Friday, December 10, 2021

Prepping for Threats: Lessons from Risk: A User’s Guide by Gen. Stanley McChrystal.

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.  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.  This post summarizes its key points, focusing on items relevant to formal civilian organizations.

McChrystal describes a system that can detect, assess, respond to, and learn from risks.**  His mental model consists of two major components: (1) ten Risk Control Factors, interrelated dimensions for dealing with risks and (2) eleven Solutions, strategies that can be used to identify and address weaknesses in the different factors.  His overall objective is to create a resilient organization that can successfully respond to challenges and threats. 

Risk Control Factors

These are things under the control of an organization and its leadership, including physical assets, processes, practices, policies, and culture.

Communication – The organization must have the physical ability and willingness to exchange clear, complete, and intelligible information, and identify and deal with propaganda or misinformation.

Narrative – An articulated organizational purpose and mission.  It describes Who we are, What we do, and Why we do it.  The narrative drives (and we’d say is informed by) values, beliefs, and action.

Structure – Organizational design defines decision spaces and communication networks, implies power (both actual and perceived authority), suggests responsibilities, and influences culture.

Technology – This is both the hardware/software and how the organization applies it.  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.

Diversity – 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.  (See our June 29, 2020 post on A Culture that Supports Dissent: Lessons from In Defense of Troublemakers by Charlan Nemeth.)

Bias – Biases are assumptions about the world that affect our outlook and decision making, and cause us to ignore or discount many risks.  In McChrystal’s view “[B]ias is an invisible hand driven by self-interest.” (See our July 1, 2021 and Dec.18, 2013 posts on Daniel Kahneman’s work on identifying and handling biases.) 

Action – Leaders have to proactively overcome organizational inertia, i.e., a bias against starting something new or changing course.  Inertia manifests in organizational norms that favor the status quo and tolerate internal resistance to change.

Timing – Getting the “when” of action right.  Leaders have to initiate action at the right time with the right speed to yield optimum impact.

Adaptability – Organizations have to respond to changing risks and environments.  Leaders need to develop their organization’s willingness and ability to change.

Leadership – Leaders have to direct and inspire the overall system, and stimulate and coordinate the other Risk Control Factors.  Leaders must communicate the vision and personify the narrative.  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 Nov. 9, 2018 post for an example of effective leadership.)


The Solutions are strategies or methods to identify weaknesses in and strengthen the risk control factors.  In McChrystal’s view, each Solution is particularly applicable to certain factors, as shown in Table 1.

Assumptions check – Assessment of the reasonableness and relative importance of assumptions that underlie decisions.  It’s the qualitative and quantitative analyses of strengths and weaknesses of supporting arguments, modified by the judgment of thoughtful people.

Risk review – Assessment of when hazards may arrive and the adequacy of the organization’s preparations.

Risk alignment check – Leaders should recognize that different perspectives on risks exist and should be considered in the overall response.

Gap analysis – Identify the space between current actions and desired goals.

Snap assessment – Short-term, limited scope analyses of immediate hazards.  What’s happening?  How well are we responding?

Communications check – Ensure processes and physical systems are in place and working.

Tabletop exercise – A limited duration simulation that tests specific aspects of the organization’s risk response.

War game (functional exercise) – A pressure test in real time to show how the organization comprehensively reacts to a competitor’s action or unforeseen event.

Red teaming – Exercises involving third parties to identify organizational vulnerabilities and blind spots.

Pre-mortem – A discussion focusing on the things mostly likely to go wrong during the execution of a plan. 

After-action review – A self-assessment that identifies things that went well and areas for improvement.


Table 1  Created by Safetymatters


Our Perspective

McChrystal did not invent any of his Risk Control Factors and we have discussed many of these topics over the years.***  His value-add is organizing them as a system and recognizing their interrelatedness.  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.

This review emphasizes McChrystal’s overall risk management model.  The book also includes many examples of risks confronted, ignored, or misunderstood in the military, government, and commercial arenas.  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.

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. 

There are hundreds of endnotes to document the text but the references are more Psychology Today than the primary sources we favor.

Bottom line: This is an easy to read example of the “management cookbook” genre.  It has a lot of familiar information in one place.


*  S. McChrystal and A. Butrico, Risk: A User’s Guide (New York: Portfolio) 2021.  Butrico is McChrystal’s speechwriter.

**  Risk to McChrystal is a combination of a threat and one’s vulnerability to the threat.  Threats are usually external to the organization while vulnerabilities exist because of internal aspects.

***  For example, click on the Management or Decision Making labels to pull up posts in related areas.

Thursday, July 1, 2021

Making Better Decisions: Lessons from Noise by Daniel Kahneman, Oliver Sibony, and Cass R. Sunstein

The authors of Noise: A Flaw in Human Judgment* examine the random variations that occur in judgmental decisions and recommend ways to make more consistent judgments.  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.  (Variability can also occur when the same decision maker revisits a previous decision situation and arrives at a different judgment.)  The decision makers may be doctors making diagnoses, engineers designing structures, judges sentencing convicted criminals, or any other situation involving professional judgment.**  Judgments can vary because of two factors: bias and noise.

Bias is systematic, a consistent source of error in judgments.  It creates an observable average difference between actual judgments and theoretical judgments that would reflect a system’s actual or espoused goals and values.  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.

Noise is random scatter, a separate, independent cause of variability in decisions involving judgment.  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.  Such inconsistency damages the credibility of the system.  Noise has three components: level, pattern, and occasion. 

Level refers to the difference in the average judgment made by different individuals, e.g., a magistrate may be tough or lenient. 

Pattern refers to the idiosyncrasies of individual judges, e.g., one magistrate may be severe with drunk drivers but easy on minor traffic offenses.  These idiosyncrasies include the internal values, principles, memories, and rules a judge brings to every case, consciously or not. 

Occasion 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.  Occasion noise can be influenced by many factors including a judge’s mood, fatigue, and recent experience with other cases. 

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.

Ways to reduce noise

Noise can be reduced through interventions at the individual or group level. 

For the individual, interventions include training to help people who make judgments realize how different psychological biases can influence decision making.  The long list of psychological biases in Noise builds on Kahneman’s work in Thinking, Fast and Slow which we reviewed on Dec. 18, 2013.  Such biases include overconfidence; denial of ignorance, which means not acknowledging that important relevant data isn’t known; base rate neglect, where outcomes in other similar cases are ignored; availability, which means the first solutions that come to mind are favored, with no further analysis; and anchoring of subsequent values to an initial offer.  Noise reduction techniques include active open-mindedness, which is the search for information that contradicts one’s initial hypothesis, or positing alternative interpretations of the available evidence; and the use of rankings and anchored scales rather than individual ratings based on vague, open-ended criteria.  Shared professional norms can also contribute to more consistent judgments.

At the group level, noise can be reduced through techniques the authors call decision hygiene.  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.  For example, a complicated decision can be broken down into multiple dimensions, and each dimension assessed individually and independently.  Group members share their judgments for each dimension, then discus them, and only then combine their findings (and their intuition) into a final decision.  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.

Noise can also be reduced or eliminated by the use of rules, guidelines, or standards. 

Rules are inflexible, thus noiseless.  However, rules (or algorithms) may also have biases coded into them or only apply to their original data set.  They may also drive discretion underground, e.g., where decision makers game the process to obtain the results they prefer.

Guidelines, such as sentencing guidelines for convicted criminals or templates for diagnosing common health problems, are less rigid but still reduce noise.  Guidelines decompose complex decisions into easier sub-judgments on predefined dimensions.  However, judges and doctors push back against mandatory guidelines that reduce their ability to deal with the unique factors of individual cases before them.

Standards are the least rigid noise reduction technique; they delegate power to professionals and are inherently qualitative.  Standards generally require that professionals make decisions that are “reasonable” or “prudent” or “feasible.”  They are related to the shared professional norms previously mentioned.  Judgments based on standards can invite controversy, disagreement, confrontation, and lawsuits.

The authors recognize that in some areas, it is infeasible, too costly, or even undesirable to eliminate noise.  One particular fear is a noise-free system might freeze existing values.  Rules and guidelines need to be flexible to adapt to changing social values or new data.

Our Perspective

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.  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. 

Many organizations examine (and excoriate) bad decisions and the “bad apples” who made them.  Organizations also need to look at “good” decisions to appreciate how much their professionals disagree when making generally acceptable judgments.  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?

You may be surprised at the amount of noise in your organization’s professional judgments.  On the other hand, is your organization’s decision making too rigid in some areas?  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?  Operators (or nurses or whoever) may follow the rules punctiliously but sometimes the train may go off the tracks. 

Bottom line: This is an important book that provides a powerful mental model for considering the many factors that influence individual professional judgments.

*  D. Kahneman, O. Sibony, and C.R. Sunstein, Noise: A Flaw in Human Judgment (New York: Little, Brown Spark) 2021.

**  “Professional judgment” implies some uncertainty about the answer, and judges may disagree, but there is a limit on how much disagreement is tolerable.

Friday, May 21, 2021

Healthcare Safety Culture and Interventions to Reduce Preventable Medical Errors

HSS OIG report cover

We have previously written about the shocking number of preventable errors in healthcare settings that result in injury or death to patients.  We have also discussed the importance of a strong safety culture (SC) in reducing healthcare error rates.  However, after 20 years of efforts, the needle has not significantly moved on overall injuries and deaths.  This post reviews healthcare’s concept of SC and research that ties SC to patient outcomes.  We offer our view on why interventions have not been more effective.

Healthcare’s Model of Safety Culture

Healthcare has a model for SC, shown in the SC primer on the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Network website.*  The model contains these key cultural features:

  • acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
  • a blame-free environment** where individuals are able to report errors or near misses without fear of reprimand or punishment
  • encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
  • organizational commitment of resources to address safety concerns.

We will critique this model later.

Healthcare Providers Believe Safety Culture is Important

A U.S. Department of Health and Human Services (HSS) report*** affirms healthcare providers’ belief that SC is important and can contribute to fewer errors and improved patient outcomes.

AHRQ administers the Patient Safety Organization (PSO) program which gathers data on patient safety events from healthcare providers.  In 2019, the HSS Office of Inspector General surveyed hospitals and PSOs to identify the PSO program’s value and challenges.  SC was one topic covered in the survey and the results confirm SC’s importance to providers.  “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)  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.  A culture of safety is one that enables individuals to report errors without fear of reprimand and to collaborate on solutions.” (p. 11) 

Healthcare Research Connects SC to Interventions to Reduced Errors

AHRQ publishes the “Making Healthcare Safer” series of reports, which represent summaries of important research on selected patient safety practices (PSPs).  The most recent (2020) edition**** recognizes SC as a cross-cutting practice, i.e., SC impacts the effectiveness of many specific PSPs. 

The section on cross-cutting practices begins by noting that healthcare is trying to learn from the experience of high reliability organizations (HROs).  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) 

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)

WalkRounds “involves leaders “walking around” to engage in face to face, candid discussions with frontline staff about patient safety incidents or near-misses.” (p. 17-16)  Team training programs focus on enhancing teamwork skills and communication between healthcare providers . . .” (p. 17-17)  CUSP is a multi-step program to assess, intervene in, and reassess a healthcare unit’s SC. (p. 17-19)

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. 

Rapid response teams (RRTs) treat deteriorating hospital patients before adverse events occur. (p. 2-1)  Weak SC and healthcare hierarchies are barriers to successful implementation of RRTs. (p. 2-10)

Alarm fatigue 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)  The cultural aspects of interventions focused on all staff members (not just nurses) assuming responsibility for addressing alarms. (p. 13-6) 

Our Perspective

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.

An inadequate model for SC

Healthcare does not have an adequate understanding of the necessary attributes of a strong SC.  

The features listed in the introduction of this post are necessary but not sufficient for a strong SC.  SC is more than good communications; it is part of the overall cultural system.  This system has feedback loops that can reinforce or extinguish attitudes and behaviors.  The attitudes of people in the system are heavily influenced by their trust in management to do the right thing.  Management’s behavior is influenced by their goals, policy constraints, environmental pressures, and incentives, including monetary compensation.

Top-to-bottom decision making in the system needs to be consistent, which means processes, priorities, practices, and rules should be defined and followed.  Goal conflicts must be consistently handled.  Decision makers must be identified to allow accountability.   Problems must be identified (without retribution except for cause), analyzed, and permanently fixed.

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. 

Healthcare is not a traditional HRO

The healthcare system looks to HROs for inspiration on SC but does not recognize one significant difference between a traditional HRO and healthcare.

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. 

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.  The inputs (patients) arrive in a wide range of “as is” conditions, from simple injuries to multiple, interacting ailments.  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.  SC in the first phase should focus on obtaining the correct diagnosis; SC in the second phase should focus on performing the prescribed corrective actions according to approved procedures, and ensuring that expected results occur. 

Inadequate models lead to piecemeal interventions      

Healthcare’s simplistic mental model for SC is part of an inaccurate mental model for the overall system.  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).  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.  For more on systems models, systemic challenges, and narrow interventions, see our Oct. 9, 2019 and Nov. 9,2020 posts.  Click on the healthcare label below to see all of the related posts.

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. 


*  Agency for Healthcare Research and Quality, Culture of Safety” (Sept. 2019).  Accessed May 4, 2021.  AHRQ is an organization within the U.S. Department of Health and Human Services.  Its mission includes producing evidence to make health care safer.

**  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.  Click on the just culture label for related posts.

***  U.S. Dept. of Health and Human Services Office of Inspector General, “Patient Safety Organizations: Hospital Participation, Value, and Challenges,” OEI-01-17-00420, Sept. 2019.

****  K.K. Hall et al, “Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices,” AHRQ Pub. No. 20-0029-EF.  (Rockville, MD: AHRQ) March 2020.  This is a 1400 page report so we are only reporting relevant highlights.

Tuesday, February 2, 2021

Organizational Change and System Dynamics Insights from The Tipping Point by Malcolm Gladwell

The Tipping Point*
is a 2002 book by Malcolm Gladwell (who also wrote Blink) 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.  Following is a summary of his key concepts.  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.

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. 


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.  All these messengers drive contagiousness although all three types are not required for every kind of epidemic.


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.  Information about the new product or idea needs to be packaged in a way that makes it attractive and difficult to resist.


General and specific environmental characteristics can encourage or discourage the spread of a phenomenon.  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.

At the more specific level, humans possess a set of tendencies that can be affected by the particular circumstances of their immediate environment.  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.  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.      

Our Perspective

We will expand some of Gladwell’s notions to emphasize how they can be applied to create organizational changes, including cultural change.  In addition, we’ll discuss how the dynamics he describes square with some aspects of system dynamics we have promoted on Safetymatters.

Organizational change

Small close-knit groups have the potential to magnify the epidemic potential of a message or idea.  “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.  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.  Many small movements can create larger movements that manifest as new or modified group norms.

In a product market, diffusion moves from innovators to early adopters to the majority and finally the laggards.  A similar model of diffusion can be applied in a formal organization.  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.  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.

System dynamics

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.  This nonlinearity helps explain why systems can be operating more or less normally then suddenly veer into failure.  Active management deliberately tries to create such changes to veer into success.  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. 

That said, Gladwell presents a linear, cause-and-effect model for change.  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.  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.

Bottom line: This is easy reading with lots of interesting case studies and quotes from talking head PhDs.  The book comes across as a long magazine article. 


*  M Gladwell, The Tipping Point (New York: Back Bay Books/Little, Brown and Co.) 2000 and 2002.

**  “Product” is used in its broadest sense; it can mean something physical like a washing machine, a political campaign, a celebrity wannabe, etc.