With undergrads at Northeastern University

It was back to Northeastern University today, this time to address Professor David Boyd's undergraduate leadership class.  You see him here with Caroline, one of the students who made a very good observation.  Pictures of two others are also included here.

Today's topic was the paradox of hospitals in America (and elsewhere).  Well-intentioned, intelligent, and well-trained doctors somehow participate in making hospitals extremely dangerous places to be.  (Listen to this story on Marketplace for more particulars on that topic.)

We spent a lot of time talking about the nature of medical errors. In particular we discussed the concept of normalization of deviance, explained nicely in this blog post by Steve Whitehead:

Each time a behavior or standard doesn’t lead to a catastrophic result, we are more tolerant of that standard.

It makes for an interesting contradiction. A history of success and positive outcomes does far more to erode our standards than a single negative outcome. The longer our success, the more normalization of deviance comes in to play.

Get away with doing something unsafe or substandard enough times and the unsafe and substandard become your standard.

Cognitive errors of this kind are rampant in organizations where work-arounds become the norm.  Each time some well intentioned, task-oriented person designs a work-around to overcome some obstacle in the workplace, it creates the potential for an unsafe or wasteful process.  Quality and safety in hospitals therefore requires a knowledge of cognitive errors and of the science of process improvement.  The leaders of such institutions need to create an environment in which mistakes and near-misses are cherished as opportunities to be "hard on the problem and soft on the person," rather than opportunities for blame and criticism.