to be paying attention - usually I am reading, punching keys on a laptop, or sleeping!  Clearly there is something going on here.  Undoubtedly, the information that the flight attendant is repeating is important (our lives could depend upon following these instructions for rarely used emergency procedures).  However, most passengers have probably heard this same brief on countless flights in the past.  So, perhaps most passengers already feel confident in their knowledge of these emergency procedures?

I started thinking about other safety procedures in the aviation industry.  I have read about aviation safety, and I have talked with many pilots about safety in the past.  Almost every procedure before, during, and after a flight is scripted on some sort of checklist.  In fact, one of the first things that pilots do in an emergency is pull out the relevant checklist.  Why?  The aviation industry wants to make sure that every step of a procedure (both routine procedures and emergency procedures) is followed in the exact sequence, every single time that the procedure is performed.  Aviation safety experts believe, and have evidence to show, that nothing whatsoever should be left to chance.  Follow the exact steps in a procedure and use the proper checklist and nothing will be forgotten.  No important steps will be left out.  No mistakes will be made.  Safety is critical - the lives of the passengers and the flight crew depend upon it.

Which brings me back to the flight attendant's safety brief.  If all of these emergency procedures were critical (and I believe that they are), then why not use a checklist or read from a script rather than memorizing the entire speech?  Why leave something like that to chance?  Would passengers pay more attention to the safety brief if the airlines placed it on an equal degree of importance as every other procedure during a flight?  If the airlines required flight attendants to use a checklist and read from a script, maybe more passengers would pay attention?

How many times do we, as leaders, send these same kinds of mixed messages?  On the one hand, we try to convince our teams that something is important to us - maybe it's a new safety initiative or new process.  Maybe in the back of our minds, we are thinking, "Here we go again.  One more new thing."  Unconsciously (or even at times, consciously), by our actions, we signal to our teams that we really don't care too much about the new initiative.  We allow our subconscious feelings and opinions out by our actions.  We say one thing and then we do another - some times, we don't even follow our new process! 

One of the worse things a leader can do is torpedo a new project or initiative by signaling to other members of the team that he or she thinks the new project is a waste of time.  I think this happens fairly frequently, and I wonder if this is what is going on with the flight attendant's safety brief.  By memorizing the safety brief when everything else on the flight has been scripted on a checklist, the flight attendants are subconsciously letting us know that what he or she is saying really doesn't matter all that much.  Interestingly enough, on the return flight, our pilot got out of his seat and came back to the cabin.  He actually picked up the microphone and started telling us how important it was that we paid attention to the flight attendant's safety instructions.  While the flight attendant still went from memory, it seemed more passengers were paying attention.

Wednesday, September 28, 2016

"The Man Who Thinks He Can"

The Internet is really a great thing!  When I was in high school, my parents had a poem or at least part of a quotation taped to our refrigerator door.  I was thinking about what to post on the blog last night and remembered the first line of the quotation.  I never knew who really had said it - one of my friends (a Green Bay Packers fan) thought it sounded like something that the great football coach, Vince Lombardi would say.  He certainly said something like it when he said, “It’s not whether you get knocked down, it’s whether you get up.”  I tried hard to remember the quotation and just could not remember enough of it, so I looked up the first line and found it all over the Internet.  As it turns out, Vince Lombardi didn't say it - the quotation is actually from a poem written by a man named Walter Wintle (as an aside, I did not find any details on the poet, even on the Internet).  The poem is called "Thinking" and was published in 1905 (the poem is also known by the title, "The Man Who Thinks He Can").  You may have heard it, but if not, here it is:

If you think you are beaten, you are;
If you think you dare not, you don't.
If you'd like to win, but you think you can't,
It is almost a cinch that you won't.


If you think you'll lose, you're lost;
For out of the world we find
Success begins with a fellow's will
It's all in the state of mind.


If you think you're outclassed, you are;
You've got to think high to rise.
You've got to be sure of yourself before
You can ever win the prize.


Life's battles don't always go
To the stronger or faster man;
But sooner or later the man who wins
Is the one who thinks he can!


I only learned the first and last stanzas of the poem.  The poem itself reminds me a lot of the classic story, "The Little Engine That Could" ("I think I can, I think I can, I think I can...").  And who knows, maybe Vince Lombardi used it to motivate the great Packers teams of the 1960's.  It really is a powerful poem.  I do believe in the absolute power of a positive attitude.  A positive attitude is one of the key drivers of success.  And in the end, it is the man (or woman) who believes in him- or herself that accomplishes his or her goals. 

Sunday, September 25, 2016

Winnie the Pooh and the Navy SEALs

There was a book that came out several years ago called, The Tao of Pooh that was written by Benjamin Hoff  (believe it or not, the book spent 49 weeks on the New York Times bestseller list).  The book used A.A. Milne's characters from the Hundred Acre Wood to explain the tenets of the Eastern philosophy of Taoism.  I never read the book (it seemed like a stretch to me, but then I don't know much about Taoism), but I do vividly remember a quote from one of Disney's Winnie the Pooh movies that has always rang true with my own belief system.  I can't remember which movie it was, but I do remember that Christopher Robin was the character who said it:

"Always remember.  You are braver than you believe.  Stronger than you seem.  And smarter than you think."

What a beautiful, poignant quote!  Basically, Christopher Robin is telling us that deep down inside of all us, there is a heart of a champion.  If we put our mind to something, we can and will accomplish anything.  The American philosopher, psychologist, and physician, William James wrote something similar along those lines in his essay, The Energies of Men:

"Beyond the very extreme of fatigue and distress, we may find amounts of ease and power we never dreamed ourselves to own; sources of strength never taxed at all because we never push through the obstruction."

Finally, there is a former Navy SEAL named David Goggins who talks about something that he calls the "40 percent rule".  In essence, when your mind is telling you that you can't go on anymore, you are really only 40% done.  Deep down, your body can handle more stress and you can face even greater challenges.  Goggins explains this is why the vast majority of individuals (he claims 99%) who start a marathon race actually finish the race.

So what does this all have to do with leadership?  More than you think.  Winnie the Pooh, William James, and the "40 percent rule" tell us that we, as leaders, can push our teams farther than they think is possible.  It's not an easy thing to do (convince someone that they can push harder past the point of physical or mental exhaustion), but it can be done.  These three examples also suggest that so-called "stretch goals" are certainly achievable with the kind of leadership that motivates, supports, and pushes individuals and teams to success.  The drive that allows marathon runners to push past "hitting the wall" at mile marker 16 or Navy SEAL candidates to survive 5 1/2 days of cold, wet, physically brutal operational training on less than 4 total hours of sleep during "Hell Week" is the same drive that will help teams to achieve aspirational, "stretch" goals in just about any other discipline. 

Thursday, September 22, 2016

"You can't lead from behind..."

I am reading a book right now about the famous Civil War Battle of Gettysburg called (oddly enough), The Battle of Gettysburg.: A Comprehensive Narrative.  It is an older book, written and published in 1913 by a former Union officer who served there named Jesse Bowman Young.  One of the book's strengths is the fact that it is more or less a firsthand account of the events that occurred by someone who was actually there during those fateful three days in July of 1863.  The battle itself is famous for the fact that it was by far the deadliest battle of the entire Civil War (and if you consider that Americans died on both sides of the battle, it was by far the deadliest three days in any war in our nation's history) and for being the turning point of the Civil War.  Young's book's other major strength is that it provides several lengthy lists of key statistics and detailed biographical sketches of the officers who served in the battle.  It is a great book, and I am really enjoying the read.


I was particularly struck by the number of field officers who died or were seriously injured during the battle.  I once read a statistic that Civil War generals were 50 percent more likely to be killed in combat than privates (the lowest rank).  Brigadier generals, who either led divisions (on rare occasions), or most commonly, brigades (note that a brigade in the Civil War comprised approximately 2,600 soldiers and a division most commonly consisted of 3 brigades). 


Related to this point, there is an exchange between General Robert E. Lee and Lieutenant General James Longstreet in another one of my favorite books, Michael Shaara's novel, The Killer Angels (the movie, Gettysburg was based upon this novel) that I believe is rather poignant.  Lee starts, "General, in the fight that's coming, I want you to stay back from the main line.  You are my only veteran commander."  After talking some more, Lee continues, "You have a very bad habit, General, of going too far forward."  Longstreet replies, "You cannot lead from behind."


Here is an important lesson for us all.  The fact that generals had a much higher chance of being killed during the Civil War than privates was simply due to the fact that during that particular war, generals usually led the battle from the actual battlefield.  In many cases, the generals led the battle by being out in front of their men, where they would be most likely to be shot at from the opposing side.  However, there was no other good way at that time in our history to motivate and direct the troops and place them in a position to win the battle.  There was no better position than out front to observe the events of the battle as they unfolded. 


There are certainly lessons for us here today.  First, leaders should lead by example.  Leaders set the tone for the whole organization - in reality, leaders (or at least how the leaders "lead") determine the overall culture in an organization.  Leaders "practice what they preach" - so many times, I hear from good leaders the phrase, "If I am not willing to do this myself, then I cannot expect my team to do it either."  Second, leaders should be out and about - it is hard, if not impossible, to lead (by example or otherwise) from an office desk.  Good leaders should subscribe to the practice of "management by walking around."  Leaders should get to know all of the members of their team - but the really great leaders also get to know people outside of their teams, all over the organization.  Leaders provide real-time feedback, which is very difficult to do if the leader is not out of his or her office and observing team members where they are doing their jobs.  Finally, and perhaps most importantly, having a leadership presence on the organization's front line is not enough.  At least one study has shown that leaders also have to help their teams with problem-solving and elimination of barriers.  One of the best ways that leaders can do this is to be great teachers, mentors, and role models.  Good leaders don't simply solve the problems on their own.  Rather, the most effective leaders enable their teams and front line employees to solve problems  on their own.  Just as General Longstreet claimed, "You cannot lead from behind."