How to Consider Unknown Unknowns: Hints from McKinsey

Our July 31, 2020 post on medical errors 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 article* provides some suggestions for getting started. There is nothing really new but it reiterates some important points we have been making here on Safetymatters.

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.

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.

Ask different questions

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?

As Hans Rosling said: “Beware of simple ideas and simple solutions. . . . Welcome complexity.” (see our Dec. 3, 2018 post)

Take multiple perspectives

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.

Other thought leaders have suggested similar approaches. For example, Ray Dalio proposes thoughtful disagreement where decision makers seek out brilliant people who disagree with them to gain a deeper understanding of decision situations (see our April 17, 2018 post) or Charlan Nemeth on the usefulness of authentic dissent in decision situations (see our June 29, 2020 post).

Recognize systems

The authors’ appreciation for systems thinking mirrors what we’ve been saying for years. (For example, see our Jan. 6, 2017 post.) 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.”


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.”

Our Perspective

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.

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.

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.


* Z. Achi and J.G. Berger, “Delighting in the Possible,” McKinsey Quarterly (March 2015).

Culture in Healthcare: Lessons from When We Do Harm by Danielle Ofri, MD

In her book*, Dr. Ofri takes a hard look at the prevalence of medical errors in the healthcare system.  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.  This post summarizes her main observations.  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.

Healthcare is provided by a system

The system includes the providers, the supporting infrastructure, and factors in the external environment.  Ofri observes that medical care is exceedingly complicated and some errors are inevitable.  Because errors are inevitable, the system should emphasize error recognition and faster recovery with a goal of harm reduction.

She shares our view that the system permits errors to occur so fixes should focus on the system and not on the individual who made an error.***  System failures will eventually trap the most conscientious provider.  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.

System “improvements” intended to increase efficiency can actually reduce effectiveness.  For example, electronic medical records can end up dictating providers’ practices, fragmenting thoughts and interfering with the flow of information between doctor and patient.****  Data field defaults and copy and paste shortcuts can create new kinds of errors.  Diagnosis codes driven by insurance company billing requirements can distort the diagnostic process.  In short, patient care becomes subservient to documentation.

Other changes can have unforeseen consequences.  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.)    

Aviation-inspired checklists have limited applicability

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.

Ofri thinks the parallels between healthcare and aviation are limited because of the complexity of human physiology.  While checklists may be helpful for procedures, doctors ascribe limited value to process checklists that guide their thinking.

Malpractice suits do not meaningfully reduce the medical error rate

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.  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.

Hospital management culture is concerned about protecting the hospital’s financial interests against threats, including lawsuits.  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.  As a consequence, it is estimated that fewer than 10% of medical errors ever come to light.  There is no national incident reporting system because of the resistance of providers, hospitals, and trial lawyers.

The reality is a malpractice suit is not practical in the vast majority of cases of possible medical error.  The bar is very high: your doctor must have provided sub-standard care that caused your injury/death and resulted in quantifiable damages.  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.***** 

Desirable cultural attributes for reducing medical errors

In Ofri’s view, culture includes hierarchy, communications skill, training traditions, work ethic, egos, socialization, and professional ideals.  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.  This must be taught by example and individuals must demand comparable behavior from their colleagues.

Providing medical care is a team business

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.  Leaders must encourage criticism, forbid scapegoating, and not allow hierarchy and egos to overrule what is right and true.  Where practical, training should be performed in groups who actually work together to build communication skills.

Doctors and nurses need time and space to think

Doctors need the time to develop differential diagnosis, to ask and answer “What else could it be?”  The provider’s thought process is the source of most diagnostic error, and subject to explicit and implicit biases, emotions, and distraction.  However, stopping to think can cause delays which can be reported as shortcomings by the tracking system.  The culture must acknowledge uncertainty (fueled by false positives and negatives), address overconfidence, and promote feedback, especially from patients.

Errors and near misses need to be reported without liability or shame.

The culture should regard reporting an adverse event as a routine and ordinary task.  This is a big lift for people steeped in the hierarchy of healthcare and the impunity of its highest ranked members.  Another factor to be overcome is the reluctance of doctors to report errors because of their feelings of personal and professional shame.

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.  In addition, there should not be any bias in how penalties are handed out, e.g., based on status.

In sum, Ofri says healthcare will always be an imperfect system.  Ultimately, what patients want is acknowledgement of errors and apology for them from doctors.

Our Perspective

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.

Her suggestions for a safer healthcare culture echo what we’ve been saying for years about the attributes of a strong safety culture.  Reducing the error rates will be hard for many reasons.  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.  The biases in decision making that she mentions are not trivial.  For one discussion of such biases, see our Dec. 18, 2013 review of Daniel Kahneman’swork.

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.  You are more responsible for your own care than you think.

*  D. Ofri, When We Do Harm (Boston: Beacon Press, 2020).

**  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%.

***  It has been suggested that the term “error” be replaced with “adverse medical event” to reduce the implicit focus on individuals.

****  Ofri believes genuine conversation with a patient is the doctor’s single most important diagnostic tool.

***** As an example of the power of money, when Medicare started fining hospitals for shortcomings, the hospitals started cleaning up their problems.

A Culture that Supports Dissent: Lessons from In Defense of Troublemakers by Charlan Nemeth

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.

Going along to get along

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)

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)

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)

“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)

Dissent adds value to the decision making process

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) 

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) 

Dissent must be authentic, 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)

Alternatives to dissent

Other, less antagonistic, approaches to improving decision making have been promoted.  Nemeth finds them lacking.

Training 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)

Classical brainstorming 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)

Demographic diversity 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)

The devil’s advocate 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)

Dissent is not free for the individual or the group

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)

Our Perspective

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.

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 April 17, 2018 review of his book Principles.  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.

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.

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. 

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.

Bottom line: This is a lucid book written for popular consumption, not an academic journal, and is worth a read. 

(Give me the liberty to know, to utter, and to argue freely according to conscience. — John Milton)


*  C. Nemeth, In Defense of Troublemakers (New York: Basic Books, 2018).

**  Kennedy learned from the Bay of Pigs fiasco.  He used a much more open and inclusive decision making process during the Cuban Missile Crisis.

***  For example, Daniel Kahneman’s research reported in Thinking, Fast and Slow, which we reviewed Dec. 18, 2013.

IAEA Working Paper on Safety Culture Traits and Attributes

Working paper cover

The International Atomic Energy Agency (IAEA) has released a working paper* 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.

Individual Responsibility 

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.”

We applaud the positive mention of “diverse thinking.”  We also believe each individual should have the duty to report unsafe situations or behavior to the appropriate authority and this duty should be specified in the attributes.

Questioning Attitude 

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.

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. 

Communication

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.

Leader Responsibility

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.

“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.

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.  

Decision-Making

“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.

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.

Work Environment 

“Trust and respect permeate the organization. . . . Differing opinions are encouraged, discussed, and thoughtfully considered.”

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.

Continuous Learning 

The organization uses multiple approaches to learn including independent and self-assessments, lessons learned from their own experience, and benchmarking other organizations.

Problem Identification and Resolution

“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.”

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?

Raising Concerns

The organization encourages personnel to raise safety concerns and does not tolerate harassment, intimidation, retaliation or discrimination for raising safety concerns. 

This is the essence of a Safety Conscious Work Environment and is sine qua non for any high hazard undertaking.

Work Planning 

“Work is planned and conducted such that safety margins are preserved.”

Our Perspective

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.

Bottom line: This concise paper is worth checking out.


*  IAEA Working Document, “A Harmonized Safety Culture Model” (May 5, 2020).  This document is not an official IAEA publication.

**  Including IAEA, WANO, INPO, and government institutions from the United States, Japan, and Finland.

***  See, for example, our August 1, 2016 post on IAEA’s document describing how to perform safety culture self-assessments.  Click on the IAEA label to see all posts related to IAEA.

Requiescat in pace – Bob Cudlin

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.

National Academies of Sciences, Engineering, and Medicine Systems Model of Medical Clinician Burnout, Including Culture Aspects

Source: Medical Academic S. Africa

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) committee report* looks at one likely contributor to the patient harm problem: clinician burnout.**  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.

The Burnout Problem and the Systems Model 

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)

The NASEM committee’s systems model has three levels: frontline care delivery, the health care organization, and the external environment.  Frontline care delivery is the environment in which care is provided.  The health care organization 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 external environment includes political, market, professional, and societal factors.

All three levels contribute to an individual clinician’s work environment, and ultimately boil down to a set of job demands and job resources for the clinician.

Recommendations

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)

The report presents six recommendations for reducing clinician burnout and fostering professional well-being:

1. Create positive work environments,
2. Create positive learning environments,
3. Reduce administrative burdens,
4. Optimize the use of health information technologies,
5. Provide support to clinicians to prevent and alleviate burnout, and foster professional well-being, and
6. Invest in research on clinician professional well-being.

Our Perspective

We’ll ask and answer a few questions about this report.

Did the committee design an actual and satisfactory systems model?

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.***

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 goal conflicts, 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)  Decision making (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).  Compensation, 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.

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.

Does culture play an appropriate role in the model and recommendations?

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.

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. 

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. 

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)

Are the recommendations useful?

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.

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.


*  National Academies of Sciences, Engineering, and Medicine, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” (Washington, DC: The National Academies Press, 2019). 

**  “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)

***  As an aside, the word “systems” is mentioned over 700 times in the report.

****  “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.

More on Mental Models in Healthcare

Source: Clipart Panda

Our August 6, 2019 post 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.

We’ll use a 2014 article* 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.   

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.

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 ideal system, not with the actual 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.

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 not 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 too rigidly following them.

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.”

Our Perspective

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. 

The hospital as formal bureaucracy

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 formal bureaucracy.  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.

Employees have two major strategies for avoiding blame: strong occupational associations and plausible deniability. 

Powerful guilds and unions 

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.

Hiding behind the procedures

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 plausible deniability, the ability to avoid personal responsibility, i.e., blame, by hiding behind the established practices and rules when negative outcomes occur.

An enabling environment 

The environment surrounding healthcare allows them to continue providing a level of service that literally kills patients.  Data opacity 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.  Weak malpractice laws are promoted by the doctors’ guild and maintained by the politicians they support.  Society in general is overly tolerant 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.

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.    


*  N. Leveson and S. Dekker, “Get To The Root Of Accidents,” 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.

**  The article is tailored for the process industry but the same thinking can be applied to service industries.

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.