Last night, I had the honor and privilege of attending a special ceremony in Columbus, Ohio - my mentor, colleague, and friend, Richard J. Brilli, MD, MCCM received the John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality & Safety. Rich has taught me so much and has done so much for my career over the years, that I would not have missed this ceremony for the world.
Those of you who have worked with Rich in the Pediatric Intensive Care Unit (PICU) will remember that he always taught about "five things." For example, there are "5 causes of arterial hypoxemia," "5 reasons that children get admitted to the PICU following spinal fusion surgery" (at least in the old days), and at least "5 bugs that can kill you." I used to joke with Rich about this when I was a PICU fellow - however, the joke was always on me. I had to laugh (inwardly, of course) on my first day of clinical service as an attending when all of the residents were waiting for me to say something half-way intelligent. I quickly reverted to the "five things" method of bedside teaching!
As I was thinking last night, there are at least "five things" that Rich has taught me about leadership. Specifically, there are "5 leadership values" that Rich taught me - these remain personal values for me to this day.
1. Honor: Rich said it best last night during his acceptance speech. "It is a blessing. It is a gift. It is a privilege to do what we do every day. Honor it." Above all else, honor the patient in front of you.
2. Courage: Rich always taught me to have the courage to stick to your core principles and your core values. Everything else flows from your core values. Stand up for what you believe in. Stand up for those who can't.
3. Commitment: Making clinical decisions about someone else's critically ill child is frightening. But you owe it to the patient to make that decision, and once you do make the decision, be strong and stay committed to it. I think the same is true in health care administration. If you honor the patients your organization is taking care of (#1) and stick to your core principles (#2), the decision you make is more than likely the correct one. Stay committed to that decision and course of action, until the information tells you it is time to make a new one.
4. Humility: Working in the PICU is difficult - on any given patient, there are probably at least 100 different ways that you can make a mistake or error and cause harm to the patient. Be humble. We work in a difficult field in healthcare - there is no place for haughtiness and ego here.
5. Patience: Rich joked last night that he had some "idiosyncracies" - he does! But he was always patient, especially with the residents and fellows. Have patience with those who work for you. Give them breathing room. Give them enough autonomy to develop (some of the best ways to learn is by making a mistake) without placing the patient in harm's way. Again, there is something here for those of us in health care administration as well. Leadership is a learned skill - it takes time and practice. Be patient with new and emerging leaders.
Again, thank you Rich for everything you have done - for your patients and their families, for all of the medical students, residents, fellows, and junior attendings that have worked with you, and for me personally. We owe you a lot more than you will ever know. Congratulations! Here's to the almighty Fick equation and "five things"!
Wednesday, November 16, 2016
Sunday, November 13, 2016
It's "gut check" time!
It has been an interesting week! The results of the recent U.S. Presidential election came as quite a shock (and dare I say, quite a disappointment) to many of us in the United States. Just about every major poll in the days and weeks prior to last Tuesday had predicted that Hillary Clinton would win a very tight race. Several political pundits had even predicted that she would win the Electoral College but lose the popular vote. The exact opposite happened - Donald Trump won the Electoral College (fairly easily) but will likely lose the popular vote by about 200,000 votes (there are still absentee votes to be counted). What happened with the predictions? How could the pollsters have been so wrong? There are a number of theories that have been put forth - for example, some experts have suggested that some of the individuals who were polled before the election were not completely honest with who they were going to support in the election. Regardless, I think that many of us will look at polls and predictions in the future with a healthy dose of skepticism.
I have talked about a number of studies that show that statistical analyses and computer algorithms are more accurate than humans in decision making in a variety of circumstances (see "Humans versus computers in decision making" from one of my earlier blog posts). I would like to suggest, however, that there is a time and place for so-called "gut feelings" - even in health care. Narayan Kandasamy and colleagues recently published a very interesting study on "gut instinct" and "gut feelings" ("Interoceptive ability predicts survival on a London trading floor"). The investigators in this study analyzed whether interoceptive ability (the ability to detect and respond to somatic signals, such as quickening heart rate, breathlessness, "butterflies in the stomach", or sweating - basically everything that a lie detector test measures) could predict whether a high-frequency trader is successful making profitable investments. High frequency trading requires quick thinking - these traders have to make a decision in a matter of seconds on whether to buy or sell a particular stock investment. Their individual livelihoods depend upon their ability to predict the right stock. Kandasamy's team of investigators theorized that successful traders used "gut instinct" to make their decisions. Those traders who could "detect" (unconsciously, of course) an increase in their heart rate would be more attuned to their gut-level instincts - these investigators, would in turn, be more likely to make the correct (i.e. profitable) decisions on their investments. The results of this study suggested the following:
1. High-frequency traders had a better interoceptive ability (i.e. they could tell the investigators their heart rate without measuring their own pulse) compared to age- and gender-matched control subjects (graduate students).
2. Interoceptive ability predicted which high-frequency traders were the most successful (as determined by their individual profit-loss statements).
3. Experienced (in terms of the number of years on the job) high-frequency traders had a better interoceptive ability than less experienced traders.
4. The traders were asked how confident they were in determining their individual heart rates - unfortunately, there was no relationship between their degree of confidence in their heart rate predictions and the accuracy of these predictions, or in the accuracy of their decision making.
This is a great study that raises a number of interesting points to ponder further. It is clear that "gut instinct" can play a role in making accurate decisions. The dilemma here is that we really can't know whose "gut feeling" is accurate. The study suggested that the traders with a lower body mass index, lower resting heart rate, and lower beat-to-beat variability had a greater degree of interoceptive ability than the rest of the traders. I am not sure what this means, but I would surmise that those traders with a lower, more consistent heart rate would be more likely to "pick up" even a subtle increase in their heart rate when trying to make a decision (the lower resting heart rate and beat-to-beat variability, in effect, improves the signal-to-noise ratio). This would suggest that we could potentially "train" an individual to respond to "gut feelings." This is, in effect, what we are doing when we perform drills and simulations (e.g. mock codes and mass casualty exercises in health care, flight simulations in aviation, and war games in the military).
We have learned to pay attention to "gut feelings" in health care. For example, Beth Crandall published a study several years ago that suggested that nurses in the neonatal ICU respond to "gut feelings" to diagnose infants with life-threatening sepsis, often before more obvious signs and symptoms manifest. We have operationalized "gut feelings" in our hospital by teaching bedside providers to verbalize their concerns about particular patients who may get sicker and require transfer to the ICU using the term "watcher" (we published this work in the journal, Pediatrics).
So, which is better - gut instinct or computerized algorithms? The answer is probably both. I think we need to work with both cognitive psychologists and human factors engineers to develop techniques and methods to fully utilize all of the information available to the bedside provider to provide the best care to our patients - both the "Big Data" available in the electronic medical record, published literature, and Internet, as well as the information provided by so-called hunches and gut feelings. We need to identify the best way to reduce the signal-to-noise ratio of our "gut feelings" through repetitive simulation training (the more realistic the better). We also need to train providers to pay attention to their "gut feelings." And perhaps most importantly, we need to identify useful indicators of whose "gut feeling" is accurate and whose is not. Humans will never be able to pull together all of the information available as rapidly (and as accurately) as a computer can do, but computers will never be able to completely replace the human providers at the bedside. For this reason, there will always be a place for "gut feelings" and "gut instincts".
I have talked about a number of studies that show that statistical analyses and computer algorithms are more accurate than humans in decision making in a variety of circumstances (see "Humans versus computers in decision making" from one of my earlier blog posts). I would like to suggest, however, that there is a time and place for so-called "gut feelings" - even in health care. Narayan Kandasamy and colleagues recently published a very interesting study on "gut instinct" and "gut feelings" ("Interoceptive ability predicts survival on a London trading floor"). The investigators in this study analyzed whether interoceptive ability (the ability to detect and respond to somatic signals, such as quickening heart rate, breathlessness, "butterflies in the stomach", or sweating - basically everything that a lie detector test measures) could predict whether a high-frequency trader is successful making profitable investments. High frequency trading requires quick thinking - these traders have to make a decision in a matter of seconds on whether to buy or sell a particular stock investment. Their individual livelihoods depend upon their ability to predict the right stock. Kandasamy's team of investigators theorized that successful traders used "gut instinct" to make their decisions. Those traders who could "detect" (unconsciously, of course) an increase in their heart rate would be more attuned to their gut-level instincts - these investigators, would in turn, be more likely to make the correct (i.e. profitable) decisions on their investments. The results of this study suggested the following:
1. High-frequency traders had a better interoceptive ability (i.e. they could tell the investigators their heart rate without measuring their own pulse) compared to age- and gender-matched control subjects (graduate students).
2. Interoceptive ability predicted which high-frequency traders were the most successful (as determined by their individual profit-loss statements).
3. Experienced (in terms of the number of years on the job) high-frequency traders had a better interoceptive ability than less experienced traders.
4. The traders were asked how confident they were in determining their individual heart rates - unfortunately, there was no relationship between their degree of confidence in their heart rate predictions and the accuracy of these predictions, or in the accuracy of their decision making.
This is a great study that raises a number of interesting points to ponder further. It is clear that "gut instinct" can play a role in making accurate decisions. The dilemma here is that we really can't know whose "gut feeling" is accurate. The study suggested that the traders with a lower body mass index, lower resting heart rate, and lower beat-to-beat variability had a greater degree of interoceptive ability than the rest of the traders. I am not sure what this means, but I would surmise that those traders with a lower, more consistent heart rate would be more likely to "pick up" even a subtle increase in their heart rate when trying to make a decision (the lower resting heart rate and beat-to-beat variability, in effect, improves the signal-to-noise ratio). This would suggest that we could potentially "train" an individual to respond to "gut feelings." This is, in effect, what we are doing when we perform drills and simulations (e.g. mock codes and mass casualty exercises in health care, flight simulations in aviation, and war games in the military).
We have learned to pay attention to "gut feelings" in health care. For example, Beth Crandall published a study several years ago that suggested that nurses in the neonatal ICU respond to "gut feelings" to diagnose infants with life-threatening sepsis, often before more obvious signs and symptoms manifest. We have operationalized "gut feelings" in our hospital by teaching bedside providers to verbalize their concerns about particular patients who may get sicker and require transfer to the ICU using the term "watcher" (we published this work in the journal, Pediatrics).
So, which is better - gut instinct or computerized algorithms? The answer is probably both. I think we need to work with both cognitive psychologists and human factors engineers to develop techniques and methods to fully utilize all of the information available to the bedside provider to provide the best care to our patients - both the "Big Data" available in the electronic medical record, published literature, and Internet, as well as the information provided by so-called hunches and gut feelings. We need to identify the best way to reduce the signal-to-noise ratio of our "gut feelings" through repetitive simulation training (the more realistic the better). We also need to train providers to pay attention to their "gut feelings." And perhaps most importantly, we need to identify useful indicators of whose "gut feeling" is accurate and whose is not. Humans will never be able to pull together all of the information available as rapidly (and as accurately) as a computer can do, but computers will never be able to completely replace the human providers at the bedside. For this reason, there will always be a place for "gut feelings" and "gut instincts".
Tuesday, November 8, 2016
HRO: Sensitivity to Operations
Okay, I confess. I have seen the movie, "Top Gun" more times than I would like to admit. The movie is a bit cheesy in parts and totally unrealistic, but it is classic 1980's. The movie does have unique appeal - in fact, the United States Library of Congress placed the film in the National Film Registry in 2015, calling the movie "culturally significant." There is a quote towards the beginning of the movie - in the infamous bar scene ("You've lost that loving feeling!"). The two protagonists of the movie, Maverick (an F-14 pilot, played by Tom Cruise in one of the roles that made him famous) and Goose (the Radar Intercept Officer, played by Anthony Edwards, who later starred in the TV series, "ER") are talking about one of the other F-14 pilots, following up on an earlier question in which Maverick had wondered who was the best pilot among all the other pilots at Top Gun. The quote goes something like this:
Goose: Mav, you want to know who's the best? That's him. Iceman. It's the way he flies - Ice cold. No mistakes. Wears you down. After enough time, you just get bored and frustrated, you do something stupid, and he's got you.
Iceman (played by the actor, Val Kilmer) is Maverick's nemesis throughout the movie (spoiler alert: they, of course, become the best of friends at the end of the movie) and does everything "by the book." One could argue that his flying is highly standardized with little variation from the textbook (if such a book on F-14 combat tactics existed) and little variation from minute-to-minute. In other words, Iceman focuses on "operational excellence", what High Reliability Organizations would call "sensitivity to operations."
Operational excellence is characterized by standardization of best practices and elimination of waste, through continuous process improvement. It is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement. Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and W. Edwards Deming.
Practically, operational excellence in a nuclear power plant (to use a different example of HRO) means that the technicians follow standard operating procedures, each and every time. The nuclear power plant technicians use checklists and other cues to help them follow highly technical procedures in the exact same sequence from shift to shift, day to day, year to year. Performance is monitored closely (monitoring is also standardized) - any deviations from normal are quickly recognized and corrected, again according to a defined, standardized protocol. The nuclear power plant technicians understand measurement and statistical process control. These technicians use measurement and statistical process control charts in order to understand what is happening in their work environment.
Operational excellence has a role to play in today's health care environment. I whole-heartedly agree that "patients are not widgets" and that "we shouldn't practice cookbook medicine." Standardization, one of the key elements in operational excellence, is NOT "cookbook medicine." There is simply no justification for why we should not standardize the care of common conditions (e.g. management of diabetic ketoacidosis, acute chest pain, or acute asthma exacerbation) or processes (e.g. care and maintenance of central lines, urinary catheters, surgical time-outs) - these are the kinds of conditions and processes that should be managed the same way, every day, by each and every member of the health care team. With the care of common conditions, there is some room to maneuver, so to speak. For example, if a patient deviates from the expected clinical course, then and only then should we deviate from a standardized treatment protocol. However, there is no reason why we should deviate from standardized protocols for surgical time-outs, shift hand-offs, or maintenance of central lines.
If hospitals are to become high reliability organizations, we must embrace the core tenets of operational excellence. We must be sensitive to operations - what is happening on the front lines of health care. The good news is that many health care organizations have demonstrated that standardization of best practices and elimination of waste through operational excellence can lead to sustained improvement in outcomes and lower costs.
Goose: Mav, you want to know who's the best? That's him. Iceman. It's the way he flies - Ice cold. No mistakes. Wears you down. After enough time, you just get bored and frustrated, you do something stupid, and he's got you.
Iceman (played by the actor, Val Kilmer) is Maverick's nemesis throughout the movie (spoiler alert: they, of course, become the best of friends at the end of the movie) and does everything "by the book." One could argue that his flying is highly standardized with little variation from the textbook (if such a book on F-14 combat tactics existed) and little variation from minute-to-minute. In other words, Iceman focuses on "operational excellence", what High Reliability Organizations would call "sensitivity to operations."
Operational excellence is characterized by standardization of best practices and elimination of waste, through continuous process improvement. It is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement. Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and W. Edwards Deming.
Practically, operational excellence in a nuclear power plant (to use a different example of HRO) means that the technicians follow standard operating procedures, each and every time. The nuclear power plant technicians use checklists and other cues to help them follow highly technical procedures in the exact same sequence from shift to shift, day to day, year to year. Performance is monitored closely (monitoring is also standardized) - any deviations from normal are quickly recognized and corrected, again according to a defined, standardized protocol. The nuclear power plant technicians understand measurement and statistical process control. These technicians use measurement and statistical process control charts in order to understand what is happening in their work environment.
Operational excellence has a role to play in today's health care environment. I whole-heartedly agree that "patients are not widgets" and that "we shouldn't practice cookbook medicine." Standardization, one of the key elements in operational excellence, is NOT "cookbook medicine." There is simply no justification for why we should not standardize the care of common conditions (e.g. management of diabetic ketoacidosis, acute chest pain, or acute asthma exacerbation) or processes (e.g. care and maintenance of central lines, urinary catheters, surgical time-outs) - these are the kinds of conditions and processes that should be managed the same way, every day, by each and every member of the health care team. With the care of common conditions, there is some room to maneuver, so to speak. For example, if a patient deviates from the expected clinical course, then and only then should we deviate from a standardized treatment protocol. However, there is no reason why we should deviate from standardized protocols for surgical time-outs, shift hand-offs, or maintenance of central lines.
If hospitals are to become high reliability organizations, we must embrace the core tenets of operational excellence. We must be sensitive to operations - what is happening on the front lines of health care. The good news is that many health care organizations have demonstrated that standardization of best practices and elimination of waste through operational excellence can lead to sustained improvement in outcomes and lower costs.
Sunday, November 6, 2016
Happy Guy Fawkes Day!
I was texting my son last night while watching college football on the television. When I asked him what he had been doing, he told me that he had just finished watching the movie, "V for Vendetta". I have never seen this movie, but I have seen enough trailers to know that the movie's protagonist wears a "Guy Fawkes" mask. "Ahhh - today is November 5, Guy Fawkes Day," I texted. I have to admit, I thought I was being particularly clever here and didn't think he would make the connection. To my surprise, my son texted back, "Yes, I know. Ever since we watched 'V for Vendetta' in my high school religion class on November 5th, I have made it an annual tradition." In other words, not only was I not being clever, my son apparently knew more about Guy Fawkes than I thought.
Guy Fawkes was one of the English Catholics who helped plan and (unsuccessfully) orchestrate the infamous Gunpowder Plot of 1605 (also known as the Jesuit Treason). The plan was to blow up the House of Lords and assassinate King James I of England, and in so doing, install James' daughter, Elizabeth (a Catholic) as the new head of state. The plot failed, and the perpetrators (including Guy Fawkes) were hanged, drawn, and quartered. Apparently, Fawkes fell from the scaffolding where he was to be hanged, breaking his neck and dying before being drawn and quartered. His name has become synonymous with the annual celebration of the failure of the Gunpowder Plot on November 5, now known as "Guy Fawkes Day." Apparently, the movie, "V for Vendetta" is an allegory for oppressive government, but that is a discussion for another day!
What struck me about this entire conversation was the importance of annual traditions - the English celebrate "Guy Fawkes Day" every year on November 5th. My son watches the movie, "V for Vendetta" every year on November 5th, remembering fondly one of his favorite high school teachers. Conceptually, we use traditions to share our common links with the past. The word tradition comes from the Latin noun, traditio which is based on the Latin verb, tradere, meaning to transmit, to hand over, to give for safekeeping. Traditions are beliefs and customs that originated in the past that are passed down from one generation to the next, more or less in the same form in which they originated.
I frequently talk about "high reliability organizations" and use the United States Navy's aircraft carrier flight operations as an example of a "high reliability organization." One of the most common criticisms that I hear is how health care is completely different than the military. "In the Navy, if you aren't compliant with the rules, you get in big trouble!" The mistaken belief is that the Navy uses strict hierarchy and authoritarian leadership to enforce strict discipline and compliance with policies, rules, and regulations. Nothing could be further from the truth. While there are certain elements of hierarchical and authoritarian leadership in the military, the most important unifying element that keeps daily operations running exactly (more or less) the same way from ship to ship across the fleet, year after year, are the traditions and customs that are handed down from past generations of sailors. Traditions are the glue that holds the Navy together.
I am not saying that all traditions are good. Some of the traditions in the Navy are no longer appropriate (perhaps they never were) - as one example, the "crossing the line" ceremony" is not quite as violent as it was in the distant past. However, for the most part, traditions are how the right "culture" is instilled in new sailors and how "culture" is maintained throughout the ship.
Most health care organizations have some important traditions. However, I would suggest that traditions are not used nearly enough. Traditions can and should be an important way to set the proper tone, encourage the proper attitudes, and build the culture that is necessary for a high-performing health care delivery organization.
Guy Fawkes was one of the English Catholics who helped plan and (unsuccessfully) orchestrate the infamous Gunpowder Plot of 1605 (also known as the Jesuit Treason). The plan was to blow up the House of Lords and assassinate King James I of England, and in so doing, install James' daughter, Elizabeth (a Catholic) as the new head of state. The plot failed, and the perpetrators (including Guy Fawkes) were hanged, drawn, and quartered. Apparently, Fawkes fell from the scaffolding where he was to be hanged, breaking his neck and dying before being drawn and quartered. His name has become synonymous with the annual celebration of the failure of the Gunpowder Plot on November 5, now known as "Guy Fawkes Day." Apparently, the movie, "V for Vendetta" is an allegory for oppressive government, but that is a discussion for another day!
What struck me about this entire conversation was the importance of annual traditions - the English celebrate "Guy Fawkes Day" every year on November 5th. My son watches the movie, "V for Vendetta" every year on November 5th, remembering fondly one of his favorite high school teachers. Conceptually, we use traditions to share our common links with the past. The word tradition comes from the Latin noun, traditio which is based on the Latin verb, tradere, meaning to transmit, to hand over, to give for safekeeping. Traditions are beliefs and customs that originated in the past that are passed down from one generation to the next, more or less in the same form in which they originated.
I frequently talk about "high reliability organizations" and use the United States Navy's aircraft carrier flight operations as an example of a "high reliability organization." One of the most common criticisms that I hear is how health care is completely different than the military. "In the Navy, if you aren't compliant with the rules, you get in big trouble!" The mistaken belief is that the Navy uses strict hierarchy and authoritarian leadership to enforce strict discipline and compliance with policies, rules, and regulations. Nothing could be further from the truth. While there are certain elements of hierarchical and authoritarian leadership in the military, the most important unifying element that keeps daily operations running exactly (more or less) the same way from ship to ship across the fleet, year after year, are the traditions and customs that are handed down from past generations of sailors. Traditions are the glue that holds the Navy together.
I am not saying that all traditions are good. Some of the traditions in the Navy are no longer appropriate (perhaps they never were) - as one example, the "crossing the line" ceremony" is not quite as violent as it was in the distant past. However, for the most part, traditions are how the right "culture" is instilled in new sailors and how "culture" is maintained throughout the ship.
Most health care organizations have some important traditions. However, I would suggest that traditions are not used nearly enough. Traditions can and should be an important way to set the proper tone, encourage the proper attitudes, and build the culture that is necessary for a high-performing health care delivery organization.
Thursday, November 3, 2016
The world has changed ("Fly the W")
I woke up this morning to a brand new world. Things changed overnight. The sun still rose up in the East. The sky was blue. The grass was green. I started the day with a cup of coffee and the morning newspaper. But things were different. On this morning, my beloved Chicago Cubs were no longer the "Loveable Losers" of the North side. Chicago Cubs - 2016 World Series Champions. It has a nice ring, don't you think?
Without a doubt, game 7 last night was the best baseball game that I have ever seen - period. It had everything. Two teams fighting for their first World Series title in many, many years. An untouchable pitcher from the Cleveland Indians became touchable. An untouchable pitcher from the Chicago Cubs also became touchable. A blown save. Extra innings. A rain delay. Every pitch seemed like it would make one team a champion and one team a runner-up. Epic. It was simply unbelievable.
For this long-suffering Cubs fan, last night was truly magical. Even now, I wonder if it was all just a dream. Cubs fans just think that way. But this team just never gave up. They didn't quit. Even down three games to one with their backs to the wall. They found a way to win. Even after blowing a three run lead in the 8th inning of game 7, they found a way to win. What a game! What a team!
But this post isn't really about the Cubs. My hat goes off to the Cleveland Indians. They never gave up. They never quit. They fought until the bitter end. Unfortunately, there had to be a winner and there had to be a loser. But the Cleveland Indians didn't lose this game. The Chicago Cubs won it. As much as I was inspired by my Cubs, I was even more inspired by the Cleveland Indians' manager, Terry Francona. He gave a truly remarkable, inspirational, humble, honorable post-game interview. What a class act. Here is some of what he said:
"You know, we ask our players to play the game with respect and to leave it on the field. That was it. They gave everything they had. And I kind of talked about it before the game, what an honor it was, but it really was. To go through that with this group and these people, it was an honor."
Well, Mr. Terry Francona, the honor was ours. You showed us everything that we could ever ask of a leader last night. You are a great manager, and you deserve your place in the Hall of Fame. I will never forget how you led your team throughout the play-offs and throughout the World Series. I will never forget your humility, your pain in losing, and your respect for this great game.
It is an unfortunate truth that even great leaders fail at times. But I think that what makes these leaders really great is how they fail. They fail with class. They fail with humility. They fail with respect. They fail with honor.
So close to Election Day, I am also reminded of another great leader who failed with class. President George H.W. Bush left a letter for the incoming President Bill Clinton on his last day of office. He said:
Dear Bill,
When I walked into this office just now I felt the same sense of wonder and respect that I felt four years ago. I know you will feel that, too.
I wish you great happiness here. I never felt the loneliness some Presidents have described.
There will be very tough times, made even more difficult by criticism you may not think is fair. I’m not a very good one to give advice; but just don’t let the critics discourage you or push you off course.
You will be our President when you read this note. I wish you well. I wish your family well.
Your success now is our country’s success. I am rooting hard for you.
Good luck – George
Respect. Honor. Humility. Class. These are the characteristics that separate the great leaders from the good leaders.
Without a doubt, game 7 last night was the best baseball game that I have ever seen - period. It had everything. Two teams fighting for their first World Series title in many, many years. An untouchable pitcher from the Cleveland Indians became touchable. An untouchable pitcher from the Chicago Cubs also became touchable. A blown save. Extra innings. A rain delay. Every pitch seemed like it would make one team a champion and one team a runner-up. Epic. It was simply unbelievable.
For this long-suffering Cubs fan, last night was truly magical. Even now, I wonder if it was all just a dream. Cubs fans just think that way. But this team just never gave up. They didn't quit. Even down three games to one with their backs to the wall. They found a way to win. Even after blowing a three run lead in the 8th inning of game 7, they found a way to win. What a game! What a team!
But this post isn't really about the Cubs. My hat goes off to the Cleveland Indians. They never gave up. They never quit. They fought until the bitter end. Unfortunately, there had to be a winner and there had to be a loser. But the Cleveland Indians didn't lose this game. The Chicago Cubs won it. As much as I was inspired by my Cubs, I was even more inspired by the Cleveland Indians' manager, Terry Francona. He gave a truly remarkable, inspirational, humble, honorable post-game interview. What a class act. Here is some of what he said:
"You know, we ask our players to play the game with respect and to leave it on the field. That was it. They gave everything they had. And I kind of talked about it before the game, what an honor it was, but it really was. To go through that with this group and these people, it was an honor."
Well, Mr. Terry Francona, the honor was ours. You showed us everything that we could ever ask of a leader last night. You are a great manager, and you deserve your place in the Hall of Fame. I will never forget how you led your team throughout the play-offs and throughout the World Series. I will never forget your humility, your pain in losing, and your respect for this great game.
It is an unfortunate truth that even great leaders fail at times. But I think that what makes these leaders really great is how they fail. They fail with class. They fail with humility. They fail with respect. They fail with honor.
So close to Election Day, I am also reminded of another great leader who failed with class. President George H.W. Bush left a letter for the incoming President Bill Clinton on his last day of office. He said:
Dear Bill,
When I walked into this office just now I felt the same sense of wonder and respect that I felt four years ago. I know you will feel that, too.
I wish you great happiness here. I never felt the loneliness some Presidents have described.
There will be very tough times, made even more difficult by criticism you may not think is fair. I’m not a very good one to give advice; but just don’t let the critics discourage you or push you off course.
You will be our President when you read this note. I wish you well. I wish your family well.
Your success now is our country’s success. I am rooting hard for you.
Good luck – George
Respect. Honor. Humility. Class. These are the characteristics that separate the great leaders from the good leaders.
Sunday, October 30, 2016
HRO: Reluctance to simplify
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.
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.
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.
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