Tuesday, August 6, 2019

Safety II Lessons for Healthcare

Rod of Asclepius  Source: Wikipedia
We recently saw a journal article* 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.

Incidence of preventable patient harm

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.

Possible interventions

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.

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, . . .” 

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, . . .”

Our Perspective

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.

We see a direct connection between this article and our Oct. 29, 2018 post 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.

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.

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.

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.

Afterword

In a subsequent interview,**** 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 client of the system to an active component.  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. 


*  M. Panagioti, K. Khan, R.N. Keers,  A. Abuzour, D. Phipps, E. Kontopantelis et al. “Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis,” BMJ 2019; 366:l4185.  Retrieved July 30, 2019.

**  The goal for patient harm is not zero.  The authors accept that “some harms cannot be avoided in clinical practice.”

***  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”.

****  M. Jagannathan, “In a review of 337,000 patient cases, this was the No. 1 most common preventable medical error,” 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.

Tuesday, May 28, 2019

The Study of Organizational Culture: History, Assessment Methods, and Insights

We came across an academic journal article* that purports to describe the current state of research into organizational culture (OC).  It’s interesting because it includes a history of OC research and practice, and a critique of several methods used to assess it.  Following is a summary of the article and our perspective on it, focusing on any applicability to nuclear safety culture (NSC).

History

In the late 1970s scholars studying large organizations began to consider culture as one component of organizational identity.  In the same time frame, practicing managers also began to show an interest in culture.  A key driver of their interest was Japan’s economic ascendance and descriptions of Japanese management practices that depended heavily on cultural factors.  The notion of a linkage between culture and organizational performance inspired non-Japanese managers to seek out assistance in developing culture as a competitive advantage for their own companies.  Because of the sense of urgency, practical applications (usually developed and delivered by consultants) were more important than developing a consistent, unified theory of OC.  Practitioners got ahead of researchers and the academic world has yet to fully catch up.

Consultant models only needed a plausible, saleable relationship between culture and organizational performance.  In academic terms, this meant that a consultant’s model relating culture to performance only needed some degree of predictive validity.  Such models did not have to exhibit construct validity, i.e., some proof that they described, measured, or assessed a client organization’s actual underlying culture.  A second important selling point was the consultants’ emphasis on the singular role of the senior leaders (i.e., the paying clients) in molding a new high-performance culture.

Over time, the emphasis on practice over theory and the fragmented efforts of OC researchers led to some distracting issues, including the definition of OC itself, the culture vs. climate debate, and qualitative vs. quantitative models of OC. 

Culture assessment methods 


The authors provide a detailed comparison of four quantitative approaches for assessing OC: the Denison Organizational Culture Survey (used by more than 5,000 companies), the Competing Values Framework (used in more than 10,000 organizations), the Organizational Culture Inventory (more than 2,000,000 individual respondents), and the Organizational Culture Profile (OCP, developed by the authors and used in a “large number” of research studies).  We’ll spare you the gory details but unsurprisingly, the authors find shortcomings in all the approaches, even their own. 

Some of this criticism is sour grapes over the more popular methods.  However, the authors mix their criticism with acknowledgement of functional usefulness in their overall conclusion about the methods: because they lack a “clear definition of the underlying construct, it is difficult to know what is being measured even though the measure itself has been shown to be reliable and to be correlated with organizational outcomes.” (p. 15)

Building on their OCP, the authors argue that OC researchers should start with the Schein three-level model (basic assumptions and beliefs, norms and values, and cultural artifacts) and “focus on the norms that can act as a social control system in organizations.” (p. 16)  As controllers, norms can be descriptive (“people look to others for information about how to act and feel in a given situation”) or injunctive (how the group reacts when someone violates a descriptive norm).  Attributes of norms include content, consensus (how widely they are held), and intensity (how deeply they are held).

Our Perspective

So what are we to make of all this?  For starters, it’s important to recognize that some of the topics the academics are still quibbling over have already been settled in the NSC space.  The Schein model of culture is accepted world-wide.  Most folks now recognize that a safety survey, by itself, only reflects respondents’ perceptions at a specific point in time, i.e., it is a snapshot of safety climate.  And a competent safety culture assessment includes both qualitative and quantitative data: surveys, focus groups, interviews, observations, and review of artifacts such as documents.

However, we may still make mistakes.  Our mental models of safety culture may be incomplete or misassembled, e.g., we may see a direct connection between culture and some specific behavior when, in reality, there are intervening variables.  We must acknowledge that OC can be a multidimensional sub-system with complex internal relationships interacting with a complicated socio-technical system surrounded by a larger legal-political environment.  At the end of the day, we will probably still have some unknown unknowns.

Even if we follow the authors’ advice and focus on norms, it remains complicated.  For example, it’s fairly easy to envision that safety could be a widely agreed upon, but not intensely held, norm; that would define a weak safety culture.  But how about safety and production and cost norms in a context with an intensely held norm about maintaining good relations with and among long-serving coworkers?  That could make it more difficult to predict specific behaviors.  However, people might be more likely to align their behavior around the safety norm if there was general consensus across the other norms.  Even if safety is the first among equals, consensus on other norms is key to a stronger overall safety culture that is more likely to sanction deviant behavior.
 
The authors claim culture, as defined by Schein, is not well-investigated.  Most work has focused on correlating perceptions about norms, systems, policies, procedures, practices and behavior (one’s own and others’) to organizational effectiveness with a purpose of identifying areas for improvement initiatives that will lead to increased effectiveness.  The manager in the field may not care if diagnostic instruments measure actual culture, or even what culture he has or needs; he just wants to get the mission accomplished while avoiding the opprobrium of regulators, owners, bosses, lawmakers, activists and tweeters. If your primary focus is on increasing performance, then maybe you don’t need to know what’s under the hood. 

Bottom line: This is an academic paper with over 200 citations but is quite readable although it contains some pedantic terms you probably don’t hear every day, e.g., the ipsative approach to ranking culture attributes (ordinary people call this “forced choice”) and Q factor analysis.**  Some of the one-sentence descriptions of other OC research contain useful food for thought and informed our commentary in this write-up.  There is a decent dose of academic sniping in the deconstruction of commercially popular “culture” assessment methods.  However, if you or your organization are considering using one of those methods, you should be aware of what it does, and doesn’t, incorporate. 


*  J.A. Chatman and C.A. O’Reilly, “Paradigm lost: Reinvigorating the study of organizational culture,” Research in Organizational Behavior (2016).  Retrieved May 28, 2019.

**  “Normal factor analysis, called "R method," involves finding correlations between variables (say, height and age) across a sample of subjects. Q, on the other hand, looks for correlations between subjects across a sample of variables. Q factor analysis reduces the many individual viewpoints of the subjects down to a few "factors," which are claimed to represent shared ways of thinking.”  Wikipedia, “Q methodology.”   Retrieved May 28, 2019.

Monday, April 1, 2019

Culture Insights from The Speed of Trust by Stephen M.R. Covey

In The Speed of Trust,* Stephen M.R. Covey posits that trust is the key competency that allows individuals (especially leaders), groups, organizations, and societies to work at optimum speed and cost.  In his view, “Leadership is getting results in a way that inspires trust.” (p. 40)  We saw the book mentioned in an NRC personnel development memo** and figured it was worth a look. 

Covey presents a model of trust made up of a framework, language to describe the framework’s components, and a set of recommended behaviors.  The framework consists of self trust, relationship trust and stakeholder trust.  Self trust is about building personal credibility; relationship trust is built on one’s behavior with others; and stakeholder trust is built within organizations, in markets (i.e., with customers), and over the larger society.  His model is not overly complicated but it has a lot of parts, as shown in the following figure.


Figure by Safetymatters

4 Cores of credibility 


Covey begins by describing how the individual can learn to trust him or herself.  This is basically an internal process of developing the 4 Cores of credibility: character attributes (integrity and intent) and competence attributes (capabilities and results).  Improvement in these areas increases self-confidence and one’s ability to project a trust-inspiring strength of character.  Integrity includes clarifying values and following them.  Intent includes a transparent, as opposed to hidden, agenda that drives one’s behavior.  Capabilities include the talents, skills, and knowledge, coupled with continuous improvement, that enable excellent performance.  Results, e.g., achieving goals and keeping commitments, are sine qua non for establishing and maintaining credibility and trust.

13 Behaviors  

The next step is learning how to trust and be trusted by others.  This is a social process, i.e., it is created through individual behavior and interaction with others.  Covey details 13 types of behavior to which the individual must attend.  Some types flow primarily, but not exclusively, from character, others from competence, and still others from a combination of the two.  He notes that “. . . the quickest way to decrease trust is to violate a behavior of character, while the quickest way to increase trust is to demonstrate a behavior of competence.” (p. 133)  Covey provides examples of each desired behavior, its opposite, and its “counterfeit” version, i.e., where people are espousing the desired behavior but actually avoiding doing it.  He describes the problems associated with underdoing and overdoing each behavior (an illustration of the Goldilocks Principle).  Behavioral change is possible if the individual has a compelling sense of purpose.  Each behavior type is guided by a set of principles, different for each behavior, as shown in the following figure.


Figure by Safetymatters

Organizational alignment

The third step is establishing trust throughout an organization.  The primary mechanism for accomplishing this is alignment of the organization’s visible symbols, underlying structures, and systems with the ideals expressed in the 4 Cores and 13 Behaviors, e.g., making and keeping commitments and accounting for results.  He describes the “taxes” associated with a low-trust organization and the “dividends” associated with a high-trust organization.  Beyond that, there is nothing new in this section.

Market and societal trust

We’ll briefly address the final topics.  Market trust is about an entity’s brand or reputation in the outside world.  Building a strong brand involves using the 4 Cores to establish, maintain or strengthen one’s reputation.  Societal trust is built on contribution, the value an entity creates in the world through ethical behavior, win-win business dealings, philanthropy and other forms of corporate social responsibility.     

Our Perspective 


Covey provides a comprehensive model of how trust is integral to relationships at every level of complexity, from the self to global relations.
 
The fundamental importance of trust is not new news.  We have long said organization-wide trust is vital to a strong safety culture.  Trust is a lubricant for organizational friction which, like physical friction, slows down activities, and makes them more expensive.  In our Safetysim*** management simulator, trust was an input variable that affected speed and effectiveness of problem resolution and overall cost performance. 

Covey’s treatment of culture is incomplete.  While he connects some of his behaviors or principles to organizational culture,**** he never actually defines culture.  It appears he thinks culture is something that “just is” or, perhaps, a consequence or artifact of performing the behaviors he prescribes.  It’s reasonable to assume Covey believes motivated individuals can behave their way to a better culture, saying “. . . behave your way into the person you want to be.” (pp. 87, 130)  His view is consistent with culture change theorists who believe people will eventually develop desired values if they model desired behavior long enough.  His recipe for cultural change boils down to “Just do it.”  We prefer a more explicit definition of culture, something along the spectrum from the straightforward notion of culture as an underlying set of values to the idea of culture as an emergent property of a complex socio-technical system. 

Trust is not the only candidate for the primary leadership or organizational competence.  The same or similar arguments could also be made about respect.  (Covey mentions respect but only as one of his 13 behaviors.)  Two-way respect is also essential for organizational success.  This leads to an interesting question: Could you respect a leader without trusting him/her?  How about some of the famous hard-ass bosses of management lore, like Harold Geneen?  Or General Patton? 

Covey is obviously a true believer in his message and his presentation has a fervor one normally associates with religious zeal.  He also includes many examples of family situations and describes how his prescriptions can be applied to families.  (Helpful if you want to manage your family like a little factory.)  Covey is a devout Mormon and his faith comes through in his writing. 

The book is an easy read.  Like many books written by successful consultants, it is interspersed with endorsements and quotes from business and political notables.  Covey includes a couple of useful self-assessment surveys.  He also offers a valuable observation: “. . . people tend to judge others based on behavior and judge themselves based on intent.” (p. 301)

Bottom line: This book is worth your time if lack of trust is a problem in your organization.


*  Stephen M. R. Covey, The Speed of Trust (New York: Free Press, 2016).  If the author’s name sounds familiar, it may be because his father, Stephen R. Covey, wrote The 7 Habits of Highly Effective People, a popular self-help book.

**  “Fiscal Year (FY) 2018 FEORP Plan Accomplishments and Successful/Promising Practices at the U.S. Nuclear Regulatory Commission (NRC),” Dec. 17, 2018.  ADAMS ML18351A243.  The agency uses The Speed of Trust concepts in manager and employee training. 

***  Safetysim is a management training simulation tool developed by Safetymatters’ Bob Cudlin.

****  For example, “A transparent culture of learning and growing will generally create credibility and trust, . . .” (p. 117)

Friday, March 8, 2019

Decision Making, Values, and Culture Change

Typical New Yorker cover
In the nuclear industry, most decisions are at least arguably “hard,” i.e., decision makers can agree on the facts and identify areas where there is risk or uncertainty.  A recent New Yorker article* on making an indisputably “soft” decision got us wondering if the methods and philosophy described in the article might provide some insight into qualitative personal decisions in the nuclear space.

Author Joshua Rothman’s interest in decision making was piqued by the impending birth of his first child.  When exactly did he decide that he wanted children (after not wanting them) and then participate with his wife to make it happen?  As he says, “If I made a decision, it wasn’t a very decisive one.”  Thus began his research into decision making methods and philosophy.

Rothman opens with a quick review of several decision making techniques.  He describes Benjamin Franklin’s “prudential algebra,” Charles Darwin’s lists of pros and cons, Leo Tolstoy’s expositions in War and Peace (where it appears the biggest decisions basically make themselves), and modern decision science processes that develop decisions through iterative activities performed by groups, scenario planning and war games. 

Eventually the author gets to decision theory, which holds that sound decisions flow from values.  Decision makers ask what they value and then seek to maximize it.  But what if “we’re unsure what we care about, or when we anticipate that what we care about might shift”?  What if we opt to change our values? 

The focus on values leads to philosophy.  Rothman draws heavily on the work of Agnes Callard, a philosopher at the University of Chicago, who believes that life-altering decisions are not made suddenly but through a more gradual process: “Old Person aspires to become New Person.”  Callard emphasizes that aspiration is different from ambition.  Ambitious people know exactly why they’re doing something, e.g., taking a class to get a good grade or modeling different behavior to satisfy regulatory scrutiny.  Aspirants, on the other hand, have a harder time because they have a less clear sense of their current activities’ value and can only hope their future selves can understand and appreciate it.  “To aspire, Callard writes, is to judge one’s present-day self by the standards of a future self who doesn’t yet exist.”

Our Perspective

We can consider the change of an organization’s culture as the integration over time of the changes in all its members’ behaviors and values.  We know that values underlie culture and significant cultural change requires shifting the actual (as opposed to the espoused) values of the organization.  This is not easy.  The organization’s more ambitious members will find it easier to get with the program; they know change is essential and are willing to adapt to keep their jobs or improve their standing.  The merely aspiring will have a harder time.  Because they lack a clear picture of the future organizational culture, they may be troubled by unexplored options, i.e., some different path or future that might be equally good or even better.  They may learn that no matter how deeply they study the experience of others, they still don’t really know what they’re getting into.  They don’t understand what the change experience will be like and how it will affect them.  They may be frustrated to discover that modeling desired new behaviors does not help because they still feel like the same people in the old culture.  Since personal change is not instantaneous, they may even get stuck somewhere between the old culture and the new culture.

Bottom line: Cultural change is harder for some people than others.  This article is an easy read that offers an introduction to the personal dynamics associated with changing one’s outlook or values.

*  J. Rothman, “The Art of Decision-Making,” The New Yorker (Jan. 21, 2019).  Retrieved March 1, 2019.