Although I’m not much of a risk taker, from time to time I take my mountain bike off the beaten track. This time, not such a wise choice. I ended up in thorned bushes. The sudden loss of speed made me tumble over. Normally you would use your legs to brace yourself against a fall. However, because I wasn’t alert enough, I failed to remove my cycling shoes from their clips and I fell over, hitting my shoulder on a tree root. Lying there in the thorns, I had no consideration for anything other then getting away from there. Happy that my bike was working just fine, I rode home.

In the weeks and months after this event, I hadn’t given it much thought, until one evening during volleyball practice. In an attempt to hit a scoring smash, I swept my left shoulder up to aim, and hit the ball with my right hand: great point! And … an excruciating pain in my left shoulder. No more practice that night. But, like with the mountain bike accident, I forgot about it. The next few practices, the pain came back every time I used my left shoulder, especially, while blocking.

Finally, I decided to go and see my family physician, who forwarded me to the hospital for a shoulder scan. Conclusion: a piece of my shoulder head had been pulled off by my tendons! Clearly, I needed surgery.

Recognize this?!

That you take things lightly when it comes to your own health?

My wife does 😉

Months after the initial incident in the bushes, I underwent two-and-a-half hours of surgery with the goal of putting the small piece of bone back on my shoulder head. After surgery, I was taken back to the nursing ward and awakened from my anesthesia. Later in the afternoon an X-ray was taken to verify the results, which would then be discussed with me.

The surgeon came to my bedside and told me, with the red of shame on his cheeks: “The X-ray shows that something went wrong! I don’t know exactly what, but the surgery has to be redone.” This was clearly not the desired result.

Immediately the next day I was operated on again, where they found out that the repaired piece of bone was in the wrong place. They corrected its position and sewed me up again, only to find out a few days later that my left arm was paralyzed! *

All bad luck, a medical error or a management mistake?

It’s commonly accepted and “unavoidable”, that sh*t happens! So, for most people my case of getting injured and then experiencing a bad operation, twice, is all just bad luck!

But what if you were the patient in this case? Or the surgeon?

My case clearly shows that people directly involved, like patients and their care givers, are strongly committed to “manage”, and if possible, correct any bad outcome.

But what about managers? I had no contact with a manager in the hospital, nor did my surgeon, during any part of my process. Not even to problem solve afterwards.

I know they have managers, but if they have no role in “managing” what happened to me, what is their role? What do they manage?

When I ask people, “What do you manage?” the answer is often, “My budget, production and/ or other (financial) results. If actuals are not in line with my plans, I take action.”

The problem with this results-oriented management approach is that you only find out in retrospect whether things went well or not. Managing by results is like driving your car while only looking in your rearview mirror. You only see where you have been, but not where you are going. This creates dangerous situations. Especially when the road changes unexpectedly, at a threshold or a curve.

What if you were managing the process, not the results?

When driving your car, you mostly look in front of you, to see what’s coming. You watch the road, your dashboard and over your shoulder, when you’re about to change lanes.

Imagine the fuel level light in your car indicates that your tank is almost empty. Then you fill up before you come to a stop. You manage the process, not the results.

What would happen if you would manage the above case full of “incidents” as a process?

Maybe I wouldn’t have ended up

• in the bushes,
• shoulder first
• ripping it later
• finding the surgical mistake after the fact
• undergoing a second surgery
• with a paralyzed arm
• in medical burn-out

If anything, this case makes clear that it’s important to manage your health by managing your personal everyday processes. When you fail to manage your process (because you are human so you do sometimes), it is very important that hospitals don’t fail to manage theirs.

If you manage your hospital processes, instead of just your results. You would for example have taken X-rays during my surgery, not after I woke up on the ward. You would have detected and corrected the error immediately, if and when it occurred.

What are you managing?

And how does this help you to avoid mistakes and hurting your patients?

Arnout

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