Building resiliency

What's the secret of building resiliency, the ability to withstand unexpected challenges, into your organization?  Lots of leaders I know take this attitude: "When the crunch comes, we'll deal with it. I'll explain that we have a burning platform, and the team will respond."

Well, yes, they will, but to the extent that you succeed in handling the crisis?  If so, will the team respond in a way that creates the potential for future success, or will the effort just get you through the crisis?

A recent story [subscription required] in the UK Health Service Journal shows what happens when an administrative fiat is issued to deal with a budget shortfall.  Excerpts:

The financial ‘stretch targets’ and emergency measures imposed by NHS regulators will fail to make significant inroads into the total provider sector deficit, analysis by HSJ reveals.

Providers had forecast a combined year-end deficit of £2.1bn at the start of 2015-16, which prompted Monitor and the NHS Trust Development Authority to order them to revisit their financial plans for the year in August.

Emergency measures were announced, such as a recruitment freeze for non-clinical roles, while many trusts were asked to work to new stretch targets or control totals.

[HSJ[ findings revealed that at least 13 of these organisations were not given stretch targets, while at least seven have declined to alter their plans. For three organisations, their positions deteriorated.

Contrast that experience with the one at my former hospital when we faced a budget crunch in 2008-9 because of the financial crisis.  For several years, we had built a culture to support a learning organization, one in which the staff felt empowered and engaged and encouraged to redesign work flows.  When the bad numbers hit, we asked people to consider whether they would be willing to make sacrifices to save the jobs of others.  They did, willingly and enthusiastically.

Brian, from finance, said:

Obviously, I want to keep this job. I’m sure I echo most people’s thoughts when I say that no one wants anyone else to be laid off, and we are all willing to do whatever is necessary to make sure that as few as possible actually lose their jobs.

Catherine, a nurse, offered:

I would be more than happy to forgo a pay raise and reduce my earned time if that would mean another person in the hospital could keep their job. I think this is a great idea and I hope my colleagues feel the same.

And Bernice, an MRI technician, agreed:

I would rather take the loss of my yearly raise than see a fellow employee laid off.

And another:

I know the next few months will be extremely difficult for all of us. But it is so comforting to know that the people I work with are not just sitting back and letting things happen.

After this afternoon’s meeting, we had our own “post-town meeting meeting” to review what you had said, and to toss around suggestions. I know those little meetings are happening all over the medical center. I have never been prouder of the people I work with and the hospital I work for.

The challenge also enhanced our internal sense of community.

Lois, a manager in our Department of Medicine, said, “I think we will learn much from the process. I even dare to believe that we will become a community of healing for one another, just as we are for our patients.”

The end result of this entire process was that we were able to balance the budget with hardly any layoffs. And much to our amazement, we achieved national renown for our hospital. Readers emailed a Boston Globe story by Kevin Cullen detailing the events to over 14,000 other people around the world. The story was also posted on the Yahoo home page for an entire day, viewed there by hundreds of thousands of people. ABC news, NBC news, and PBS all came to do feature stories, seen by millions of viewers.

The pride among our staff was palpable. Patients, too, felt a part of the story and helped spread the word. Here’s a note from Bob, who had had cardiac surgery at our hospital:

I just watched the NBC clip about the employees of BI. I must tell you how much I appreciated the care that I received from all of the folks who attended to me while I was recovering from my surgery. This is most true of the ‘low-level’ employees. The folks who helped me wash, brought me my meals and took me for my x-rays were all professional and courteous. For this reason alone, I am so glad to hear of the efforts all of the BIDMC employees to ensure that everyone can keep their jobs.

About a year and a half later, we were able to restore the salary and benefits to our staff, and even pay a small bonus when our business improved. Jerry wrote a typical response: 

I’m sure you were inundated with thank you emails for this bonus, but I felt the need to add mine to the list. I also wanted to mention that when I told my wife about this she said, “What a wonderful place to work. That would have never happened at my company.”

I’m sure the five hundred dollars will come in handy, but the fact that our leadership even thought of this is what makes BIDMC such a great place to work. We came together when times were tough, and now we are sharing the wealth as finances improve. To me this sounds more like a family than a workplace.

In appreciation: Vivian Li

The worth of a city can be measured in part by the caliber of the people who devote themselves to its improvement.  By that measure, Boston has much to credit from the engagement of Vivian Li as long-time head of the Boston Harbor Association, created to promote a clean, alive and accessible Boston Harbor.  Many have considered her the unofficial mayor of Boston's waterfront for the last quarter century, and that would not be a bad summary.

She's now off to new adventures in Pittsburgh, and there is a farewell celebration for her tonight.  For today, I'll skip her many accomplishments but rather focus on her approach and demeanor.  

I don't know of anyone in this city who has worked with Vivian who doesn't admire her and consider her a friend and colleague.  Those of us who worked at the Massachusetts Water Resources Authority certainly viewed her in that light. Invariably pleasant and respectful in her dealings--even in the most contentious disputes--she has approached her job with intelligence, judgment, and good humor. Her objective has always been to achieve the public good.  But her other objective has been to achieve a coalition for the public good, to build the institutional and community infrastructure to support the wise use of the waterfont resource. In that regard, her legacy will outlast her tenure at TBHA.

I join thousands who know her in wishing her well and happiness.  Pittsburgh, you've landed a gem!

Will no one rid me of this priest?

As we consider the leadership failures that led to the current debacle at Volkswagen, we can take a lesson from English history.

Henry II, facing a disagreement with Archbishop of Canterbury Thomas Beckett in 1164, is reported to have shouted out in frustration, “Will no one rid me of this troublesome priest?” Four knights heard what Henry had shouted and interpreted it to mean that the king wanted Beckett dead. They rode to Canterbury and did the deed.

This story exemplifies the term myrmidon. From this source, we get the following definition: "A loyal follower; especially: a subordinate who executes orders unquestioningly or unscrupulously."

One of the dangers for a CEO is the tendency for your subordinates to take what you say and execute it to a degree you never intended.

Now, let's take a quick look at the VW story, courtesy of the New York Times:

Martin Winterkorn, Volkswagen’s chief executive, took the stage four years ago at the automaker’s new plant in Chattanooga, Tenn., and outlined a bold strategy. The company, he said, was in the midst of a plan to more than triple its sales in the United States in just a decade — setting it on a course to sweep by Toyota to become the world’s largest automaker.

“By 2018, we want to take our group to the very top of the global car industry,” he told the two United States senators, the governor of Tennessee and the other dignitaries gathered for the opening of Volkswagen’s first American factory in decades.

One way Volkswagen aimed to achieve its lofty goal was by betting on diesel-powered cars — instead of hybrid-electric vehicles like the Toyota Prius — promising high mileage and low emissions without sacrificing performance. 

The determination by Mr. Winterkorn, the company’s hard-charging chief executive, to surpass Toyota put enormous strain on his managers to deliver growth in America.

Volkswagen officials now state that Mr. Wintrerkorn knew nothing of the regulatory cheating that his engineers had designed into the company's engines.  Some are skeptical:

“For something of this magnitude, one would expect that the CEO would know, and if he doesn’t know, then he’s willfully ignorant,” said Jeffrey A. Thinnes, a former Daimler executive who works as a consultant for European companies on compliance and ethics issues.

We may never know.  But what we can be sure of is that the myrmidons at VW thought they were carrying out the intent of the CEO.

Part of the school day

For several years, I've had the pleasure of expanding my role as referee of youth league soccer games to officiate in high school games.  Although covering some of the same age groups, there is a different feel to these school games.  School loyalties are different from town team loyalties.  Coaches are more often professional and paid rather than being volunteer parents.

One of the things drilled into the referees is that the matches are "part of the school day." We're told that the main value of the athletic endeavors is that they are part of the curriculum. The coaches, we are advised, have a teaching role, just like in the classroom. Indeed, many of the coaches are classroom teachers, too, during the previous hours in the day.  Our job is to defer to these teachers in matters of deportment and discipline (while of course officiating the game in a fair manner and one which helps ensure the safety of the teenagers.)

So, what happens to all that when the coach loses it?  When, in the excitement and stress of the match, he or she feels that calls are not going their way and when he or she loudly and persistently dissents from the calls made by the referees.

In youth soccer matches, the established ethic is that the coach shall not dissent, in word or deed, from the calls made by the referee.  Indeed, a coach can be disciplined--and even ejected--for doing so to excess.  Not so in the high school matches (except in very extreme cases.)  When the yelling begins, you maintain your composure as a referee and just continue to do your best.

I don't have a problem with that.  I personally have taken a lot more heat as a public official and CEO than I get from the sidelines of a soccer match.  I've had hundreds of people screaming at me in public meetings, death threats from aggrieved parties, not to mention really nasty commentators in the media.  I've learned to breathe deeply and go on.

No, the problem I have relates to the setting: The game is supposed to be part of the school day. The coach's role is that of a teacher.  What possible lesson is being taught to the students when the coach engages in obnoxious and disrespectful behavior to uniformed officials who main job is to use their judgment to maintain a fair and safe environment?  Who is there to remind the coaches that the circumstances of the game should not overtake their roles as mentors and role models for the children?

Blindfolds on? Good, let's lead.

My Australian friend Marie Bismark and colleagues published an article a couple of years ago about the role of boards in clinical governance in over 80 health service boards in the state of Victoria.  There was one remarkably revealing quote about the 233 board members who answered the survey:

Almost every respondent believed the overall quality of care their service delivered was as good as, or better than, the typical Victorian health service.

In an earlier article, Ashish Jha and Arnold Epstein found similar results:

When asked about their current level of performance, respondents from 66 percent of U.S. hospitals rated their institution’s performance on the Joint Commission core measures or HQA measures as better or much better than that of the typical U.S. hospital.  Only 1 percent reported that their institution’s performance was worse or much worse than the typical hospital. Among the low-performing hospitals, no respondent reported that their performance was worse or much worse than that of the typical U.S. hospital, while 58 percent reported their performance to be better or much better. 
 

Hospital Board Chairs’ Perceptions Of Hospital Performance, Compared With A Typical U.S. Hospital, On The Joint Commission Core Measures, 2007–08

Marie and her co-authors suggest:

A recognised cause of these so-called "Lake Wobegon effects" named after Garrison Keillor's fictional community in which all the women are strong, all the men are good looking, all the children are above average, is unavailability or underuse of reliable information on peer performance.

I'd go a step further. A couple of months ago, I recalled

a wonderful story from Amitai Ziv, the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv.  He relates how Israeli fighter pilots would return from their missions and debrief how things went.  The self-reported reviews of performance were very good.  Then, the air force installed recording devices on the planes, and it turns out that the actual performance was not nearly as good as had previously been reported.  The conclusion: It's not that people are poorly intentioned or attempt to mislead about their performance. It's just that we tend to think we are doing better than we actually are.  

I think the issue is not the unavailability of reliable information on peer performance.  I think the issue is a failure, in the first instance, to even measure one's own performance and to share that with one's own team. After all, the issue is not so much benchmarking.  That only goes so far.  As I've often said, there is no virture in benchmarking to a substandard norm.

So, the first step is to accurately collect one's own data and make it transparent to your own team. It is that transparency--more than benchmarking--that will establish the creative tension in an organization that will drive people to meet their own stated standard of clinical excellence.  A smart board does not have to apply pressure on its staff by drawing comparisons with others. Rather, they take governance steps to demand transparency, so that the deep sense of purpose that is inherent in the clinical staff is employed to stimulate the team to do better on their own.

"Visiting relatives can be annoying."

Noam Chomsky is one of the world's treasures, the greatest living expert in the field of linguistics.  When you get a hear him talk, it is like absorbing great music.  If you are like me, you don't grasp a lot of what he says.  After all, how do you even begin to assimilate his 60 years of research in the field into your own head as he presents his points of view and his evidence? Nonetheless, it is a wonderful experience, and I was so pleased to have a chance to watch and listen at an MIT seminar last week. What follows is a short exposition of what I thought I heard and learned! I follow with an extrapolation to issues of negotiation and leadership.

Turning briefly to the popular literature, Deborah Tannen wrote a great book a few years ago, called You Just Don't Understand, about how "women and men live in different worlds...made of different words." She demonstrated how miscommunication is rampant between the sexes.

Noam goes well beyond this characterization of communication problems. His view is that "language is not designed for communication." That's language, not talking.  Stick with me.  He points out that the development of the generative process for language formation that's in our brains was a relatively recent evolutionary event, occurring in the last 60,000 years or so.  It's evolutionary value seems to be mainly an internal one, providing us with a personal ability to conceptualize, plan, and conceive.  He posits that the mechanism of language is based on the simplest possible construction, "a minimalist computational system."

In contrast, the externalization of language through our sensory and motor systems--whether through talking or sign language or touch--has nothing to do with language formation.  Those sensory and motor systems existed for eons before language evolved.  Indeed, humans and apes have virtually identical sensory and motor systems.

The relatively primitive mechanism that maps language onto and through the sensory and motor systems is quite imperfect in presenting the concepts and ideas that our internal language creates. Accordingly, the recipient of the language does not get a totally clear picture of what the speaker means.  In the words of someone at the seminar, "So you're saying that language is there to let me think. Never mind about the listener." "Exactly," said Noam.

The title of this post is a highly simplified example.  "Visiting relatives can be annoying."  Is it the relatives who are annoying or is it a visit to relatives that is annoying?  The sentence is ambiguous even though the speaker likely has a clear concept in his or her mind.

I know it's risky to extrapolate from the deep philosophy and science of linguistics theory to everyday matters of human behavior, but permit me to take some leaps to fields in which you and I are involved every day.

So, let's leave Noam behind for a minute and acknowledge that most of the failures that occur in negotiating satisfactory and lasting agreements are often tied to miscommunication.  The ability of one party to fully understand the interests of the other and the resultant ability to engage in value creating deals often fall flat on their face because of a failure to communicate.  (Yes, I know that sometimes such a failure is intentional on the part of one party or the other. I'm talking about cases in which both parties have an interest in achieving a successful negotiated agreement.)

Likewise, leaders who attempt to carry out strategic initiatives for their organizations often find themselves frustrated by the staff's lack of commitment to those new directions.  Later they find out that their seemingly clear messaging to their staff was not fully understood.  (Yes, I know that sometimes people are recalcitrant. I'm talking about folks who want to be on board with the corporate direction.)

Those of us who teach negotiation and leadership often offer suggestions to people to help enhance communication and understanding. (Active listening is one such technique.) What I didn't understand before hearing Noam was how deeply embedded is not only the possibility of miscommunication, but the likelihood of it.  You don't have to understand all of his science to accept the conclusion that all of us have a special duty to expect--and try to overcome--the cognitive glitches that exist when we talk and listen.

"Our patients are sicker."

There are several archetypal lies in America (and other countries!):

"The check is in the mail."

"I'll still respect you in the morning."

"I'm from the government, and I'm here to help you."

"I'm from academia, and I'm here to clarify things."

And many in the medical world have now added:

"Our patients are sicker."

The last Lake-Wobegon-inspired one occurs when you present a hospital leader or a doctor with risk-adjusted data showing that their record on quality and safety is below that of other places.  (An accompanying phrase is often, "I don't believe the data.")

A study from the Annals of Surgery a few years ago (Volume 250, Number 6, December 2009)  refutes this view of the world.  A friend summarizes:

Some people thought that hospitals with higher mortality rates had higher complication rates, but that seems not to be the driving factor behind increased mortality, at least according to this study. Using the Medicare database, this group found that the risk of complications such as pneumonia, MI, hemorrhage, etc. after high risk surgery was only slightly different (36.4% vs. 32.7%) between high and low mortality hospitals; however, the risk of dying from a complication once it occurred (i.e. failure to rescue) was much worse in the worst performing hospitals compared to the best (16.7% vs. 6.8%). This failure to rescue was in fact the major contributor to the 2.5 fold increase in risk-adjusted mortality at the worst performing hospitals compared to the best (8% vs. 3%).  

The authors concluded that high mortality hospitals are "not as good at recognition and management of complications once they occur." Although data on what makes a hospital good at patient rescue is limited, much of it may be related to trigger systems, teamwork, nursing culture and availability of certain services as they outlined in their interesting discussion.

In summary, the way work is organized in a hospital and a culture of communication and respect matter, even if "your patients are sicker."

"I don't trust nurses."

At a recent training program in quality and safety improvement, one focusing on the topic of communication in clinical settings, a second year resident said firmly, "I don't trust nurses. I don't pay attention to what they say."

Now, this might be a case of extrapolation from something that residents are often told, "Don't trust anybody." In that context, "trust" is not used the way commonly understood. No, in that case, it means, "Do your own analysis of the patient's condition and don't assume that what you heard from someone else is still correct." That's fine.

But that wasn't the context of this young doctor's remark. Here, rather, was an affirmative statement about the value of nurses and about their judgment.

We could consider this an isolated case of an arrogant person and let it go at that, but I fear what we saw here is a more commonly occurring disrespect for those "underneath us" in many clinical settings, manufacturing industries, and service organizations.

Here's a story about a young, wise doctor named Michael Howell, excerpted from my book Goal Play!

Michael had some intuition about how to solve the problem of decompensating patients based on his literature review of articles from Australia. Early in 2005, he led a six-week pilot program on two medical wards and one surgical ward to test out his version of rapid response teams. Under this program, if a nurse notices that a patient has developed a certain condition, based on a standardized set of criteria (“triggers”), the nurse is required to call the doctor, the senior nurse in charge, and the respiratory therapist—and they all come to see the patient. They collaborate on a plan of care for the patient going forward. Regardless of the time of day or night, the intern/resident then calls the attending doctor in charge of the patient to let him/her know that the patient has “triggered."

Under Michael’s plan, the standard set of triggers is based on changes in heart rate, blood pressure, oxygen saturation, urine output, an acute change in the patient’s conscious state, or a marked nursing concern. The last one, “marked nursing concern,” means that if the nurse has any concern whatsoever about the patient, based on observation or instinct, s/he is authorized to call a trigger.

Well, it turned out that Howell’s program was incredibly effective. 

Over the course of the first year, the hospital observed significant reductions in “code blue” cardiac arrest events and a significant reduction (a 47% decrease) in relative risk of non-ICU death for our patients. Residents now needed to practice emergency resuscitation mainly in the simulation center because so few actual patients needed it. What a lovely problem to have. We also learned a lot about teamwork, communication, and systems of care as a result of closely reviewing our responses to called triggers.

Here's something else we learned over time. There were many objections at the start of this program from attending physicians and residents that certain "lazy" or "inexperienced" or "uninformed" nurses would use the RRT "marked nursing concern" trigger as an excuse to pass the buck on certain patients.

Well, we learned instead that triggers based on "marked nursing concern" (amounting over several years to 38% in total and 18% in the absence of other vital sign criteria) were as or more likely than the other categories to accurately reflect the fact that a patient was in trouble. Putting it another way, if we had not recognized the unique ability of nurses to be especially attentive to patients' conditions, a number of people at our hospital would have decompensated, perhaps leading to their death. (The 18% figure amounts to over a thousand patients during the five-year study period.)

When you think about it, then, the attitude reflected in the resident's statement--"I don't trust nurses. I don't pay attention to what they say."--is not just arrogant. It is negligent. Research of malpractice claims shows that a failure in communication is often a contributing cause to the error leading to a lawsuit.

As Kathleen Bartholomew notes: "When nurses and physician don't communicate, it's the patient who loses every time." A person who has decided that he or she will habitually ignore the information provided by another member of the team invites error and harm.

I surely never want to be cared for by this young doctor!  Who is more likely to have an accurate sense of the patient's condition than the nurse? After all, nurses are at the patient's bedside for much of the day, while doctors drop by from time to time. Attentiveness to a patient's needs cannot be measured by whether an "MD" follows a clinician's name instead of an "RN."

The magic ratio of 5:1

Those of us involved in sports coaching are often told that the most effective mix of positive reinforcement to negative comments is 5:1.  I think this ratio might derive from research in the 1970's by Robert and Evelyn Kirkhart.*  They found that children in classrooms thrived when the ratio of feedback was 5 parts positive feedback to 1 part constructive feedback. In contrast, children sunk into despair if the ratio fell down to 2:1 or 1:1.

Not just any praise worked.  It was more effective if praise was truthful and related in real time to a specific event. It also had to be sincere and credible to have an impact.

I'm told, too, that a video analysis of the practice sessions run by John Wooden, arguably the greatest coach of all time, showed that 87% of his comments were positive reinforcement. Hmm, about a 5:1 ratio.

By the way--and maybe (or maybe not) a bit off our topic today--it was John Guttman in the 1990s who extended the research to married couples, showing that marriages were considerably more stable if there were five times as many positive feelings and interactions between husband and wife as there were negative. Guttman termed this the "magic ratio."

By contrast, I know of many leaders who intentionally run their companies as "low praise zones."  When I was in the state government, one of my colleagues did so for his agency.  He berated people when they made errors (sometimes calling them late at night) and would seldom, if ever, give them praise for a job well done. Nonetheless, many of his managers adored him, were loyal to him, and did every thing possible to make him satisfied. The agency, by the way, was successful in its mission in many respects.

It appeared to me that these managers were engaged in a relationship pattern equivalent to that of a codependent abused spouse.  I've since seen it in other settings.

In the hospital world, for example, I've seen a chief of surgery who behaved in a similar fashion to my government colleague.  Nary a kind word would come out of his mouth.  He ruled with fear, anger, and disdain. And yet his underlings--whether attending physicians or residents--would suck it up and take it, almost as a badge of honor.  They remained intensely loyal to him.  The surgery department, by the way, was quite good.

In the music world, I've seen a conductor of the same ilk.  Sarcasm and mean-spirited gossip were his weapons of choice.  People who were the conductor's favorites on one day would discover that, on another, they were in the dog house. And yet, as above, the members of the ensemble were remarkably loyal.  The music production of this group, by the way, was excellent.

I'd like to say that the 5:1 ratio is the way to go to produce a team of engaged and creative individuals best suited to carry out the mission of an organization.  It troubles me to think that the Commander Queeg approach I've just summarized might work as well.  All I know is that it would make me extremely uncomfortable to behave in such a way, and so I've tended to attract managers who prefer my approach and who have accomplished great things in places I've led.

If you are a leader in an organization, where do you stand on the spectrum of 5:1 versus 1:5?
--
* Kirkhart, Robert; Kirkhart, Evelyn (1972). "The Bruised Self: Mending in the Early Years". In Yamamoto, Kaoru. The Child and His Image: Self Concept in the Early Years. New York: Houghton Mifflin. ISBN 0-395-12571-5.

Lessons from near misses

If our goal is to lead our places to be learning organizations, we must help our folks understand that near misses are gems that should stimulate us to focus on underlying process failure. Why? Well, for every adverse event that is reported in a service or manufacturing organization, there are literally hundreds of near misses.  Each one represents an opportunity to correct a systemic problem that could someday lead to a catastrophic event. Let's look at a recent example from health care.

Bud Shaw published a powerful and deeply disturbing story in the New York Times this past week.  Shaw, a surgeon, was at his daughter's bedside in the hospital when he recognized that she had a serious problem:

I’ve been watching the monitor for hours. Natalie’s asleep now and I’m worried about her pulse. It’s edging above 140 beats per minute again and her blood oxygen saturation is becoming dangerously low. I’m convinced that she’s slipping into shock. She needs more fluids. I ring for the nurse.

I know about stuff like septic shock because for more than 20 years I was a transplant surgeon, and some of our patients got incredibly sick after surgery. So when I’m sitting in an I.C.U. in Omaha terrified that Natalie, my 17-year-old daughter, might die, I know what I’m talking about. I tell the nurse that Natalie needs to get another slug of intravenous fluids, and fast.

The hospital's staff was unresponsive. Shaw broke into the crash cart and administered the saline solution himself. Luckily, things worked out.

After three days in the hospital, Natalie got better. A new chest X-ray showed that there was much less fluid in her chest. Her fever resolved. They changed one of the antibiotics and the nausea she had had all but disappeared. They told her she could go home. They prescribed antibiotics for her to take at home, and removed her IV catheter.

We could say a lot about this incident. The part I'd focus on is what happened after. Shaw doesn't say, but I'm willing to bet that there was minimal or no debriefing of this case by the hospital staff. I say that not because I know the facts: It's just that the pattern of behavior related by Shaw is indicative of a hospital that is well behind when it comes to clinical process improvement.

First, though, let's look at the science, things that are taught in every medical school and nursing school and every residency training program.  Failure to rescue is a major cause of mortality and morbidity in hospitals.  Its causes, though, are multifactorial and the condition often presents itself in subtle ways.  Patient safety expert Robert Wachter has noted:

Analysis of deaths and unexpected cardiopulmonary arrests in hospitals often find signs of patient deterioration that went unnoticed for hours preceding the tragic turn of events. (Understanding Patient Safety, page 283.)

How might the hospital's clinical leadership have helped people learn from this near miss?  The discussion must be set up to "be hard on the problems and soft on the people," making clear that the debriefing is not an investigation targeted at finding fault or assigning blame.  It is an examination of the elements of our work flow that could lead other well intentioned doctors and nurses to similar results in the future.  Let's look at just a few such elements that might be relevant in this case.

What was it that led us to premature closure in Natalie's case?  The symptoms were there to see, yet the doctors and nurses had decided that it wasn't serious. How can we improve our ability to avoid the cognitive error of diagnostic anchoring?

What could our team learn from the fact that a concerned parent could not get the staff to respond? Do we have a protocol in place to activate a rapid response team when key patient indicators warrant? Do we have a patient- or family-activated rapid response program?

Does we use any predictive analytic tools to assess severity of illness that can be tracked over time?

My late colleague Donald Schön once described a learning organization as one "capable of bringing about its own transformation."  This is a powerful concept. It suggests that sustained improvement in a place requires--almost as a Zen master might say--that change must come from within.  Near misses provide excellent opportunities for that kind of learning if the leader engenders a sense of responsibility to notice them and act on the information they offer.

A change

To my loyal readers:

I've been writing this blog for over 9 years, starting during my tenure as CEO of Beth Israel Deaconess Medical Center,  and continuing now over four years later.  During that time, I've had a chance to tell many stories and express lots of opinions with regard to various aspects of the health care industry, and you have rewarded me with your readership and your comments.  I am deeply grateful for that opportunity and for that connection with so many of you.

As my life has moved on, my other activities have evolved. While health care will always be an underlying interest for me (and anybody else getting older!), I am getting more and more distant from the day-to-day policy issues and industry struggles.  There are other people who are better suited to write about those matters.

So, starting after the Labor Day break, I am planning to shift the focus of this blog to topics where I might be able to contribute to people in a broader range of industries and sectors.  The focus will be on my core set of activities and interests--negotiation theory and practice, leadership training and mentoring, and teaching.  Some days, clinical process improvement will be covered, as that subject overlaps all of those topics--but you will not be seeing stories about health care policy, industry structure, market power, and the like.

I'm also going to reduce the frequency of these posts, from the current daily schedule driven by current events to something more sensible (and personally sustainable!)

I'm hoping not to leave my health care followers behind, but I am hoping that others, too, will find the topics of value.  Please continue to stay in touch and, as you have done so generously in the past, forward these links to others who might be interested.

Thank you.

MA Health Quality Partners display variation

Here's some nice work from the Massachusetts Health Quality Partners, a part of their Practice Pattern Variation Analysis (PPVA) program. There are 40 conditions identified by MHQP where they have identified significant differences in the use of medical services for similar conditions. The idea is that:

Clinical leadership can address the causes of the variation and determine whether the variation is clinically warranted, how to initiate change if it is not, and consider how the variation impacts quality, safety and cost. Through PPVA, the medical community can work  toward adoption of community developed standards and actions that will improve quality care for patients.

I think this is a thoughtful approach to variation, one that is engaging and respectful of clinicians.  I was interested to see this recent example:

One of the conditions MHQP's PPVA program identified as a strong opportunity to better understand variation was the frequency of ultrasounds during pregnancy.  

Major epidemiological studies on this matter have not been undertaken since the 1990s, when the equipment emitted only one eighth of the acoustic energy being emitted with today's modern equipment (2012 British Institute of Radiology). Moreover, an analysis of published literature released by the Cochran Collaboration on fetal ultrasound concluded that "routine scans do not seem to be associated with reductions in adverse outcomes for babies" (Cochrane Collaboration 2010).

In 2014 MHQP's statewide PPVA program  identified the number of ultrasounds after the first trimester in uncomplicated pregnancies as one of over 40 conditions that demonstrated significant practice variation among clinical providers.  MHQP engaged with Massachusetts Chapter of the American College of Obstetricians and Gynecologists and concluded that  for the Massachusetts commercial patient population, the average number of ultrasounds per uncomplicated pregnancy after the first trimester was greater than 4, with patients receiving between as few as 1 and as many as  9 ultrasounds per pregnancy.