There's an old Hindu parable about an elephant and five blind men (the number of blind men varies in different versions of the story). In the story, each blind man touches the elephant in order to describe to the others what an elephant is like. As each blind man touches a different part of the elephant, the description varies significantly, and not one description is exactly correct.
The American poet John Godfrey Saxe immortalized the story in the American lexicon with his version, which can be found here. In Saxe's version, there are six blind men. The first blind man touches the elephant's side and states that the elephant is like a wall. The second blind man touches the elephant's tusk and states that the elephant is like a spear. The third blind man touches the elephant's trunk and states that the elephant is like a snake. The fourth blind man touches the elephant's leg and states that the elephant is like a tree. The fifth blind man touches the elephant's ear and states that the elephant is like a fan. The sixth blind man touches the elephant's tail and states that the elephant is like a rope.
The "Blind Men and the Elephant" is a perfect example of how different perspectives can provide vastly different explanations of a particular event. I am reminded of a great movie, called Vantage Point, starring Dennis Quaid, Forest Whitaker, Sigourney Weaver, and William Hurt. Dennis Quaid plays a U.S. Secret Service agent trying to protect the President of the United States (played by William Hurt). The movie is unique in that it tells the same story eight different times - each from the vantage point of a different character in the movie. There was a similar movie in 1950 called Rashomon, which has given rise to the phenomenon known as the "Rashomon Effect" in cognitive psychology.
Collectively, this Hindu parable and these two movies describe the situation in which multiple perspectives can lead to multiple explanations (some of which may be completely wrong) of an event. We see examples of the "Rashomon effect" in health care today. Consider the case of a physician who commits a 10-fold dosing error with a particular medication order (note that in pediatrics, medication dosing is based on body weight, so that medications are administered on a mg medication per kg body weight basis). Why did this dosing error occur? The simplest explanation is that the physician had a momentary lapse in judgment and made a decimal point error in the calculation. Upon further review, however, the physician was in the last hour of a 36 hour shift (this particular case occurred prior to the implementation of duty-hour restrictions for residents). Moreover, the bedside nurse was relatively new to the hospital and didn't want to question the physician's authority. Finally, the medication was a verbal order (i.e. not written down - again, before the days of computerized physician order entry) and was administered in an emergency to a critically ill infant in the Pediatric Intensive Care Unit. For this reason, the pharmacist, who would have normally reviewed and filled the medication order, was not involved in the case. Multiple checkpoints for medication safety were bypassed. Had we talked to each individual - the physician, the nurse, and the pharmacist - we likely would have heard vastly different stories. Only by putting all three versions of the event together could we learn the true root cause of the medication error.
High reliability organizations (HROs) are characterized by a reluctance to simplify interpretation of events. HROs understand that we live in a complex, unpredictable world and that the easiest explanation (often the first explanation) is usually not the complete story. HROs do not fall victim to either the Rashomon effect or to the related phenomenon of "groupthink" (more on groupthink in a future post). HROs conduct thorough, in-depth investigations of adverse events, usually interviewing multiple individuals to get different perspectives, in order to get to the root-cause of the event.
We can easily see that if we relied simply on only one of the blind men's explanations, we would never fully understand what an elephant looks like. It is only by putting together all six explanations that we come close to knowing the truth. The simplest explanation (often the easiest explanation) is rarely the correct one. Dig deeper for the truth and do not simplify.
Sunday, October 30, 2016
Wednesday, October 26, 2016
HRO: Preoccupation with Failure
The first defining characteristic of high reliability organizations (HROs) is a preoccupation with failure. High reliability organizations do not consider failures as things to avoid at all cost. Rather, HROs believe that failures represent opportunities to learn and improve their systems. As Thomas Watson, founder of International Business Machines (IBM) once said,"If you want to increase your success rate, double your failure rate." Individuals in HROs report their mistakes, even when nobody else is looking! HROs do not punish individuals who make mistakes. On the contrary, in many cases, individuals who report their mistakes are often rewarded!
A couple of examples from US Navy aircraft carrier flight operations are illustrative of the kind of preoccupation of failure that is necessary to become a HRO. Debris and other loose objects can be very dangerous on the flight deck - if a foreign object or piece of debris (or on rare occasions, one of the aircraft mechanics) is sucked up into the aircraft engine, the plane can no longer fly. For this reason, each and every day while the aircraft carrier is at sea, every single individual on the flight deck, regardless of rank, lines up at the back of the flight deck and walks slowly to the other end, picking up any piece of debris or foreign object along the way (foreign object damage, or FOD walk). There is a popular story of an aircraft mechanic who once lost a screwdriver while working on one of the planes. He notified his supervisor, who then notified his supervisor (and so on through the chain of command). The incident triggered a FOD walk, and the screwdriver was found. Was the mechanic punished? Absolutely not. He was recognized by the commanding officer in a ceremony later that same cruise. The last example of "preoccupation with failure" involves the pilots. In the early days of naval aviation, pilots were guided back to the flight deck by the landing signal officer (LSO), affectionately known as "paddles". The LSO was also an experienced pilot. Today, pilots use advanced technology to assist the landing. However, the LSO remains as an important part of the landing process. Each and every landing is graded by the LSO. Pilots who do not pass muster receive additional training and instruction, and if they continue to have problems, they may be permanently grounded. The LSO provides the ultimate "peer review" for all the pilots in the squadron. These landings are also videotaped and broadcast throughout the ship - every one on the ship can watch these landings (PBS once broadcast a special segment on flight deck operations aboard the USS Nimitz - there is an excellent video showing an example of several pilots landing on a rolling, pitching flight deck at night!).
So what would "preoccupation with failure" look like in a hospital? A hospital on its way to becoming a HRO usually has a "reporting culture" where slips, lapses, mistakes, and errors are reported without fear of punishment. These hospitals view errors as opportunities to learn and get better. HRO-like hospitals fully embrace training through simulation - simulation provides a safe, nonstressful environment in which processes can be learned and tested, often using real world scenarios. Finally, these hospitals fully leverage peer review as a way to identify problems early, so that they can be corrected. I know of some hospitals that videotape record all of the trauma resuscitations in the emergency department - these videotaped resuscitations are later watched and critiqued in a safe, blame-free environment by all members of the team. The videotape recording is used as a teaching tool to improve and learn. The HRO experts Karl Weick and Kathleen Sutcliffe published a short list of questions that hospitals can use to assess whether they are "preoccupied with failure"
There are some experts who feel that "preoccupation with failure" is too pessimistic and focuses too much on events in the past. These experts suggest that hospitals should be preoccupied with success by focusing on what they need to do in the future in order to be successful. While I can certainly appreciate this sentiment, I think this view misses the point. A preoccupation with failure doesn't have to be pessimistic at all. I think the key (and perhaps Weick and Sutcliffe should have used a different terminology here) is that HROs are focused on LEARNING.
A couple of examples from US Navy aircraft carrier flight operations are illustrative of the kind of preoccupation of failure that is necessary to become a HRO. Debris and other loose objects can be very dangerous on the flight deck - if a foreign object or piece of debris (or on rare occasions, one of the aircraft mechanics) is sucked up into the aircraft engine, the plane can no longer fly. For this reason, each and every day while the aircraft carrier is at sea, every single individual on the flight deck, regardless of rank, lines up at the back of the flight deck and walks slowly to the other end, picking up any piece of debris or foreign object along the way (foreign object damage, or FOD walk). There is a popular story of an aircraft mechanic who once lost a screwdriver while working on one of the planes. He notified his supervisor, who then notified his supervisor (and so on through the chain of command). The incident triggered a FOD walk, and the screwdriver was found. Was the mechanic punished? Absolutely not. He was recognized by the commanding officer in a ceremony later that same cruise. The last example of "preoccupation with failure" involves the pilots. In the early days of naval aviation, pilots were guided back to the flight deck by the landing signal officer (LSO), affectionately known as "paddles". The LSO was also an experienced pilot. Today, pilots use advanced technology to assist the landing. However, the LSO remains as an important part of the landing process. Each and every landing is graded by the LSO. Pilots who do not pass muster receive additional training and instruction, and if they continue to have problems, they may be permanently grounded. The LSO provides the ultimate "peer review" for all the pilots in the squadron. These landings are also videotaped and broadcast throughout the ship - every one on the ship can watch these landings (PBS once broadcast a special segment on flight deck operations aboard the USS Nimitz - there is an excellent video showing an example of several pilots landing on a rolling, pitching flight deck at night!).
So what would "preoccupation with failure" look like in a hospital? A hospital on its way to becoming a HRO usually has a "reporting culture" where slips, lapses, mistakes, and errors are reported without fear of punishment. These hospitals view errors as opportunities to learn and get better. HRO-like hospitals fully embrace training through simulation - simulation provides a safe, nonstressful environment in which processes can be learned and tested, often using real world scenarios. Finally, these hospitals fully leverage peer review as a way to identify problems early, so that they can be corrected. I know of some hospitals that videotape record all of the trauma resuscitations in the emergency department - these videotaped resuscitations are later watched and critiqued in a safe, blame-free environment by all members of the team. The videotape recording is used as a teaching tool to improve and learn. The HRO experts Karl Weick and Kathleen Sutcliffe published a short list of questions that hospitals can use to assess whether they are "preoccupied with failure"
There are some experts who feel that "preoccupation with failure" is too pessimistic and focuses too much on events in the past. These experts suggest that hospitals should be preoccupied with success by focusing on what they need to do in the future in order to be successful. While I can certainly appreciate this sentiment, I think this view misses the point. A preoccupation with failure doesn't have to be pessimistic at all. I think the key (and perhaps Weick and Sutcliffe should have used a different terminology here) is that HROs are focused on LEARNING.
Monday, October 24, 2016
High Reliability Organizations - A Very Brief Introduction
We hear a lot about so-called high reliability organizations (HROs) these days. Regulatory agencies such as the Center for Medicare and Medicaid (CMS), the Joint Commission, and the Leapfrog Group have all embraced the concept that health care delivery organizations should aspire to become HRO's. HRO theory started with the analysis of three vastly different organizations - the US Navy nuclear-powered aircraft carrier, the USS Carl Vinson, the Federal Aviation Administration's Air Traffic Control system, and Pacific Gas and Electric's nuclear power plant at Diablo Canyon by an eclectic group of investigators - Rear Admiral (retired) Tom Mercer, Todd LaPorte, Gene Rochlin, and Karlene Roberts (all at the University of California at Berkeley). Additional contributions to the HRO literature have been provided by Karl Weick, Paul Schulman, and Kathleen Sutcliffe. But what exactly is a "high reliability organization"? HROs are usually defined as organizations that somehow avoid catastrophic accidents, even though they normally exist in an environment where normal accidents can be expected to occur by virtue of the complexity of the organization and by the nature of the industry. Examples of HROs have included flight deck operations on US Navy aircraft carriers, nuclear power plants, commercial aviation, NASA, and forest fire fighting operations.
Interestingly enough, every single HRO has, at one time or another, experienced catastrophic accidents. For example, NASA has had the space shuttle Challenger and Columbia accidents, while the nuclear power industry has experienced the Three Mile Island and, more recently, the Fukushima Daiichi disasters. Even the highly acclaimed Toyota Production System (many experts have claimed that Toyota has been one of the more recent examples of a HRO) has experienced difficulties. As such, there are certainly lessons that we, in health care, can learn from HRO's past successes and failures (I wrote a recent article on this topic, available here). Karl Weick and Kathleen Sutcliffe have written extensively on HRO principles in their excellent book entitled "Managing the Unexpected". Weick and Sutcliffe explain that all HROs have five key organizational characteristics in common:
1. Preoccupation with failure
2. Reluctance to simplify interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise
In the next few blog posts, I plan to discuss in greater detail each specific characteristic. Whether hospitals can become HROs is debatable - some experts even suggest that hospitals can NEVER become HROs (for example, see the article here). I would argue that most HROs will never admit that they are, in fact, highly reliable organizations. In other words, the first characteristic - "preoccupation with failure" suggests (in my opinion) that most prototypical HROs are so focused on failure that they will never claim that they are HROs. So, beware the hospital that claims to be a HRO!
Interestingly enough, every single HRO has, at one time or another, experienced catastrophic accidents. For example, NASA has had the space shuttle Challenger and Columbia accidents, while the nuclear power industry has experienced the Three Mile Island and, more recently, the Fukushima Daiichi disasters. Even the highly acclaimed Toyota Production System (many experts have claimed that Toyota has been one of the more recent examples of a HRO) has experienced difficulties. As such, there are certainly lessons that we, in health care, can learn from HRO's past successes and failures (I wrote a recent article on this topic, available here). Karl Weick and Kathleen Sutcliffe have written extensively on HRO principles in their excellent book entitled "Managing the Unexpected". Weick and Sutcliffe explain that all HROs have five key organizational characteristics in common:
1. Preoccupation with failure
2. Reluctance to simplify interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise
In the next few blog posts, I plan to discuss in greater detail each specific characteristic. Whether hospitals can become HROs is debatable - some experts even suggest that hospitals can NEVER become HROs (for example, see the article here). I would argue that most HROs will never admit that they are, in fact, highly reliable organizations. In other words, the first characteristic - "preoccupation with failure" suggests (in my opinion) that most prototypical HROs are so focused on failure that they will never claim that they are HROs. So, beware the hospital that claims to be a HRO!
Tuesday, October 18, 2016
The Sorcerer's Apprentice
One of my favorite Disney scenes was the short sketch adapted from Goethe's poem, The Sorcerer's Apprentice in the 1940 movie, Fantasia. In the movie, Mickey Mouse plays the part of the apprentice to the great wizard, "Yen Sid" (note - Disney spelled backwards). I actually never realized that the movie was based on a Goethe poem until relatively recently, and I was quite surprised to see that the movie (except for the fact that the main character is a mouse) follows the poem almost exactly! Here is the text of the poem:
That old sorcerer has vanished
And for once has gone away!
Spirits called by him, now banished,
My commands shall soon obey.
Every step and saying
That he used, I know,
And with sprites obeying
My arts I will show.
Flow, flow onward
Stretches many
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
Come, old broomstick, you are needed,
Take these rags and wrap them round you!
Long my orders you have heeded,
By my wishes now I've bound you.
Have two legs and stand,
And a head for you.
Run, and in your hand
Hold a bucket too.
Flow, flow onward
Stretches many,
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
See him, toward the shore he's racing
There, he's at the stream already,
Back like lightning he is chasing,
Pouring water fast and steady.
Once again he hastens!
How the water spills,
How the water basins
Brimming full he fills!
Stop now, hear me!
Ample measure
Of your treasure
We have gotten!
Ah, I see it, dear me, dear me.
Master's word I have forgotten!
Ah, the word with which the master
Makes the broom a broom once more!
Ah, he runs and fetches faster!
Be a broomstick as before!
Ever new the torrents
That by him are fed,
Ah, a hundred currents
Pour upon my head!
No, no longer
Can I please him,
I will seize him!
That is spiteful!
My misgivings grow the stronger.
What a mien, his eyes how frightful!
Brood of hell, you're not a mortal!
Shall the entire house go under?
Over threshold over portal
Streams of water rush and thunder.
Broom accurst and mean,
Who will have his will,
Stick that you have been,
Once again stand still!
Can I never, Broom, appease you?
I will seize you,
Hold and whack you,
And your ancient wood
I'll sever,
With a whetted axe I'll crack you.
He returns, more water dragging!
Now I'll throw myself upon you!
Soon, O goblin, you'll be sagging.
Crash! The sharp axe has undone you.
What a good blow, truly!
There, he's split, I see.
Hope now rises newly,
And my breathing's free.
Woe betide me!
Both halves scurry
In a hurry,
Rise like towers
There beside me.
Help me, help, eternal powers!
Off they run, till wet and wetter
Hall and steps immersed are Iying.
What a flood that naught can fetter!
Lord and master, hear me crying! -
Ah, he comes excited.
Sir, my need is sore.
Spirits that I've cited
My commands ignore.
"To the lonely
Corner, broom!
Hear your doom.
As a spirit
When he wills, your master only
Calls you, then 'tis time to hear it."
So what does this poem have to do with leadership? In my opinion, quite a lot. In the poem (and in the movie), the sorcerer's apprentice tries to cut corners by casting a spell on the broomsticks. Unfortunately, while he remembers the spell needed to enchant the broomsticks, he has forgotten the spell that turns the broomsticks back to normal. In other words, he has set something in motion that he is quite powerless to stop. Luckily, the sorcerer returns in the end to cast the proper spell, and everything returns back to normal. In the movie, Fantasia, the sorcerer scolds Mickey Mouse and sends him on his way. It's almost as if he is saying, "Go back to your chores and don't mess with magic until you are ready!"
I think that Goethe is telling us something more. One of the best ways to learn is through failure. Thomas Edison reportedly failed so many times before he was successful in creating the light bulb that he claimed, "I didn't fail. I found 10,000 ways how NOT to build a light bulb." As the author, J.K. Rowling said, "It is impossible to live without failing at something, unless you live so cautiously that you might as well not have lived at all, in which case you have failed by default." Nike had a fantastic commercial when I was growing up, in which Michael Jordan kept talking about how many times he had failed. At the end of the commercial (right before the Nike swoosh appears with the famous "Just Do It"), Michael Jordan says, "I have failed over and over and over again. And that is why I succeed." In other words, FAILURE is how WE LEARN. It is one of the best ways that we do learn - and more often than not, the lessons we learn through failure are the ones that stick in our minds. FOREVER. I still remember, to this day, the word I missed to win my school Spelling Bee in 6th grade ("aggravate") - as my PE teacher told me as I walked slowly off the stage, "You will never ever misspell that word again." And I haven't (incidentally, I also remember my losing word in the 7th grade Spelling Bee, "masonry").
As leaders, one of the greatest things that we can do is to give the members of our team the chance to fail. More likely than not, in the majority of circumstances, there is enough slack in the system to allow our team members to experiment and learn. If they do fail, more often than not, we can rescue them, as in the "Sorcerer's Apprentice" story. Give folks a chance - more often than not, they will surprise us and succeed. However, even if they do fail, they will learn a lesson that they will never forget.
That old sorcerer has vanished
And for once has gone away!
Spirits called by him, now banished,
My commands shall soon obey.
Every step and saying
That he used, I know,
And with sprites obeying
My arts I will show.
Flow, flow onward
Stretches many
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
Come, old broomstick, you are needed,
Take these rags and wrap them round you!
Long my orders you have heeded,
By my wishes now I've bound you.
Have two legs and stand,
And a head for you.
Run, and in your hand
Hold a bucket too.
Flow, flow onward
Stretches many,
Spare not any
Water rushing,
Ever streaming fully downward
Toward the pool in current gushing.
See him, toward the shore he's racing
There, he's at the stream already,
Back like lightning he is chasing,
Pouring water fast and steady.
Once again he hastens!
How the water spills,
How the water basins
Brimming full he fills!
Stop now, hear me!
Ample measure
Of your treasure
We have gotten!
Ah, I see it, dear me, dear me.
Master's word I have forgotten!
Ah, the word with which the master
Makes the broom a broom once more!
Ah, he runs and fetches faster!
Be a broomstick as before!
Ever new the torrents
That by him are fed,
Ah, a hundred currents
Pour upon my head!
No, no longer
Can I please him,
I will seize him!
That is spiteful!
My misgivings grow the stronger.
What a mien, his eyes how frightful!
Brood of hell, you're not a mortal!
Shall the entire house go under?
Over threshold over portal
Streams of water rush and thunder.
Broom accurst and mean,
Who will have his will,
Stick that you have been,
Once again stand still!
Can I never, Broom, appease you?
I will seize you,
Hold and whack you,
And your ancient wood
I'll sever,
With a whetted axe I'll crack you.
He returns, more water dragging!
Now I'll throw myself upon you!
Soon, O goblin, you'll be sagging.
Crash! The sharp axe has undone you.
What a good blow, truly!
There, he's split, I see.
Hope now rises newly,
And my breathing's free.
Woe betide me!
Both halves scurry
In a hurry,
Rise like towers
There beside me.
Help me, help, eternal powers!
Off they run, till wet and wetter
Hall and steps immersed are Iying.
What a flood that naught can fetter!
Lord and master, hear me crying! -
Ah, he comes excited.
Sir, my need is sore.
Spirits that I've cited
My commands ignore.
"To the lonely
Corner, broom!
Hear your doom.
As a spirit
When he wills, your master only
Calls you, then 'tis time to hear it."
So what does this poem have to do with leadership? In my opinion, quite a lot. In the poem (and in the movie), the sorcerer's apprentice tries to cut corners by casting a spell on the broomsticks. Unfortunately, while he remembers the spell needed to enchant the broomsticks, he has forgotten the spell that turns the broomsticks back to normal. In other words, he has set something in motion that he is quite powerless to stop. Luckily, the sorcerer returns in the end to cast the proper spell, and everything returns back to normal. In the movie, Fantasia, the sorcerer scolds Mickey Mouse and sends him on his way. It's almost as if he is saying, "Go back to your chores and don't mess with magic until you are ready!"
I think that Goethe is telling us something more. One of the best ways to learn is through failure. Thomas Edison reportedly failed so many times before he was successful in creating the light bulb that he claimed, "I didn't fail. I found 10,000 ways how NOT to build a light bulb." As the author, J.K. Rowling said, "It is impossible to live without failing at something, unless you live so cautiously that you might as well not have lived at all, in which case you have failed by default." Nike had a fantastic commercial when I was growing up, in which Michael Jordan kept talking about how many times he had failed. At the end of the commercial (right before the Nike swoosh appears with the famous "Just Do It"), Michael Jordan says, "I have failed over and over and over again. And that is why I succeed." In other words, FAILURE is how WE LEARN. It is one of the best ways that we do learn - and more often than not, the lessons we learn through failure are the ones that stick in our minds. FOREVER. I still remember, to this day, the word I missed to win my school Spelling Bee in 6th grade ("aggravate") - as my PE teacher told me as I walked slowly off the stage, "You will never ever misspell that word again." And I haven't (incidentally, I also remember my losing word in the 7th grade Spelling Bee, "masonry").
As leaders, one of the greatest things that we can do is to give the members of our team the chance to fail. More likely than not, in the majority of circumstances, there is enough slack in the system to allow our team members to experiment and learn. If they do fail, more often than not, we can rescue them, as in the "Sorcerer's Apprentice" story. Give folks a chance - more often than not, they will surprise us and succeed. However, even if they do fail, they will learn a lesson that they will never forget.
Sunday, October 16, 2016
"Every one of my patients is a VIP"
Several years ago, I was approached by a grandparent of one of my patients in the ICU who told me, "Treat this girl as if you were treating the President of the United States." Luckily, this kind of request has been relatively rare during my career. However, I am proud of my response - "Sir, I treat every patient that I have as if he or she was the President of the United States. My ICU is full of "very important patients" tonight."
There seems to be a belief that health care providers can adjust up or down their ability to treat the patients that are in front of them. It's almost like some would have you believe that doctors and nurses are saying to themselves, "You know what, I am kind of tired tonight. Maybe I will take the night off and just give 50% effort tonight." Alternatively, when confronted with a patient who happens to be related (or as more commonly the case, the relative of a friend of a friend of a friend) to someone important, these same health care providers say, "Wow. I better be on my 'A game' tonight." Really?!?!? Come on. I am absolutely, 100% confident that in the vast majority of circumstances, everyone working in health care today are giving their absolute best effort for every single patient, every single time.
VIP ("very important patient") care is not the best care. First, place yourself in the shoes of the healthcare worker in front of you. Knowing that the patient you are caring for is someone important (or at least knows someone that is important) can be intimidating and anxiety-provoking. Second, at times the VIP demands to be cared for by the senior most physician (frequently one of the physicians in the C suite) - never mind that in many cases, these senior physicians infrequently provide care and don't have the requisite volume of patients to maintain the skills that got them to their station in life. As an example, on the night that President Abraham Lincoln was shot, a young physician named Charles Leale happened to be at Ford's Theatre watching the same play. Dr. Leale immediately responded by conducting what would now be described as a primary survey - noting no pulse, he opened Lincoln's airway by repositioning his head and neck and depressed his tongue by placing two fingers in the President's mouth (note - this is not how we do this now!). Lincoln started breathing again and his pulse returned. Leale was later joined by more senior physicians (the Army Surgeon General, Dr. Joseph K. Barnes, for one). While Leale was only 23 years old, he was familiar with all of the latest theories on the care of battlefield injuries. He disagreed with the care being provided by the senior physicians but was overruled due to his "inexperience." Significantly, two modern-day neurosurgeons reviewed Lincoln's care and suggested that if Leale's instructions had been followed, Lincoln may have survived the assassination attempt, albeit with significant neurological sequelae! There are several additional cases in the more recent literature, especially when care is provided to Hollywood celebrities, such as Michael Jackson, Joan Rivers, and Prince.
We can do better - and we should. We need to recognize "VIP syndrome" and do our best to avoid it. Drs. Jorge Guzman, Madhu Sasidhar, and James Stoller recently published an article on the VIP syndrome, suggesting nine different things that health care administers should do to guard against it:
1. Don't bend the rules.
2. Work as a team, not in silos.
3. Communicate, communicate, communicate.
4. Carefully manage communications with the media
5. Resist "chairperson's syndrome"
6. Care should occur where it is most appropriate
7. Protect the patient's security
8. Be careful about accepting or declining gifts
9. Be careful about working with the patient's personal physician
To these guiding principles, I would add another. Sending a senior member of the hospital to "check in on the patient" may or may not be appropriate (I happen to believe that it is not). However, at a minimum, these kinds of visits need to be conducted tactfully, respectfully, and carefully (in terms of the providers at the bedside and NOT the VIP). Visitation guidelines and HIPAA laws should still apply here. Finally, and perhaps most importantly, please don't insult the integrity of the caregiver at the bedside by informing her or him that the patient is a VIP. To all providers at the bedside, every patient is a VIP!
There seems to be a belief that health care providers can adjust up or down their ability to treat the patients that are in front of them. It's almost like some would have you believe that doctors and nurses are saying to themselves, "You know what, I am kind of tired tonight. Maybe I will take the night off and just give 50% effort tonight." Alternatively, when confronted with a patient who happens to be related (or as more commonly the case, the relative of a friend of a friend of a friend) to someone important, these same health care providers say, "Wow. I better be on my 'A game' tonight." Really?!?!? Come on. I am absolutely, 100% confident that in the vast majority of circumstances, everyone working in health care today are giving their absolute best effort for every single patient, every single time.
VIP ("very important patient") care is not the best care. First, place yourself in the shoes of the healthcare worker in front of you. Knowing that the patient you are caring for is someone important (or at least knows someone that is important) can be intimidating and anxiety-provoking. Second, at times the VIP demands to be cared for by the senior most physician (frequently one of the physicians in the C suite) - never mind that in many cases, these senior physicians infrequently provide care and don't have the requisite volume of patients to maintain the skills that got them to their station in life. As an example, on the night that President Abraham Lincoln was shot, a young physician named Charles Leale happened to be at Ford's Theatre watching the same play. Dr. Leale immediately responded by conducting what would now be described as a primary survey - noting no pulse, he opened Lincoln's airway by repositioning his head and neck and depressed his tongue by placing two fingers in the President's mouth (note - this is not how we do this now!). Lincoln started breathing again and his pulse returned. Leale was later joined by more senior physicians (the Army Surgeon General, Dr. Joseph K. Barnes, for one). While Leale was only 23 years old, he was familiar with all of the latest theories on the care of battlefield injuries. He disagreed with the care being provided by the senior physicians but was overruled due to his "inexperience." Significantly, two modern-day neurosurgeons reviewed Lincoln's care and suggested that if Leale's instructions had been followed, Lincoln may have survived the assassination attempt, albeit with significant neurological sequelae! There are several additional cases in the more recent literature, especially when care is provided to Hollywood celebrities, such as Michael Jackson, Joan Rivers, and Prince.
We can do better - and we should. We need to recognize "VIP syndrome" and do our best to avoid it. Drs. Jorge Guzman, Madhu Sasidhar, and James Stoller recently published an article on the VIP syndrome, suggesting nine different things that health care administers should do to guard against it:
1. Don't bend the rules.
2. Work as a team, not in silos.
3. Communicate, communicate, communicate.
4. Carefully manage communications with the media
5. Resist "chairperson's syndrome"
6. Care should occur where it is most appropriate
7. Protect the patient's security
8. Be careful about accepting or declining gifts
9. Be careful about working with the patient's personal physician
To these guiding principles, I would add another. Sending a senior member of the hospital to "check in on the patient" may or may not be appropriate (I happen to believe that it is not). However, at a minimum, these kinds of visits need to be conducted tactfully, respectfully, and carefully (in terms of the providers at the bedside and NOT the VIP). Visitation guidelines and HIPAA laws should still apply here. Finally, and perhaps most importantly, please don't insult the integrity of the caregiver at the bedside by informing her or him that the patient is a VIP. To all providers at the bedside, every patient is a VIP!
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.
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.
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 maître 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.
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.
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.
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