Wednesday, September 26, 2012

Leaders fail: The blame game continues

Salem witch trial: No defense possible in this court
If hospitals ever hope to create a culture of continuous improvement, the people in charge need to learn how to help people learn from mistakes rather than blaming them when mistakes are made.  Again and again, we hear stories that indicate a failure to realize this fundamental leadership lesson.

Witch hanging:  The result of hysterical blame for ill fortunes
One case occurred last year, an error regarding a kidney transplant at UPMC, where a surgeon was demoted and a nurse was suspended for what was later diagnosed as a series of systemic problems in the organization. Another had a more tragic turn, when a Seattle nurse committed suicide months after being disciplined for administering a fatal dose to an infant, again in an environment with underlying systemic problems.

I quote myself from the blog post describing that last story:

My regular readers know that my former hospital faced a similar issue following a wrong-side surgery. Would we punish the surgeon and others involved in the case? We decided not to, not because they had suffered enough themselves from the error, but because we felt that a "just culture" approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses. The head of our faculty practice put it well:

If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are.

Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job. As Tom Botts from Royal Dutch Shell commented about deaths on one of his company's oil rigs:

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.

It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.

But here we go again.  NBC News reported from Ohio:

A nurse who accidentally disposed of a living donor's kidney during a transplant said she didn't realize it was in chilled, protective slush that she removed from an operating room....

[The hospital] said poor oversight and communication and insufficient policies were factors in the kidney's disposal, which prompted the voluntary, temporary suspension of the hospital's living-donor kidney transplant program and led to reviews by health officials and a consulting surgeon hired by the hospital.

The medical center suspended two nurses after the incident; one was later fired, and the other resigned, the hospital said. A surgeon was stripped of his title as director of some surgical services, and a surgical services administrator put on paid leave has resumed work.

Witch cucking justice: If you survive the dunking you must be a witch
As in the UPMC and Seattle cases, is it possible for anyone working in this hospital to read these three paragraphs and not say, "There but for the grace of God go I"?  Think about how the leadership approach that was employed will drive reporting of errors and near misses underground.

The hospital's actions reflect a failure of the leadership to recognize its role in the problems.  Contrast that with real leaders, like Tom Botts mentioned above, and Paul Wiles, former CEO of the Novant Health system, discussing preventable infants' deaths in one his hospitals:

My objective today is to confess.  I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties [by focusing instead on the traditional set of executive duties (financial, planning, and such)].

If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.

Marty Makary recently wrote about the persistent level of errors that occur in hospitals, decrying the lack of progress in quality and safety improvement.  When you read stories like this one from Ohio, you have no doubt of one major contributing factor, leaders who don't understand what Wiles has stated so eloquently.


Richard said...

Paul - well said. The failure to be personally accountable is running rampant in many aspects of our lives – from finance to football… The reality is that in healthcare, in our hospitals, the end game is a lot more important.

I have been fortunate to spend time with Linda Galindo who wrote The 85% Solution

Her work is a reminder that when we use phrases like “personal” before the word “accountability” it resonates more with us as leaders, instead of being able to put it in the third person, as if accountability is something you do to people as oppose to taking it for yourself.

Personal accountability is the willingness, after the event, to answer for the outcomes – good, bad, indifferent and ugly. Standing around blaming, pointing fingers and doing the “woulda, shoulda, coulda” is a complete waste of time, money and other resources – not to mention the fact that in the space of healthcare it is reprehensible for the patient, family, caregiver and others that are impacted by error.

Personal accountability becomes a natural way of leading when you acknowledge that, as leaders, we are the culture, and every day we either choose to empower ourselves and take the personal ownership to commit to results, or not – the beauty of this is that the choice is ours. If the choice is that we like what we see and want to keep blaming others, as so eloquently stated by Paul Wiles, those talents may be better placed elsewhere. If it is to be it is up to me…

Thanks Paul.

RalfLippold said...

Many thanks Paul for your thorough and emotionally touching story. What counts in a car plant for a faulty car, or just a part, may lead (as described) to loss, or severe damage of human life.

Seeing the systemic dynamics is not what is taught nowadays at school, university or upper levels - so one can not blame the individual, nor the system. What becomes clear that the individual entrenched in the system has almost no chance to gain a broader view in order to learn about the possible impacts of his/her action in the context of the system.

What has brought me to writing this comment, and in the first place pulled me into reading your story is the double attendance at Hans Werner Henze's "Wir erreichen den Fluss / We come to the River". The story though playing in war times, pretty much shows the unintended impacts of individual behavior on a system (due to the structure, and the mental models at play in this system). Perhaps my review (even though in German) can bring another facet into the understanding what makes leadership decisions, and behavior today in changing times, even more important than ever.


Best regards from Dresden

Anonymous said...

This is beside the point, but there HAS to be more to the story in that Ohio case. NOTHING leaves the OR, not even a bag of trash, until the case is done and the patient is out of the room. Ever. (if the sponge count is incorrect at the end of the case, everything in the room is searched to find the missing sponge; in most cases, it has been simply misplaced or accidentally tossed, not left in the patient.)

Bill said...

From a quality and safety chat room:

This presumably was an extremely rare event, i.e. it has not been reported previously. As such it is extremely unlikely to occur again even without any intervention. As a result any intervention is virtually guaranteed to be successful, i.e. the event will not occur again. Then the investigation and the intervention will be declared to be a success, if anyone even tracks the post intervention period.

Does anyone remember "may your house be safe from tigers"? In most parts of the world that wish will be successful.

Brian said...

It was beyond discouraging to read the hospital’s response. I guess we can’t expect a complete culture change yet, but how many examples do we need?

Anonymous said...

To Bill; 'rare event' depends on the width of your definition of similar events. In my hospital, an axillary lymph node dissection on a cancer patient was once thrown out with the trash instead of sent to pathology - granted, not the exact same situation, but the system problems leading to it may be the same - or they may not! And that's the problem, there is never enough public information for these judgements to be made. As regards this case, a newspaper article today said a Texas transplant surgeon hired to investigate stated there were no systemic or cultural problems to indicate the hospital might be at risk for such an incident, and that the nurse had not followed standard surgical procedure. Now, on what basis might he be making that judgement? I doubt there are standards to back up either component of that statement.
Since we are never given the full story (or, not till months later), learning opportunities are quashed early.


e-Patient Dave said...

Beyond agreeing of course with your view, I'll note that my wife is the ninth-great-granddaughter of Rebecca Nurse (Nourse) (Wikipedia), the last woman hanged in the witch hysteria. Her home still stands in Danvers, MA, formerly known as Salem Village.

Of peripheral interest is the genetic right-ear deafness in the family, affecting my wife and many relatives. (A family reunion could serve as a hearing aid store.) Some accounts say the last straw, to the judge, was her failure to answer some questions. The judge sat at her right. (Who knows if that was a factor.)

I'm not an expert on the history but as I recall, the next woman accused by the children happened to be the governor's wife. At that point he decided enough was enough. It appears that wife was quite lucky that her husband liked her.

Doug said...

In reading the article below from the Soccer America Daily blog, I am reminded of the many times you note a martyr of transparency that helps make the next step in improvement possible. Thanks again,

Ref who missed England goal favors GLT

Jorge Larrionda, the referee who failed to see a shot by England's Frank Lampard cross the goal line at the 2010 World Cup, says he's in favor of using goal-line technology (GLT) to aid match officials. Uruguayan official was running the middle during England's 4-1 loss to Germany in the first round that featured a Lampard shot clearly landing beyond the goal line after hitting the crossbar but not ruled a goal.

Hired by FIFA to help train top-flight referees, Larrionda admits he suffered through a difficult World Cup. Yet he believes his error led to a positive change; the convincing of FIFA president Sepp Blatter that GLT was needed.

"It's for the global benefit of the sport,'' Larrionda regarding the use of technology. "It's all about protecting the game and to have credible soccer."

The Dec. 6-16 FIFA Club World Cup in Japan will test both the systems approved by FIFA: the British system Hawk-Eye that uses multiple cameras to track the ball, and the German-Danish project GoalRef that uses magnetic sensors in the goal frame to monitor a special ball.

Joannalyne said...

Very well said. I also work in a hospital and I think that the number 1 contributing factor to errors and near misses is the hospital policy itself. If the management will have a clear sense of responsibility and accountability, like Mr. Wiles, errors will be prevented.