HRO: Deference to Expertise

I recently picked up an old book about the game of chess the other day.  I never really was all that good at chess, but I have always wanted to be better.    It really is an amazing game and is much more complex than most people think.  I was talking to my son (who is a much better player than me) who suggested that I learn about some of the classic opening moves.  Standardization has been on my mind a lot lately, and I thought perhaps I could develop a few "standard opening move" sequences, depending upon the moves that the other player made in response.  Perhaps I could even develop a playbook of sorts - if my opponent does this, then I should do this in response.  So I actually started to right down some possibilities in a small notebook.  This was going to be great!  I was finally going to be able to play chess like the pro's!  However, while I was doing some research on the Internet (looking for tips and pointers), I came across an article that stated there are 20 possible opening chess moves (16 possible pawn moves plus 4 possible knight moves - the rest of the pieces can't be moved until one of the pawns has moved out of the way) for the first player, the White player.  Similarly, White's opponent (the Black player) also has 20 possible opening moves.  Once Black has moved, White is now faced with 400 possible moves.  Once White has moved a second time, the Black player has 5,362 possible moves.  After that, the numbers get really out of hand (see the calculation here).  In other words, even if I did want to write down all the possible moves, I would need more than just one notebook!  I would probably need an entire library of notebooks.  There is just simply no way to be able to follow a specific kind of algorithm that takes into account every possible contingency.  As much as I would like to plan out all my possible moves in a "chess playbook," it is just not possible.

High reliability organizations (HROs) have already figured this out.  It would be really great if the leadership team of a HRO could script out the desired response for every single contingency that the rest of the organization could face in the future.  Unfortunately, just like in my game of chess, it is just not possible to cover every possible contingency.  The very nature of the environments that HROs exist in precludes any kind of script, checklist, or playbook that covers every possible issue.  So how do HROs deal with this issue?  They push decision making, especially in times of crisis, as much as possible to the frontline leaders and managers.  The true experts - the individuals who know their systems the best - are found on the frontlines and not in the board room!  Moreover, there is no way that an executive leader can have a full understanding of all the information that is at the frontline.  Even with the best communication plans and systems, the individuals who will have the most up-to-date and most accurate information will be the ones on the frontline.  The military has a term for the rapidly evolving, chaotic, confusing, and unpredictable nature of combat known as the "fog of war."  I think this concept applies to what most HROs deal with on a daily basis!  As a famous Marine Corps general once said, "Once the shooting starts, all plans fall apart."

The military has developed a variation on the "deference to expertise" theme known as "commander's intent" (based upon an earlier concept developed by the German military during the early days of World War II, called "auftragstaktik").  Frontline leaders (who are usually far removed from their commanding officers) are provided with a set of orders and instructions that describe the overall goals and objectives of a particular mission, the tactics and strategy that will be used, and the resources that will be immediately available.  In other words, the frontline leaders are given a rough blueprint of the battle plan and are then told to go and complete the mission.  "Commander's intent" is a really beautiful example of the last defining characteristic of a high reliability organization - "deference to expertise."

I am not against standardization in health care - in fact, I think we need to standardize, as much as possible, as many key processes that lend themselves to standardization.  Used in such a manner, standardization can and will improve outcomes and reduce costs.  However, I do think that we need to be careful not to over-script and over-plan for every possibility - there is just no feasible way to do that.  We would be much better off taking a cue from the military ("commander's intent") and other HROs, who leverage their frontline experts as much as possible.  Do these frontline leaders have specific and detailed instructions?  Yes - absolutely.  Do these frontline leaders have guidelines and guardrails within which they are free to make decisions?  They sure do.  Developing these concepts will require education and training - over and over and over again.  It is the right kind of investment to make though, and it will make a significant difference for our patients.  For now, I guess I better go back to learning more about the different kinds of chess moves and practice, practice, practice!