Who done it?!

2 June 2021

Arnout Orelio
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It’s not easy to admit, but even in the health care sector things still go wrong, regularly. Think of medication errors, post-operative infections, misdiagnoses, … , or as happened to me: a shoulder operation that had to be redone the next day, during which a nerve in my arm was damaged.

Usually patients, doctors and the hospital resolve this mishap, together, to everyone’s satisfaction. Sometimes this is not the case and the ‘mistake’ develops into a disciplinary case (or a “claim”).

A study by the Dutch research institute Nivel (2019) shows that physicians often feel criminalized, attacked and angry during a disciplinary case. Resulting in negative consequences for their health and functioning. Quite understandable, as usually the trigger for a disciplinary case is that ‘the victim’ and/or their relatives feel misunderstood, disagree with the proposed approach to their “case” and/or are highly emotional. This impedes a dialogue and so an independent party, such as the disciplinary board, is asked to make a decision. This then has repercussions on the doctor, who more easily feels personally attacked by the other party. The question from that point on is no longer “what went wrong?” but “who done it (wrong)?”

Of course, we all want disciplinary cases and claims to lead to the prevention of errors in the future. But they seem to be used mainly to “get even”, “get our way” or “punish the guilty”.

Are we overshooting the mark by putting blame first?

“Employees are responsible for only 6% of problems, 94% stem from the system”
W. Edwards Deming

Preventing mistakes requires that we learn from them. That seems to be hampered here because:

  • Sharing information is no longer in everyone’s interest.
  • When blame is proven or disproven, the analysis is done.
  • The focus is on the “big” incidents.
  • People are less open to feedback.
  • The vast majority of causes, namely those in the system, are mostly ignored.
  • This ensures that the opportunity to learn is actually lost once it comes to a disciplinary case.

What can you do to ensure that “mistakes” do not lead to conflict and disciplinary cases, but to continuous improvement and learning?

In 2004, Mrs. Mary McClinton died at Virginia Mason Medical Centre (USA) because of a medical error: she was injected chlorhexidine instead of contrast medium. Both fluids are transparent and were in similar stainless steel trays.

VMMC’s response was 180 degrees different than usual:

  • They gave full disclosure of the error, including to the media.
  • They sought to “blame” the healthcare system, a management responsibility, rather than healthcare professionals.
  • They developed a patient safety alert system to signal and deal with all deviations and (near) incidents as soon as they surfaced.
  • Every year they still honor Mrs. Mary McClinton.

This has had an enormous impact on their safety culture and the number of incidents: these have been greatly reduced.

The example of Virginia Mason, demands a lot of leadership from the hospital’s management. This raises the question: “how can you – as an individual physician or manager – prevent people from feeling blamed and therefore not being more open to learning from the “mistake”?

How does fact-finding and problem-solving work when people on your team are stressed, frustrated or angry? When you and a team member are looking at the same situation from different perspectives? When you have performance issues that turn into conflict between people?

Recently gave an interview to share how I help emerging leaders pursue evidence-based leadership.

Interview with Arnout Orelio

First of all, stick to the facts!

How people feel and how they think about the situation at the moment is also part of the facts. Accepting this for the moment helps tremendously to have empathy for all involved.

There are two important (lean) leadership skills for sticking to the facts, helping you to turn mistakes into improvement and learning.

Deep observation at the location of the problem (Genchi Genbutsu”)

One of the most important values in a (lean) improvement culture is “Genchi Genbutsu”. This is Japanese and means: Go to the actual place yourself and investigate how things really are with your team, your processes and the problems you are trying to solve. It is the way to ensure that you keep testing your assumptions with the actual situation. It helps you to make better decisions and you show that you believe that not you but the people who do the work are the knowledgable ones.

By observing, without judgment, you start to see the real problems and it becomes clear what the strategy should be to get better. The problems and causes will reveal themselves and there is an immediate opportunity to involve the team in the analysis and solutions. Leaving out judgment, makes room for the facts.

Ask questions

The most powerful tool for a leader is asking questions. If my toolbox could be limited to just one tool, I would choose “asking questions”. But then again, how do you do that?

In our culture, having answers is valued much higher than asking questions, so we tend to tell mostly. To engage others, build relationships and solve problems, asking questions and listening are much more important. At a conference on listening in health care, it was stated that 80% of diagnoses in patients can be made with listening alone. To this end, however, it is also essential to ask the right questions.

Open questions such as who, what, where, when, why, how and how often (also known as 5xW, 2xH) give us a glimpse into the mind of the other person. Asking these questions, in the workplace, in response to our own observations, allows for shared learning. And the answers can be tested immediately in reality.

Asking questions starts with your own attitude: one of humility (regarding one’s own knowledge) and genuine interest in the other person and their answers. As a leader, you are most effective when you have the attitude of a student, are curious and ask open-ended questions.

After you have identified the problem through observation and questioning, it is time to investigate what is causing the problem. Again, asking questions is very valuable. It is important to keep asking until you have found the source of the problem, the root cause. By removing the root cause, you can prevent the problem from coming back. Rule of thumb here is 5-times “why”. This means that you should ask “why is that?” at least five times in a row to get to the root cause. Because “why?” can be perceived as threatening or accusatory, it is probably better to ask “how come?” or “what’s the reason?”

At its core, it is all about wanting to learn and improve from our mistakes. Perhaps it is time for us too to hold the system accountable rather than the individual physician?

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