One of the cultural shifts that the health care industry is currently navigating is a move away from a culture centered on blame for mistakes or errors, towards one centered on looking the structure as a whole to make health care safer. In the past, and to a certain extent this is still present in a lot of health care organizations, if someone forgets to run a test on a patient, the post-incident investigation centers on who is responsible for the error. Once the guilty party is discovered, they are disciplined. That marks the end of the investigation and the end of the incident.
But with the conversion towards a pay-for-performance model of healthcare, and with increasing concerns about medical errors and the devastating effects they can have, there are now calls to recognize that a single employee works within a system, and it is possible that an error or mistake is actually a sign of a broken system; if that is the case, disciplining the employee will not save the next patient, who is still being treated by the same system, and thus still at risk of experiencing the same error. Instead of stopping the investigation with the person who made the error, the investigation is expanded outward into a Root Cause Analysis, where you examine the system the person is operating in to see if something could have been done to prevent the error from occurring in the future. For example, if a test was not run on a patient, is there a way to prompt your CPOE to remind you to run it? If the error was the result of poor training, what training can be used to address this? These are the kinds of things you are looking for in an RCA.
To be honest this is not an easy culture shift to make, just ask any nurse who has tried to report a doctor making an error that puts a patient at risk. But it is an important step towards making healthcare safer and more effective, which is one of the primary goals in the switch towards the pay-for-performance model. But that begs the question how does one measure effectiveness? To look at that, you need to look at productivity, and that’s a whole new subject area.
Last weekend I was browsing through the Ted Talks website, when I found this fascinating presentation by Yves Morieux, a Senior Partner and Managing Director of the Boston Consulting Group’s Institute for Organization. In June 2015, Yves gave a wonderful presentation at Ted@BCGLondon titled How Too Many Rules At Work Keep You From Getting Things Done. (A word of warning…Yves has a very thick French accent. I had no trouble understanding him after studying the language in college and even studying abroad in France one summer during my university days, but if you are having trouble following him a transcript and subtitle option are available just underneath the video.)
Yves uses the analogy of a relay race to demonstrate how current measures of efficiency are actually counterproductive in the modern working world. In the race, the United States team is the favorite to win, because they have the objectively measured fastest runners. Two of the fastest women in the world are on the team. Their best times in previous performances beat the French relay team by 3.2 meters. And yet, when the race is run, the French team wins the race, despite being slower and having slower times based on best performances.
Why does this happen? It all goes back to what Yves calls The Holy Trinity of Efficiency: Clarity, Accountability and Measurement. Pointing out that business memos and business plans constantly call for increased clarity, in the case of the relay race this would mean that a runner would want the clarity of knowing exactly how far they were supposed to run…for example 95 meters vs. 97 meters. Once they reached that distance, regardless of whether the next runner was there to take the baton, the first runner would simply stop and drop the baton.
It is as though the runners on the team were saying, “Let’s be clear — where does my role really start and end?Am I supposed to run for 95 meters, 96, 97…?” It’s important, let’s be clear.
– Yves Morieux
Next comes accountability, which often times boils down to “Who can I blame when things fail?” To have true accountability in the relay race, Yves argues, you would have to put a dedicated person in between two runners, a person whose only job is to take the baton from the first runner and pass it to the second. That way there would a clear indication of who was responsible if the baton was dropped. As Yves points out, you would achieve accountability this way…but you would never win another race. What does this mean when you translate it back to the business world?
We are creating organizations able to fail, but in a compliant way, with somebody clearly accountable when we fail.
Next is measurement. In the relay scenario, Yves points out that in order to pass the baton, you need to put energy into your arm…which will come at the cost of energy going to your legs, thus your speed will slow down. In the business world, Yves also points out that people are only going to do what they can be measured on, as part of the accountability phase. If what you do cannot be measured by your employer, employees are unlikely to do it. Essentially, do to things that cannot be measured by these metrics to demonstrate either clarity, accountability or measurement is a risk…one the most employees aren’t willing to take.
This Holy Trinity, Yves argues, was great when the world was simpler. When businesses were simpler and value was easier to gain with a minimal amount of input. But the world has become too complex for the efficiency metrics we have in place, Yves argues. In that circumstance, the demand for clarity as the business becomes more complex results in the creation of more interfaces, more metrics, more layers. These weigh down productivity, and when overall results suffer we continue to add more layers of interfaces and measurements in an attempt to figure out what is causing the decrease. What is needed, according to Yves, is cooperation, which multiplies all of the efforts put towards an end in ways the metrics will never be able to measure.
Our organizations are wasting human intelligence. They have turned against human efforts. When people don’t cooperate, don’t blame their mindsets, their mentalities, their personality — look at the work situations.
This brings me back to Root Cause Analysis and the cultural transition within healthcare organizations. What Yves is arguing for is essentially what RCA and other culture change methods in healthcare are aiming to achieve; a thorough look at the systems that make up a facility, and how people work within that system. While other industries may be heading this direction as well, they are doing so in the name of profit or increased productivity overall. Healthcare organizations are doing so to increase safety and prevent adverse health events and errors that cause irreparable harm to patients, as well as to decrease the skyrocketing costs of healthcare. I think it is a fascinating change that I will continue to watch (and hopefully participate in) to see if it can help solve both declining productivity and increase patient safety.