Monday, August 10, 2015

Learning from Mistakes

Over two years ago, the folks over at the athenahealth kindly invited me to submit columns to their Health Leadership Forum, and I have done so on an occasional basis since them. As I recently reviewed the columns, I realized that my own thoughts on the topics of leadership and coaching have evolved a bit, and I thought my readers over here at Not Running A Hospital might enjoy witnessing the transition. So for several days, I will be reprinting the posts from the Forum over here. Comments are welcome at the original site and here. Today's reprint is from a post dated May 3, 2013, "Learning from Mistakes."

As a leader, you must do everything you can to encourage people to admit mistakes they have made and to call out problems they have found in the organization. (As Amy Edmondson of Harvard Business School similarly suggested in an earlier post). If people think they will get in trouble for having erred, or for having brought up a systemic problem in the organization, those errors and problems will go unreported. The person and the organization will thereby lose an opportunity to grow and improve. Accordingly, a strong commitment not only to transparency but to a just culture is essential to achieve continuous improvement.

Leadership’s role in such matters is determinative of process improvement in the organization. Equally important, it also empowers the personal and professional growth of people in the firm.

MIT Management Professor Edgar H. Schein has described the communications ethic inherent in such an environment as follows: “Team members have to learn how to analyze and critique their own and each other’s task performance without threatening each other’s face or humiliating each other. That means that subordinates have to learn how to tell potentially negative things to their superiors, and superiors have to learn how to not punish their subordinates for telling the truth if that truth is inconvenient. That, in turn, requires the ability to give and receive feedback in a constructive manner.” (Helping, How to Offer, Give, and Receive Help, Barrett-Kohler Publishers, Inc. San Francisco. 2009. Page 118.)

But true process improvement also requires leaders to go one step further, to take ownership of flaws in their organization. Paul Wiles, former President and CEO of Novant Health in Winston-Salem, NC, once told me and a group of hospital CEOs a heart-wrenching story about an infant’s death from sepsis in his hospital, which was tracked to an MRSA (antibiotic-resistant staph) infection. The infection was part of a spread of a bug in his neonatal intensive care unit (NICU) that reached 18 infants in all and may have contributed to the deaths of two others.

“This was a direct result of staff not washing their hands appropriately,” he said. Since that event, “We have been on a relentless hand hygiene campaign.”

The crux of his entire presentation was this comment: “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,’ ” he noted, by focusing instead on the traditional set of executive duties (financial, planning, and such). Wiles ended his talk to the CEOs in the audience, saying, “If you cannot see the face of your own relative in a patient, or if you cannot 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.”

But it is not just leaders in the hospital world who have come to these conclusions. Let’s head to an oil rig in the North Sea.

A number of years ago, Tom Botts was involved in a tragedy aboard an oil rig in which he personally had to call off the search for men missing at sea. Deeply shaken, when he later moved on to be Executive Vice President for Shell Oil Company’s exploration and production activities in Europe, he decided that he would implement the most comprehensive program possible to protect workers’ safety at these remote outposts in the ocean. Notwithstanding that new program—the best in the industry—two men lost their lives on a North Sea oil rig when they mistakenly went into a portion of the facility that should have been off-limits. It would have been easy to blame the two men who, after all, entered a prohibited area. Instead, Tom launched a thorough, top-to-bottom review of the organization.

He explained, “We decided to be as open and transparent about the incident as possible and went through a ‘Deep Learning’ journey involving hundreds of people that examined in detail all the root causes that contributed to the accident to get a clear picture of the system that produced the fatalities. Even though the two men who were killed could have made better decisions, my senior leadership team and I could find places where we ‘owned’ the system that led to the tragedy.”

“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 organization to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.”

Tom continued, “Once you take that step of committing to transparency and learning, it sets a high bar and it is very hard (probably impossible) to take it back. This approach has helped make us stronger and more aware of the impact of our daily decisions.”

Turning back to health care, Dr. Charles Denham wrote an article in which he related the practice of nursing chief Jeannette Ives-Erickson, Senior Vice President For Patient Care and Chief Nurse at Massachusetts General Hospital. When a nurse makes an error in caring for a patient, Jeanette calls the involved nurse into her office and asks one question: “Did you do this on purpose?” When the nurse answers, “No,” then Jeannette says, “Well then it is my fault… errors stem from system flaws … I am responsible for creating safe systems.”

Chuck notes, “In a few short moments with a caregiver after an accident, the leader declares ownership of the systems envelope, and the performance envelope of her caregivers, and creates a healing constructive opportunity to prevent a repeat occurrence.” (“May I have the envelope please.” Journal of Patient Safety. 2008 Jun;4(2):119–123.)

Chuck properly warns us that it is easy to “automatically fall in a name-blame-shame cycle, citing violated policies, and ignore the laws of human performance and our responsibility as leaders.” It is up to us as leaders to be mindful of the results of such behavior on our part. The bad example we set cascades through the organizations. Mistakes and near-misses go underground, as people fear that reporting will just get them into trouble. Opportunities to improve our systems are lost, along with the potential for personal and professional growth on the part of our staff.

In contrast, behaving like Wiles, Botts, or Ives-Erickson empowers those working with us. People evolve individually and collectively into a learning organization. Each person feels that he or she is valued, understands his or her place in the firm, and goes home able to say, “I accomplished something worthwhile today.”


Carole said...

Dear Father in Heaven
Putting you first and foremost, thank you for this answered prayer of many through Mr. Levy's given, and blessed position in life. I ask you to touch the readers hearts and their comments. And that they are read by the people, harmed patients, and the families who lost loved ones from medical errors you intended this for.

Mr. Levy
Do you really have any idea how special you really are? You are no accident sir, what you posted today is God's work and will. You know as well as I do there's power in prayer. Everything you think, say and do is because of that. I do want you to understand who you are and what you do makes a huge difference in the people's lives you touch every single day. What's amazing!! Is you're just getting started "Wow". I'm more than a reader I'm a believer.

Anonymous said...

I will be sending this on to some health care systems. BRAVO to those who have taken ownership and responsibility. Health care would improve in this country if they are all like that.

Thank you for an uplifting post showing some progress.

Paul Levy said...

Dear Carole,

Thanks, but I think you overstate by quite a bit my role and influence in all of this. There are many others who have been at it longer and more efffectively than I. But I greatly appreciate the thought.

Carole said...

Yesterday still broken-hearted, but thank goodness today is a better day because of hopeful and encouraging post like this one. Thanks to everyone who wants to make a difference, and does!

Mark Juckett said...

A nice description of a learning process that seems so simple to any kid or young adult learning a new skill, but hampered by the incredible feeling of shame and attendant protective response that occurs in the health care setting. I think the next frontier in open discussions and learning from experience is within the peer review process among physicians. While focusing on events, such as a surgical procedure, lends to a more simplistic evaluation of undesired outcome, the "cognitive" specialties such as rheumatology, oncology, and ICU care require more in-depth screens to find the opportunities to learn and perhaps a more open exchanges of ideas on how best to implement best-practice that does not seem well supported by hospital QI practice or physician groups. I hope the ongoing national focus on experiential learning, practice improvement and safety will enter physician peer review domain - particularly in non-procedural oriented specialties.

Bob said...

Great stuff.

I'm still concerned about the "Did you do it on purpose?" anecdote. People will be stupid and do stupid and careless things. (As you get higher up the chain, you expect and usually find that people are smarter and more attentive and the mistakes that are made at are a higher level of thinking. But that's another story.) So, if you are in charge of a system with people of lesser capabilities below you in the organization, is it incumbent on you to design a system that these lesser-capable people can operate flawlessly?

I'd say, no. You have to do your best to compensate for their deficiencies, but there will be instances inevitably where they have to be human and make good choices, no matter how well laid out the procedures are. When they fail, is it a systemic failure? Sometimes, but sometimes not. The "on purpose" thing gets to me somehow. Are we who are serious and take responsibility supposed to take all the blame for the idiots and unserious and unresponsible people who are supposed to be doing their jobs? We can huff and we can puff and we can motivate, and there will always be people who are just screwing up because they are dumb and/or unserious.

In the end it comes to the same thing, you look at the errors and try to redesign the system so that fewer errors are possible and fewer are made, and you try to bring everyone to the goal of the organization instead of their personal proclivities and desires.

There is always the split between the goals of the organization and the personal goals of those who work there. And you can only do so much to merge them. I tried to do that at Bayside, to tell our staff that they were in healthcare for a reason, and show how they were part of the team, etc., and it made a big difference, especially for those who were ambitious. But we all have our attention spans, we all have our tendencies to view things through our own narrow lenses, and in the end, a leader can't be taking all the responsibility when an employee screws up.

So, asking someone if they meant to do something, while it works as a heuristic because it leads to a good end, to me doesn't capture to reality of responsibility. It lets them off too easy. I'd say, the system needs to be strengthened to account for human frailty, which you (the nurse) have demonstrated in this instance. We'll look at the system, and you look at what you did and why.

Paul Levy said...

If you go through James Reason's just culture algorithm, he addresses just those points. The key there is for everyone to understand the algorithm so they know discipline or punishment won't be imposed in an arbitrary fashion. We were very explicit about such things at our hospital, and others likewise have been.

Unknown said...

This is a great article. Thank you for reprinting it and the ones that will follow. These stories show the benefit of the managerial style that accepts the responsibility for systems performance, quality and safety, and then practices double-loop learning with personal involvement and transparency as a constant approach to leadership. Your stories demonstrate that relationships matter. Leadership sets the tone for the culture in the organization and a culture of learning from mistakes requires an environment of trust which can not exist without leadership that is transparent, supportive and involved.