tag:blogger.com,1999:blog-41706238397361919502024-03-06T12:55:26.341-08:00Safetymatters: Safety culture information, analysis and managementBob Cudlinhttp://www.blogger.com/profile/08502712287881656493noreply@blogger.comBlogger395125tag:blogger.com,1999:blog-4170623839736191950.post-55469903302808683642024-03-02T11:34:00.000-08:002024-03-02T11:36:26.149-08:00Boeing’s Safety Culture Under the FAA’s Microscope<p><span style="font-size: medium;"><span style="font-family: verdana;">The Federal Aviation Administration (FAA) recently
released its <a href="https://www.faa.gov/sites/faa.gov/files/Sec103_ExpertPanelReview_Report_Final.pdf" target="_blank">report</a>* on the safety culture (SC) at Boeing.<span> </span>The FAA Expert Panel was tasked with
reviewing SC after two crashes involving the latest models of Boeing’s 737 MAX
airplanes.<span> </span>The January 2024 door plug
blowout happened as the report was nearing completion and reinforces the
report’s findings.</span></span></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_BjAqgGOLe9BQ9NAF-Mzq-ipcPEgjCkyny2bHhnle6b6S2hcalW083oorgClyvZD7e0qRLiwibR9ePwW5Ge0Nuqawp4xeP7zEY-mBljQ7kewOZUwyoMN8z4r37OSP0UiHqXmdOBJH4b5rPfNX9wKKHnJsHsJorLVPdGCaqZBq3Rxp_gtdFSabqinl2rIm/s1158/Boeing%20737%20door%20plug%20L%20Wasson%20AP.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="944" data-original-width="1158" height="163" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_BjAqgGOLe9BQ9NAF-Mzq-ipcPEgjCkyny2bHhnle6b6S2hcalW083oorgClyvZD7e0qRLiwibR9ePwW5Ge0Nuqawp4xeP7zEY-mBljQ7kewOZUwyoMN8z4r37OSP0UiHqXmdOBJH4b5rPfNX9wKKHnJsHsJorLVPdGCaqZBq3Rxp_gtdFSabqinl2rIm/w200-h163/Boeing%20737%20door%20plug%20L%20Wasson%20AP.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">737 MAXX door plug<br /></td></tr></tbody></table><p></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">The report has been summarized and widely reported in
mainstream media and we will not review all its findings and recommendations
here.<span> </span>We want to focus on two parts of
the report that address topics we have long promoted as being keys to
understanding how strong (or weak) an organization’s SC is, viz., an
organization’s decision-making processes and executive compensation.<span> </span>In addition, we will discuss a topic that’s
new to us, how to ensure the independence of employees whose work includes
assessing company work products from the regulator’s perspective.</span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;"><b>Decision-making</b></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">An organization’s decision-making processes create some
of the most visible artifacts of the organization’s culture: a string of
decisions (guided by policies, procedures, and priorities) and their
consequences.</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The report begins with a clear FAA description of decision-making’s
important role in a Safety Management System (SMS) and an organization’s
overall management.<span> </span>In part, an “SMS is
all about decision-making. Thus it has to be a decision-maker's tool, not a
traditional safety program separate and distinct from business and operational
decision making.” (p. 10) </span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">However, the panel’s finding on Boeing’s SMS is a mixed
bag.<span> </span>“Boeing provided evidence that it
is using its SMS to evaluate product safety decisions and some business
decisions. The Expert Panel’s review of Boeing’s SMS documentation revealed
detailed procedures on how to use SMS to evaluate product safety decisions, but
there are <b>no detailed procedures on how
to determine which business decisions affect safety or how they should be
evaluated under SMS</b>.” (emphasis added) (p. 35)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The associated recommendation is “Develop detailed
procedures to determine which business activities should be evaluated under SMS
and how to evaluate those decisions.” (ibid.)<span>
</span>We think the recommendation addresses the specific problem identified in
the finding.</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">One of the major inputs to a decision-making system is an
organization’s priorities.<span> </span>The FAA says
safety should always be the top priority but Boeing’s commitment to safety has
arguably weakened over time.</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">“Boeing provided the Expert Panel with a copy of the
Boeing Safety Management System Policy, dated April 2022, which states, in
part, “… we make safety our top priority.” Boeing revised this policy in August
2023 with . . . <span> </span>a change to the message
“we make safety our top priority” to “safety is our foundation.”” (p. 29)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Lowering the bar did not help.<span> </span>“The [Expert] panel observed documentation,
survey responses, and employee interviews that did not provide objective
evidence of a foundational commitment to safety that matched Boeing’s
descriptions of that objective.” (p. 22)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Boeing also created seeds of confusion for its safety decision
makers.<span> </span>Boeing implemented its SMS to
operate alongside (and not replace or integrate with) its existing safety
program.</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">“During interviews, Boeing employees highlighted that SMS
implementation was not to disrupt existing safety program or systems. <span> </span>SMS operating procedure documents spoke of SMS
as the overarching safety program but then also provided segregation of
SMS-focused activities from legacy safety activities . . .” (p. 24)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><b style="font-family: verdana;">Executive compensation</b></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">We have long said that if safety performance is important
to an organization then their senior managers’ compensation should have a
safety performance-related component.<span> </span></span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Boeing has included safety in its executive financial incentive
program.<span> </span>Safety is one of five factors
comprising operational performance which, in turn, is combined with financial
performance to determine company-level performance.<span> </span>Because of the weights used in the incentive
model, “The Product Safety measure comprised approximately 4% of the overall
2022 Annual Incentive Award.” (p. 28)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Is 4% enough to influence executive behavior?<span> </span>You be the judge.</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><b style="font-family: verdana;">Employee
independence from undue management influence <span> </span></b></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Boeing’s relationship with the FAA has an aspect that we
don’t see in other industries.<span> </span></span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Boeing holds an Organization Designation Authorization
(ODA) from the FAA. This allows Boeing to “make findings and issue
certificates, i.e., perform discretionary functions in engineering,
manufacturing, operations, airworthiness, or maintenance on behalf of the [FAA]
Administrator.” (p. 12)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Basically, the FAA delegates some of its authority to
Boeing employees, the ODA Unit Members (UMs), who then perform certain assessment
and certification tasks.<span> </span>“When acting as
a representative of the Administrator, an individual is required to perform in
a manner consistent with the policies, guidelines, and directives of the FAA.
When performing a delegated function, an individual is legally distinct from,
and must act independent of, the ODA holder.” (ibid.) <span> </span>These employees are supposed to take the FAA’s
view of situations and apply the FAA’s rules even if the FAA’s interests are in
conflict with Boeing’s business interests.<span>
</span></span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">This might work in a perfect world but in Boeing’s world,
it’s had and has problems, primarily “Boeing’s restructuring of the management
of the ODA unit decreased opportunities for interference and retaliation
against UMs, and provides effective organizational messaging regarding
independence of UMs. However, the restructuring, while better, <b>still allows opportunities for retaliation
to occur, particularly with regards to salary and furlough ranking</b>.” (emphasis
added) (p. 5)<span> </span>In addition, “The ability
to comply with the ODA’s approved procedures is present; however, the
integration of the SMS processes, procedures, and data collection requirements
has not been accomplished.” (p. 26)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">To an outsider, this looks like bad organizational design
and practices.<span> </span></span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The U.S. commercial nuclear industry offers a useful
contrast.<span> </span>The regulator (Nuclear
Regulatory Commission) expects its licensees to follow established procedures,
perform required tests and inspections, and report any problems to the
NRC.<span> </span>Self-reporting is key to an
effective relationship built on a base of trust.<span> </span>However, it’s “trust but verify.”<span> </span>The NRC has their own full-time employees in
all the power plants, performing inspections, monitoring licensee operations,
and interacting with licensee personnel.<span>
</span>The inspectors’ findings can lead, and have led, to increased oversight
of licensee activities by the NRC.</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><b style="font-family: verdana;">Our perspective</b></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">It’s obvious that Boeing has emphasized production over
safety.<span> </span>The problems described above are
evidence of broad systemic issues which are not amenable to quick fixes.<span> </span>Integrating SC into everyday decision-making
is hard work of the “continuous improvement” variety; it will not happen by
management fiat.<span> </span>Adjusting the
compensation plan will require the Board to take safety more seriously.<span> </span>Reworking the ODA program to eliminate all
pressures and goal conflicts may not be possible; this is a big problem because
the FAA has effectively deputized 1,000 people to perform FAA functions at
Boeing. (p. 25)</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The report only covers the most visible SC issues.<span> </span>Complacency, normalization of deviation, the
multitude of biases that can affect decision-making, and other corrosive
factors are perennial threats to a strong SC and can affect “the natural drift
in organizations.” (p. 40) <span> </span>Such drift
may lead to everything from process inefficiencies to tragic safety failures.</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Boeing has taken one step: they fired the head of the 737
MAX program.**<span> </span>Organizations often toss
a high-level executive into a volcano to appease the regulatory gods and buy
some time.<span> </span>Boeing’s next challenge is that
the FAA has given Boeing 90 days to fix its quality problems highlighted by the
door plug blowout.***</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Bottom line: Grab your popcorn, the show is just
starting.<span> </span>Boeing is probably too big to
fail but it is definitely going to be pulled through the wringer.<span> </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;"><br /></span></span>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">*<span> </span>“<a href="https://www.faa.gov/sites/faa.gov/files/Sec103_ExpertPanelReview_Report_Final.pdf" target="_blank">Section 103Organization Designation Authorizations (ODA) for Transport Airplanes Expert Panel Review Report</a>,” Federal Aviation Administration (Feb. 26, 2024).<span> </span></span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">**<span> </span>N. Robertson, “<a href="https://thehill.com/policy/transportation/4481299-boeing-fires-head-of-737-max-program/" target="_blank">Boeing fires head of 737 Max program</a>,” The Hill (Feb. 21, 2024).</span></span></p>
<p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">***<span> </span>D. Shepardson
and V. Insinna, “<a href="https://www.reuters.com/business/aerospace-defense/faa-tells-boeing-come-up-with-plan-90-days-fix-quality-issues-2024-02-28/" target="_blank">FAA gives Boeing 90 days to develop plan to address quality issues</a>,” Reuters (Feb. 28, 2024). </span></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-89162842441295786112023-10-06T15:01:00.000-07:002023-10-06T15:01:55.497-07:00A Straightforward Recipe for Changing Culture<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody><tr><td style="text-align: center;"><img alt="Center for Open Science" class="hs-image-widget " height="120" src="https://www.cos.io/hubfs/Logos/cos_anniversary_resized.png" style="height: auto; margin-left: auto; margin-right: auto; max-width: 100%;" title="Center for Open Science" width="200" /></td></tr><tr><td class="tr-caption" style="text-align: center;">Source: COS website<br /></td></tr></tbody></table><p><span style="font-family: verdana;"><span style="font-size: medium;"></span></span></p><p><br /><span style="font-size: medium;"><span style="font-family: verdana;">We recently came across a clear, easily communicated <a href="https://www.cos.io/blog/strategy-for-culture-change" target="_blank">road map for implementing cultural change</a>.* We’ll provide some background information on the author’s motivation for developing the road map, a summary of it, and our perspective on it.<br /><br />The author, Brian Nosek, is executive director of the Center for Open Science (COS). The mission of COS is to increase the openness, integrity, and reproducibility of scientific research. Specifically, they propose that researchers publish the initial description of their studies so that original plans can be compared with actual results. In addition, researchers should “share the materials, protocols, and data that they produced in the research so that others could confirm, challenge, extend, or reuse the work.” Overall, the COS proposes a major change from how much research is presently conducted.<br /><br />Currently, a lot of research is done in private, i.e., more or less in secret, usually with the objective of getting results published, preferably in a prestigious journal. Frequent publishing is fundamental to getting and keeping a job, being promoted, and obtaining future funding for more research, in other words, having a successful career. Researchers know that publishers generally prefer findings that are novel, positive (e.g., a treatment is effective), and tidy (the evidence fits together). <br /><br />Getting from the present to the future requires a significant change in the <i>culture</i> of scientific research. Nosek describes the steps to implement such change using a pyramid, shown below, as his visual model. Similar to Abraham Maslow’s Hierarchy of Needs, a higher level of the pyramid can only be achieved if the lower levels are adequately satisfied.</span></span></p><p><span style="font-size: medium;"><span style="font-family: verdana;"><br /></span></span></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><img alt="" 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" style="margin-left: auto; margin-right: auto;" /></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: verdana;"><span style="font-size: x-small;">Source: "Strategy for Culture Change"</span></span></td></tr></tbody></table><span style="font-size: medium;"></span><span style="font-family: verdana;"><span style="font-size: medium;"> <br /></span></span><p><span style="font-family: verdana;"><span style="font-size: medium;">Each level represents a different step for changing a culture:<br /><br />• <i>Infrastructure</i> refers to an open source database where researchers can register their projects, share their data, and show their work.<br />• The <i>User Interface</i> of the infrastructure must be easy to use and compatible with researchers' existing workflows.<br />• New research <i>Communities</i> will be built around new norms (e.g., openness and sharing) and behavior, supported and publicized by the infrastructure.<br />• <i>Incentives</i> refer to redesigned reward and recognition systems (e.g., research funding and prizes, and institutional hiring and promotion schemes) that motivate desired behaviors.<br />• Public and private <i>Policy</i> changes codify and normalize the new system, i.e., specify the new requirements for conducting research.<br /> <br /><b>Our Perspective</b><br /><br />As long-time consultants to senior managers, we applaud Nosek’s change model. It is straightforward and adequately complete, and can be easily visualized. We used to spend a lot of time distilling complicated situations into simple graphics that communicated strategically important points.<br /><br />We also totally support his call to change the reward system to motivate the new, desirable behaviors. We have been promoting this viewpoint for years with respect to safety culture: If an organization or other entity values safety and wants safe activities and outcomes, then they should compensate the senior leadership accordingly, i.e., pay for safety performance, and stop promoting the nonsense that safety is intrinsic to the entity’s functioning and leaders should provide it basically for free.<br /><br />All that said, implementing major cultural change is not as simple as Nosek makes it sound.<br /><br />First off, the status quo can have enormous sticking power. Nosek acknowledges it is defined by strong norms, incentives, and policies. Participants know the rules and how the system works, in particular they know what they must do to obtain the rewards and recognition. Open research is an anathema to many researchers and their sponsors; this is especially true when a project is aimed at creating some kind of competitive advantage for the researcher or the institution. Secrecy is also valued when researchers may (or do) come up with the “wrong answer” – findings that show a product is not effective or has dangerous side effects, or an entire industry’s functioning is hazardous for society. <br /><br />Second, the research industry exists in a larger environment of social, political and legal factors. Many elected officials, corporate and non-profit bosses, and other thought leaders may say they want and value a world of open research but in private, and in their actions, believe they are better served (and supported) by the existing regime. The legal system in particular is set up to reinforce the current way of doing business, e.g., through patents.<br /><br />Finally, systemic change means fiddling with the system dynamics, the physical and information flows, inter-component interfaces, and feedback loops that create system outcomes. To the extent such outcomes are emergent properties, they are created by the functioning of the system itself and cannot be predicted by examining or adjusting separate system components. Large-scale system change can be a minefield of unexpected or unintended consequences.<br /><br />Bottom line: A clear model for change is essential but system redesigners need to tread carefully. <br /><br /><br />* B. Nosek, “<a href="https://www.cos.io/blog/strategy-for-culture-change" target="_blank">Strategy for Culture Change</a>,” blog post (June 11th, 2019).</span></span><br /></p>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-25403470486699358042023-08-04T14:00:00.000-07:002023-08-04T14:00:42.090-07:00Real Systems Pursue Goals<span style="font-family: verdana; font-size: medium;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcXHz07ejcYf-fQht4t4_dGnBasihEQNQfmspRMCnhrSxPWBReeSkfO1tJPzvoOmE1XiT-2MwWFFc2dNCYC8gKb7wWwl1TFCGyc6-aMJ7pWgt82n_HKatBdUvWvaDtIiH1mKBxko27t6zMxRpWWObCyfzOwagIuYLUcnYH282vlPnTDZC69HuQK_mxWCk3/s628/SafetySim%20output.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img alt="System Model Control Panel" border="0" data-original-height="425" data-original-width="628" height="136" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcXHz07ejcYf-fQht4t4_dGnBasihEQNQfmspRMCnhrSxPWBReeSkfO1tJPzvoOmE1XiT-2MwWFFc2dNCYC8gKb7wWwl1TFCGyc6-aMJ7pWgt82n_HKatBdUvWvaDtIiH1mKBxko27t6zMxRpWWObCyfzOwagIuYLUcnYH282vlPnTDZC69HuQK_mxWCk3/w200-h136/SafetySim%20output.jpg" title="System Model Control Panel" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">System Model Control Panel</td></tr></tbody></table>On March 10, 2023 we posted about a medical journal editorial that advocated for incorporating more systems thinking in hospital emergency rooms’ (ERs) diagnostic processes. Consistent with Safetymatters’ core beliefs, we approved of using systems thinking in complicated decision situations such as those arising in the ER. <br /></span><p class="MsoNoSpacing"></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">The article prompted a</span><span style="font-family: verdana; font-size: medium;"> letter to the editor in which the
author said the approach described in the original editorial wasn’t a true
systems approach because it wasn’t specifically goal-oriented.<span> </span>We agree with that author’s viewpoint.<span> </span>We often argue for more systems thinking and describe
mental models of systems with components, dynamic relationships among the components,
feedback loops, control functions such as rules and culture, and decision maker
inputs.<span> </span>What we haven’t emphasized as
much, probably because we tend to take it for granted, is that a bona fide
system is <i>teleological</i>, i.e.,
designed to achieve a goal.<span> </span></span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">It’s important to understand what a system’s goal is.<span> </span>This may be challenging because the system’s
goal may contain multiple sub-goals.<span> </span>For
example, a medical clinician may order a certain test.<span> </span>The lab has a goal: to produce accurate,
timely, and reliable results for tests that have been ordered.<span> </span>But the clinician’s goal is different: to
develop a correct diagnosis of a patient’s condition.<span> </span>The goal of the hospital of which the
clinician and lab are components may be something else: to produce generally
acceptable patient outcomes, at reasonable cost, without incurring undue legal
problems or regulatory oversight.<span> </span>System
components (the clinician and the lab) may have goals which are hopefully supportive
of, or at least consistent with, overall system goals.</span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">The top-level system, e.g., a healthcare provider, may not
have a single goal, it may have multiple, independent goals that can conflict
with one another.<span> </span>Achieving the best
quality may conflict with keeping costs within budgets.<span> </span>Achieving perfect safety may conflict with
the need to make operational decisions under time pressure and with imperfect
or incomplete information.<span> </span>One of the
most important responsibilities of top management is defining how the system
recognizes and deals with goal conflict.</span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">In addition to goals, we need to discuss two other
characteristics of full-fledged systems: a measure of performance and a defined
client.*<span> </span> <br /></span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">The <i>measure of
performance</i> shows the system designers, users, managers, and overseers how
well the system’s goal(s) are being achieved through the functioning of system
components as affected by the system’s decision makers.<span> </span>Like goals, the measure of performance may
have multiple dimensions or sub-measures.<span>
</span>In a well-designed system, the summation of the set of sub-measures
should be sufficient to describe overall system performance.<span> </span></span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">The <i>client</i> is
the entity whose interests are served by the system.<span> </span>Identifying the client can be tricky.<span> </span>Consider a city’s system for serving its
unhoused population.<span> </span>The basic system consists
of a public agency to oversee the services, entities (often nongovernmental
organizations, or NGOs) that provide the services, suppliers (e.g., landlords
who offer buildings for use as housing), and the unhoused population.<span> </span>Who is the client of this system, i.e., who
benefits from its functioning?<span> </span>The
politicians, running for re-election, who authorize and sustain the public
agency? <span> </span>The public agency bureaucrats
angling for bigger budgets and more staff?<span>
</span>The NGOs who are looking for increased funding?<span> </span>Landlords who want rent increases?<span> </span>Or the unhoused who may be looking for a
private room with a lockable door, or may be resistant to accepting any
services because of their mental, behavioral, or social problems?<span> </span>It’s easy to see that many system
participants do better, i.e., get more pie, if the “homeless problem” is never
fully resolved.</span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">For another example, look at the average public school
district in the U.S.<span> </span>At first blush, the
students are the client.<span> </span>But what about
the elected state commissioner of education and the associated bureaucracy that
establish standards and curricula for the districts?<span> </span>And the elected district directors and
district bureaucracy?<span> </span>And the parents’
rights organizations?<span> </span>And the teachers’
unions?<span> </span>All of them claim to be working
to further the students’ interests but what do they really care about?<span> </span>How about political or organizational power,
job security, and money?<span> </span>The students could
be more of a secondary consideration.</span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;">We could go on.<span>
</span>The point is we are surrounded by many social-legal-political-technical
systems and who and what they are actually serving may not be those they
purport to serve.</span></p>
<p class="MsoNoSpacing"><span style="font-family: verdana; font-size: medium;"><span> </span></span></p>
<span style="font-family: verdana; font-size: medium;"><span style="line-height: 115%;">*<span> </span>These system characteristics are taken from the
work of a systems pioneer, Prof. C. West Churchman of UC Berkeley.<span> </span>For more information, see his <b>The Design of Inquiring Systems</b> (New
York: Basic Books) 1971.</span></span>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-90952248558491861132023-05-25T15:17:00.003-07:002023-05-26T17:03:26.242-07:00The National Academies on Behavioral Economics<p><span style="font-family: verdana;"><span style="font-size: medium;"></span></span></p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhi7IYocBG5EbafpwVh2xcrJiXGfie8FwvPPqnnUEKI9Upiu-MbMLx3XmeCSmzgriQ7CgLgS9ozlsWr2Q_OmWtt6X7IHQ3M6BYYJkpQFR-yuYZCmJQhFe_dY0gJiSB2GhBXmqyv_DGDuD8gmzRyoIm8JiktIi2-_6IQE-O0scoTE_Vjf5t0irxLEfoFjA/s389/Natl%20Acad%20Behavioral%20Economics.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="389" data-original-width="257" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhi7IYocBG5EbafpwVh2xcrJiXGfie8FwvPPqnnUEKI9Upiu-MbMLx3XmeCSmzgriQ7CgLgS9ozlsWr2Q_OmWtt6X7IHQ3M6BYYJkpQFR-yuYZCmJQhFe_dY0gJiSB2GhBXmqyv_DGDuD8gmzRyoIm8JiktIi2-_6IQE-O0scoTE_Vjf5t0irxLEfoFjA/s320/Natl%20Acad%20Behavioral%20Economics.jpg" width="211" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Report cover<br /></td></tr></tbody></table><span style="font-family: verdana;"><span style="font-size: medium;">A National Academies of Sciences, Engineering, and Medicine (NASEM) committee recently published a <a href="https://nap.nationalacademies.org/catalog/26874/behavioral-economics-policy-impact-and-future-directions" target="_blank">report</a>* on the contributions of behavioral economics (BE) to public policy. BE is “an approach to understanding human behavior and decision making that integrates knowledge from psychology and other behavioral fields with economic analysis.” (p. Summ-1)<br /><br />The report’s first section summarizes the history and development of the field of behavioral economics. Classical economics envisions the individual person as a decision maker who has all relevant information available, and makes rational decisions that maximize his overall, i.e. short- and long-term, self-interest. In contrast, BE recognizes that actual people making real decisions have many built-in biases, limitations, and constraints. The following five principles apply to the decision making processes behavioral economists study:<br /><br /><i>Limited Attention and Cognition</i> - The extent to which people pay limited attention to relevant aspects of their environment and often make cognitive errors.<br /><br /><i>Inaccurate Beliefs</i> - Individuals can have incorrect perceptions or information about situations, relevant incentives, their own abilities, and the beliefs of others.<br /><br /><i>Present Bias</i> - People tend to disproportionately focus on issues that are in front of them in the present moment.<br /><br /><i>Reference Dependence and Framing</i> - Individuals tend to consider how their decision options relate to a particular reference point, e.g., the status quo, rather than considering all available possibilities. People are also sensitive to the way decision problems are framed, i.e., how options are presented, and this affects what comes to their attention and can lead to different perceptions, reactions, and choices.<br /><br /><i>Social Preferences and Social Norms</i> - Decision makers often consider how their decisions affect others, how they compare with others, and how their decisions imply values and conformance with social norms.<br /><br />The task of policy makers is to acknowledge these limitations and present decision situations to people in ways that people can comprehend and help them make decisions that will serve their own and society’s interests. In practice this means decision situations “can be designed to modify the habitual and unconscious ways that people act and make decisions.” (p. Summ-3)<br /><br />Decision situation designers use various interventions to inform and guide individuals’ decision making. The NASEM committee mapped 23 possible interventions against the 5 principles. It’s impractical to list all the interventions here but the more graspable ones include: <br /><br /><i>Defaults</i> – The starting decision option is the designer’s preferred choice; the decision maker must actively choose a different option.<br /><br /><i>De-biasing</i> – Attempt to correct inaccurate beliefs by presenting salient information related to past performance of the individual decision maker or a relevant reference group.<br /><br /><i>Mental Models</i> – Update or change the decision maker’s mental representation of how the world works.<br /><br /><i>Reminders</i> – Use reminders to cut through inattention, highlight desired behavior, and focus the decision maker on a future goal or desired state.<br /><br /><i>Framing</i> – Focus the decision maker on a specific reference point, e.g., a default option or the negative consequences of inaction (not choosing any option).<br /><br /><i>Social Comparison and Feedback</i> - Explicitly compare an individual’s performance with a relevant comparison or reference group, e.g., the individual’s professional peers.<br /><br />Interventions can range from “nudges” that alter people’s behavior without forbidding any options to designs that are much stronger than nudges and are, in effect, efforts to enforce conformity.<br /><br />The bulk of the report describes the theory, research, and application of BE in six public policy domains: health, retirement benefits, social safety net benefits, climate change, education, and criminal justice. The NASEM committee reviewed current research and interventions in each domain and recommended areas for future research activity. There is too much material to summarize so we’ll provide a single illustrative sample.<br /><br />Because we have written about culture and safety practices in the healthcare industry, we will recap the report’s discussion of efforts to modify or support medical clinicians’ behavior. Clinicians often work in busy, sometimes chaotic, settings that place multiple demands on their attention and must make frequent, critical decisions under time pressure. On occasion, they provide more (or less) health care than a patient’s clinical condition warrants; they also make errors. Research and interventions to date address present bias and limited attention by changing defaults, and invoke social norms by providing information on an individual’s performance relative to others. An example of a default intervention is to change mandated checklists from opt-in (the response for each item must be specified) to opt-out (the most likely answer for each item is pre-loaded; the clinician can choose to change it). An example of using social norms is to provide information on the behavior and performance of peers, e.g., in the quantity and type of prescriptions written.<br /><br /><i>Overall recommendations</i><br /><br />The report’s recommendations are typical for this type of overview: improve the education of future policy makers, apply the key principles in public policy formulation, and fund and emphasize future research. Such research should include better linkage of behavioral principles and insights to specific intervention and policy goals, and realize the potential for artificial intelligence and machine learning approaches to improve tailoring and targeting of interventions.<br /><br /><b>Our Perspective</b><br /><br />We have written about decision making for years, mostly about how organizational culture (values and norms) affect decision making. We’ve also reviewed the insights and principles highlighted in the subject report. For example, our <a href="https://www.safetymattersblog.com/2013/12/thinking-fast-and-slow-by-daniel.html" target="_blank">December 18, 2013 post on Daniel Kahneman’s work</a> described people’s built-in decision making biases. Our <a href="https://www.safetymattersblog.com/2022/06/guiding-people-to-better-decisions.html" target="_blank">June 6, 2022 post on Thaler and Sunstein’s book <b>Nudge</b></a> discussed the application of behavioral economic principles in the design of ideal (and ethical) decision making processes. These authors’ works are recognized as seminal in the subject report.<br /><br />On the subject of ethics, the NASEM committee’s original mission included considering ethical issues related to the use of behavioral economics but ethics’ mention is the report is not much more than a few cautionary notes. This is thin gruel for a field that includes many public and private actors deciding what people should do instead of letting them decide for themselves.<br /><br />As evidenced by the report, the application of behavioral economics is widespread and growing. It’s easy to see its use being supercharged by artificial intelligence and machine learning. “Behavioral economics” sounds academic and benign. Maybe we should start calling it <i><b>behavioral engineering</b></i>.<br /><br />Bottom line: Read this report. You need to know about this stuff. <br /><br /><br />* National Academies of Sciences, Engineering, and Medicine, “<a href="https://nap.nationalacademies.org/catalog/26874/behavioral-economics-policy-impact-and-future-directions" target="_blank">Behavioral Economics: Policy Impact and Future Directions</a>,” (Washington, DC: The National Academies Press, 2023).</span></span><br /><p></p>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-8671681647623700762023-03-10T07:44:00.000-08:002023-03-10T07:44:24.407-08:00A Systems Approach to Diagnosis in Healthcare Emergency Departments<p><span style="font-family: verdana;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiMtfbSpB-v6OKrcEEbuSU4bMmjI7AHLfhDFIrz_gBXvD4bnen9s7W5YQUr2ImgRx7olmGe78Imj1KubBtELh4TL0g6JUB3EXYOw_-a-JkgwJbPrALHxVh0aZqhaZ5Hs_pZvDP56W6argMhaIZP-xdkriYFCSyaPN8rXybaTO_T0JH2Z0Ggm03Kmv03Q/s428/JAMA.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="210" data-original-width="428" height="98" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiMtfbSpB-v6OKrcEEbuSU4bMmjI7AHLfhDFIrz_gBXvD4bnen9s7W5YQUr2ImgRx7olmGe78Imj1KubBtELh4TL0g6JUB3EXYOw_-a-JkgwJbPrALHxVh0aZqhaZ5Hs_pZvDP56W6argMhaIZP-xdkriYFCSyaPN8rXybaTO_T0JH2Z0Ggm03Kmv03Q/w200-h98/JAMA.jpg" width="200" /></a></span></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-size: medium;">JAMA logo<br /></span></td></tr></tbody></table><span style="font-size: medium;"><br />A recent <a href="https://click.alerts.jamanetwork.com/click/axac-2n0b4y-86dewf-iq6u9226/" target="_blank">op-ed* in JAMA</a> advocated greater use of systems thinking to reduce diagnostic errors in emergency departments (EDs). The authors describe the current situation – diagnostic errors occur at an estimated 5.7% rate – and offer 3 insights why systems thinking may contribute to interventions that reduce this error rate. We will summarize their observations and then provide our perspective.<br /><br />First, they point out that diagnostic errors are not limited to the ED, in fact, such errors occur in <i>all</i> specialties and areas of health care. Diagnosis is often complicated and practitioners are under time pressure to come up with an answer. The focus of interventions should be on reducing incorrect diagnoses that result in harm to patients. Fortunately, studies have shown that “just 15 clinical conditions accounted for 68% of diagnostic errors associated with high-severity harms,” which should help narrow the focus for possible interventions. However, simply doing more of the current approaches, e.g., more “testing,” is not going to be effective. (We’ll explain why later.)<br /><br />Second, diagnostic errors are often invisible; if they were visible, they would be recognized and corrected in the moment. The system needs “practical value-added ways to define and measure diagnostic errors in real time, . . .”<br /><br />Third, “Because of the perception of personal culpability associated with diagnostic errors, . . . health care professionals have relied on the heroism of individual clinicians . . . to prevent diagnostic errors.” Because humans are not error-free, the system as it currently exists will inevitably produce some errors. Possible interventions include checklists, cognitive aids, machine learning, and training modules aimed at the Top 15 problematic clinical conditions. “The paradigm of how we interpret diagnostic errors must shift from trying to “fix” individual clinicians to creating systems-level solutions to reverse system errors.”<br /><br /><b>Our Perspective</b><br /><br />It will come as no surprise that we endorse the authors’ point of view: healthcare needs to utilize more systems thinking to increase the safety and effectiveness of its myriad diagnostic and treatment processes. Stakeholders must acknowledge that the current system for delivering healthcare services has error rates consistent with its sub-optimal design. Because of that, tinkering with incremental changes, e.g., the well-publicized effort to reduce infections from catheters, will yield only incremental improvements in safety. At best, they will only expose the next stratum of issues that are limiting system performance.<br /><br />Incremental improvements are based on fragmented mental models of the healthcare system. Proper systems thinking starts with a complete mental model of a healthcare system and how it operates. We have described a more complete mental model in other posts so we will only summarize it here. A model has components, e.g., doctors, nurses, support staff, and facilities. And the model is dynamic, which means components are not fixed entities but ones whose quality and quantity varies over time. In addition, the inter-relationships between and among the components can also vary over time. Component behavior is directed by both relatively visible factors – policies, procedures, and practices – and softer control functions such as the level of trust between individuals, different groups, and hierarchical levels, i.e., bosses and workers. Importantly, component behavior is also influenced by feedback from other components. These feedback loops can be positive or negative, i.e., they can reinforce certain behaviors or seek to reduce or eliminate them. For more on mental models, see our <a href="https://www.safetymattersblog.com/2021/05/hss-oig-report-cover-wehave-previously.html" target="_blank">May 21, 2021</a>, <a href="https://www.safetymattersblog.com/2019/11/national-academies-of-sciences.html" target="_blank">Nov. 6, 2019</a>, and <a href="https://www.safetymattersblog.com/2019/10/more-on-mental-models-in-healthcare.html" target="_blank">Oct. 9, 2019</a> posts.<br /><br />One key control factor is organizational culture, i.e., the values and assumptions about reality shared by members. In the healthcare environment, the most important subset of culture is safety culture (SC). Safety should be a primary consideration in all activities in a healthcare organization. For example, in a strong SC, the reporting of an adverse event such as an error should be regarded as a routine and ordinary task. The reluctance of doctors to report errors because of their feelings of personal and professional shame, or fear of malpractice allegations or discipline, must be overcome. For more on SC, see our <a href="https://www.safetymattersblog.com/2021/05/hss-oig-report-cover-wehave-previously.html" target="_blank">May 21, 2021</a> and <a href="https://www.safetymattersblog.com/2020/07/culture-in-healthcare-lessons-from-when.html" target="_blank">July 31, 2020</a> posts.<br /><br />Organizational structure is another control factor, one that basically defines the upper limit of organizational performance. Does the existing structure facilitate communication, learning, and performance improvement or do silos create barriers? Do professional organizations and unions create focal points the system designer can leverage to improve performance or are they separate power structures whose interests and goals may conflict with those of the larger system? What is the quality of management’s behavior, especially their decision making processes, and how is management influenced by their goals, policy constraints, environmental pressures (e.g., to advance equity and diversity) and compensation scheme? <br /><br />As noted earlier, the authors observe that EDs depend on individual doctors to arrive at correct diagnoses in spite of inadequate information or time pressure and doctors who can do this well are regarded as heroes. We note that doctors who are less effective may be shuffled off to the side or in egregious cases, labeled “bad apples” and tossed out of the organization. This is an incorrect viewpoint. Competent, dedicated individuals are necessary, of course, but the system designer should focus on making the system more error tolerant (so any errors cause no or minimal harm) and resilient (so errors are recognized and corrective actions implemented.) <br /><br />Bottom line: more systems thinking is needed in healthcare and articles like this help move the needle in the correct direction.<br /><br /><br />* J.A. Edlow and P.J. Pronovost, “<a href="https://click.alerts.jamanetwork.com/click/axac-2n0b4y-86dewf-iq6u9226/" target="_blank">Misdiagnosis in the Emergency Department: Time for a System Solution</a>,” JAMA (Journal of the American Medical Association), Vol. 329, No. 8 (Feb. 28, 2023), pp. 631-632.</span></span><br /></p>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-40742346045829773952022-11-17T13:53:00.001-08:002022-11-17T14:06:01.707-08:00A Road Map for Reducing Diagnostic Errors in Healthcare<p><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqGyv9YM7HSlEUcPzUGDhHkHKEjVZ8GBECulDdMb9zj2U1BwUrMvIk5Q-BeWN_sLJBzWuN_YRtC_usTs6hGNyfgDOWL9OxTK385ZsKZy0BVagQOy_6NZOd_ELfnFZgN4D6ndyLF6I9xqHXZlNR000bvKxkoVhYJt1FcLlL2WLA0SBS_pLgAu2oS-1Gug/s752/Joint%20Comm%20Safer%20Dx%20Checklist.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="527" data-original-width="752" height="224" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqGyv9YM7HSlEUcPzUGDhHkHKEjVZ8GBECulDdMb9zj2U1BwUrMvIk5Q-BeWN_sLJBzWuN_YRtC_usTs6hGNyfgDOWL9OxTK385ZsKZy0BVagQOy_6NZOd_ELfnFZgN4D6ndyLF6I9xqHXZlNR000bvKxkoVhYJt1FcLlL2WLA0SBS_pLgAu2oS-1Gug/w320-h224/Joint%20Comm%20Safer%20Dx%20Checklist.jpg" width="320" /></a></span></div><span style="font-size: medium;">A <a href="https://www.jointcommissionjournal.com/article/S1553-7250(22)00180-5/fulltext" target="_blank">recent article</a>* about how to reduce diagnostic errors in healthcare caught our attention, for a couple of reasons. First, it describes a fairly comprehensive checklist of specific practices to address diagnostic errors, and second, the practices include organizational culture and reflect systems thinking, both subjects dear to us. The checklist’s purpose is to help an organization rate its current performance and identify areas for improvement.<br /><br />The authors used a reasonable method to develop the checklist: they convened an anonymous Delphi group, identified and ranked initial lists of practices, shared the information among the group, then collected and organized the updated rankings. The authors then sent the draft checklist to several hospital managers, i.e., the kind of people who would have to implement the approach, for their input on feasibility and clarity. The final checklist was then published.<br /><br />The checklist focuses on <i>diagnostic</i> errors, i.e., missed, delayed, or wrong diagnoses. It does not address other major types of healthcare errors, e.g., botched procedures, drug mix-ups, or provider hygiene practices.<br /><br />The authors propose 10 practices, summarized below, to assess current performance and direct interventions with respect to diagnostic errors:<br /><br />1. Senior leadership builds a “board-to-bedside” accountability framework to measure and improve diagnostic safety.<br /><br />2. Promote a just culture and create a psychologically safe environment that encourages clinicians and staff to share opportunities to improve diagnostic safety without fear of retribution.<br /><br />3. Create feedback loops to increase information flow about patients’ diagnostic and treatment-related outcomes after handoffs from one provider/department to another.<br /><br />4. Develop multidisciplinary perspectives to understand and address contributory factors in the analysis of diagnostic safety events.<br /><br />5. Seek patient and family feedback to identify and understand diagnostic safety concerns.<br /><br />6. Encourage patients to review their health records and ask questions about their diagnoses and related treatments.<br /><br />7. Prioritize equity in diagnostic safety efforts.<br /><br />8-10. Establish standardized systems and processes to (1) encourage direct, collaborative interactions between treating clinical teams and diagnostic specialties; (2) ensure reliable communication of diagnostic information between care providers and with patients and families; and (3) close the loop on communication and follow up on abnormal test results and referrals. <br /><br /><b>Our Perspective</b><br /><br />We support the authors recognition that diagnostic errors are difficult to analyze; they can involve clinical uncertainty, the natural evolution of diagnosis as more information becomes available, and cognitive errors, all exacerbated by system vulnerabilities. Addressing such errors requires a systems approach. <br /><br />The emphasis on a just culture and establishing feedback loops is good. We would add the importance of management commitment to fixing and learning from identified problems, and a management compensation plan that includes monetary incentives for doing this.<br /><br />However, we believe the probability of a healthcare organization establishing dedicated infrastructure to address diagnostic errors is very low. First, the authors recognize there is no existing business case to address such errors. In addition, we suspect there is some uncertainty around how often such errors occur. The authors say these errors affect at least 5% of US adult outpatients annually but that number is based on a single <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145460/" target="_blank">mini-meta study</a>.**<br /><br />As a consequence, senior management is not currently motivated by either fear (e.g., higher costs, excessive losses to lawsuits, regulatory sanctions or fines, or reputational loss) or greed (e.g., professional recognition or monetary incentives) to take action. So our recommended first step should be to determine which types of medical errors present the greatest threats to an institution, how many occur, and then determine what can be done to prevent them or minimize their consequences. (See our <a href="https://www.safetymattersblog.com/2020/07/culture-in-healthcare-lessons-from-when.html" target="_blank">July 31, 2020 post on Dr. Danielle Ofri’s book</a> <b>When We Do Harm</b> for more on medical errors.) <br /><br />Second, the organization has other competing goals demanding attention and resources so management’s inclination will be to minimize costs by simply extending any existing error identification and resolution program to include diagnostic errors.<br /><br />Third, diagnosis is not a cut-and-dried process, like inserting a catheter, double-checking patients’ names, or hand washing. The diagnostic process is essentially probabilistic, with different diagnoses possible from the same data, and to some degree, subjective. Management probably does not want a stand-alone system that second guesses and retrospectively judges doctors’ decisions and opinions. Such an approach could be perceived as intruding on doctors’ freedom to exercise professional judgment and is bad for morale.<br /><br />Bottom line: The checklist is well-intentioned but a bit naïve. It is a good guide for identifying weak spots and hazards in a healthcare organization, and the overall approach is not necessarily limited to diagnostic errors. <br /><br /><br />* Singh, H., Mushtaq, U., Marinez, A., Shahid, U., Huebner, J., McGaffigan, P., and Upadhyay, D.K., “<a href="https://www.jointcommissionjournal.com/article/S1553-7250(22)00180-5/fulltext" target="_blank">Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to Address Diagnostic Errors</a>,” The Joint Commission Journal on Quality and Patient Safety, No. 48, Aug. 10, 2022, pp. 581–590. The Joint Commission is an entity that inspects and accredits healthcare providers, mainly hospitals.<br /><br />** Singh, H., Meyer, A.N.D., and Thomas, E.J., “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145460/" target="_blank">The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations</a>,” BMJ Quality and Safety, Vol. 23, No. 9, April 2014, pp. 727–731. </span><br /><br /><p></p>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-86184236388822600352022-09-22T11:42:00.000-07:002022-09-22T11:42:33.155-07:00Culture in the Healthcare Industry<p><!--[if gte mso 9]><xml>
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<![endif]--><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvxQsFNMPyyMxR2A65fLdtB1aZT-MiDt5d_niQyqMmqwMoOyABDkqsBFXqFWD-D9Lka9CXeWPURxNOV64BmdwUNJVg_wow3AieCgUL-hsem2_Rk0cYMXPDEmEH8ZQlR2KscPyISvsPDiSardeSyQUd4HhbL3S667YVEK401CQIeHaAg14ovtyMd28O-A/s309/JAMA%20NE%20J%20of%20Med.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="174" data-original-width="309" height="113" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvxQsFNMPyyMxR2A65fLdtB1aZT-MiDt5d_niQyqMmqwMoOyABDkqsBFXqFWD-D9Lka9CXeWPURxNOV64BmdwUNJVg_wow3AieCgUL-hsem2_Rk0cYMXPDEmEH8ZQlR2KscPyISvsPDiSardeSyQUd4HhbL3S667YVEK401CQIeHaAg14ovtyMd28O-A/w200-h113/JAMA%20NE%20J%20of%20Med.jpg" width="200" /></a></span></div><span style="font-family: verdana;"><span style="font-size: medium;">A couple of articles recognizing the importance of cultural factors in the healthcare space recently caught our attention. The authors break no new ground but we’re reporting these articles because they appeared in a couple of the U.S.’s most prestigious medical journals. <br /><br />We begin with an opinion piece in The Journal of the American Medical Association (JAMA).* The authors’ focus is on clinician burnout (<a href="https://www.safetymattersblog.com/2019/11/national-academies-of-sciences.html" target="_blank">which we discussed on Nov. 6, 2019</a>) but they cite earlier work on the importance of quality and culture in the healthcare workplace, including “the culture changes needed for effective teamwork and optimizing the authentic voice of every team member. . . . [and examining] the consequences of medical hierarchy and inequity.” <br /><br />One of the references in the JAMA piece is an earlier article by two of the authors in The New England Journal of Medicine.** This article discusses how the National Academy of Medicine (NAM) and its predecessor entities have influenced the trajectory of the discussion of healthcare effectiveness, starting by documenting the wide scope of inappropriate care prescribed to patients, i.e., the overuse of ineffective medical practices. Their seminal 1999 report, “To Err Is Human,” estimated that 44,000 to 98,000 Americans die in hospitals each year because of medical errors. <br /><br />Their 2001 report, “Crossing the Quality Chasm,” defined a framework for healthcare quality with six dimensions: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. In practice, the quality of healthcare services has improved since then in several specific areas, e.g., reduced rates of acquired infections, but “wholesale, systemic improvement in quality of care has proven difficult to bring to scale.” <a href="https://www.safetymattersblog.com/2020/11/setting-bar-for-healthcare-patient-care.html" target="_blank">We wrote about the lack of progress on Nov. 9, 1920.</a> One significant ongoing problem is that efforts to increase provider accountability, e.g., ascertaining if providers are delivering appropriate care, has resulted in a negative impact on clinicians’ morale. “The United States has yet to find for health care the wisest balance between accountability, which is critical, and supports for a trusting culture of growth and learning, which, as the NAM asserts, is the essential foundation for continual improvement.”<br /><br /><b>Our Perspective</b><br /><br />None of this information is new. What is worth noting is how cultural aspects have become important topics for discussion at the highest levels of healthcare policy.<span> </span></span></span><p><span style="font-family: verdana;"><span style="font-size: medium;"><span>If you have been following our healthcare posts on Safetymatters, you know we have discussed the challenges and the progress, or lack thereof, in reducing errors and increasing effectiveness. We have emphasized the role of a strong safety culture in the delivery of high quality services. Click on the healthcare label to see all of our related posts.<br /><br />Healthcare has a long way to go to catch up with other industries that have integrated high levels of safety and quality into their daily operations. To illustrate healthcare’s current position, we will repurpose a recent McKinsey article on corporate ESG (Environment, Social, Governance) attributes.*** McKinsey uses a 3-category framework (Minimum, Common, and Next level practices) to describe a business’s ESG character. For our purposes, we will replace ESG with safety and quality (S&C), and excerpt and adapt specific attributes that could and should exist in a healthcare organization.<br /><br /><i>Minimum practices</i> – focus on risk mitigation and do no harm measures<br /><br />• React to external social-legal-political trends<br />• Address obvious vulnerabilities<br />• Meet baseline standards<br />• Pledge to minimal commitment levels<br /><br /><i>Common practices</i> – substantive efforts, more proactive than reactive<br /><br />• Track major trends and develop strategies to address them<br />• Identify strengths and use them to move toward S&C goals<br />• Comply with voluntary standards and perform above average<br />• Engage with stakeholder groups to understand what matters to them<br /><br /><i>Next level practices</i> – full integration of S&C into strategy and operations<br /><br />• View S&C as essential components of overall strategy<br />• Link clearly articulated leadership areas with S&C goals<br />• Embed S&C in capital and resource allocation<br />• Tie S&C to employee incentives and evaluations<br />• Ensure that S&C reports cover the entity’s full set of operations<br /><br />Our judgment is that most healthcare entities, especially hospitals, demonstrate minimum practices and are trying to get ahead of the curve by implementing some common practices. Some entities may claim to be using next level practices, but these are generally narrow or limited efforts. The industry’s biggest challenge is getting the entrenched guilds of doctors and nurses, accustomed to working in protective silos, to fully embrace increased accountability. At the same time, senior management must create, maintain, and manage a non-punitive work environment and a just culture. <br /><br /><br />* Rotenstein, L.S., Berwick, D.M., and Cassel, C.K., “<a href="https://jamanetwork.com/journals/jama/fullarticle/2794541" target="_blank">Addressing Well-being Throughout the Health Care Workforce: The Next Imperative</a>,” JAMA, Vol. 328, No. 6 (Aug. 9, 2022), pp. 521-22. Published online July 18, 2022. JAMA is a peer-reviewed journal published by the American Medical Association.<br /><br />** Berwick, D.M., and Cassel, C.K., “<a href="https://www.nejm.org/doi/10.1056/NEJMp2005126">The NAM and the Quality of Health Care — Inflecting a Field</a>,” The New England Journal of Medicine, Vol. 383, No. 6 (Aug. 6, 2020), pp. 505-08. <br /><br />*** Pérez, L., Hunt, V., Samandari, H, Nuttall, R., and Bellone, D., “<a href="https://www.mckinsey.com/capabilities/sustainability/our-insights/how-to-make-esg-real?cid=other-eml-nsl-mip-mck&hlkid=fd34907e8a7b42d1a4d7ab4b3f1039ef&hctky=2961276&hdpid=b84efc58-1b90-48ca-83cf-ab5bedb249a5" target="_blank">How to make ESG real</a>,” McKinsey Quarterly (Aug. 2022).</span><br /></span></span><br /></p>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-49091618378594701552022-07-29T13:09:00.000-07:002022-07-29T13:09:34.846-07:00A Lesson from the Accounting Profession: Don’t Cheat on the Ethics Test<p><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-BSXu1347V-78Z5REfuM4dX0Y5aPEjd128dCQDuAmaivJIiAbnLb_5KYpYkZba7HMsiCPea_Ans_B9G7FskcoXL-t6rsg2W_cdUyqNPDlySA3VnsNkv4VTpDjRXrj45yKn0b4lC69J50Ugv5RGRFFMXO1hJiZj2ihmfZhPp-2bvTg27E5qP5EQdMfng/s650/SEC%20Ernst%20and%20Young%20Order.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="419" data-original-width="650" height="206" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-BSXu1347V-78Z5REfuM4dX0Y5aPEjd128dCQDuAmaivJIiAbnLb_5KYpYkZba7HMsiCPea_Ans_B9G7FskcoXL-t6rsg2W_cdUyqNPDlySA3VnsNkv4VTpDjRXrj45yKn0b4lC69J50Ugv5RGRFFMXO1hJiZj2ihmfZhPp-2bvTg27E5qP5EQdMfng/s320/SEC%20Ernst%20and%20Young%20Order.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">SEC Order<br /></td></tr></tbody></table><div style="text-align: center;"><span style="font-size: medium;"></span></div><span style="font-size: medium;"><br /><span style="font-family: verdana;">Accounting, like many professions, requires practitioners
to regularly demonstrate competence and familiarity with relevant knowledge and
practices.<span> </span>One requirement for Certified
Public Accountants (CPAs) is to take an on-line, multiple-choice test covering
professional ethics.<span> </span>Sounds easy but the
passing grade is relatively high so it’s not a slam dunk.<span> </span>Some Ernest & Young (EY) audit accountants
found it was easier to pass if they cheated by using answer keys and sharing the
keys with their colleagues.<span> </span>They were
eventually caught and got into big trouble with the U.S. Securities and
Exchange Commission (SEC).<span> </span>Following is a
summary of the scandal as it evolved over time per the <a href="https://www.sec.gov/litigation/admin/2022/34-95167.pdf" target="_blank">SEC order</a>* and our view
on what the incident says about EY’s culture.
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">During 2012-15, some EY employees were exploiting
weaknesses in the company’s test software to pass tests despite not having a
sufficient number of correct answers.<span> </span>EY
learned about this problem in 2014.<span> </span>In
2016, EY learned that professionals in one office improperly shared answer
keys.<span> </span>EY repeatedly warned personnel
that cheating on tests was a violation of the firm’s code of ethics but did not
implement any additional controls to detect this misconduct.<span> </span>The cheating continued into 2021.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">In 2019 the SEC discovered cheating at another accounting
firm and fined them $50 million.<span> </span>As part
of the SEC’s 2019 investigation, the agency asked EY if they had any problems
with cheating.<span> </span>In their response, EY
said they had uncovered instances in the past but implied they had no current
problems.<span> </span>In fact, EY management had recently
received a tip about cheating and initiated what turned out to be an extensive
investigation that by late 2019 “<span class="fontstyle01">confirmed that audit professionals
in multiple offices cheated on CPA ethics exams</span>.” (p. 6)<span> </span>However, EY never updated their response to
the SEC.<span> </span>Eventually EY told the Public
Company Accounting Oversight Board (PCAOB)** about the problems, and the PCAOB
informed the SEC – 9 months after the SEC’s original request for information
from EY. </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">In the U.S., the relationship between government regulators
and regulated entities is based on the expectation that communications from the
regulated entities will be complete, truthful, and updated on a timely basis if
new information is discovered or developed.<span>
</span>Lying to or misleading the government, either through commission or
omission, is a serious matter.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Because of EY’s violation of a PCAOB rule and EY’s misleading
behavior with the SEC, the company was censured, fined $100 million, and
required to implement a host of corrective actions, summarized below.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><i>Review of Policies
and Procedures</i></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">“EY shall evaluate . . . the sufficiency and adequacy of
its quality controls, policies, and procedures relevant to ethics and integrity
and to responding to Information Requests” (p. 9)<span> </span>In particular, EY will evaluate “whether EY’s
<b>culture</b> [emphasis added] is
supportive of ethical and compliant conduct and maintaining integrity,
including strong, explicit, and visible support and commitment by the firm’s
management” (p. 10)</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><i>Independent Review
of EY’s Policies and Procedures</i></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">“EY shall require that the Policies and Procedures IC [Independent
Consultant] conduct a review of EY’s Policies and Procedures to determine
whether they are designed and being implemented in a manner that provides
reasonable assurance of compliance with all professional standards . . . . EY
shall adopt, as soon as practicable, all recommendations of the Policies and
Procedures IC in its report. . . . EY’s Principal Executive Officer must
certify to the Commission staff in writing that (i) EY has adopted and has
implemented or will implement all recommendations of the Policies and
Procedures IC in its report . . .” (pp. 10-12)</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><i>Independent Review
of EY’s Disclosure Failures</i></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">“EY’s Special Review Committee shall require that the
Remedial IC conduct a review . . . of EY’s conduct relating to the Commission
staff’s June 2019 Information Request, including whether any member of EY’s
executive team, General Counsel’s Office, compliance staff, or other EY
employees contributed to the firm’s failure to correct its misleading
submission.” (p. 12)<span> </span>Like the Policies
and Procedures review, EY must adopt the recommendations in the Remedial IC
Report and EY’s Principal Executive Officer must certify their adoption to the
SEC.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><i>Notice to Audit
Clients, Training, and Certifications</i></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">“Within 10 business days after entry of this Order, EY
shall provide all of its issuer audit clients and SEC-registered broker-dealer
audit clients a copy of this Order. . . . all audit professionals and all EY
partners and employees who, at any time prior to March 3, 2020, were aware (i)
of the Division of Enforcement’s June 19, 2019 request, (ii) of EY’s June 20,
2019 response, and (iii) that an employee had made a tip on June 19, 2019
concerning cheating shall complete a minimum of 6 hours every 6 months of
ethics and integrity training by an independent training provider . . . . EY’s
Principal Executive Officer shall also certify that the training requirements .
. . have been completed.” (pp. 14-15)</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><b>Our Perspective</b></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">A company’s culture includes the values and assumptions
that underlie daily work life and influence decision making.<span> </span>What can we infer about EY’s culture from the
behavior described above?</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">First, what managers did after they discovered the
cheating – issuing memos and waving their arms – did not work.<span> </span>Even if EY terminated some employees, perhaps
the worst offenders or maybe the least productive ones, EY did not make their testing
process more robust or secure.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Second, senior leadership has not suffered from this
scandal.<span> </span>There is no indication any
senior managers have been disciplined or terminated because of the misconduct.<span> </span>The head of EY’s U.S. operations left at the
end of her 4-year term, but her departure was apparently due to a disagreement
with her boss, EY’s global chief executive.<span>
</span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Third, there has been no apparent change in the
employees’ task environments, e.g., their workload expectations and
compensation program.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Conclusion: EY management tolerated the cheating because
their more important priorities were elsewhere.<span>
</span>It’s safe to assume that EY, like other professional service firms, primarily
values and rewards technical competence and maximizing billable hours.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">We see two drivers for possible changes: the $100 million
fine and the mandated review by “Independent Consultants.”<span> </span>(EY’s self-review will likely be no more
useful than their previous memos and posturing.)</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><i>What needs to be
done?<span> </span></i></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">To begin, senior leadership has to say fixing the cheating
problem is vitally important, and walk the talk by adjusting company practices
to reinforce the task’s importance.<span>
</span>Leadership has to commit to a company corrective action program that recognizes,
analyzes, and permanently fixes all significant company problems as they arise
– not after their noses are rubbed into action by the regulator. <span> </span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">In addition, there have to be visible changes in the
audit professionals’ task environment.<span>
</span>The employees need to get work time, in the form of unbilled overhead
hours, to prepare for tests.<span> </span>The
compensation scheme needs to add a component to recognize and reward ethical
behavior – with clients and internally.<span>
</span>The administration of ethics tests needs to be made more secure, on a
par with the accounting exams the employees take.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><br /></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">* <span> </span>Securities and
Exchange Commission, <a href="https://www.sec.gov/litigation/admin/2022/34-95167.pdf" target="_blank">Other Release No.: 34-95167</a> Re: Ernst & Young LLP (June
28, 2022). <span> </span>All quotes in our post are
from the SEC order.<span> </span>There is also an
associated <a href="https://www.sec.gov/news/press-release/2022-114" target="_blank">SEC press release</a>.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">** <span> </span>The Public
Company Accounting Oversight Board establishes auditing and professional
practice standards for registered public accounting firms, such as EY, to
follow in the preparation of audit reports for public companies.<span> </span>PCAOB members are appointed by the SEC.</span></span></p>
<p></p>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-43091156189579300912022-06-06T13:21:00.000-07:002022-06-06T13:21:15.858-07:00Guiding People to Better Decisions: Lessons from Nudge by Richard Thaler and Cass Sunstein<p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmn3kEaeo8BSrwxLw3FjP5iwEU4NSivkhn1b7kgaDqZdBOsyhd-nGueyaqHeYgZpZjF2_IRUqMFm3tEVN1UBzCVpm0qpy_u1QIYSRTMavurQIPXYb7QgKjYt7spVmYMqcwv7XhDfFR3cmbKSaeunhD-DS5fgePy71i8QFDYfqXrNlzHPbz3AnO8Dx1zg/s343/Thaler%20Sunstein%20Nudge.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="343" data-original-width="227" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmn3kEaeo8BSrwxLw3FjP5iwEU4NSivkhn1b7kgaDqZdBOsyhd-nGueyaqHeYgZpZjF2_IRUqMFm3tEVN1UBzCVpm0qpy_u1QIYSRTMavurQIPXYb7QgKjYt7spVmYMqcwv7XhDfFR3cmbKSaeunhD-DS5fgePy71i8QFDYfqXrNlzHPbz3AnO8Dx1zg/w133-h200/Thaler%20Sunstein%20Nudge.jpg" width="133" /></a></span></div><span style="font-size: medium;">Safetymatters reports on organizational culture, the
values and beliefs that underlie an organization’s essential activities.<span> </span>One such activity is decision-making (DM) and
we’ve said an organization’s DM processes should be robust and replicable.<span> </span>DM must incorporate the organization’s
priorities, allocate its resources, and handle the inevitable goal conflicts which
arise.</span><p></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">In a related area, we’ve written about the biases that
humans exhibit in their personal DM processes, described most notably in the
work by Daniel Kahneman.*<span> </span>These biases
affect decisions people make, or contribute to, on behalf of their
organizations, and personal decisions that only impact the decision maker
himself. </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Thaler and Sunstein also recognize that humans are not
perfectly rational decision makers (citing Kahneman’s work, among others) and
seek to help people make better decisions based on insights from behavioral
science and applied economics.<span> </span><b>Nudge</b>** focuses on the presentation of decision
situations and alternatives to decision makers on public and private sector
websites.<span> </span>It describes the nitty-gritty
of identifying, analyzing, and manipulating decision factors, i.e., the
architecture of choice.<span> </span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">The authors examine the choice architecture for a
specific class of decisions: where groups of people make individual choices
from a set of alternatives.<span> </span>Choice
architecture consists of curation and navigation tools.<span> </span>Curation refers to the set of alternatives
presented to the decision maker.<span>
</span>Navigation tools sound neutral but small details can have a significant
effect on a decider’s behavior.<span></span></span></span><span style="font-family: verdana;"><span style="font-size: medium;"> </span></span></p><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">The authors discuss many examples including choosing a
healthcare or retirement plan, deciding whether or not to become an organ donor,
addressing climate change, and selecting a home mortgage.<span> </span>In each case, they describe different ways of
presenting the decision choices, and their suggestions for an optimal approach.
<span> </span>Their recommendations are guided by their
philosophy of “libertarian paternalism” which means decision makers should be
free to choose, but should be guided to an alternative that would maximize the decider’s
utility, as defined by the decision maker herself. </span></span><span style="font-family: verdana;"></span><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><span style="font-family: verdana;"></span></p><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><b>Nudge</b> concentrates
on <i>which</i> alternatives are presented
to a decider and <i>how</i> they are
presented.<span> </span>Is the decision maker asked
to opt-in or opt-out with respect to major decisions?<span> </span>Are many alternatives presented or a subset
of possibilities? <span> </span>A major problem in the
real world is that people can have difficulty in seeing how choices will end up
affecting their lives.<span> </span>What is the
default if the decision maker doesn’t make a selection?<span> </span>This is important: default options are
powerful nudges; they can be welfare enhancing for the decider or self-serving
for the organization.<span> </span>Ideally, default
choices should be “consistent with choices people would make if they all the
relevant information, were not subject to behavioral biases, and had the time
to make a thoughtful choice.” (p. 261)</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Another real world problem is that much choice
architecture is bogged down with <i>sludge</i>
- the inefficiency in the choice system – including barriers, red tape, delays,
opaque costs, and hidden or difficult to use off-ramps (e.g., finding the path
to unsubscribe from a publication).</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">The authors show how private entities like social media
companies and employers, and public ones like the DMV, present decision
situations to users.<span> </span>Some entities have
the decider’s welfare and benefit in mind, others are more concerned with their
own power and profits.<span> </span>It’s no secret
that markets give companies an incentive to exploit our DM frailties to
increase profits. <span> </span>The authors explicitly
do not support the policy of “presumed consent” embedded in many choice
situations where the designer has assumed a desirable answer and is trying to
get more deciders to end up there.<span> </span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">The authors’ view is their work has led to many
governments around the world establishing “nudge” departments to identify
better routes for implementing social policies.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><b>Our Perspective</b></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">First, the authors have a construct that is totally
consistent with our notion of a system.<span> </span>A
true teleological system includes a designer (the authors), a client (the
individual deciders), and a measure of performance (utility as experienced by
the decider).<span> </span>Because we all agree,
we’ll give them an A+ for conceptual clarity and completeness.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Second, they pull back the curtain to reveal the
deliberate (or haphazard) architecture that underlies many of our on-line experiences
where we are asked or required to interact with the source entities.<span> </span>The authors make clear how often we are being
prodded and nudged.<span> </span>Even the most
ostensibly benign sites can suggest what we should be doing through their
selection of default choices.<span> </span>(In
fairness, some site operators, like one’s employer, are themselves under the
gun to provide complete data to government agencies or insurance
companies.<span> </span>They simply can’t wait
indefinitely for employees to make up their minds.)<span> </span>We need to be alert to defaults that we
accept without thinking and choices we make when we know what others have
chosen; in both cases, we may end up with a sub-optimal choice for our
particular circumstances.<span> </span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Thaler and Sunstein are respectable academics so they
include lots of endnotes with references to books, journals, mainstream media,
government publications, and other sources.<span>
</span>Sunstein was Kahneman’s co-author for <b>Noise</b>, which <a href="https://www.safetymattersblog.com/2021/07/making-better-decisions-lessons-from.html" target="_blank">we reviewed on July 1, 2021</a>.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><span></span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Bottom line: <b>Nudge</b>
is an easy read about how choice architects shape our everyday experiences in the
on-line world where user choices exist.<span> </span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"> </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">*<span> </span>Click on the
Kahneman label for all our posts related to his work.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">**<span> </span>R.H. Thaler and
C.R. Sunstein, <b>Nudge</b>, final ed. (New
Haven: Yale University Press) 2021.</span></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-42057419927575142502022-03-31T16:05:00.002-07:002022-03-31T16:05:55.189-07:00The Criminalization of Safety in Healthcare?<p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPFuJa4yi9G6T_ngzXryxrwTdCibaQj2Z_8UCQqP2SIkBPp2PtxQpERiBZ3SqTph4L6zfnGtbqOkc1uNbMTp0W-m70JWY0HDUEBbEr05LM9Jup81EGe40SjgjiGrsY1e16mQB0y629WtNzkbXcU8y3JdPaoslj0o6YSM7l1OMX6m0n5SSGF8wPFMuNOw/s2800/Scales%20of%20justice.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="2800" data-original-width="2800" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPFuJa4yi9G6T_ngzXryxrwTdCibaQj2Z_8UCQqP2SIkBPp2PtxQpERiBZ3SqTph4L6zfnGtbqOkc1uNbMTp0W-m70JWY0HDUEBbEr05LM9Jup81EGe40SjgjiGrsY1e16mQB0y629WtNzkbXcU8y3JdPaoslj0o6YSM7l1OMX6m0n5SSGF8wPFMuNOw/w200-h200/Scales%20of%20justice.jpg" width="200" /></a></span></div><span style="font-size: medium;"><br /><span style="font-family: verdana;">On March 25, 2022 a former nurse at Vanderbilt University
Medical Center (VUMC) was convicted of gross neglect of an impaired adult and
negligent homicide as a consequence of a fatal drug error in 2017.*<span> </span></span></span><p></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Criminal prosecutions for medical errors are rare, and
healthcare stakeholders are concerned about what this conviction may mean for
medical practice going forward.<span> </span>A major
concern is practitioners will be less likely to self-report errors for fear of
incriminating themselves.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">We have previously written about the intersection of
criminal charges and safety management and practices.<span> </span>In 2016 Safetymatters’ Bob Cudlin authored a
3-part series on this topic.<span> </span>(See his
<a href="https://www.safetymattersblog.com/2016/05/the-criminalization-of-safety-part-1_24.html" target="_blank">May 24</a>, <a href="https://www.safetymattersblog.com/2016/05/the-criminalization-of-safety-part-2.html" target="_blank">May 31</a>, and <a href="https://www.safetymattersblog.com/2016/06/the-criminalization-of-safety-part-3.html" target="_blank">June 7</a> posts.)<span> </span>Consistent
with our historical focus on systems thinking, Bob reviewed examples in
different industries and asked “where does culpability really lie - with
individuals? culture? the corporation? or the complex socio-technical systems
within which individuals act?”</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">“Corporations inherently, and often quite intentionally,
place significant emphasis on achieving operational and business goals.<span> </span>These goals at certain junctures may conflict
with assuring safety.<span> </span>The <i>de facto</i> reality is that it is up to the
operating personnel to constantly rationalize those conflicts in a way that
achieves acceptable safely.”</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">We are confident this is true in hospital nurses’ working
environment.<span> </span>They are often
short-staffed, working overtime, and under pressure from their immediate task
environments and larger circumstances such as the ongoing COVID pandemic.<span> </span>The ceaseless evolution of medical technology
means they have to adapt to constantly changing equipment, some of which is
problematic.<span> </span>Many/most healthcare
professionals believe errors are inevitable.<span>
</span>See our <a href="https://www.safetymattersblog.com/2019/08/safety-ii-lessons-for-healthcare.html" target="_blank">August 6, 2019</a> and <a href="https://www.safetymattersblog.com/2020/07/culture-in-healthcare-lessons-from-when.html" target="_blank">July 31, 2020</a> posts for more information
about the extent, nature, and consequences of healthcare errors. </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">At VUMC, medicines are dispensed from locked cabinets
after a nurse enters various codes. <span> </span>The
hospital had been having technical problems with the cabinets in early 2017 prior
to the nurse’s error.<span> </span>The nurse could
not obtain the proper drug because she was searching using its brand name
instead of its generic name.<span> </span>She entered
an override that allowed her to access additional medications and selected the
wrong one, a powerful paralyzing agent.<span>
</span>The nurse and other medical personnel noted that entering overrides on
the cabinets was a common practice. </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">VUMC’s problems extended well beyond troublesome medicine
cabinets.<span> </span>An investigator said VUMC had
“a heavy burden of responsibility in this matter.”<span> </span>VUMC did not report the medication error as
required by law and told the local medical examiner’s office that the patient died
of “natural” causes. <span> </span>VUMC avoided criminal
charges because prosecutors didn’t think they could prove gross
negligence.<span> </span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"><b>Our Perspective</b></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">As Bob observed in 2016, “The reality is that
criminalization is at its core a “disincentive.”<span> </span>To be effective it would have to deter actions
or decisions that are not consistent with safety but not create a minefield of
culpability. . . . <span> </span>Its best use is
probably as an ultimate boundary, to deter intentional misconduct but not be an
unintended trap for bad judgment or inadequate performance.”</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">In the instant case, the nurse did not intend to cause
harm but her conduct definitely reflected bad judgment and unacceptable
performance.<span> </span>She probably sealed her own
fate when she told law enforcement she “probably just killed a patient” and the
licensing board that she had been “complacent” and “distracted.”<span> </span><span> </span></span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">But we see plenty of faults in the larger system, mainly
that VUMC used cabinets that held dangerous substances and had a history of
technical glitches but allowed users to routinely override cabinet controls to
obtain needed medicines.<span> </span>As far we can
tell, VUMC did not implement any compensating safety measures, such as
requiring double checking by a colleague or a supervisor’s presence when
overrides were performed or “dangerous” medications were withdrawn.</span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">In addition, VUMC’s organizational culture was on full
display with their inadequate and misleading reporting of the patient’s
death.<span> </span>VUMC has made no comment on the
nurse’s case.<span> </span>In our view, their overall
strategy was to circle the wagons, seal off the wound, and dispose of the bad
apple.<span> </span>Nothing to see here, folks. </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Going forward, the remaining VUMC nurses will be on high
alert for awhile but their day-to-day task demands will eventually force them
to employ risky behaviors in an environment that requires such behavior to
accomplish the mission but lacks defense in depth to catch errors before they
have drastic consequences.<span> </span>The nurses will/should
be demanding a safer work environment.</span></span></p><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">Bottom line: Will this event mark a significant moment
for accountability in healthcare akin to the George Floyd incident’s impact on
U.S. police practices?<span> </span>You be the judge.
</span></span><span style="font-family: verdana;"></span><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span></p><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">For additional Safetymatters insights click the
healthcare label below. </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;"> </span></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><span style="font-size: medium;">
</span></span><p class="MsoNoSpacing"><span style="font-family: verdana;"><span style="font-size: medium;">*<span> </span>All discussion
of the VUMC incident is based on reporting by National Public Radio (NPR).<span> </span>See B. Kelman, “<a href="https://www.npr.org/sections/health-shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next" target="_blank">As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?</a>” NPR, March 22, 2022; “<a href="https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea" target="_blank">In Nurse’s Trial, Investigator Says Hospital Bears ‘Heavy’ Responsibility for Patient Death</a>,” NPR, March 24, 2022; “<a href="https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient" target="_blank">Former nurse found guilty in accidental injection death of 75-year-old patient</a>,” NPR, March 25, 2022. </span></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-4119768969769603522022-02-02T14:07:00.000-08:002022-02-02T14:07:48.958-08:00A Massive Mental Model: Lessons from Principles for Dealing with the Changing World Order by Ray Dalio<p class="MsoNoSpacing"><span style="font-size: small;"><span style="font-family: verdana;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEg39-1wXof0zTxYydmj9s-Xx42-Xq6W5GOuCXedXDJkRX_X8YkLiXI45jT7tkaXDkHFYn3YwS6itEv6EiYyhaPV4X2Xfnkrqqv5cQZvhVHazeybY5UlEl7XL14X-92r4xkw1VuGTUOte4pZ7FJ-ryQgg2IUNRj9y4xh1C2dzt8SXaIEUmTh2eLNLe6W_Q=s473" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="473" data-original-width="359" height="200" src="https://blogger.googleusercontent.com/img/a/AVvXsEg39-1wXof0zTxYydmj9s-Xx42-Xq6W5GOuCXedXDJkRX_X8YkLiXI45jT7tkaXDkHFYn3YwS6itEv6EiYyhaPV4X2Xfnkrqqv5cQZvhVHazeybY5UlEl7XL14X-92r4xkw1VuGTUOte4pZ7FJ-ryQgg2IUNRj9y4xh1C2dzt8SXaIEUmTh2eLNLe6W_Q=w152-h200" width="152" /></a></span></div><span style="font-size: small;"><span style="font-size: medium;">At Safetymatters, we have emphasized several themes over
the years, including the importance of developing complete and realistic <i>mental models</i> of systems, often large,
complicated, socio-technical organizations, to facilitate their analysis.<span> </span>A mental model includes the significant
factors that comprise the system, their interrelationships, system dynamics (how
the system functions over time), and system outputs and their associated
metrics.</span></span><p></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">This post outlines an ambitious and grand mental model:
the recurring historical arc exhibited by all the world’s great empires as
described in Ray Dalio’s new book.* Dalio examined empires from ancient China
through the 20<sup>th</sup> century United States.<span> </span>He identified 18 factors that establish and demonstrate
a great society’s rise and fall: 3 “Big Cycles,” 8 different types of power an
empire can exhibit, and 7 other determinants.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"><i>Three Big Cycles<span> </span></i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The big cycles have a natural progression and are influenced
by human innovation, technological development, and acts of nature.<span> </span>They occur over an empire’s 250 year lifetime
of emergence, rise, topping out, decline, and replacement by a new dominant
power. </span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The <i>financial</i>
cycle initially supports prosperity but debt builds over time, then governments
accommodate it by printing more money** which eventually leads to a currency
devaluation, debt restructuring (including defaults), and the cycle starts
over. <span> </span>These cycles typically last about
50 to 100 years so can occur repeatedly over an empire’s lifetime.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The <i>political</i>
cycle starts with a new order and leadership, then resource allocation systems
are built, productivity and prosperity grow, but lead to excessive spending and
widening wealth gaps, then bad financial conditions (e.g., depressions), civil
war or revolution, and the cycle starts over.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The <i>international</i>
cycle is dominated by raw power dynamics.<span>
</span>Empires build power and, over time, have conflicts with other countries
over trade, technology, geopolitics, and finances.<span> </span>Some conflicts lead to wars.<span> </span>Eventually, the competition becomes too
costly, the empire weakens, and the cycle starts over.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"><i>Dimensions and
measures of power</i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">An empire can develop and exercise power in many ways; these
are manifestations and measures of the empire’s competitive advantages relative
to other countries.<span> </span>The 8 areas are education,
cost competitiveness, innovation and technology, economic output, share of
world trade, military strength, financial center strength, and reserve currency
status.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"><i>Other determinants</i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">These include natural attributes and events, internal
financial/political/legal practices, and measures of social success and
satisfaction.<span> </span>Specific dimensions are geology,
resource allocation efficiency, acts of nature, infrastructure and investment,
character/civility/determination, governance/rule of law, gaps in wealth,
opportunity and cultural values.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">The 18 factors interact with each other, typically
positively reinforcing each other, with some leading others, e.g., a society
must establish a strong education base to support innovation and technology development. <span> </span>Existing conditions and
determinants propel changes that create new conditions and determinants.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"><b>System dynamics</b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Evolution is the macro driving force that creates the
system dynamic over time.<span> </span>In Dalio’s
view “Evolution is the biggest and only permanent force in the universe . . .”
(p. 27)<span> </span>He also considers other factors
that shape an empire’s performance.<span> </span>The
most important of these are self-interest, the drive for wealth and power, the
ability to learn from history, multi-generational differences, time frames for
decision making, and human inventiveness.<span>
</span>Others include culture, leadership competence, and class relationships.<span> </span>Each of these factors can wax and/or wane
over the course of an empire’s lifetime, leading to changes in system
performance.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Dalio uses his model to describe (and share) his version
of the economic-political history of the world, and the never-ending struggles
of civilizations over the accumulation and distribution of wealth and power.<span> </span>Importantly, he also uses it to inform his
worldwide investment strategies.<span> </span>His archetype
models are converted into algorithms to monitor conditions and inform investment
decisions.<span> </span>He believes all financial markets
are driven by growth, inflation, risk premiums (e.g., to compensate for the
risk of devaluation), and discount rates. </span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"><b>Our Perspective</b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Dalio’s model is ambitious, extensive, and
complicated.<span> </span>We offer it up an extreme
example of mental modeling, i.e., identifying all the important factors in a
system of interest and defining how they work together to produce
something.<span> </span>Your scope of interest may be
more limited – a power plant, a hospital, a major corporation – but the concept
is the same. </span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Dalio is the billionaire founder of hedge fund
Bridgewater Associates.<span> </span>He has no
shortage of ego or self-confidence.<span> </span>He name-drops
prominent politicians and thinkers from around the world to add weight to his
beliefs.<span> </span>We reviewed his 2017 book <a href="https://www.safetymattersblog.com/2018/04/nuclear-safety-culture-insights-from.html" target="_blank"><b>Principles</b> on April 17, 2018</a> to show an
example of a hard-nosed, high performance business culture.<span> </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">He is basically a deterministic thinker who views the
world as a large, complex machine.<span> </span>His
modeling emphasizes cause-effect relationships that evolve and repeat over time.<span> </span>He believes a perfect model would perfectly
forecast the future so we assume he views the probabilistic events that occur
at network branching nodes as consequences of an incomplete, i.e., imperfect
model.<span> </span>In contrast, we believe that some
paths are created by events that are essentially probabilistic (e.g.,
“surprising acts of nature”) or the result of human choices.<span> </span>We agree that human adaptation, learning, and
inventiveness are keys to productivity improvements and social progress, but we
don’t think they can be completely described in mechanical cause-effect terms.<span> </span>Some system conditions are emergent, i.e.,
the consequence of a system’s functioning, and other things occur simply by
chance.<span> </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">This book is over 500 pages, full of data and
tables.<span> </span>Individual chapters detail the
history of the Dutch, British, American, and Chinese empires over the last 500
years.<span> </span>The book has no index so
referring back to specific topics is challenging. Dalio is not a scholar and gives scant or no
credit to thinkers who used some of the same archetypes long before him.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">We offer no opinion on the accuracy or completeness of
Dalio’s version of world history, or his prognostications about the future,
especially U.S.-China relations.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">Bottom line: this is an extensive model of world history,
full of data; the analyses of the U.S. and China*** are worth reading.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"> </span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">*<span> </span>R. Dalio, <b>Principles for Dealing with the Changing
World Order </b>(New York: Avid Reader Press) 2021.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;">**<span> </span>If the new
money and credit goes into economic productivity, it can be good for the
society.<span> </span>But the new supply of money can
also cheapen it, i.e., drive its value down, reducing the desire of people to
hold it and pushing up asset prices.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNoSpacing"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
<span style="line-height: 115%;">***<span> </span>Dalio summarizes the Chinese
political-financial model as “Confucian values with capitalist practices . . .”
(p. 364)</span></span></span>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-76374315030780061562021-12-10T14:41:00.002-08:002021-12-10T14:43:39.803-08:00Prepping for Threats: Lessons from Risk: A User’s Guide by Gen. Stanley McChrystal.<p class="MsoNormal"><a href="https://1.bp.blogspot.com/-_qAvjWC__lg/YbPUBKkesdI/AAAAAAAAEGk/QSzsCDnKcjoJsoIRCbEnReAIwu0OsJw_wCNcBGAsYHQ/s474/McChrystal%2BRisk.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="474" data-original-width="474" height="200" src="https://1.bp.blogspot.com/-_qAvjWC__lg/YbPUBKkesdI/AAAAAAAAEGk/QSzsCDnKcjoJsoIRCbEnReAIwu0OsJw_wCNcBGAsYHQ/w200-h200/McChrystal%2BRisk.jpg" width="200" /></a><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"><span style="font-size: medium;"><span style="font-family: verdana;"><span><span style="line-height: 115%;"></span></span></span></span>Gen. McChrystal was a U.S. commander in Afghanistan;
you may remember he was fired by President Obama for making, and allowing
subordinates to make, disparaging comments about then-Vice President
Biden.<span> </span>However, McChrystal was widely
respected as a soldier and leader, and his recent book* on strengthening an
organization’s “risk immune system” caught our attention.<span> </span>This post summarizes its key points, focusing
on items relevant to formal civilian organizations. </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">McChrystal describes a system that can detect, assess,
respond to, and learn from risks.**<span> </span>His mental
model consists of two major components: (1) ten <i>Risk Control Factors</i>, interrelated dimensions for dealing with
risks and (2) eleven <i>Solutions</i>, strategies
that can be used to identify and address weaknesses in the different factors.<span> </span>His overall objective is to create a resilient
organization that can successfully respond to challenges and threats.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Risk
Control Factors</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">These are things under the control of an organization
and its leadership, including physical assets, processes, practices, policies,
and culture. </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><a name="OLE_LINK2"><i><span style="line-height: 115%;">Communication</span></i></a><span><span style="line-height: 115%;"> – The organization must have the physical
ability and willingness to exchange clear, complete, and intelligible
information, and identify and deal with propaganda or misinformation.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Narrative</span></i></span><span><span style="line-height: 115%;"> – An articulated organizational purpose
and mission.<span> </span>It describes Who we are, What
we do, and Why we do it.<span> </span>The narrative
drives (and we’d say is informed by) values, beliefs, and action.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Structure</span></i></span><span><span style="line-height: 115%;"> – Organizational design defines decision
spaces and communication networks, implies power (both actual and perceived
authority), suggests responsibilities, and influences culture. </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Technology</span></i></span><span><span style="line-height: 115%;"> – This is both the hardware/software and
how the organization applies it.<span> </span>It
include an awareness of how much authority is being transferred to machines,
our level of dependence on them, our vulnerability to interruptions, and the unintended
consequences of new technologies.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Diversity</span></i></span><span><span style="line-height: 115%;"> – Leaders must actively leverage different
perspectives and abilities, inoculate the organization against groupthink, i.e.,
norms of consensus, and encourage productive conflict and a norm of
skepticism.<span> </span>(See our <a href="https://www.safetymattersblog.com/2020/06/a-culture-that-supports-dissent-lessons.html" target="_blank">June 29, 2020 post
on <b>A Culture that Supports Dissent:
Lessons from In Defense of Troublemakers</b></a> by Charlan Nemeth.)</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Bias</span></i></span><span><span style="line-height: 115%;"> – Biases are assumptions about the world
that affect our outlook and decision making, and cause us to ignore or discount
many risks.<span> </span>In McChrystal’s view “[B]ias
is an invisible hand driven by self-interest.” (See our <a href="https://www.safetymattersblog.com/2021/07/making-better-decisions-lessons-from.html" target="_blank">July 1, 2021</a> and <a href="https://www.safetymattersblog.com/2013/12/thinking-fast-and-slow-by-daniel.html" target="_blank">Dec.18, 2013</a> posts on Daniel Kahneman’s work on identifying and handling biases.)<span> </span></span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Action</span></i></span><span><span style="line-height: 115%;"> – Leaders have to proactively overcome
organizational inertia, i.e., a bias against starting something new or changing
course.<span> </span>Inertia manifests in organizational
norms that favor the status quo and tolerate internal resistance to change.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Timing</span></i></span><span><span style="line-height: 115%;"> – Getting the “when” of action right.<span> </span>Leaders have to initiate action at the right
time with the right speed to yield optimum impact. </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Adaptability</span></i></span><span><span style="line-height: 115%;"> – Organizations have to respond to
changing risks and environments.<span> </span>Leaders
need to develop their organization’s willingness and ability to change.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Leadership</span></i></span><span><span style="line-height: 115%;"> </span></span><span style="line-height: 115%;">– Leaders have to direct
and inspire the overall system, and stimulate and coordinate the other Risk
Control Factors.<span> </span>Leaders must communicate
the vision and personify the narrative.<span>
</span>In practice, they need to focus on asking the right questions and sense
the context of a given situation, embracing the new before necessity is
evident. (See our <a href="https://www.safetymattersblog.com/2018/11/nuclear-safety-culture-lessons-from.html" target="_blank">Nov. 9, 2018</a> post for an example of effective leadership.)</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Solutions</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The Solutions are strategies or methods to identify
weaknesses in and strengthen the risk control factors.<span> </span>In McChrystal’s view, each Solution is particularly
applicable to certain factors, as shown in Table 1.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><a name="OLE_LINK1"><i><span style="line-height: 115%;">Assumptions
check</span></i></a><span><span style="line-height: 115%;"> –
Assessment of the reasonableness and relative importance of assumptions that
underlie decisions. <span> </span>It’s the qualitative
and quantitative analyses of strengths and weaknesses of supporting arguments,
modified by the judgment of thoughtful people. </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Risk
review</span></i></span><span><span style="line-height: 115%;"> –
Assessment of when hazards may arrive and the adequacy of the organization’s preparations.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Risk
alignment check</span></i></span><span><span style="line-height: 115%;"> –
Leaders should recognize that different perspectives on risks exist and should
be considered in the overall response.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Gap
analysis</span></i></span><span><span style="line-height: 115%;"> –
Identify the space between current actions and desired goals.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Snap
assessment</span></i></span><span><span style="line-height: 115%;"> –
Short-term, limited scope analyses of immediate hazards. What’s happening?<span> </span>How well are we responding? </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Communications
check</span></i></span><span><span style="line-height: 115%;"> –
Ensure processes and physical systems are in place and working.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Tabletop
exercise</span></i></span><span><span style="line-height: 115%;"> –
A limited duration simulation that tests specific aspects of the organization’s
risk response.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">War
game (functional exercise)</span></i></span><span><span style="line-height: 115%;"> –
A pressure test in real time to show how the organization comprehensively reacts
to a competitor’s action or unforeseen event.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Red
teaming</span></i></span><span><span style="line-height: 115%;"> –
Exercises involving third parties to identify organizational vulnerabilities
and blind spots.</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">Pre-mortem</span></i></span><span><span style="line-height: 115%;"> – A discussion focusing on the things mostly
likely to go wrong during the execution of a plan.<span> </span></span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><i><span style="line-height: 115%;">After-action
review</span></i></span><span><span style="line-height: 115%;"> –
A self-assessment that identifies things that went well and areas for
improvement.</span></span></span></span></p><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span><span style="line-height: 115%;"><br /> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="page-break-after: avoid;"><span style="font-size: medium;"><span style="font-family: verdana;"><span><span>
</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoCaption"><span style="font-size: medium;"><span style="font-family: verdana;"><span><span style="color: windowtext;"><img alt="" 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/> <br /></span></span></span></span></p><p class="MsoCaption"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span><span style="color: windowtext;">Table
</span></span><span><span style="color: windowtext;"><span>1</span></span></span></b><span><span style="color: windowtext;"><span> </span></span></span><span style="font-size: small;"><span><span style="color: windowtext; font-weight: normal;">Created by
Safetymatters</span></span></span><span><span style="color: windowtext;"></span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
<span></span>
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;"></span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;"> </span></b></span></span></p><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Our
Perspective</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">McChrystal did not invent any of his Risk Control
Factors and we have discussed many of these topics over the years.***<span> </span>His value-add is organizing them as a system
and recognizing their interrelatedness.<span>
</span>The entire system has to perform to identify, prepare for, and respond
to risks, i.e., threats that can jeopardize the organization’s mission success.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">This review emphasizes McChrystal’s overall risk
management model.<span> </span>The book also includes
many examples of risks confronted, ignored, or misunderstood in the military,
government, and commercial arenas.<span> </span>Some,
like Blockbuster’s failure to acquire Netflix when it had the opportunity, had
poor outcomes; others, like the Cuban missile crisis or Apollo 13, worked out
better.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The book appears aimed at senior leaders but all
managers from department heads on up can benefit from thinking more
systematically about how their organizations respond to threats from, or
changes in, the external environment.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">There are hundreds of endnotes to document the text but
the references are more Psychology Today than the primary sources we favor.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Bottom line: This is an easy to read example of the
“management cookbook” genre.<span> </span>It has a
lot of familiar information in one place.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"> </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">*<span> </span>S. McChrystal
and A. Butrico, <b>Risk: A User’s Guide</b>
(New York: Portfolio) 2021.<span> </span>Butrico is
McChrystal’s speechwriter.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">**<span> </span>Risk to
McChrystal is a combination of a <i>threat</i>
and one’s <i>vulnerability</i> to the
threat.<span> </span>Threats are usually external to
the organization while vulnerabilities exist because of internal aspects. </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">***<span> </span>For example,
click on the Management or Decision Making labels to pull up posts in related
areas.</span></span></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-20731571549623791272021-07-01T13:26:00.005-07:002021-07-02T20:36:26.363-07:00Making Better Decisions: Lessons from Noise by Daniel Kahneman, Oliver Sibony, and Cass R. Sunstein<p class="MsoNormal"><span style="font-size: small;"><span style="font-family: verdana;"></span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsnirhQPqkp0vgh_pxL7ZB7ZDthUsVfERMk9h1PLW0dYJXF_llyQLqsW63a3bEg-6PtREJH0FWlTPk-7UwU-lNgCbPtdi5WjQ5sSTHFZaBZPNC-oXWyBXRL9LCtBYBu7NXThv4TTlJvkLI/s729/Kahneman+Noise.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="729" data-original-width="474" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsnirhQPqkp0vgh_pxL7ZB7ZDthUsVfERMk9h1PLW0dYJXF_llyQLqsW63a3bEg-6PtREJH0FWlTPk-7UwU-lNgCbPtdi5WjQ5sSTHFZaBZPNC-oXWyBXRL9LCtBYBu7NXThv4TTlJvkLI/s320/Kahneman+Noise.jpg" /></a></span></div><span style="font-size: small;"><br /></span><!--[if gte mso 9]><xml>
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</xml><![endif]--><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The authors of <b>Noise:
A Flaw in Human Judgment*</b> examine the random variations that occur in
judgmental decisions and recommend ways to make more consistent judgments.<span> </span>Variability is observed when two or more
qualified decision makers review the same data or face the same situation and
come to different judgments or conclusions.<span>
</span>(Variability can also occur when the <i>same</i>
decision maker revisits a previous decision situation and arrives at a <i>different</i> judgment.)<span> </span>The decision makers may be doctors making
diagnoses, engineers designing structures, judges sentencing convicted
criminals, or any other situation involving professional judgment.**<span> </span>Judgments can vary because of two factors:
bias and noise.</span></span></span><p></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Bias</span></i><span style="line-height: 115%;">
is systematic, a consistent source of error in judgments.<span> </span>It creates an observable average difference
between actual judgments and theoretical judgments that would reflect a
system’s actual or espoused goals and values.<span>
</span>Bias may be exhibited by an individual or a group, e.g., when the criminal
justice system treats members of a certain race or class differently from
others.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Noise</span></i><span style="line-height: 115%;">
is random scatter, a separate, independent cause of variability in decisions
involving judgment.<span> </span>It is similar to the
residual error in a statistical equation, i.e., noise may have a zero average (because
higher judgments are balanced by lower ones) but noise can create large
variability in individual judgments.<span> </span>Such
inconsistency damages the credibility of the system.<span> </span>Noise has three components: level, pattern,
and occasion.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Level</span></i><span style="line-height: 115%;">
refers to the difference in the average judgment made by different individuals,
e.g., a magistrate may be tough or lenient.<span>
</span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Pattern</span></i><span style="line-height: 115%;">
refers to the idiosyncrasies of individual judges, e.g., one magistrate may be
severe with drunk drivers but easy on minor traffic offenses.<span> </span>These idiosyncrasies include the internal
values, principles, memories, and rules a judge brings to every case,
consciously or not.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Occasion</span></i><span style="line-height: 115%;">
refers to a random instability, e.g., where a fingerprint examiner looking at
the same prints finds a match one day and no match on another day. <span> </span>Occasion noise can be influenced by many
factors including a judge’s mood, fatigue, and recent experience with other
cases.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Based on a review of the available literature and their
own research, the authors suggest that noise can be a larger contributor to
judgment variability than bias, with stable pattern noise larger than level
noise or occasion noise.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Ways
to reduce noise</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Noise can be reduced through interventions at the
individual or group level.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">For the individual, interventions include training to
help people who make judgments realize how different psychological biases can
influence decision making.<span> </span>The long list
of psychological biases in <b>Noise</b>
builds on Kahneman’s work in <b>Thinking,
Fast and Slow</b> which <a href="https://www.safetymattersblog.com/2013/12/thinking-fast-and-slow-by-daniel.html" target="_blank">we reviewed on Dec. 18, 2013</a>.<span> </span>Such biases include <i>overconfidence</i>; <i>denial of
ignorance</i>, which means not acknowledging that important relevant data isn’t
known; <i>base rate neglect</i>, where
outcomes in other similar cases are ignored; <i>availability</i>, which means the first solutions that come to mind are
favored, with no further analysis; and <i>anchoring</i>
of subsequent values to an initial offer.<span>
</span>Noise reduction techniques include <i>active
open-mindedness</i>, which is the<i> </i>search
for information that contradicts one’s initial hypothesis, or positing <i>alternative interpretations</i> of the
available evidence; and the use of <i>rankings</i>
and <i>anchored scales</i> rather than
individual ratings based on vague, open-ended criteria. <span> </span><i>Shared
professional norms</i> can also contribute to more consistent judgments.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">At the group level, noise can be reduced through
techniques the authors call decision hygiene.<span>
</span>The underlying belief is that obtaining multiple, independent judgments
can increase accuracy, i.e., lead to an answer that is closer to the true or
best answer.<span> </span>For example, a complicated
decision can be broken down into multiple dimensions, and each dimension
assessed individually and independently.<span>
</span>Group members share their judgments for each dimension, then discus
them, and only then combine their findings (and their intuition) into a final
decision. <span> </span>Trained decision observers can
be used to watch for signs that familiar biases are affecting someone’s decisions
or group dynamics involving position, power, politics, ambition and the like
are contaminating the decision process and negating actual independence.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Noise can also be reduced or eliminated by the use of
rules, guidelines, or standards.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Rules</span></i><span style="line-height: 115%;">
are inflexible, thus noiseless.<span> </span>However,
rules (or algorithms) may also have biases coded into them or only apply to
their original data set.<span> </span>They may also drive
discretion underground, e.g., where decision makers game the process to obtain
the results they prefer.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Guidelines</span></i><span style="line-height: 115%;">,
such as sentencing guidelines for convicted criminals or templates for
diagnosing common health problems, are less rigid but still reduce noise.<span> </span>Guidelines decompose complex decisions into
easier sub-judgments on predefined dimensions.<span>
</span>However, judges and doctors push back against mandatory guidelines that
reduce their ability to deal with the unique factors of individual cases before
them.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Standards</span></i><span style="line-height: 115%;"> are
the least rigid noise reduction technique; they delegate power to professionals
and are inherently qualitative.<span>
</span>Standards generally require that professionals make decisions that are
“reasonable” or “prudent” or “feasible.”<span>
</span>They are related to the shared professional norms previously
mentioned.<span> </span>Judgments based on standards
can invite controversy, disagreement, confrontation, and lawsuits.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The authors recognize that in some areas, it is
infeasible, too costly, or even undesirable to eliminate noise.<span> </span>One particular fear is a noise-free system
might freeze existing values.<span> </span>Rules and
guidelines need to be flexible to adapt to changing social values or new data. </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Our
Perspective</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">We have long promoted the view that decision making
(the process) and decisions (the artifacts) are crucial components of a
socio-technical system, and have a significant two-way influence relationship
with the organization’s culture.<span>
</span>Decision making should be guided by an organization’s policies and
priorities, and the process should be robust, i.e., different decision makers should
arrive at acceptably similar decisions.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Many organizations examine (and excoriate) bad
decisions and the “bad apples” who made them.<span>
</span>Organizations also need to look at “good” decisions to appreciate how
much their professionals disagree when making generally acceptable
judgments.<span> </span>Does the process for making
judgments develop the answer best supported by the facts, and then adjust it
for preferences (e.g., cost) and values (e.g., safety), or do the fingers of
the judges go on the scale at earlier steps?</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">You may be surprised at the amount of noise in your
organization’s professional judgments.<span>
</span>On the other hand, is your organization’s decision making too rigid in
some areas?<span> </span>Decisions made using rules can
be quicker and cheaper than prolonged analysis, but may lead to costly errors. which
approach has a higher cost for errors?<span> </span>Operators
(or nurses or whoever) may follow the rules punctiliously but sometimes the train
may go off the tracks.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Bottom line:<span> </span>This is an important book that provides a powerful mental model for
considering the many factors that influence individual professional judgments.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"><br /></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">*<span> </span>D. Kahneman,
O. Sibony, and C.R. Sunstein, <b>Noise: A
Flaw in Human Judgment</b> (New York: Little, Brown Spark) 2021.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">**<span> </span>“Professional
judgment” implies some uncertainty about the answer, and judges may disagree,
but there is a limit on how much disagreement is tolerable.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal"><span style="font-size: small;"><span style="font-family: verdana;"><span style="line-height: 115%;"><br /></span></span></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-88147638551001221922021-05-21T11:32:00.021-07:002021-05-22T14:33:15.481-07:00Healthcare Safety Culture and Interventions to Reduce Preventable Medical Errors<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSgWz00Osr7os0PblaDbeEa5dMlmbajLYdplHGVDo-dfkMv4mSj0ubejo080PR_jDqaLvK9C8mnDaVfzjHonWqcnoTq6yMKpsSWe5QbERtLY6Hba6pncIRp0kJw6NPZYRLHkRbHvynclj_/s596/HSS+OIG+PSO+report+Sep+2019.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="596" data-original-width="570" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSgWz00Osr7os0PblaDbeEa5dMlmbajLYdplHGVDo-dfkMv4mSj0ubejo080PR_jDqaLvK9C8mnDaVfzjHonWqcnoTq6yMKpsSWe5QbERtLY6Hba6pncIRp0kJw6NPZYRLHkRbHvynclj_/w191-h200/HSS+OIG+PSO+report+Sep+2019.jpg" width="191" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">HSS OIG report cover<br /></td></tr></tbody></table><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">We
have previously written about the shocking number of preventable errors in
healthcare settings that result in injury or death to patients.<span> </span>We have also discussed the importance of a
strong safety culture (SC) in reducing healthcare error rates.<span> </span>However, after 20 years of efforts, the
needle has not significantly moved on overall injuries and deaths.<span> </span>This post reviews healthcare’s concept of SC
and research that ties SC to patient outcomes.<span>
</span>We offer our view on why interventions have not been more effective.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Healthcare’s Model of Safety Culture</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;"></span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Healthcare
has a model for SC, shown in the SC primer on the Agency for Healthcare
Research and Quality’s (AHRQ) Patient Safety Network <a href="https://psnet.ahrq.gov/primer/culture-safety#" target="_blank">website</a>.*<span> </span>The model contains these key cultural
features:</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><ul style="text-align: left;"><li><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"><span><span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="line-height: 115%;">acknowledgment of the high-risk nature of an
organization's activities and the determination to achieve consistently safe
operations</span></span></span></li><li><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"><span><span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="line-height: 115%;">a blame-free environment** where
individuals are able to report errors or near misses without fear of reprimand
or punishment</span></span></span></li><li><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"><span><span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="line-height: 115%;">encouragement of collaboration across ranks
and disciplines to seek solutions to patient safety problems</span></span></span></li><li><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"><span><span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="line-height: 115%;">organizational commitment of resources to
address safety concerns.</span></span></span></li></ul><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">We
will critique this model later.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"></span>
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Healthcare Providers Believe Safety
Culture is Important</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"></span>
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">A U.S.
Department of Health and Human Services (HSS) <a href="https://www.oig.hhs.gov/oei/reports/oei-01-17-00420.pdf" target="_blank">report</a>*** affirms healthcare
providers’ belief that SC is important and can contribute to fewer errors and
improved patient outcomes.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">AHRQ
administers the Patient Safety Organization (PSO) program which gathers data on
patient safety events from healthcare providers.<span> </span>In 2019, the HSS Office of Inspector General surveyed
hospitals and PSOs to identify the PSO program’s value and challenges.<span> </span>SC was one topic covered in the survey and
the results confirm SC’s importance to providers.<span> </span>“Among hospitals that work with PSOs, 80
percent find that feedback and analysis on patient safety events have helped
prevent future events, and 72 percent find that such feedback has helped them
understand the causes of events.” (p. 10)<span>
</span>Furthermore, “Nearly all (95 percent) hospitals that work with a PSO
found that their PSOs have helped improve the culture of safety at their
facilities.<span> </span>A culture of safety is one
that enables individuals to report errors without fear of reprimand and to
collaborate on solutions.” (p. 11)<span> </span></span><b><span style="line-height: 115%;"> <br /></span></b></span></span></p><p><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Healthcare Research Connects SC to Interventions
to Reduced Errors</span></b><span style="line-height: 115%;"></span></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">AHRQ
publishes the “Making Healthcare Safer” series of reports, which represent
summaries of important research on selected patient safety practices (PSPs).<span> </span>The most recent <a href="https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/making-healthcare-safer-III.pdf" target="_blank">(2020) edition</a>**** recognizes
SC as a cross-cutting practice, i.e., SC impacts the effectiveness of many
specific PSPs.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The
section on cross-cutting practices begins by noting that healthcare is trying
to learn from the experience of high reliability organizations (HROs).<span> </span>HROs have many safety-enhancing attributes
included committed leaders, a SC where staff identify and correct all deviations
that could lead to unsafe conditions, an environment where adverse events or
near misses are reported without fear of blame or recrimination, and practices
to identify a problem’s scope, root causes, and appropriate solutions. (p.
17-1)</span><span style="line-height: 115%;"> </span></span></span></p><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The
report identified several categories of practices that are used to improve healthcare
SC: Leadership WalkRounds, Team Training, Comprehensive Unit-based Safety
Programs (CUSP), and interventions that implemented multiple methods. (p.
17-13)</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">WalkRounds</span></i><span style="line-height: 115%;"> “involves
leaders “walking around” to engage in face to face,</span></span></span><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"> candid
discussions with frontline staff about patient safety incidents or near-misses.”
(p. 17-16)<span> </span>“<i>Team training</i> programs focus on enhancing teamwork skills and
communication between healthcare providers . . .” (p. 17-17)<span> </span><i>CUSP</i>
is a multi-step program to assess, intervene in, and reassess a healthcare
unit’s SC. (p. 17-19)</span></span></span><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span></p><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The
report also covers 17 specific areas where harm/errors can occur and highlights
SC aspects associated with two such areas: developing rapid response teams and
dealing with alarm fatigue in hospitals.</span><span style="line-height: 115%;"> </span></span></span></p><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Rapid response teams</span></i><span style="line-height: 115%;">
(RRTs) treat deteriorating hospital patients before adverse events occur. (p.
2-1)<span> </span>Weak SC and healthcare hierarchies
are barriers to successful implementation of RRTs. (p. 2-10)</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Alarm fatigue</span></i><span style="line-height: 115%;">
occurs because of high exposure to medical device alarms, many of which are
loud or false alarms, that lead to desensitization, missed alarms or delayed
responses. (p. 13-1)<span> </span>The cultural
aspects of interventions focused on all staff members (not just nurses)
assuming responsibility for addressing alarms. (p. 13-6)</span><span style="line-height: 115%;"> </span></span></span></p><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><b><span style="line-height: 115%;">Our Perspective</span></b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">We
have three problems with healthcare’s efforts to reduce harm to patients: (1) the
quasi-official healthcare mental model of safety culture is incomplete, (2) healthcare’s
assumption that it can model itself on HROs ignores a critical systemic
difference, and (3) an inadequate overall system model leads to fragmented,
incremental improvement projects.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">An inadequate model for SC</span></i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Healthcare
does not have an adequate understanding of the necessary attributes of a strong
SC. <span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The
features listed in the introduction of this post are necessary but not sufficient
for a strong SC.<span> </span>SC is more than good
communications; it is part of the overall cultural system.<span> </span>This system has <i>feedback loops</i> that can reinforce or extinguish attitudes and
behaviors.<span> </span>The <i>attitudes</i> of people in the system are heavily influenced by their <i>trust</i> in management to do the right
thing.<span> </span><i>Management’s behavior</i> is influenced by their goals, policy
constraints, environmental pressures, and incentives, including monetary
compensation.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Top-to-bottom
<i>decision making</i> in the system needs
to be consistent, which means processes, priorities, practices, and rules should
be defined and followed.<span> </span><i>Goal conflicts</i> must be consistently
handled.<span> </span>Decision makers must be
identified to allow <i>accountability</i>.<span> </span><i>Problems</i>
must be identified (without retribution except for cause), analyzed, and
permanently fixed.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Lack
of attention to the missing attributes is one reason that healthcare SC has
been slow to strengthen and unfavorable patient outcomes are still at
unacceptable levels.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Healthcare is not a traditional HRO</span></i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">The
healthcare system looks to HROs for inspiration on SC but does not recognize one
significant difference between a traditional HRO and healthcare.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">When
we consider other HROs, e.g., nuclear power plants, off-shore drilling
operations, or commercial aviation, we understand that they have significant interactions
with their respective environments, e.g., regulators, politicians, inspectors, suppliers,
customers, activists, etc.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Healthcare
is different because its customers are basically the feedstock for the
“factory” and healthcare has to accept those inputs “as is”; in other words, unlike
a nuclear power plant, healthcare cannot define and enforce a set of
specifications for its inputs.<span> </span>The
inputs (patients) arrive in a wide range of “as is” conditions, from simple
injuries to multiple, interacting ailments.<span>
</span>The healthcare system has to accomplish two equally important
objectives: (1) correctly identify a patient’s problem(s) and (2) fix them in a
robust, cost-effective manner.<span> </span>SC in the
first phase should focus on obtaining the <i>correct
diagnosis</i>; SC in the second phase should focus on performing the prescribed
corrective actions according to approved procedures, and ensuring that <i>expected results</i> occur.<span> </span></span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i><span style="line-height: 115%;">Inadequate models lead to piecemeal
interventions<span> </span><span> </span></span></i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Healthcare’s
simplistic mental model for SC is part of an inaccurate mental model for the overall
system.<span> </span>The current system model is
fragmented and leads researchers and practitioners to think small (on silos) when
they could be thinking big (on the enterprise).<span>
</span>An SC intervention that focuses on tightening process controls in one
small area cannot move the needle on system-wide SC or overall patient
outcomes.<span> </span>For more on systems models,
systemic challenges, and narrow interventions, see our <a href="https://www.safetymattersblog.com/2019/10/more-on-mental-models-in-healthcare.html" target="_blank">Oct. 9, 2019</a> and <a href="https://www.safetymattersblog.com/2020/11/setting-bar-for-healthcare-patient-care.html" target="_blank">Nov. 9,2020</a> posts.<span> </span>Click on the healthcare
label below to see all of the related posts. </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">Bottom
line: Healthcare SC can have a direct impact on the probabilities that specific
harms will occur, and their severity if they do but accurate models of culture are essential. </span></span></span></p><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;"> </span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span class="js-about-item-abstr"><span style="line-height: 115%;">*<span> </span>Agency
for Healthcare Research and Quality, </span></span><span style="line-height: 115%;">“<a href="https://psnet.ahrq.gov/primer/culture-safety#" target="_blank">Culture of Safety</a>” (Sept.
2019).<span> </span>Accessed May 4, 2021.<span> </span>AHRQ <span class="js-about-item-abstr">is an
organization within the U.S. Department of Health and Human Services.<span> </span>Its mission includes </span>producing
evidence to make health care safer.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">**<span> </span>The “blame-free” environment has evolved into
a “just culture” where human errors, especially those caused by the task system
context, are tolerated but taking shortcuts and reckless behavior are
disciplined.<span> </span>Click on the just culture
label for related posts.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">***<span> </span>U.S. Dept. of Health and Human Services
Office of Inspector General, “<a href="https://www.oig.hhs.gov/oei/reports/oei-01-17-00420.pdf" target="_blank">Patient Safety Organizations: Hospital Participation, Value, and Challenges</a>,” OEI-01-17-00420, Sept. 2019.</span></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p class="MsoNormal" style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><span style="line-height: 115%;">****<span> </span>K.K. Hall et al, “<a href="https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/making-healthcare-safer-III.pdf" target="_blank">Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices</a>,”
AHRQ Pub. No. 20-0029-EF.<span> </span>(Rockville,
MD: AHRQ) March 2020.<span> </span>This is a 1400
page report so we are only reporting relevant highlights.</span></span></span></p>
<br />Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-50792065638840598892021-02-02T09:54:00.000-08:002021-02-02T09:54:06.804-08:00Organizational Change and System Dynamics Insights from The Tipping Point by Malcolm Gladwell<span style="font-family: verdana;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiJAxlN0s-4sgC2UM7-rFr5Rzw-pc1RX3nVyYY3m0cQsjJltiOlaX5_QVJr1rCdpYTjaiy27nNtF2M8iu6djzrghvbkIDL4t8_RRvu9zqExqLD4w7Y_lE6frSIo6cPzu7dxnzMHz6ChzTs/s520/Gladwell+tipping+point.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="520" data-original-width="342" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiJAxlN0s-4sgC2UM7-rFr5Rzw-pc1RX3nVyYY3m0cQsjJltiOlaX5_QVJr1rCdpYTjaiy27nNtF2M8iu6djzrghvbkIDL4t8_RRvu9zqExqLD4w7Y_lE6frSIo6cPzu7dxnzMHz6ChzTs/w131-h200/Gladwell+tipping+point.jpg" width="131" /></a></div><br />The
Tipping Point*</span></b><span style="font-size: 12pt; line-height: 115%;"> is a 2002 book by Malcolm Gladwell (who
also wrote <b style="mso-bidi-font-weight: normal;">Blink</b>) that uses the
metaphor of a viral epidemic to explain how some phenomenon, e.g., a product**,
an idea, or a social norm, can suddenly reach a critical mass and propagate rapidly
through society.<span style="mso-spacerun: yes;"> </span>Following is a summary
of his key concepts.<span style="mso-spacerun: yes;"> </span>Some of his ideas
can inform strategies for implementing organizational change, especially
cultural change, and reflect attributes of system dynamics that we have
promoted on Safetymatters.</span>
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">In brief, epidemics spread when they have the right sort
of people to transmit the infectious agent, the agent itself has an attribute
of stickiness, and the environment supports the agent and facilitates
transmission.<span style="mso-spacerun: yes;"> </span></span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 115%;">People</span></i></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">An epidemic thrives on three different types of people:
people who connect with lots of other people, people who learn about a new
product or idea and are driven to tell others, and persuasive people who sell
the idea to others.<span style="mso-spacerun: yes;"> </span>All these messengers
drive contagiousness although all three types are not required for every kind
of epidemic.</span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 115%;">Stickiness</span></i></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">A virus needs to attach itself to a host; a new product
promotion needs to be memorable, i.e., stick in people’s minds and spur them to
action, for example Wendy’s “Where’s the beef?” campaign or the old “Winston
tastes good . . .” jingle.<span style="mso-spacerun: yes;"> </span>Information about
the new product or idea needs to be packaged in a way that makes it attractive
and difficult to resist. </span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 115%;">Context</span></i></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">General and specific environmental characteristics can
encourage or discourage the spread of a phenomenon.<span style="mso-spacerun: yes;"> </span>For a general example in the social
environment consider the Broken Windows theory which holds that intolerance of
the smallest infractions can lead to overall reductions in crime rates.<span style="mso-spacerun: yes;"></span><span style="mso-spacerun: yes;"></span></span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">At the more specific level, humans possess a set of
tendencies that can be affected by the particular circumstances of their immediate
environment.<span style="mso-spacerun: yes;"> </span>For example, we are more
likely to comply with someone in a uniform (a doctor, say, or a police officer)
than a scruffy person in jeans.<span style="mso-spacerun: yes;"> </span>If
people believe there are many witnesses to a crime, it’s less likely that
anyone will try to stop or report the criminal activity; individual
responsibility is diffused to the point of inaction.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;">Our
Perspective</span></b></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">We will expand some of Gladwell’s notions to emphasize
how they can be applied to create organizational changes, including cultural
change.<span style="mso-spacerun: yes;"> </span>In addition, we’ll discuss how
the dynamics he describes square with some aspects of system dynamics we have
promoted on Safetymatters.</span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 115%;">Organizational
change</span></i></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">Small close-knit groups have the potential to magnify
the epidemic potential of a message or idea. <span style="mso-spacerun: yes;"> </span>“Close-knit” means people know each other well
and even store information with specific individuals (the subject matter
experts) to create a kind of overall group memory.<span style="mso-spacerun: yes;"> </span>These bonds of memory and peer pressure can
facilitate the movement of new ideas into and around the group, affecting the
group’s shared mental models of everything from the immediate task environment
to the larger outside world.<span style="mso-spacerun: yes;"> </span>Many small
movements can create larger movements that manifest as new or modified group
norms.</span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">In a product market, diffusion moves from innovators to
early adopters to the majority and finally the laggards.<span style="mso-spacerun: yes;"> </span>A similar model of diffusion can be applied
in a formal organization.<span style="mso-spacerun: yes;"> </span>Organizational
managers trying to implement cultural changes should consider this diffusion
model when they are deciding who to appoint to initiate, promote, and
promulgate new or different cultural values or behaviors.<span style="mso-spacerun: yes;"> </span>Ideally, they should start with
well-connected, respected people who buy into the new attributes, can explain
them to others, and influence others to try the new behaviors. </span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 115%;">System
dynamics</span></i></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">This whole book is about how intrusions can disrupt an
existing social system, for good or bad, and result in epidemic, i.e.,
nonlinear effects.<span style="mso-spacerun: yes;"> </span>This nonlinearity helps
explain why systems can be operating more or less normally then suddenly veer
into failure.<span style="mso-spacerun: yes;"> </span>Active management
deliberately tries to create such changes to veer into success.<span style="mso-spacerun: yes;"> </span>Just think about how social media has upset
the loci of power in our society: elected leaders and experts now have larger
megaphones but so does the mob.<span style="mso-spacerun: yes;"> </span></span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">That said, Gladwell presents a linear, cause-and-effect
model for change.<span style="mso-spacerun: yes;"> </span>He does not consider
more complex system features such as feedback loops or deliberate attempts to modify,
deflect, co-opt or counteract the novel input.<span style="mso-spacerun: yes;">
</span>For example, a manager can try to establish new behaviors by creating a
reinforcing loop of rewards and recognition in a small group, and then recreating
it on an ever-larger scale.</span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">Bottom line: This is easy reading with lots of interesting
case studies and quotes from talking head PhDs.<span style="mso-spacerun: yes;">
</span>The book comes across as a long magazine article.<span style="mso-spacerun: yes;"> </span></span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;"> </span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">*<span style="mso-spacerun: yes;"> </span>M Gladwell, <b style="mso-bidi-font-weight: normal;">The Tipping Point</b> (New York: Back Bay
Books/Little, Brown and Co.) 2000 and 2002.</span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-size: 12pt; line-height: 115%;">**<span style="mso-spacerun: yes;"> </span>“Product” is
used in its broadest sense; it can mean something physical like a washing
machine, a political campaign, a celebrity wannabe, etc.</span></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-15068758398390748522020-12-14T14:17:00.000-08:002020-12-14T14:17:24.576-08:00Implications of Randomness: Lessons from Nassim Taleb<p style="margin-bottom: 0in;"><span style="font-size: medium;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEieh0Z6pxsW11_Fdcn3SPTwGIqWIXmD0V6dy8C9IwTXuRhEQaw5Pg92_JpGEAl0WWSzrBaNUr-nOfUjA0mO481FUkOjiTRbd5GQN_JrPVDZA8B5XQVtetQmONXULpACj1eLQmwqylUoib_w/s720/Taleb+fooled+by+randomness.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="720" data-original-width="489" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEieh0Z6pxsW11_Fdcn3SPTwGIqWIXmD0V6dy8C9IwTXuRhEQaw5Pg92_JpGEAl0WWSzrBaNUr-nOfUjA0mO481FUkOjiTRbd5GQN_JrPVDZA8B5XQVtetQmONXULpACj1eLQmwqylUoib_w/w136-h200/Taleb+fooled+by+randomness.jpg" width="136" /></a></span></div><span style="font-size: medium;"><span style="font-family: verdana;">Most
of us know Nassim Nicholas Taleb from his bestseller <b>The Black
Swan</b>. However, he wrote an earlier book, <b>Fooled by
Randomness</b><span style="font-weight: normal;">*</span>, in which he
laid out one of his seminal propositions: a lot of things in life
that we believe have identifiable, deterministic causes such as
prescient decision making or exceptional skills, are actually the
result of more random processes. Taleb focuses on financial markets
but we believe his observations can refine our thinking about
organizational decision making, mental models, and culture. </span></span>
<p></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">We'll
begin with an example of how Taleb believes we misperceive reality.
Consider a group of stockbrokers with successful 5-year track
records. Most of us will assume they must be unusually skilled.
However, we fail to consider how many other people started out as
stockbrokers 5 years ago and fell by the wayside because of poor
performance. Even if <i>all</i> the stockbrokers were less skilled
than a simple coin flipper, some would still be successful over a 5
year period. The survivors are the result of an essentially random
process and their track records mean very little going forward.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Taleb
ascribes our failure to correctly see things (our inadequate mental
models) to several biases. First is the <i>hindsight</i> bias where
the past is always seen as deterministic and feeds our willingness to
backfit theories or models to experience after it occurs. Causality
can be very complex but we prefer to simplify it. Second, because of
<i>survivorship</i> bias, we see and consider only the current
survivors from an initial cohort; the losers do not show up in our
assessment of the probability of success going forward. Our
<i>attribution</i> bias tells us that successes are due to skills,
and failures to randomness. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Taleb
describes other factors that prevent us from being the rational
thinkers postulated by classical economics or Cartesian philosophy.
One set of factors arises from how are brains are hardwired and
another set from the way we incorrectly process data presented to us.
</span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">The
brain wiring issues include the work of Daniel Kahneman who describes
how we use and rely on heuristics (mental shortcuts that we invoke
automatically) to make day-to-day decisions. Thus, we make many
decisions without really thinking or applying reason, and we are
subject to other built-in biases, including our overconfidence in
small samples and the role of emotions in driving our decisions. We
reviewed Kahneman's work at length in <a href="https://www.safetymattersblog.com/2013/12/thinking-fast-and-slow-by-daniel.html" target="_blank">our Dec. 18, 2013 post</a>. Taleb
notes that we also have a hard time recognizing and dealing with
risk. Risk detection and risk avoidance are mediated in the
emotional part of the brain, not the thinking part, so rational
thinking has little to do with risk avoidance.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">We
also make errors when handling data in a more formal setting. For
example, we ignore the mathematical truth that initial sample sizes
matter greatly, much more than the sample size as a percentage of the
overall population. We also ignore regression to the mean, which
says that absent systemic changes, performance will eventually return
to its average value. More perniciously, ignorant or unethical
researchers will direct their computers to look for <i>any</i>
significant relationship in a data set, a practice that can often
produce a spurious relationship because all the individual tests have
their own error rates. “Data snoops” will define some rule, then
go looking for data that supports it. Why are researchers inclined
to fudge their analyses? Because research with no significant result
does not get published. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><b>Our
Perspective</b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">We'll
start with the obvious: Taleb has a large ego and is not shy about
calling out people with whom he disagrees or does not respect. That
said, his observations have useful implications for how we
conceptualize the socio-technical systems in which we operate, i.e.,
our mental models, and present specific challenges for the culture of
our organizations.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">In our
view, the three driving functions for any system's performance over
time are determinism (cause and effect), choice (decision making),
and probability. At heart, Taleb's world view is that the world
functions more <em><span style="font-style: normal;">probabilistically
</span></em>than most people
realize. A method he employs to illustrate alternative futures is
Monte Carlo simulation, which we used to forecast nuclear power plant
performance back in the 1990s. We wanted plant operators to see that
certain low-probability events, i.e., Black Swans**, could occur in
spite of the best efforts to eliminate them via plant design,
improved equipment and procedures, and other means. Some unfortunate
outcomes could occur because they were baked into the system from the
get-go and eventually manifested. This is what Charles Perrow meant
by “normal accidents” where normal system performance excursions
go beyond system boundaries. For more on Perrow, see <a href="https://www.safetymattersblog.com/2013/08/normal-accidents-by-charles-perrow.html" target="_blank">our Aug. 29,2013 post</a>.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Of
course, the probability distribution of system performance may not be
stationary over time. In the most extreme case, when all system
attributes change, it's called regime change. In addition, system
performance may be nonlinear, where small inputs may lead to a
disproportionate response, or poor performance can build slowly and
suddenly cascade into failure. For some systems, no matter how
specifically they are described, there will inherently be some
possibility of errors, e.g., consider healthcare tests and diagnoses
where both false positives and false negatives can be non-trivial
occurrences. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">What
does this mean for organizational culture? For starters, the
organization must acknowledge that many of its members are inherently
somewhat irrational. It can try to force greater rationality on its
members through policies, procedures, and practices, instilled by
training and enforced by supervision, but there will always be leaks.
A better approach would be to develop defense in depth designs,
error-tolerant sub-systems with error correction capabilities, and a
“just culture” that recognizes that honest mistakes will occur. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Bottom
line: You should think awhile about how many aspects of your work
environment have probabilistic attributes. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"> </span></span></p><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">*
N.N. Taleb, <b>Fooled by Randomness</b>, 2<sup>nd</sup> ed. (New
York: Random House) 2004. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;">
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">**
Black swans are not always bad. For example, an actor can have one
breakthrough role that leads to fame and fortune; far more actors
will always be waiting tables and parking cars.</span></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-30907448113937662832020-11-09T11:26:00.000-08:002020-11-09T11:26:50.848-08:00Setting the Bar for Healthcare: Patient Care Goals from the Joint Commission<p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left;"><tbody><tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-U5mK67HfhuI/X6mWYnQI_hI/AAAAAAAADyg/D44_SNag6Q0l5-1OJUx6dLbtnpA26FOCgCNcBGAsYHQ/s800/Joint%2BCommission%2BHQ.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="600" data-original-width="800" height="150" src="https://1.bp.blogspot.com/-U5mK67HfhuI/X6mWYnQI_hI/AAAAAAAADyg/D44_SNag6Q0l5-1OJUx6dLbtnpA26FOCgCNcBGAsYHQ/w200-h150/Joint%2BCommission%2BHQ.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Joint Commission HQ<br /></td></tr></tbody></table>The
need for a more effective safety culture (SC) in the field of
healthcare is acute: every year tens of thousands of patients are
injured or unnecessarily die while in U.S. hospitals. The scope of
the problem became widely known known with the publication<span style="font-weight: normal;">
of “<a href="https://www.nap.edu/catalog/9728/to-err-is-human-building-a-safer-health-system" target="_blank">To Err is Human: Building a Safer Health System</a>”* in 2000.
This report included two key observations: (1) the cause of the
injuries and deaths is not </span>bad
people in health care, rather the people are working in bad systems
that need to be made safer and (2) legitimate liability concerns
discourage the reporting of errors, which means less feedback to the
system and less learning from mistakes.</span></span><p></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">It's
20 years later. Is the healthcare system safer than it was in 2000?
Yes. Is safety performance at a satisfactory level? No. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">For
evidence, we need look no further than a <a href="https://www.jointcommission.org/resources/news-and-multimedia/blogs/high-reliability-healthcare/2019/11/to-err-is-human-the-next-20-years/" target="_blank">Nov. 18, 2019 blog post** byDr. Mark Chassin</a>, president and CEO of the Joint Commission (JC), the
entity responsible for establishing standards for healthcare
functions and patient care, and evaluating, accrediting, and
certifying healthcare organizations based on their compliance with
the standards. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Dr.
Chassin summarized the current situation as follows: “The health
care industry has directed a substantial amount of time, effort, and
resources at solving the problems, and we have seen some progress.
That progress has typically occurred one project at a time, with
hard-working quality professionals applying a “one-size-fits-all”
best practice to address each problem. The resulting improvements
have been pretty modest, difficult to sustain, and even more
difficult to spread.” </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Going
forward, he says the industry can make substantial progress by
committing to zero harm, overhauling the organizational culture, and
utilizing proven process improvement techniques. He singles out the
aviation and nuclear power industries for having similar commitments.
</span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">But
achieving substantial, sustained improvement is a big lift. To get a
feel for how big, let's look at the <a href="https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/simplified_2020-hap-npsgs-eff-july-final.pdf" target="_blank">2020 goals and strategies</a> the JC
has established for patient care in hospitals, in other words, where
the performance bar is set today.*** We will try to inform your own
judgment about their scope and sufficiency by comparing them with
corresponding activities in the nuclear power industry. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i>1.
Identify patients correctly by using at least two ways to identify
them. <br /></i><br />This is a
major challenge in a hospital where many patients are entering and
leaving the system every day, being transferred to and from different
departments, and being treated by multiple individuals who have
different roles and ranks, and are treating patients at different
levels of intensity for different periods of time. There is really
no analogue in the closed, controlled personnel environment of a
power plant.<br /><br /><i>2.
Improve staff communication by getting important test results to the
right staff person on time.</i>
<br /></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">This
should be a familiar challenge to people in any organization,
including a power plant, where functions may exist in different
organizational silos with their own procedures, vocabulary, and
priorities.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i>3.
Use medicines safely by labeling medicines that are not labeled,
taking extra care with patients on blood thinners, and managing
patients' medicine records for accuracy, completeness, and possible
interactions. </i><br /><br />This
is similar to requirements to accurately label, control, and manage
the use of all chemicals used in an industrial facility. <br /></span></span> <span style="font-size: medium;"><span style="font-family: verdana;"><br /><i>4.
Use alarms safely by ensuring that alarms on medical equipment are
heard and responded to on time.</i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">In a
hospital, it is a problem when multiple alarms are going off at the
same time, with differing degrees of urgency for personnel attention
and response. In power plants, operators have been known to turn off
alarms that are reporting too many false positives. These situations
call out for operating and maintenance standards and practices that
ensure all activated alarms are valid and deserving of a response.
<br /><br /><i>5. Prevent
infection by adhering to Centers for Disease Control or World Health
Organization hand cleaning guidelines.</i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">The
aim is to keep bad bugs from circulating. Compare this prctice to
the myriad procedures, personnel, and equipment dedicated to ensuring
nuclear power plant radioactivity is kept in an identified,
controlled, and secure environment. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i>6.
Identify patient safety risks by reducing the risk for suicide.</i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Compare
this with the wellness, fitness for duty, and behavioral observation
programs at every nuclear power plant. <br /><br /><i>7.
Prevent mistakes in surgery by making sure that the correct surgery
is done on the correct patient and at the correct place on the
patient’s body, and pausing before the surgery to make sure that a
mistake is not being made.</i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">This
is similar to tailgate meetings before maintenance activities and
using the STAR (Stop-Think-Act-Review) approach before and during
work. Think of the potential for error in mirror-image plants;
people are bi-lateral but subject to the similar risks.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><b>Our
Perspective</b></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">The
JC's set of goals is thin gruel to show after 20 years. In our view,
efforts to date reflect two major shortcomings: a lack of progress in
defining and strengthening SC, and a lack of any shared
understanding of what the relevant system consists of, how it
functions, and how to improve it. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i>Safety
Culture</i> <br /></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Our
<a href="https://www.safetymattersblog.com/2020/07/culture-in-healthcare-lessons-from-when.html" target="_blank">July 31, 2020 post on <b>When
We Do Harm</b> by Dr.
Danielle Ofri</a> discussed the key attributes for a strong healthcare
SC, i.e., one where the probability of errors is much lower than it
is today. In Ofri's view, the
primary cultural attribute for reducing errors is a willingness of
individuals to assume ownership and get the necessary things done,
even if it's not in their specific job description, amid a diffusion
of responsibility in their task environment. Secondly, all members
of the organization, regardless of status, should have the ability
(or duty even) to point out problems and errors without fear of
retribution. The culture should regard reporting an adverse event as
a routine and ordinary task. Third, organizational leaders,
including but not limited to senior managers, must
encourage criticism, forbid scapegoating, and not allow hierarchy and
egos to overrule what is right and true. There should be deference
to proven expertise and widely held authority to say “stop” when
problems become apparent. </span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><i>The
Healthcare System</i></span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">The
healthcare system includes the providers, the supporting
infrastructure, external environmental factors, e.g., regulators and
insurance companies, the patients and their families, and all the
interrelationships
and dynamics between
these components.
An important dynamic is feedback, where the quality and quantity of
output from one component influences performance in other system
components. System dynamics create homeostasis, fluctuations, and
all levels of performance
from superior to failure. Other organizational variables, e.g.,
management decision-making practices and priorities, and the
compensation scheme, provide context for system functioning. For
more on system attributes, please see our <a href="https://www.safetymattersblog.com/2019/10/more-on-mental-models-in-healthcare.html" target="_blank">Oct.9, 2019 post</a> or click
the healthcare label.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">Bottom
line: Compare the JC's efforts with the vast array of safety and
SC-related policies, procedures, practices, activities, and dedicated
personnel in your workplace. Healthcare has a long way to go.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"><br /></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;"></span></span><span style="font-size: medium;"><span style="font-family: verdana;">*
Institute of Medicine (L.T. Kohn et al), “<a href="https://www.nap.edu/catalog/9728/to-err-is-human-building-a-safer-health-system" target="_blank">To Err Is Human: Building a Safer Health System</a>” (Washington, D.C.: The National Academies
Press) 2000. Retrieved Nov. 5, 2020.</span></span><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">** M.
Chassin, “<a href="https://www.jointcommission.org/resources/news-and-multimedia/blogs/high-reliability-healthcare/2019/11/to-err-is-human-the-next-20-years/" target="_blank">To Err is Human: The Next 20 Years</a>,” blog post (Nov.
18, 2019). Retrieved Nov. 1, 2020.</span></span></p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;"></span></span>
</p><span style="font-size: medium;"><span style="font-family: verdana;">
</span></span><p style="margin-bottom: 0in;"><span style="font-size: medium;"><span style="font-family: verdana;">***
The Joint Commission, “<a href="https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/simplified_2020-hap-npsgs-eff-july-final.pdf" target="_blank">2020Hospital National Patient Safety Goals</a>,” simplified
version (July, 2020). Retrieved Nov. 1, 2020.</span></span><span face="Verdana, sans-serif">
</span>
</p>
<p style="margin-bottom: 0in;"><br />
</p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-45681918656143640942020-08-25T12:59:00.004-07:002020-11-03T09:28:30.102-08:00How to Consider Unknown Unknowns: Hints from McKinsey<span style="font-size: small;"><span style="font-family: verdana;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJNyxQwD-c2TdqCNxce7ClGHXedjzzwAhWLVH3YJZNVU_bPgB8_VV6MlQjrJkaYspSwFxE45StXFnmZoN8j6rZ2I0oCTlmaxPEcur1VdMOtO3Y2OtWrSBP0iEg7T_8TNYaWa4ToMVs0L7M/s150/McKinsey+quarterly+cover.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="84" data-original-width="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJNyxQwD-c2TdqCNxce7ClGHXedjzzwAhWLVH3YJZNVU_bPgB8_VV6MlQjrJkaYspSwFxE45StXFnmZoN8j6rZ2I0oCTlmaxPEcur1VdMOtO3Y2OtWrSBP0iEg7T_8TNYaWa4ToMVs0L7M/s0/McKinsey+quarterly+cover.jpg" /></a></div><span style="font-size: medium;">Our <a href="https://www.safetymattersblog.com/2020/07/culture-in-healthcare-lessons-from-when.html" target="_blank">July 31, 2020 post on medical errors</a> discussed the importance of the “differential diagnosis” where a doctor thinks “I believe this patient has X but what else could it be?” We can usually consider that as a decision situation with known unknowns, i.e., looking for another needle in a haystack based on the available evidence. But what if you don’t know what you don’t know? How do you create other possibilities, threats or opportunities, or different futures out of thin air? A 2015 McKinsey <a href="https://www.mckinsey.com/business-functions/strategy-and-corporate-finance/our-insights/delighting-in-the-possible?cid=other-eml-cls-mip-mck&hlkid=80fd2500a99d4c0dac506babd9c3593e&hctky=2961276&hdpid=4ff741b8-74a8-4601-a191-6e33c4b990a2#" target="_blank">article</a>* provides some suggestions for getting started. There is nothing really new but it reiterates some important points we have been making here on Safetymatters. <br /><br /> The authors begin by noting executives’ decision making processes often coalesce around “managing the probable,” i.e., attempting to fit a current decision into a model that has worked before. The questions they ask and the data they seek tend to narrow, not expand, the decision and its context. This is an efficient way to approach many everyday decisions but excessively simple models are not appropriate for complicated decisions like how to approach a changing market or define a market that does not yet exist. All models constrain the eventual solution and simple models constrain it the most, perhaps leading to a totally wrong answer. <br /><br /> Decision situations that are dramatically different, complex, and uncertain require a more open-ended approach, the authors call it “leading the possible.” In such situations, decision makers should acknowledge they don’t know how uncertain environmental conditions will unfold or complex systems will evolve. The authors propose three non-traditional mental habits to identify and explore the possibilities. <br /><br /> <i>Ask different questions</i> <br /><br /> Ask questions that open up possibilities rather than narrowing the discussion and constraining the solution. Sample questions include: What do I expect not to find? How could I adjust to the unexpected? What might I be discounting or explaining away too quickly? What would happen if I changed one or more of my core assumptions? We would add: Is fear of missing out prodding me to move too rashly or complacency allowing me to not move at all? <br /><br /> As Hans Rosling said: “Beware of simple ideas and simple solutions. . . . Welcome complexity.” (see our <a href="https://www.safetymattersblog.com/2018/12/nuclear-safety-culture-lessons-from.html" target="_blank">Dec. 3, 2018 post</a>) <br /><br /> <i>Take multiple perspectives <br /></i><br /> Decision makers, especially senior managers, need to escape the echo chamber of the sycophants who surround them. They should consider how people who are very different from themselves might view the same decision situation. They can consult people who are knowledgeable but frustrating or irritating, or outside their usual internal circle such as junior staff, or even dissatisfied customers. Such perspectives can be insightful and surprising. <br /><br /> Other thought leaders have suggested similar approaches. For example, Ray Dalio proposes <i>thoughtful disagreement</i> where decision makers seek out brilliant people who disagree with them to gain a deeper understanding of decision situations (see our <a href="https://www.safetymattersblog.com/2018/04/nuclear-safety-culture-insights-from.html" target="_blank">April 17, 2018 post</a>) or Charlan Nemeth on the usefulness of <i>authentic dissent</i> in decision situations (see our <a href="https://www.safetymattersblog.com/2020/06/a-culture-that-supports-dissent-lessons.html" target="_blank">June 29, 2020 post</a>). <br /><br /> <i>Recognize systems <br /></i><br /> The authors’ appreciation for systems thinking mirrors what we’ve been saying for years. (For example, see our <a href="https://www.safetymattersblog.com/2017/01/reflections-on-nuclear-safety-culture.html" target="_blank">Jan. 6, 2017 post</a>.) Decision makers should be looking at the evolution of the forest, not examining individual trees. We need to acknowledge and accept that “Elements in a system can be connected in ways that are not immediately apparent.” The widest view is the most powerful but people have “been trained to follow our natural inclination to examine the component parts. We assume a straightforward and linear connection between cause and effect. Finally, we look for root causes at the center of problems. In doing these things, we often fail to perceive the broader forces at work.” <br /><br /> <br />The authors realize that leaders who can apply the new habits may have different attributes than earlier senior managers. Traditional leaders are clear, confident, and decisive. However, their preference for managing the probable leaves them more open to being blindsided. In contrast, new leaders need to exhibit “humility, a keen sense of their own limitations, an insatiable curiosity, and an orientation to learning and development.” <br /><br /> <b>Our Perspective <br /></b><br /> This article promotes more expansive mental models for decision making in formal organizations, models that deemphasize reliance on reductionism and linear, cause-effect thinking. We applaud the authors’ intent. <br /><br /> McKinsey is pretty good at publishing small bite “news you can use” articles. However, they do not contain any of the secret sauce for which McKinsey charges its clients top dollar. <br /><br /> Bottom line: Some of you don’t want to read 300 page books on management so here’s an 8 page article with a few good points. <br /><br /> <br />* Z. Achi and J.G. Berger, “<a href="https://www.mckinsey.com/business-functions/strategy-and-corporate-finance/our-insights/delighting-in-the-possible?cid=other-eml-cls-mip-mck&hlkid=80fd2500a99d4c0dac506babd9c3593e&hctky=2961276&hdpid=4ff741b8-74a8-4601-a191-6e33c4b990a2#" target="_blank">Delighting in the Possible</a>,” McKinsey Quarterly (March 2015).</span></span></span> Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-58323810217662068072020-07-31T10:13:00.006-07:002020-08-23T16:20:44.382-07:00Culture in Healthcare: Lessons from When We Do Harm by Danielle Ofri, MD<p class="MsoNormal"><font size="3"><span face="" style="font-family: "verdana";"></span></font></p><div class="separator" style="clear: both; text-align: center;"><font size="3"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA-cfgTKtXK6YVIxr53HTDlaqFF5W2Y-XaPNZ9rBRBHJhnp8rqQYpqbhnFJpZAf6grRvgC4NOKZh-nyz-iWI-0ykaiugqK6yDUeJ10zQJdz7kMBF4n2bca7nxr3fBhv1ETj4TOd5fctKTJ/s248/Ofri+Harm.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="248" data-original-width="180" height="198" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA-cfgTKtXK6YVIxr53HTDlaqFF5W2Y-XaPNZ9rBRBHJhnp8rqQYpqbhnFJpZAf6grRvgC4NOKZh-nyz-iWI-0ykaiugqK6yDUeJ10zQJdz7kMBF4n2bca7nxr3fBhv1ETj4TOd5fctKTJ/w144-h198/Ofri+Harm.jpg" width="144" /></a></font></div><span style="font-family: verdana;"><font size="3">In her book*, Dr. Ofri takes a hard look at the prevalence
of medical errors in the healthcare system.<span>
</span>She reports some familiar statistics** and fixes, but also includes
highly detailed case studies where errors large and small cascaded over time and
the patients died.<span> </span>This post summarizes
her main observations.<span> </span>She does not
provide a tight summary of a less error-prone healthcare culture but she drops
enough crumbs that we can infer its desirable attributes.
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><b>Healthcare is
provided by a system </b></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">The system includes the providers, the supporting
infrastructure, and factors in the external environment. <span> </span>Ofri observes that medical care is exceedingly
complicated and some errors are inevitable. <span> </span>Because errors are inevitable, the system
should emphasize error recognition and faster recovery with a goal of harm
reduction.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">She shares our view that the <i>system</i> permits errors to occur so fixes should focus on the system and
not on the <i>individual</i> who made an
error.***<span> </span>System failures will
eventually trap the most conscientious provider. <span> </span>She opines that most medical errors are the
result of a cascade of actions that compound one another; we would say the
system is tightly coupled.</font></span></p><span style="font-family: verdana;"><font size="3">System “improvements” intended to increase efficiency can actually
reduce effectiveness.<span> </span>For example,
electronic medical records can end up dictating providers’ practices,
fragmenting thoughts and interfering with the flow of information between
doctor and patient.****<span> </span>Data field
defaults and copy and paste shortcuts can create new kinds of errors.<span> </span>Diagnosis codes driven by insurance company billing
requirements can distort the diagnostic process.<span> </span>In short, patient care becomes subservient to
documentation.
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Other changes can have unforeseen consequences.<span> </span>For example, scheduling fewer working hours
for interns leads to fewer diagnostic and medication errors but also results in
more patient handoffs (where half of adverse medical events are rooted.)<span> </span><span> </span></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><b>Aviation-inspired
checklists have limited applicability</b></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Checklists have reduced error rates for certain procedures
but can lead to unintended consequences, e.g., mindless check-off of the items
(to achieve 100% completion in the limited time available) and provider focus
on the checklist while ignoring other things that are going on, including
emergent issues.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Ofri thinks the parallels between healthcare and aviation
are limited because of the complexity of human physiology.<span> </span>While checklists may be helpful for <i>procedures</i>, doctors ascribe limited
value to <i>process</i> checklists that
guide their thinking.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><b>Malpractice suits do
not meaningfully reduce the medical error rate</b></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Doctors fear malpractice suits so they practice defensive
medicine, prescribing extra tests and treatments which have their own risks of
injury and false positives, and lead to extra cost.<span> </span>Medical equipment manufacturers also fear lawsuits
so they design machines that sound alarms for all matters great and small;
alarms are so numerous they are often simply ignored by the staff.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Hospital management culture is concerned about protecting
the hospital’s financial interests against threats, including lawsuits.<span> </span>A Cone of Silence is dropped over anything
that could be considered an error and no information is released to the public,
including family members of the injured or dead patient.<span> </span>As a consequence, it is estimated that fewer
than 10% of medical errors ever come to light. <span> </span>There is no national incident reporting system
because of the resistance of providers, hospitals, and trial lawyers. </font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">The reality is a malpractice suit is not practical in the
vast majority of cases of possible medical error.<span> </span>The bar is very high: <i>your</i> doctor must have provided <i>sub-standard</i>
care that <i>caused</i> your injury/death
and resulted in <i>quantifiable</i> damages.
<span> </span>Cases are very expensive and
time-consuming to prepare and the legal system, like the medical system, is
guided by money so an acceptable risk-reward ratio has to be there for the
lawyers.*****<span> </span></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><b>Desirable cultural
attributes for reducing medical errors</b></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">In Ofri’s view, culture includes hierarchy, communications
skill, training traditions, work ethic, egos, socialization, and professional
ideals.<span> </span>The primary cultural attribute
for reducing errors is a willingness of individuals to assume ownership and get
the necessary things done amid a diffusion of responsibility.<span> </span>This must be taught by example and
individuals must demand comparable behavior from their colleagues. </font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><i>Providing medical care
is a team business</i></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Effective collaboration among team members is key, as is the
ability (or duty even) of lower-status members to point out problems and errors
without fear of retribution.<span> </span>Leaders
must encourage criticism, forbid scapegoating, and not allow hierarchy and egos
to overrule what is right and true.<span> </span>Where
practical, training should be performed in groups who actually work together to
build communication skills.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><i>Doctors and nurses
need time and space to think</i></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Doctors need the time to develop differential diagnosis, to
ask and answer “What else could it be?”<span> </span>The
provider’s thought process is the source of most diagnostic error, and subject
to explicit and implicit biases, emotions, and distraction.<span> </span>However, stopping to think can cause delays
which can be reported as shortcomings by the tracking system. <span> </span>The culture must acknowledge uncertainty (fueled
by false positives and negatives), address overconfidence, and promote
feedback, especially from patients.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><i>Errors and near misses
need to be reported without liability or shame.</i></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">The culture should regard reporting an adverse event as a
routine and ordinary task.<span> </span>This is a big
lift for people steeped in the hierarchy of healthcare and the impunity of its
highest ranked members.<span> </span>Another factor
to be overcome is the reluctance of doctors to report errors because of their
feelings of personal and professional shame.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Ofri speaks favorably of a “just culture” that recognizes
that unintentional error is possible, but risky behavior like taking shortcuts
requires (system) intervention, and negligence should be disciplined.<span> </span>In addition, there should not be any bias in
how penalties are handed out, e.g., based on status. </font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">In sum, Ofri says healthcare will always be an imperfect
system.<span> </span>Ultimately, what patients want
is acknowledgement of errors and apology for them from doctors.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><b>Our Perspective</b></font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Ofri’s major contribution is her review of the evidence
showing how pervasive medical errors are and how the healthcare industry works
overtime to deny and avoid responsibility for them.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Her suggestions for a safer healthcare culture echo what
we’ve been saying for years about the attributes of a strong safety
culture.<span> </span>Reducing the error rates will
be hard for many reasons.<span> </span>For example,
Ofri observes medical training forges a lifelong personal identity and
reverence for tradition; in our view, it also builds in resistance to change.<span> </span>The biases in decision making that she
mentions are not trivial.<span> </span>For one
discussion of such biases, see our <a href="https://www.safetymattersblog.com/2013/12/thinking-fast-and-slow-by-daniel.html" target="_blank">Dec. 18, 2013 review of Daniel Kahneman’swork</a>.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">Bottom line: After you read this, you will be clutching your
rosary a little tighter if you have to go to a hospital for a major injury or illness.<span> </span>You are more responsible for your own care
than you think. </font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3"><br /></font></span></p><span style="font-family: verdana;"><font size="3">*<span> </span>D. Ofri, <b>When We Do Harm</b> (Boston: Beacon Press,
2020).
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">**<span> </span>For example, a
study reporting that almost 4% of hospitalizations resulted in medical injury,
of which 14% were fatal, and doctors’ diagnostic accuracy is estimated to be in
the range of 90%.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">***<span> </span>It has been
suggested that the term “error” be replaced with “adverse medical event” to
reduce the implicit focus on individuals.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">****<span> </span>Ofri believes
genuine conversation with a patient is the doctor’s single most important
diagnostic tool.</font></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"></span></p><span style="font-family: verdana;"><font size="3">
</font></span><p class="MsoNormal"><span style="font-family: verdana;"><font size="3">***** As an example of the power of money, when Medicare
started fining hospitals for shortcomings, the hospitals started cleaning up
their problems.</font></span></p>
Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-27282519674773039482020-06-29T08:56:00.004-07:002020-08-02T20:24:05.430-07:00A Culture that Supports Dissent: Lessons from In Defense of Troublemakers by Charlan Nemeth<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-6hhshQxlaZk/XvoMbFrzubI/AAAAAAAADs0/nFqhXyvevbAndkGyv-WOs_fUjYSBKgLugCNcBGAsYHQ/s1600/Nemeth%2BTroublemakers.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="720" data-original-width="474" height="200" src="https://1.bp.blogspot.com/-6hhshQxlaZk/XvoMbFrzubI/AAAAAAAADs0/nFqhXyvevbAndkGyv-WOs_fUjYSBKgLugCNcBGAsYHQ/s200/Nemeth%2BTroublemakers.jpg" width="131" /></a></div>
<font size="3"><span style="font-family: verdana;"><span>Charlan Nemeth is a psychology professor at the University of California, Berkeley. Her research and practical experience inform her conclusion that the presence of authentic dissent during the decision making process leads to better informed and more creative decisions. This post presents highlights from her 2018 book* and provides our perspective on her views.<br /><br /><b>Going along to get along</b><br /><br />Most people are inclined to go along with the majority in a decision making situation, even when they believe the majority is wrong. Why? Because the majority has power and status, most organizational cultures value consensus and cohesion, and most people want to avoid conflict. (179) <br /><br />An organization’s leader(s) may create a culture of agreement but consensus, aka the tyranny of the majority, gives the culture its power over members. People consider decisions from the perspective of the consensus, and they seek and analyze information selectively to support the majority opinion. The overall effect is sub-optimal decision making; following the majority requires no independent information gathering, no creativity, and no real thinking. (36,81,87-88) <br /><br />Truth matters less than group cohesion. People will shape and distort reality to support the consensus—they are complicit in their own brainwashing. They will willingly “unknow” their beliefs, i.e., deny something they know to be true, to go along. They live in information bubbles that reinforce the consensus, and are less likely to pay attention to other information or a different problem that may arise. To get along, most employees don’t speak up when they see problems. (32,42,98,198)<br /><br />“Groupthink” is an extreme form of consensus, enabled by a norm of cohesion, a strong leader, situational stress, and no real expectation that a better idea than the leader’s is possible. The group dynamic creates a feedback loop where people repeat and reinforce the information they have in common, leading to more extreme views and eventually the impetus to take action. Nemeth’s illustrative example is the decision by President John Kennedy and his advisors to authorize the disastrous Bay of Pigs invasion.** (140-142)<br /><br /><b>Dissent adds value to the decision making process</b><br /><br />Dissent breaks the blind following of the majority and stimulates thought that is more independent and divergent, i.e., creates more alternatives and considers facts on all sides of the issue. Importantly, the decision making process is improved even when the dissenter is wrong because it increases the group’s chances of identifying correct solutions. (7-8,12,18,116,180) <br /><br />Dissent takes courage but can be contagious; a single dissenter can encourage others to speak up. Anonymous dissent can help protect the dissenter from the group. (37,47) <br /><br />Dissent must be <i>authentic</i>, i.e., it must reflect the true beliefs of the dissenter. To persuade others, the dissenter must remain consistent in his position. He can only change because of new or changing information. Only authentic, persistent dissent will force others to confront the possibility that they may be wrong. At the end of the day, getting a deal may require the dissenter to compromise, but changing the minds of others requires consistency. (58,63-64,67,115,190)<br /><br /><b>Alternatives to dissent</b><br /><br />Other, less antagonistic, approaches to improving decision making have been promoted. Nemeth finds them lacking.<br /><br /><i>Training</i> is the go to solution in many organizations but is not very effective in addressing biases or getting people to speak up to realities of power and hierarchies. Dissent is superior to training because it prompts reconsidering positions and contemplating alternatives. (101,107)<br /><br />Classical <i>brainstorming</i> incorporates several rules for generating ideas, including withholding criticism of ideas that have been put forth. However, Nemeth found in her research that allowing (but not mandating) criticism led to more ideas being generated. In her view, it’s the “combat between different positions that provides the benefits to decision making.” (131,136) <br /><br /><i>Demographic diversity</i> is promoted as a way to get more input into decisions. But demographics such as race or gender are not as helpful as diversity of skills, knowledge, and backgrounds (and a willingness to speak up), along with leaders who genuinely welcome different viewpoints. (173,175,200)<br /><br />The <i>devil’s advocate</i> approach can be better than nothing, but it generally leads to considering the negatives of the original position, i.e., the group focuses on better defenses for that position rather than alternatives to it. Group members believe the approach is fake or acting (even when the advocate really believes it) so it doesn’t promote alternative thinking or force participants to confront the possibility that they may be wrong. The approach is contrived to stimulate divergent thinking but it actually creates an illusion that all sides have been considered while preserving group cohesion. (182-190,203-04)<br /><br /><b>Dissent is not free for the individual or the group</b><br /><br />Dissenters are disliked, ridiculed, punished, or worse. Dissent definitely increases conflict and sometimes lowers morale in the group. It requires a culture where people feel safe in expressing dissent, and it’s even better if dissent is welcomed. The culture should expect that everyone will be treated with respect. (197-98,209)<br /><br /><b>Our Perspective</b><br /><br />We have long argued that leaders should get the most qualified people, regardless of rank or role, to participate in decision making and that alternative positions should be encouraged and considered. Nemeth’s work strengthens and extends our belief in the value of different views. <br /><br />If dissent is perceived as an honest effort to attain the truth of a situation, it should be encouraged by management and tolerated, if not embraced, by peers. Dissent may dissuade the group from linear cause-effect, path of least resistance thinking. We see a similar practice in Ray Dalio’s concepts of an idea meritocracy and radical open-mindedness, described in our <a href="https://www.safetymattersblog.com/2018/04/nuclear-safety-culture-insights-from.html" target="_blank">April 17, 2018 review of his book <b>Principles</b></a>. In Dalio’s firm, employees are expected to engage in lively debate, intellectual combat even, over key decisions. His people have an obligation to speak up if they disagree. Not everyone can do this; a third of Dalio’s new hires are gone within eighteen months.<br /><br />On the other hand, if dissent is perceived as self-serving or tattling, then the group will reject it like a foreign virus. Let’s face it: nobody likes a rat.<br /><br />We agree with Nemeth’s observation that training is not likely to improve the quality of an organization’s decision making. Training can give people skills or techniques for better decision making but training does not address the underlying values that steer group decision making dynamics. <br /><br />Much academic research of this sort is done using students as test subjects.*** They are readily available, willing to participate, and follow directions. Some folks think the results don’t apply to older adults in formal organizations. We disagree. It’s easier to form stranger groups with students who don’t have to worry about power and personal relationships than people in work situations; underlying psychological mechanisms can be clearly and cleanly exposed. <br /><br />Bottom line: This is a lucid book written for popular consumption, not an academic journal, and is worth a read.<i> </i></span><br />
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<span><i>(Give me the liberty to know, to utter, and to argue freely according to conscience. — John Milton)</i><br /><br /><br />* C. Nemeth, <b>In Defense of Troublemakers</b> (New York: Basic Books, 2018).<br /><br />** Kennedy learned from the Bay of Pigs fiasco. He used a much more open and inclusive decision making process during the Cuban Missile Crisis.<br /><br />*** For example, Daniel Kahneman’s research reported in <b>Thinking, Fast and Slow</b>, which we <a href="https://www.safetymattersblog.com/2013/12/thinking-fast-and-slow-by-daniel.html" target="_blank">reviewed Dec. 18, 2013</a>.</span></span></font>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-87264217397934314252020-06-15T11:37:00.003-07:002020-08-02T20:25:11.594-07:00IAEA Working Paper on Safety Culture Traits and Attributes<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh10fMkJB42-KM3s1xesKLkmbrsL3ATSoncHLbEzNAH-cfFJp_rSTVKHUh-mSPtVaI1oR3EBiyy3egKRH-geXsRT1576691YJJW8THQaB51IhvGD4Lj8FHbNkFIGOhkDld9SefMTNLxPRHB/s1600/IAEA+harmonized+SC+model+May+2020.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="552" data-original-width="447" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh10fMkJB42-KM3s1xesKLkmbrsL3ATSoncHLbEzNAH-cfFJp_rSTVKHUh-mSPtVaI1oR3EBiyy3egKRH-geXsRT1576691YJJW8THQaB51IhvGD4Lj8FHbNkFIGOhkDld9SefMTNLxPRHB/s200/IAEA+harmonized+SC+model+May+2020.jpg" width="161" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small;">Working paper cover</span></td></tr>
</tbody></table>
<font size="3"><span><span style="font-family: "verdana", sans-serif;">The International Atomic Energy Agency (IAEA) has released a <a href="https://www.iaea.org/sites/default/files/20/05/harmonization_05_05_2020-final_002.pdf" target="_blank">working paper</a>* that attempts to integrate (“harmonize”) the efforts by several different entities** to identify and describe desirable safety culture (SC) traits and attributes. The authors have also tried to make the language of SC less nuclear power specific, i.e., more general and thus helpful to other fields that deal with ionizing radiation, such as healthcare. Below we list the 10 traits and highlight the associated attributes that we believe are most vital for a strong SC. We also offer our suggestions for enhancing the attributes to broaden and strengthen the associated trait’s presence in the organization.<br /><br /><i>Individual Responsibility</i> </span></span><br />
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<span><span style="font-family: "verdana", sans-serif;">All individuals associated with an organization know and adhere to its standards and expectations. Individuals promote safe behaviors in all situations, collaborate with other individuals and groups to ensure safety, and “accept the value of diverse thinking in optimizing safety.”<br /><br />We applaud the positive mention of “diverse thinking.” We also believe each individual should have the <i>duty</i> to report unsafe situations or behavior to the appropriate authority and this duty should be specified in the attributes.<br /><br /><i>Questioning Attitude</i> </span></span><br />
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<span><span style="font-family: "verdana", sans-serif;">Individuals watch for anomalies, conditions, behaviors or activities that can adversely impact safety. They stop when they are uncertain and get advice or help. They try to avoid complacency. “They understand that the technologies are complex and may fail in unforeseen ways . . .” and speak up when they believe something is incorrect.<br /><br />Acknowledging that technology may “fail in unforeseen ways” is important. Probabilistic Risk Assessments and similar analyses do not identify all the possible ways bad things can happen. <br /><br /><i>Communication</i><br /><br />Individuals communicate openly and candidly throughout the organization. Communication with external organizations and the public is accurate. The reasons for decisions are communicated. The expectation that safety is emphasized over competing goals is regularly reinforced. <br /><br /><i>Leader Responsibility</i><br /><br />Leaders place safety above competing goals, model desired safety behaviors, frequently visit work areas, involve individuals at all levels in identifying and resolving issues, and ensure that resources are available and adequate. <br /><br />“Leaders ensure rewards and sanctions encourage attitudes and behaviors that promote safety.” An organization’s reward system is a hot button issue for us. Previous SC framework documents have never addressed management compensation and this one doesn’t either. If SC and safety performance are important then people from top executives to individual workers should be rewarded (by which we mean paid money) for doing it well.<br /><br />Leaders should also address work backlogs. Backlogs send a signal to the organization that sub-optimal conditions are tolerated and, if such conditions continue long enough, are implicitly acceptable. Backlogs encourage workarounds and lack of attention to detail, which will eventually create challenges to the safety management system. <br /><br /><i>Decision-Making</i><br /><br />“Individuals use a consistent, systematic approach to evaluate relevant factors, including risk, when making decisions.” Organizations develop the ability to adapt in anticipation of unforeseen situations where no procedure or plan applies.<br /><br />We believe the decision making process should be robust, i.e., different individuals or groups facing the same issue should come up with the same or an equally effective solution. The organization’s approach to decision making (goals, priorities, steps, etc.) should be documented to the extent practical. Robustness and transparency support efficient, effective communication of the reasons for decisions. <br /><br /><i>Work Environment</i> </span></span><br />
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<span><span style="font-family: "verdana", sans-serif;">“Trust and respect permeate the organization. . . . Differing opinions are encouraged, discussed, and thoughtfully considered.”<br /><br />In addition, senior managers need to be trusted to tell the truth, do the right things, and not sacrifice subordinates to evade the managers’ own responsibilities.<br /><br /><i>Continuous Learning</i> </span></span><br />
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<span><span style="font-family: "verdana", sans-serif;">The organization uses multiple approaches to learn including independent and self-assessments, lessons learned from their own experience, and benchmarking other organizations. <br /><br /><i>Problem Identification and Resolution</i><br /><br />“Issues are thoroughly evaluated to determine underlying causes and whether the issue exists in other areas. . . . The effectiveness of the actions is assessed to ensure issues are adequately addressed. . . . Issues are analysed to identify possible patterns and trends. A broad range of information is evaluated to obtain a holistic view of causes and results.”<br /><br />This is good but could be stronger. Leaders should ensure the most knowledgeable individuals, regardless of their role or rank, are involved in addressing an issue. Problem solvers should think about the systemic relationships of issues, e.g., is an issue caused by activity in or feedback from some other sub-system, the result of a built-in time delay, or performance drift that exceeded the system’s capacities? Will the proposed fix permanently address the issue or is it just a band-aid? <br /><br /><i>Raising Concerns</i><br /><br />The organization encourages personnel to raise safety concerns and does not tolerate harassment, intimidation, retaliation or discrimination for raising safety concerns. <br /><br />This is the essence of a Safety Conscious Work Environment and is <i>sine qua non</i> for any high hazard undertaking.<br /><br /><i>Work Planning</i> </span></span><br />
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<span><span style="font-family: "verdana", sans-serif;">“Work is planned and conducted such that safety margins are preserved.”<br /><br /><b>Our Perspective</b><br /><br />We have never been shy about criticizing IAEA for some of its feckless efforts to get out in front of the SC parade and pretend to be the drum major.*** However, in this case the agency has been content, so far, to build on the work of others. It’s difficult for any organization to develop, implement, and maintain a strong, robust SC and the existence of many different SC guidebooks has never been helpful. This is one step in the right direction. We’d like to see other high hazard industries, in particular healthcare organizations such as hospitals, take to heart SC lessons learned from the nuclear industry.<br /><br />Bottom line: This concise paper is worth checking out. <br /><br /><br />* IAEA Working Document, “<a href="https://www.iaea.org/sites/default/files/20/05/harmonization_05_05_2020-final_002.pdf" target="_blank">A Harmonized Safety Culture Model</a>” (May 5, 2020). This document is not an official IAEA publication.<br /><br />** Including IAEA, WANO, INPO, and government institutions from the United States, Japan, and Finland.<br /><br />*** See, for example, our <a href="https://www.safetymattersblog.com/2016/08/nuclear-safety-culture-self-assessment.html" target="_blank">August 1, 2016 post</a> on IAEA’s document describing how to perform safety culture self-assessments. Click on the IAEA label to see all posts related to IAEA.</span></span></font>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-20584076576693720792019-12-19T09:52:00.004-08:002020-08-02T20:27:36.144-07:00Requiescat in pace – Bob Cudlin<!--[if gte mso 9]><xml>
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<![endif]--><font size="3"><span style="font-family: verdana;"><span>Robert L. Cudlin passed away on Nov. 23, 2019. Bob was a co-founder of Safetymatters and a life-long contributor to the nuclear industry. He started at the Nuclear Regulatory Commission where he was a member of the NRC response team at Three Mile Island after the 1979 accident. He later worked on Capitol Hill as the nuclear safety expert for a Senate committee. He spent the bulk of his career consulting to nuclear plant owners, board members, and senior managers. His consulting practice focused on helping clients improve their plants’ safety and reliability performance. Bob was a systems thinker who was constantly looking for new insights into organizational performance and evolution. He will be missed.</span></span></font> Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-33515649031179300392019-11-06T11:24:00.003-08:002020-08-02T20:28:09.494-07:00National Academies of Sciences, Engineering, and Medicine Systems Model of Medical Clinician Burnout, Including Culture Aspects<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-5YKApAkR_ws/XcMcPVYxhcI/AAAAAAAADmw/H-HbC5VQFJEAt_5W2et9IU9u-5KwgiTygCNcBGAsYHQ/s1600/Doctor%2Bburnout.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1413" data-original-width="1539" height="183" src="https://1.bp.blogspot.com/-5YKApAkR_ws/XcMcPVYxhcI/AAAAAAAADmw/H-HbC5VQFJEAt_5W2et9IU9u-5KwgiTygCNcBGAsYHQ/s200/Doctor%2Bburnout.jpg" width="200" /></a></td></tr>
<tr align="right"><td class="tr-caption"><i><span style="font-size: x-small;">Source: Medical Academic S. Africa</span></i></td></tr>
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<font size="3"><span><span style="font-family: "verdana", sans-serif;">We have been posting about preventable harm to health care patients, emphasizing how improved organizational mental models and attention to cultural attributes might reduce the incidence of such harm. A new National Academies of Sciences, Engineering, and Medicine (NASEM) <a href="https://doi.org/10.17226/25521" target="_blank">committee report</a>* looks at one likely contributor to the patient harm problem: <i>clinician burnout</i>.** The NASEM committee purports to use a systems model to analyze burnout and develop strategies for reducing burnout while fostering professional well-being and enhancing patient care. This post summarizes the 300+ page report and offers our perspective on it.<br /><br /><i>The Burnout Problem and the Systems Model</i> </span></span><br />
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<span><span style="font-family: "verdana", sans-serif;">Clinician burnout is caused by stressors in the work environment; burnout can lead to behavioral and health issues for clinicians, clinicians prematurely leaving the healthcare field, and poorer treatment and outcomes for patients. This widespread problem requires a “systemic approach to burnout that focuses on the structure, organization, and culture of health care.” (p. 3)<br /><br />The NASEM committee’s systems model has three levels: frontline care delivery, the health care organization, and the external environment. <i>Frontline care delivery</i> is the environment in which care is provided. The <i>health care organization</i> includes the organizational culture, payment and reward systems, processes for managing human capital and human resources, the leadership and management style, and organizational policies. The <i>external environment</i> includes political, market, professional, and societal factors.<br /><br />All three levels contribute to an individual clinician’s work environment, and ultimately boil down to a set of <i>job demands</i> and <i>job resources</i> for the clinician.<br /><br /><i>Recommendations</i><br /><br />The report identifies multiple factors that need to be considered when developing interventions, including organizational values and leadership; a work system that provides adequate resources, facilitates team work, collaboration, communication, and professionalism; and an implementation approach that builds a learning organization, reward systems that align with organizational values, nurtures organizational culture, and uses human-centered design processes. (p. 7)<br /><br />The report presents six recommendations for reducing clinician burnout and fostering professional well-being:<br /><br />1. Create positive work environments,<br />2. Create positive learning environments,<br />3. Reduce administrative burdens,<br />4. Optimize the use of health information technologies,<br />5. Provide support to clinicians to prevent and alleviate burnout, and foster professional well-being, and<br />6. Invest in research on clinician professional well-being. <br /><br /><b>Our Perspective</b><br /><br />We’ll ask and answer a few questions about this report.<br /><br /><i>Did the committee design an actual and satisfactory systems model?</i><br /><br />We have promoted systems thinking since the inception of Safetymatters so we have some clear notions of what should be included in a systems model. We see both positives and missing pieces in the NASEM committee’s approach.***<br /><br />On the plus side, the tri-level model provides a useful and clear depiction of the health care system and leads naturally to an image of the work world each clinician faces. We believe a model should address certain organizational realities—goal conflict, decision making, and compensation—and this model is minimally satisfactory in these areas. A clinician’s potential <i>goal conflicts</i>, primarily maintaining a patient focus while satisfying the organization’s quality measures, managing limited resources, achieving economic goals, and complying with regulations, is mentioned once. (p. 54) <i>Decision making</i> (DM) specifics are discussed in several areas, including evidenced-based DM (p. 25), the patient’s role in DM (p. 53), the burnout threat when clinicians lack input to DM (p. 101), the importance of participatory DM (pp. 134, 157, 288), and information technology as a contributor to DM (p. 201). <i>Compensation</i>, which includes incentives, should align with organizational values (pp. 10, 278, 288), and should not be a stressor on the individual (p. 153). Non-financial incentives such as awards and recognition are not mentioned.<br /><br />On the downside, the model is static and two-dimensional. The interrelationships and dynamics among model components are not discussed at all. For example, the importance of trust in management is mentioned (p. 132) but the dynamics of trust are not discussed. In our experience, “trust” is a multivariate function of, among other things, management’s decisions, follow-through, promise keeping, role modeling, and support of subordinates—all integrated over time. In addition, model components feed back into one another, both positively and negatively. In the report, the use of feedback is limited to clinicians’ experiences being fed back to the work designers (pp. 6, 82), continuous learning and improvement in the overall system (pp. 30, 47, 51, 157), and individual work performance recognition (pp. 103, 148). It is the system dynamics that create homeostasis, fluctuations, and all levels of performance from superior to failure.<br /><br /><i>Does culture play an appropriate role in the model and recommendations?</i><br /><br />We know that organizational culture affects performance. And culture is mentioned throughout this report as a system component with the implication that it is an important factor, but it is not defined until a third of the way through the report.**** The NASEM committee apparently assumes everyone knows what culture is, and that’s a problem because groups, even in the same field, often do not share a common definition of culture.<br /><br />But the lack of a definition doesn’t stop the authors from hanging all sorts of attributes on the culture tree. For example, the recommendation details include “Nurture (establish and sustain) organizational culture that supports change management, psychological safety, vulnerability, and peer support.” (p. 7) This is mostly related to getting clinicians to recognize their own burnout and seek help, and removing the social stigma associated with getting help. There are a lot of moving parts in this recommendation, not the least of which is overcoming the long-held cultural ideal of the physician as a tough, all-knowing, powerful authority figure. <br /><br />Teamwork and participatory decision making are promoted (pp. 10, 51) but this can be a major change for organizations that traditionally have strong silos and value adherence to established procedures and protocols. <br /><br />There are bromides sprinkled through the report. For example, “Leadership, policy, culture, and incentives are aligned at all system levels to achieve quality aims and promote integrity, stewardship, and accountability.” (p. 25) That sounds worthy but is a huge task to specify and implement. Same with calling for a culture of continuous learning and improvement, or in the committee’s words a “Leadership-instilled culture of learning—is stewarded by leadership committed to a culture of teamwork, collaboration, and adaptability in support of continuous learning as a core aim” (p. 51)<br /><br /><i>Are the recommendations useful?</i><br /><br />We hope so. We are not behavioral scientists but the recommendations appear to represent sensible actions. They may help and probably won’t hurt—unless a health care organization makes promises that it cannot or will not keep. That said, the recommendations are pretty vanilla and the NASEM committee cannot be accused of going out on any limbs.<br /><br />Bottom line: Clinician burnout undoubtedly has a negative impact on patient care and outcomes. Anything that can reduce burnout will improve the performance of the health care system. However, this report does not appreciate the totality of cultural change required to implement the modest recommendations.<br /><br /><br />* National Academies of Sciences, Engineering, and Medicine, “<a href="https://doi.org/10.17226/25521" target="_blank">Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being</a>,” (Washington, DC: The National Academies Press, 2019). </span></span><br />
<span><span style="font-family: "verdana", sans-serif;"><br />** “Burnout is a syndrome characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work.” (p. 1) “Clinician burnout is associated with an increased risk of patient safety incidents . . .” (p. 2) <br /><br />*** As an aside, the word “systems” is mentioned over 700 times in the report.<br /><br />**** “Organizational culture is defined by the fundamental artifacts, values, beliefs, and assumptions held by employees of an organization (Schein, 1992). An organization’s culture is manifested in its actions (e.g., decisions, resource allocation) and relayed through organizational structure, focus, mission and value alignment, and leadership behaviors” (p. 99) This is good but it should have been presented earlier in the report.</span></span></font>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-18720932174807030112019-10-09T09:44:00.003-07:002020-08-02T20:28:46.914-07:00More on Mental Models in Healthcare<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8VaKUspqeOLGNLplJaewfKDS3GZh-o0o6Ycf_sfudnbhawB0rwatQVYZxzlpi2subwVQtvPm2fDx4bkWrtCL2nTPLjxHu8KUZPnopAMPCgWlwZUD-2_OVf5SkkRV-UtwdrgM0OeDCHuZH/s1600/Hospital+clipart+panda.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="425" data-original-width="400" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8VaKUspqeOLGNLplJaewfKDS3GZh-o0o6Ycf_sfudnbhawB0rwatQVYZxzlpi2subwVQtvPm2fDx4bkWrtCL2nTPLjxHu8KUZPnopAMPCgWlwZUD-2_OVf5SkkRV-UtwdrgM0OeDCHuZH/s200/Hospital+clipart+panda.jpg" width="188" /></a></td></tr>
<tr align="right"><td class="tr-caption">Source: Clipart Panda</td></tr>
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<font size="3"><span><span style="font-family: "verdana", sans-serif;">Our <a href="https://www.safetymattersblog.com/2019/08/safety-ii-lessons-for-healthcare.html" target="_blank">August 6, 2019 post</a> discussed the appalling incidence of preventable harm in healthcare settings. We suggested that a better mental model of healthcare delivery could contribute to reducing the incidence of preventable harm. It will come as no surprise to Safetymatters readers that we are referring to a systems-oriented model.<br /><br />We’ll use a <a href="https://www.chemicalprocessing.com/articles/2014/get-to-the-root-of-accidents/" target="_blank">2014 article</a>* by Nancy Leveson and Sidney Dekker to describe how a systems approach can lead to better understanding of why accidents and other negative outcomes occur. The authors begin by noting that 70-90% of industrial accidents are blamed on individual workers.** As a consequence, proposed fixes focus on disciplining, firing, or retraining individuals or, for groups, specifying their work practices in ever greater detail (the authors call this “rigidifying” work). This is the Safety I mental model in a nutshell, limiting its view to the “what” and “who” of incidents. <br /><br />In contrast, systems thinking posits the behavior of individuals can only be understood by examining the context in which their behavior occurs. The context includes management decision-making and priorities, regulatory requirements and deficiencies, and of course, organizational culture, especially safety culture. Fixes that don’t consider the overall process almost guarantee that similar problems will arise in the future. “. . . human error is a symptom of a system that needs to be redesigned.” Systems thinking adds the “why” to incident analysis.<br /><br />Every system has a designer, although they may not be identified as such and may not even be aware they’re “designing” when they specify work steps or flows, or define support processes, e.g., procurement or quality control. Importantly, designers deal with an <i>ideal</i> system, not with the <i>actual</i> constructed system. The actual system may differ from the designer's original specification because of inherent process variances, the need to address unforeseen conditions, or evolution over time. Official procedures may be incomplete, e.g., missing unlikely but possible conditions or assume that certain conditions cannot occur. However, the people doing the work must deal with the constructed system, however imperfect, and the conditions that actually occur.<br /><br />The official procedures present a doubled-edged threat to employees. If they adapt procedures in the face of unanticipated conditions, and the adaptation turns out to be ineffective or leads to negative outcomes, employees can be blamed for <i>not</i> following the procedures. On the other hand, if they stick to the procedures when conditions suggest they should be adapted and negative outcomes occur, the employees can be blamed for <i>too rigidly</i> following them.<br /><br />Personal blame is a major problem in System I. “Blame is the enemy of safety . . . it creates a culture where people are afraid to report mistakes . . . A safety culture that focuses on blame will never be very effective in preventing accidents.”<br /><br /><b>Our Perspective</b><br /><br />How does the above relate to reducing preventable harm in healthcare? We believe that structural and cultural factors impede the application of systems thinking in the healthcare field. It keeps them stuck in a Safety I worldview no matter how much they pretend otherwise. <br /><br /><i>The hospital as formal bureaucracy</i><br /><br />When we say “healthcare” we are referring to a large organization that provides medical care, a hospital is the smallest unit of analysis. A hospital is literally a textbook example of what organizational theorists call a <i>formal bureaucracy</i>. It has specialized departments with an official division of authority among them—silos are deliberately created and maintained. An administrative hierarchy mediates among the silos and attempts to guide them toward overall goals. The organization is deliberately impersonal to avoid favoritism and behavior is prescribed, proscribed and guided by formal rules and procedures. It appears hospitals were deliberately designed to promote System I thinking and its inherent bias for blaming the individual for negative outcomes.<br /><br />Employees have two major strategies for avoiding blame: strong occupational associations and plausible deniability. <br /><br /><i>Powerful guilds and unions</i> </span></span><br />
<br />
<span><span style="font-family: "verdana", sans-serif;">Medical personnel are protected by their silo and tribe. Department heads defend their employees (and their turf) from outsiders. The doctors effectively belong to a guild that jealously guards their professional authority; the nurses and other technical fields have their unions. These unofficial and official organizations exist to protect their members and promote their interests. They do not exist to protect patients although they certainly tout such interest when they are pushing for increased employee headcounts. A key cultural value is members do not rat on other members of their tribe so problems may be observed but go unreported. <br /><br /><i>Hiding behind the procedures</i><br /><br />In this environment, the actual primary goal is to conform to the rules, not to serve clients. The safest course for the individual employee is to follow the rules and procedures, independent of the effect this may have on a patient. The culture espouses a value of patient safety but what gets a higher value is <i>plausible deniability</i>, the ability to avoid personal responsibility, i.e., blame, by hiding behind the established practices and rules when negative outcomes occur.<br /><br /><i>An enabling environment</i> </span></span><br />
<br />
<span><span style="font-family: "verdana", sans-serif;">The environment surrounding healthcare allows them to continue providing a level of service that literally kills patients. <i>Data opacity</i> means it’s very difficult to get reliable information on patient outcomes. Hospitals with high failure rates simply claim they are stuck with or choose to serve the sickest patients. <i>Weak malpractice laws</i> are promoted by the doctors’ guild and maintained by the politicians they support. Society in general is <i>overly tolerant</i> of bad medical outcomes. Some families may make a fuss when a relative dies from inadequate care but settlements are paid, non-disclosure agreements are signed, and the enterprise moves on.<br /><br />Bottom line: It will take powerful forces to get the healthcare industry to adopt true systems-oriented thinking and identify the real reasons why preventive harm occurs and what corrective actions could be effective. Healthcare claims to promote evidence-based medicine; they need to add evidence-based harm reduction strategies. Industry-wide adoption of the aviation industry’s confidential reporting system for errors would be a big step forward. <br /><br /><br />* N. Leveson and S. Dekker, “<a href="https://www.chemicalprocessing.com/articles/2014/get-to-the-root-of-accidents/" target="_blank">Get To The Root Of Accidents</a>,” ChemicalProcessing.com (Feb 27, 2014). Retrieved Oct. 7, 2019. Leveson is an MIT professor and long-standing champion of systems thinking; Dekker has written extensively on Just Culture and Safety II concepts. Click on their respective labels to pull up our other posts on their work.<br /><br />** The article is tailored for the process industry but the same thinking can be applied to service industries.</span></span></font>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0tag:blogger.com,1999:blog-4170623839736191950.post-30939876553782898202019-08-06T12:48:00.003-07:002020-08-02T20:29:13.084-07:00Safety II Lessons for Healthcare<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-MoH7t8YAC4Q/XUnYRDhUm4I/AAAAAAAADkM/kw9LvSRJ1jkh-qmzu4HL5HiPPxxE6RoyACLcBGAs/s1600/Rod%2Bof%2BAsclepius.jpg" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="358" data-original-width="93" height="200" src="https://1.bp.blogspot.com/-MoH7t8YAC4Q/XUnYRDhUm4I/AAAAAAAADkM/kw9LvSRJ1jkh-qmzu4HL5HiPPxxE6RoyACLcBGAs/s200/Rod%2Bof%2BAsclepius.jpg" width="51" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small;">Rod of Asclepius <span style="font-size: x-small;">Source: Wikipedia</span></span></td></tr>
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<font size="3"><span><span style="font-family: "verdana", sans-serif;">We recently saw a <a href="https://www.bmj.com/content/366/bmj.l4185" target="_blank">journal article</a>* about the incidence of preventable patient harm in medical care settings. The rate of occurrence of harm is shocking, at least to someone new to the topic. We wondered if healthcare providers and researchers being constrained by Safety I thinking could be part of the problem. Below we provide a summary of the article, followed by our perspective on how Safety II thinking and practices might add value.<br /><br /><b>Incidence of preventable patient harm</b><br /><br />The meta-analysis reviewed 70 studies and over 300,000 patients. The overall incidence of patient harm (e.g., injury, suffering, disability or death) was 12% and half of that was deemed preventable.** In other words, “Around one in 20 patients are exposed to preventable harm in medical care.” 12% of the preventable patient harm was severe or led to death. 25% of the preventable incidents were related to drugs and 24% to other treatments. The authors did not observe any change in the preventable harm rate over the 19 years of data they reviewed.<br /><br /><b>Possible interventions</b><br /><br />In fairness, the article’s focus was on calculating the incidence of preventable harm, not on identifying or fixing specific problems. However, the authors do make several observations about possible ways to reduce the incidence rate. The article had 11 authors so we assume these observations are not just one person’s to-do list but rather represent the collective thoughts of the author group.<br /><br />The authors note “Key sources of preventable patient harm could include the actions of healthcare professionals (errors of omission or commission), healthcare system failures, or involve a combination of errors made by individuals, system failures, and patient characteristics.” They believe occurrences could be avoided “by reasonable adaptation to a process, or adherence to guidelines, . . .” <br /><br />The authors suggest “A combination of individual-level measures (eg, educational interventions for practitioners), system-level*** measures (eg, human-centred design of healthcare tasks and work environments), and organisational-level measures (eg, introducing quality monitoring and improvement processes) are likely to be a promising strategy for mitigating preventable patient harm, . . .”<br /><br /><b>Our Perspective</b><br /><br />Let’s get one thing out of the way: no other industry on the planet would be allowed to operate if it unnecessarily harmed people at the rate presented in this article. As a global society, we accept, or at least tolerate, a surprising incidence of preventable harm to the people the healthcare system is supposed to be trying to serve.<br /><br />We see a direct connection between this article and our <a href="https://www.safetymattersblog.com/2018/10/safety-culture-what-are-contributors-to.html" target="_blank">Oct. 29, 2018 post</a> where we reviewed Sydney Dekker’s analysis of patient harm in a health care facility. Dekker’s report also highlighted the differences between the traditional Safety I approach to safety management and the more current Safety II approach.<br /><br />As we stated in that post, in Safety I the root cause of imperfect results is the individual and constant efforts are necessary (e.g., training, monitoring, leadership, discipline) to create and maintain the individual’s compliance with work as designed. In addition, the design of the work is subject to constant refinement (or “continuous improvement”). In the preventable harm article, the authors’ observations look a lot like Safety I to us, with their emphasis on getting the individual to conform with work as designed, e.g, educational interventions (i.e., training), adherence to guidelines and quality monitoring, and improved design (i.e., specification) of healthcare tasks.<br /><br />In contrast, in Safety II normal system functioning leads to mostly good and occasionally bad results. The focus of Safety II interventions should be on activities that increase individual capacity to affect system performance and/or increase system robustness, i.e., error tolerance and an increased chance of recovery when errors inevitably occur. When Dekker’s team reviewed cases with harm vs. cases with good outcomes, they observed that the good outcome cases “had more positive characteristics, including diversity of professional opinion and the possibility to voice dissent, keeping the discussion on risk alive and not taking past success as a guarantee for safety, deference to proven expertise, widely held authority to say “stop,” and pride of workmanship.” We don’t see any evidence of this approach in the subject article.<br /><br />Could Safety II thinking reduce the incidence of preventable harm in healthcare? Possibly. But what’s clear is that doing more of the same thing (more training, task specification and monitoring) has not improved the preventable harm rate over 19 years. Maybe it’s time to think about the problems using a different mental model. <br /><br /><b>Afterword </b><br /><br />In a subsequent <a href="https://www.marketwatch.com/story/in-a-review-of-337000-patient-cases-this-was-the-no-1-most-common-medical-error-2019-07-22?siteid=nwhpf" target="_blank">interview</a>,**** the lead author of the study said “providers and health-care systems need to “train and empower patients to be active partners” in their own care.” This is a significant change in the model of the health care system, from the patient being the <i>client</i> of the system to an active <i>component</i>. Such empowerment is especially important where the patient’s individual characteristics may make him/her more susceptible to harm. The author’s advice to patients is tantamount to admitting that current approaches to diagnosing and treating patients are producing sub-standard results. <br /><br /><br />* M. Panagioti, K. Khan, R.N. Keers, A. Abuzour, D. Phipps, E. Kontopantelis et al. “<a href="https://www.bmj.com/content/366/bmj.l4185" target="_blank">Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis</a>,” BMJ 2019; 366:l4185. Retrieved July 30, 2019.<br /><br />** The goal for patient harm is not zero. The authors accept that “some harms cannot be avoided in clinical practice.”<br /><br />*** When the authors say “system” they are not referring to the term as we use it in Safetymatters, i.e., a complex collection of components, feedback loops and environmental interactions. The authors appear to limit the “system” to the immediate context in which healthcare is provided. They do offer a hint of a larger system when they comment about the “need to gain better insight about the systemic and cultural circumstances under which preventable patient harm occurs”.<br /><br />**** M. Jagannathan, “<a href="https://www.marketwatch.com/story/in-a-review-of-337000-patient-cases-this-was-the-no-1-most-common-medical-error-2019-07-22?siteid=nwhpf" target="_blank">In a review of 337,000 patient cases, this was the No. 1 most common preventable medical error</a>,” MarketWatch (July 28, 2019). Retrieved July 30, 2019. This article included a list of specific steps patients can take to be more active, informed, and effective partners in obtaining health care.</span></span></font>Lewis Connerhttp://www.blogger.com/profile/08283295941018353006noreply@blogger.com0