Hawaii
under attack! Incoming missiles! People ran here and there.
Representative Tulsi Gabbard, always a bastion of sober
consideration, gathered her family in the bathroom. On Maui, Peter
Shenkin slept, thinking it wasn't worth getting up for. His partner
in gym ownership, Logan, out golfing when his party was flagged back
to the clubhouse, objected. “It's probably an error,” quoth
Logan, “and if it's not and we're going to be incinerated, at least
let's see if we can get a few more holes in.” Golfers are rarely
dissuaded from their chosen path.
In
the end, of course, it was an error, the origin of which was depicted
this way: one employee going off duty was presented on the computer
screen with the choice of two buttons, one saying no attack and one
saying yes attack. He chose the wrong one and the debacle unfolded.
Understandable calls for his head have been unavailing – Pete says
that in Hawaii, everyone is someone else's cousin and can be called a
“good guy” – and according to the Honolulu Star-Advertiser, he
has not been cooperating with the investigation. We'll see what
happens.
Aside
from the insight this event affords to the quality of Hawaiian
governmental organization – one of the states where implementation
of an Obamacare insurance exchange collapsed ignominiously to the
surprise of few – it reminds me of my experience in running a
pediatric practice. All practices are faced with the problem of how
to maintain and improve quality. How can we do what we are supposed
to do, what we want to do, what we need to do? How can we make sure
all our prevention is done completely and correctly, how can we make
sure our patients receive excellent customer service, how can we be
sure we diagnose correctly, follow up correctly, remember everything
we need to remember? It's a challenge not altogether different from
the one that faced Hawaiian Civil Defense, at which they failed so
miserably.
When
you come down to it, there are two basic ways to deliver high quality
and reliability. One we can call
Professional
Enhancement
(PE). PE aims to improve the knowledge, skill, and motivation of the
employee or the clinician. The other one we can call Systematic
Reengineering
(SR), where the focus is not on the individual but rather on the
system. PE aims to put things into the brain of the individual. SR
aims to put things into Standard Operating Procedures, which are
outside the individual brain, but exist instead on routines, on
paper, or in a computer.
In
medicine, clinicians tend to think in terms of PE. We are all used
to this, because this is what we were exposed to in all our years of
schooling and clinical training. Remember this, there will be a
test! Don't forget to put this in your differential diagnosis! Did
you check to make sure the referral was completed? They are all over
us, and we come to think we should be all over ourselves as we move
into practice. That is our SOP – remember! It's not bad training
per
se,
but it's incomplete.
Students
of organizations take another tack. While they are aware of the
requirements of knowledge, intelligence, and mindfulness of
individuals in organizations, they tend to think not primarily in
terms of PE, but rather in terms of SR. (Or sometimes not so aware,
as this from W. Edwards Deming: “Ranking
(of personnel) is a farce. Apparent performance is mostly
attributable to the system
that the individual works in, not to the individual himself.”i)
SR comes from the context of QI in industry, where establishing
regular procedures decreases variability, with the mantra
“do-it-once-do-it-right.” The SR approach finds recurrent
stereotypic situations within medicine’s endless complexity that
can be choreographed for standard execution with low variation, and
hence higher quality. SR introduces changes in how the system
operates by introducing such elements as care plans, flow sheets,
forms, and reminders, all of which could now theoretically be made so
much easier with Electronic Medical Records. (In practice, of
course, EMRs being the oft-reviled cumbersome obstacles that are best
avoided, not so much – but I'm sure that's temporary. Pretty
sure.) The goal of SR is for the clinical team to operate ensconced
in a system where the easiest thing to do is also the right thing to
do.
Those
familiar with the work of Danny Kahneman will recognize the
similarity of the distinction of PE and SR to his difference of
thinking fast and thinking slow.ii
If you do something routinely, it becomes a reflex and you don't
have to think very hard about it, you just do it automatically and
it's the right thing to do. As a matter of fact, thinking about it
can lead to a problem which in sports is called, somewhat
inelegantly, “the yips.”iii
Having a behavior embedded in a system within an organization is the
equivalent of thinking habitually, and therefore fast. When you have
to cogitate about what the right thing is to do, when you have to
search your memory bank, when there is nothing in the system to guide
you and no button to push or menu to bring up, that's the equivalent
of thinking slow, and is prone to error.
The
key to management and organizational analysis is to realize that both
approaches are applicable depending on the situation. For many
situations – perhaps for all situations where one can think of a
good system – SR is best. Clearly, for instance, narcotics control
is better handled by a computerized check-in-check-out system than by
education on the harms of addiction. In our own practice we
approached the complex question of asthma, where I was bedeviled by
clinicians opining “well, what I
like to do is....” Instead of the extreme PE approach leading to
everyone's taking his or own special path, we tried to have standard
approaches, where one check mark led to a bevy of actions that were
SOP for standard asthmatics. One check mark led to doing the right
thing at the right time every time – at least for those who
accepted the system. Docs are a tough crowd.
Some
say that SR is inevitably superioriv,
but it seems to me that this would be true primarily for stereotypic
situations – immunizations, for instance. PE needs to be the
primary approach of choice for human relations, complex diagnoses,
unique situations, and judgments as members of adaptive
organizations. Empathy is better achieved by education and
reinforcement than by signs on the wall saying “We Care.” As
clinicians we understand very well the non-SR behaviors of being
reflective, seeking the hidden meaning behind patient visits, and
continually trying to detect disease early from small clues.v
Clinicians remember when a stray piece of medical knowledge led to a
clever diagnosis, or when even in the midst of a busy schedule they
were patient with a patient and then made an important diagnosis. We
recall the meaning we bring to some patients’ lives, and
vice-versa.
This
is the core of traditional medical quality. Silicon Valley has a lot
to add to medicine – a lot! – but the day is far off when these
qualities will be replaced.
To
be practical, if you are involved in managing an organization, when
faced with a quality issue, the first question to ask is often, can
we put this into a systematic routine? If so, that's the way to go,
with the usual problems of implementation, including operator
acceptance and understanding. Sometimes, however, as with empathy,
the solution will not be SR, but rather PE. And likewise, if you
look hard enough, I think that very often the solutions will be a
mixture. If your problem is friendly reception at the front desk,
part of the solution will be education and practice on how to be
friendly, and some of the solution will be rewriting the job
description and finding good ways of measurement and feedback. Most
times, it seems that an artful mix is required.
Which
brings us back to the missile attack. What if this error had been
made in a hospital? My friend Paul Levy, former CEO of Beth Israel
Deaconess Hospital in Boston, is fond of recounting his intelligent
approach to error. If a nurse makes a dosing error, for instance,
and he or she is called in to recount the circumstances in the
process of seeking the root cause of the error, he likes to ask: “Did
you intend to do what you did?” It would be unusual for the answer
to be “Yes.” His inference, then, is that most often one should
seek the error in the system that led the nurse to give the wrong
dose. It can be something as simple as two vials of different
strengths that look virtually the same sitting side by side in the
refrigerator, leaving it to the nurse to make a difficult distinction
as to which is which. Fair enough – systems problem. Amazon, King
of Systems, fixes this by storing similar looking items at a distance
from one another. I often differ with Paul, however, in leaving it
at that and exonerating the perpetrator. Yes, it is expected that
people will make mistakes, but it is also fair to ask how often that
particular person has made mistakes, whether sloppiness in endemic to
that person, whether mis-assignments are habitually made by that
supervisor, etc. To me, it's always a mix.
So
if the non-cooperating nuclear missile attack declarer was confused
by similar looking buttons sitting side by side – basically, an
attractive nuisance – that's a systems problem. If there is no
second check necessary in sending out the attack notice, that's a
systems problem. If there is no way to expeditiously correct an
error in something less than the 38 minutes it took in Hawaii while
Tulsi Gabbard was cowering in her bathroom, when the governor knew
within 2 minutes that it was an error but couldn't tweet out a
correction because he forgot his Twitter password, that's a systems
problem (not to mention a Governor problem.)vi
Instead of calling for the head of the careless employee, it's the
head of the system designer that should be called for. Differing
with Paul, I'm always looking for incompetence, and in this case the
probability that the job was awarded to someone with a connection,
this being Hawaii.
Or,
if the employee, despite his inevitably being somebody's protected
cousin, if he continues to be uncooperative, it's entirely possible
that he could suffer not from the original act, but because of
obstruction of justice. Yes, it's a system, but in the end, systems
are manned by people, and everyone has to take responsibility.
It
will be interesting to see what happens, especially as the one-term
Governor is being challenged. It will be interesting to see if
anyone is implicated, and if anyone suffers anything, and if an “A
team” is brought in to fix the system, à la Obamacare, and if
people then wonder why there wasn't an A Team in the first instance.
But
in the end it was only the public who suffered. And poor Tulsi in
the bathroom. No heads will likely roll, cousins will keep their
jobs, and another contract will be let to a putative A Team, headed
by someone else's cousin. Hawaii....
Budd
Shenkin
iDeming
WE, The New Economics for Industry, Government, and Education.
1994, MIT Press, Cambridge, Massachusetts.
ivShojania
KG, and Grimshaw JM. Evidence-Based Quality Improvement: The State
of the Science. Health Affairs 2005; 24:138-150.
vMiller
WL, McDaniel RR, Jr., Crabtree BF, et al., Practice Jazz:
Understanding Variation in Family Practices Using Complexity
Science. J of Family Practice 2001; 50: 872-878.
