Thursday, September 06, 2007

Lesson from Missoula

One of the most moving speeches I have read is one given by Don Berwick, the head of the Institute for Healthcare Improvement, at his 1999 annual symposium. It was entitled Escape Fire, and it drew lessons from a tragic fire at Mann Gulch in Montana.

Here is a summary from the link above: "When fire surrounded more than a dozen firefighters on the hillside, their leader had an unusual idea for survival. He burned an area of pasture around him and lay down in the dead grass in hopes the fire would pass over him (an escape fire). His team found the method too risky and refused to join him. Most of them perished in the inferno, while their leader survived. Dr. Berwick's message to health care professionals is that rejecting innovative ideas will have grave consequences on the industry."

I had occasion recently to visit the smokejumpers headquarters in Missoula, Montana. You would be hard-pressed to imagine a more dedicated group of people, who risk their lives by parachuting into remote areas to snuff out forest fires. As you can imagine, too, this is a group that pays a lot of attention to safety and that has a terrific record on that front. By any measure, we in health care have a lot to learn from them.

Imagine my surprise then, when I conversed with one of the crew and asked a simple question based a picture in the wall of the HQ. It showed a jumper leaving a plane in a "sitting" position, legs out front. I simply asked, "Is that the expected body position?" The man I asked said that it was a generally good position in that the aerodynamics tended to twist the person's body in the right direction to avoid tangling up in the airplane or other problems.

But then he said that for a tall person, the position could be problematic in that some percentage of the time, the aerodynamics would actually twist you in the wrong way, leaving the jumper a bit disoriented and his parachute apparatus in an uncomfortable position. So, he said, he learned to bend his legs up under his butt and take a more cannonball position leaving the plane. This would avoid the unexpected twist after leaving the airplane. Later, in talking with other jumpers, he learned that some of them did the same thing. So, there was an informal "rule of thumb" that was in play for some of the jumpers for many years.

Here was the interesting punch line: Notwithstanding the long-standing existence of this helpful informal knowledge, it has only been recently that this alternate form of jumping position was formally included in the smokejumpers' training curriculum.

The lesson for the rest of us: If an absolutely superb, tight-knit, highly focused, and disciplined organization like the smokejumpers occasionally experiences informal work-arounds to safety and quality issues -- with inherent delays in systemic education and improvement -- imagine the degree to which this occurs in complicated places like hospitals.


Anonymous said...

Oh, yes, this is very common indeed. Some quality organization once called it the "hidden hospital", I forget which one. It referred to the way the people in the trenches get things done by using an informal network of "doers" rather than the formally established system. Be interesting if management ever actually asked those people how best to do things, eh?

Anonymous said...

With respect to the Mann Gulch Fire (Levy Blog of 6 September) readers may be interested in a book on the fire by Norman Mclean (who wrote "A River Runs Through It"). It is entitled "Young Men And Fire" and is in print (Amazon) or, probably, in a local library. It is riveting reading.

Rob said...

The number one killer of EMR implementation is failure to acknowledge that very thing.

People resent being told to do something counter to what they've been doing manually. They resent that the computer is going to hold them accountable to a system that was already broken and not allow the workaround. They resent being left out of the logical, technical analysis that was completely blind to reality on the floor. Rightfully so.

Excellent story and analogy, and I'll pack that away in my kit.

Mark Turuk said...


How things 'officially' work, and how things 'really' get done. And yes, it happens, to some degree, in every organization.

Ideally, there isn't much dissonance between the officially sanctioned method/procedure and the unofficial work-around.

In some other industries, I've seen some of the 'old pros' hold on to unofficial, but very valuable knowledge, so that they have something to teach the newbs, and thus protect their status... not always and not necessarily in a bad way, it must be said.



EB said...

At a former hospital I worked at, an ED clerical supervisor had such an informal network of "doers" at the hospital, she could sometimes get things done faster than the CEO's assistant!

Christine G. said...

Folk Singer James Keelaghan wrote a song about that incident called "Cold Missouri Waters" which was later covered by Dar Williams, Richard Shindell and Lucy Kaplansky (all folk stars in their own right who banded together and did an album under the name Cry Cry Cry).

It is an amazing song. I prefer the Cry Cry Cry version to the original by Keelaghan.

Thank you for this entry and for reminding me of it. It has been a few years since I've listened to it, and will iTunes it here to pull it down and listen now...

Anonymous said...

Another angle on this is that complex organizations need to consciously manage the communication between their "core platform" systems and their "edge adaptive" systems.

Core platform systems are the ones that define the essential, longer term, pervasive processes that are vital to the smooth functioning of the organization and usually involve several functions or departments (e.g. how medications are dispensed). Edge adaptive systems are where the action is, where the experience actually happens. It is important that those working at the edge can take in new information and adapt behavior accordingly (e.g. the nurse notices that many patients have trouble swallowing bitter tasting tablet X, and that coating it in applesauce helps).

The key is to have mechanisms in place so that what is discovered at the edge (where innovation often occurs) is transmitted back to the core to be assessed and, if appropriate, incorporated and disseminated in a systematic way.

Mark Graban said...

The "hidden workplace" certainly exists in every industry!

We have to start encouraging employees to start fixing the systems instead of working around them heroically every day.

In the case of the jumpers, it sounds like they taught "standardized work," as we would call it from the perspective of the "Lean" methodology. But the standardized work wasn't sufficient for tall people. We need to test our processes and standardized work to make sure they really are sufficient and workable for all.

We need to create a culture where people are free to speak up and make suggestions about changing the standardized work, rather than keeping their improvements or workarounds secret for fear of punishment for not following the imposed standard.

Interesting stuff, the human dynamics of this all.

Richard Wittrup said...

It supports my observation of some years ago that what makes hospitals work is the determination of staff to do their jobs despite the obstacles that medical staff and management put in their way.

Anonymous said...

This issue, plus the comments, explain why one of the best managers I ever knew practiced what he called MBWA: Management by Walking Around. He'd talk to people and find out how things were going in the trenches. His division was the fastest growing in the company, and as they grew, the policies and practices were routinely aligned with what works.

Also, I was moved by Rob's comment about this issue blocking adoption of electronic medical records. I care a lot about EMR, and I never would have connected those issues.

Anonymous said...

An absolutely superb, tight-knit, highly focused, and disciplined organization like the smokejumpers occasionally experiences informal work-arounds to safety and quality issues -- and get away with it -- Only because their self-preservation instincts are fully aroused in the face of certain death and the primal bonding between the team members is difficult to replicate elsewhere without a fright & flight/or perish stimulus.The information sharing is cent-percent sincere.
But Yes, your observation is very acute and your point is well taken.

Anonymous said...

Hi. Been following your blog for a while. Nice mix of content. I must also recommend "Young Men and Fire" by Norman Maclean, a former University of Chicago literature teacher and the author of "A River Runs Through It." It is a beautiful exploration of mortality, by the the aging Maclean, a native of the area.



Anonymous said...

Another piece of random trivia related to mkeamy's comment: Norman McLean wrote "Young Men and Fire" while he was living in a fire tower, working as a wildfire lookout!

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