"Before I make a mistake..."

Legendary Dutch football player and manager Johan Cruyff is widely regarded as one of the greatest football players in the history of the sport, having won the Ballon d'Or (a player of the year award which current football stars Lionel Messi and Cristiano Ronaldo have won seven times and five times, respectively) three times in the 1970's.  After retiring as a player, he became one of the greatest managers of all time, leading the professional clubs, Ajax (1985-1988), Barcelona (1988-1996), and Catalonia (2009-2013).  Cruyff has had a major influence on the sport and has been a strong proponent of a style of play known as "total football" (for all of you Ted Lasso fans out there, the formation known as the "False 9" mentioned in the second season of the show is a major tactic in this style).

Cruyff is also known for often stating the obvious in a rather humorous and lighthearted way (similar to the legendary New York Yankees player Yogi Berra).  For example, Cruyff once said, "You have got to shoot, otherwise you can't score."  He also said, "To win you have to score one more goal than your opponent."  And here is one of my favorites, "I'm not religious.  In Spain, all 22 players make the sign of the cross before they enter the pitch.  If it works all matches must therefore end in a draw."

More germane to what I most frequently write about it here in this blog, Cruyff once said, "Before I make a mistake, I don't make that mistake."  Again, on the surface it seems that Cruyff is stating the obvious.  If you unpack the quote a little more though, it actually is quite a profound statement.  How can someone not make a mistake before they actually make it?  It's easier than it sounds, and it comes down to two safety concepts borrowed from other so-called High Reliability Organizations - the time-out and the huddle.  

Time-outs have become the standard before and after every surgical or bedside procedure performed in the hospital.  While pre-procedural time-outs were originally designed to confirm the right patient, the right procedure, and the right surgical site, they have evolved far beyond their original intended use.  Time-outs make sure that all members of the surgical care team know each other by name and by role.  During the time-out, the plan for the procedure is clearly communicated to all of the members of the team, and any concerns that are raised get addressed before proceeding further.  When performed well, the team develops a shared understanding (known in the safety world as a "shared mental model") of the plan.  

Time-outs were initially performed at the beginning of the procedure, but now they are performed at each critical stage of the procedure, as well as at the end as a final debrief.  The Joint Commission has identified some of the most common errors when performing time-outs:

1. Time-outs occurring before all staff members are ready or before prep and drape occurs

2. Performing time-outs without full participation of the staff

3. Lack of senior leadership engagement in the time-out

4. Staff feeling passive or unable to speak up (an issue of psychological safety)

5. Distractions or rushed time-outs

When done well, time-outs reflect a patient-centered safety culture and create an environment of trust and psychological safety, so that team members feel empowered to report patient safety concerns without fear of reprisal.  Huddles are related to the time-out, though they are generally a little longer in duration than the time-out and generally occur at the beginning of a hospital shift or clinic.  The overall goal of the huddle is to review the scheduled events of the day and highlight any areas of potential concern.  Huddles are used in a number of industries outside health care (see my previous post "The morning huddle").

Huddles can be structured in a number of different ways, and some hospitals (notably The Cleveland Clinic and Intermountain Healthcare) have adopted the concept of tiered huddles, which generall start at the unit (microsystem) level, eventually rolling up through the meso- and macro-system levels.  For example, here is what tiered huddles look like at our children's hospital (more or less - I've simplified the structure slightly):

Tier One: Unit-based Huddle (team members working on an inpatient unit huddle at the start of a nursing shift )

Tier Two: Inpatient Huddle (representatives from each inpatient unit huddle together shortly after the unit-based huddles end)

Tier Three: System-wide Huddle (representatives from the inpatient, ambulatory, peri-operative, and emergency department huddle together, along with key stakeholders from security, safety, information technology, etc huddle together at 9:45 AM every morning)

Huddles generally work best when they occur in person, however hospitals have experimented with virtual and hybrid models as well.

So you see, Cruyff's statement wasn't really that far off base.  With time-outs and huddles, we can stop mistakes before they occur.  Recognizing that we can't prevent every mistake from occurring, time-outs and huddles can mitigate the impact of these mistakes and stop them from compounding and causing harm.