But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Monday, July 7, 2008

A lesson from Tom

I have received many thoughtful comments below about our wrong-side surgical error, but there is one that deserves some special attention. It is from Tom Botts from Royal Dutch Shell, and I repeat it in its entirety here:

Paul: thanks for having the courage and commitment as a senior leader of a large organisation to role model open and honest dialogue when a mistake is made. Surely that is the best way to ensure learning takes place and improve the chances that the same mistake will not be made in the future.

I am a senior executive in the oil and gas industry, and we work incredibly hard to ensure our operations are safe, every day. But sometimes mistakes are made and we have to be aware of systems and behaviours that discourage open and honest dialogue (people fearing there is more to lose than gain by being open). The short term result of transparency is often a lot of second-guessing and finger pointing. But it's important we break through those barriers, as you are doing, and decide to stay focused on the longer term goal of learning and preventing future mistakes.

In my business, we had a tragic incident several years ago where two men lost their lives. 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, and to get a clear picture of the system that produced the fatalities. Even though the two men that were killed could have made better decisions, my senior leadership team and I could find places where we “owned” the system that lead 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 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.

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. I wish you full success in your learning journey and encourage you to stick with it!

While I really appreciate Tom's point about having the courage to disclose errors, he may overstate the fortitude needed to do that. In fact, one could argue that in today's media environment, it has become more or less standard "crisis management" practice to disclose corporate errors. Admittedly, the medicine and the hospital world is slow to adopt that approach, but it is likely to do so more and more.

The real courage is the one shown by Tom and his team: 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. Please understand the personal context for him, as explained by our mutual friend Jessica Lipnack:

As head of Shell's UK operations at the time, Tom staked his reputation on safety in this very dangerous industry. A massive campaign ensued. You couldn't walk through a vestibule in any of the facilities without seeing a video about safety. There were signs everywhere. From the largest areas of risk - on the rigs - to the smallest - walking down the hall with a hot cup of coffee without a lid on it, people were encouraged to help one another be more safe. I can recall being reprimanded (in a helpful way) a number of times for not holding onto a railing while climbing stairs, this on dry land in a completely stable building, not even on a seaborne vessel.

Then, unbelievably, two young men died on a rig. They'd gone down into what is called a "leg" of the rig without the proper safety equipment. One was 22, the other, perhaps 30 or so. Very young. Completely unnecessary. Despite everything Tom and his safety group had done, despite training, equipment, and extensive conversation.

The one thing I recall Tom saying is this: He was most surprised by his own faulty thinking, that everything he believed about how something like this could happen was plain wrong, that he had false beliefs about learning, and that he couldn't believe that he'd gotten to that point in his life and been so dead wrong. And this is a person who thinks deeply about organizations and how to change them.

I don't believe we have yet gotten to that point here at BIDMC. Sure, we believe in disclosure and transparency. Sure, we have established superb goals for patient quality and safety. Sure, we have instituted an important program to improve the work place and reinforce the value of every person working here. But these are baby steps along this journey.

When I say "we", I mean myself, our clinical Chiefs, and our senior management team. I don't think we are sufficiently self-reflective yet to question our own underlying assumptions and frameworks about how people learn, how bad habits are erased, and how flexible and thoughtful good work habits are created. The standard to which we should be held accountable by our Boards is whether we will grow to learn the lesson presented by Tom and his colleagues. And will we do it fast enough to avoid unnecessary tragedy in this hospital.

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