The past decade made one thing clear about robotic cardiac surgery: it is a tough project to get off the ground.  Most attribute this to a long and hazardous initial phase where the performance of a robotic team gets worse before it gets better.  This is an agonizing and well-known issue with any innovation.  Start-up companies in Silicon Valley also have to deal with this period.  They call it “Death Valley”.  Surgeons have preferred a more euphemistic term: the “learning curve”.  A myriad of endpoints get worse – longer case times, more risk for complications, more bleeding, greater costs/case and problems with team morale.  There may be some role for training prior to initiating the cases on actual patients as a means of shortening the learning phase.  However, nurses, doctors, technicians, etc aren’t accustomed to learning in the classroom or on simulators.  They learn on the job through direct patient experience.  They know their performance gradually improves through trial and error.  The main downside of this method of learning is the error.   In the context of cardiac surgery, this can be lethal and puts overwhelming pressure on learning fast.  When it doesn’t happen that way, patients can be harmed.

It is often overlooked that robotic heart surgery involves learning curves outside the OR as well.  For instance, consider those in hospital administration.  Their job is to monitor the quality and profitability of all clinical programs.  A project as high profile, high risk and dynamic as robotic heart surgery poses a formidable challenge to this job.  Starting a robotic program means substituting a completely unknown procedure for a mature, highly reproducible open operation that has generated consistent quality and substantial profits crucial for running the hospital.

Most hospitals are highly conservative and static environments and have a culture that tends to be not very supportive of innovation.  In order to make decisions responsive to the needs of innovation, respond appropriately to dynamic conditions, and correct problems before they escalate, hospital administrators need information.  This information is hard to come by because CEOs and other executives often have no clinical background.  As a result, they rarely communicate directly with those on the front lines.  That hinders their ability to monitor the program in real time.  Absent this information, they become susceptible to the reverberating effects of a phenomenon known as the “hype cycle”.  This cycle describes the change in expectations over time at institutions that implement high tech innovations.  To summarize, there is over-enthusiasm followed by excessive disillusionment about robotic surgery before and after the results of its learning curve are revealed.  This creates a question whether robotic heart surgery is a viable project. Big shifts in expectations combined with unclear understanding of reality makes the answer to this question quite ambiguous.  Ambiguity creates complexity and means decision making is difficult.  There are a few rebel leaders that thrive on this ambiguity and see it as an opportunity.  They use it as a mandate to develop/enhance a new set of managerial and leadership skills.  But for most, ambiguity is a threat.  The bad habits of a typical hospital CEO come home to roost when the hospital attempts to adopt something like robotic CABG.  They just want ambiguity to go away.  They do this by denying it (ignoring a bad a program and allowing it to fester) or overreacting (cutting short a good program).

So it is the psychological makeup of hospital CEOs that hold the key to making hospitals more hospitable to innovation.  The blueprint for how CEOs can create change is widely available to those that are interested.  The first step is to completely reorganize both their daily tasks and long-term goals around the needs of innovation. They must help change the culture away from one that blames and shames the clinician(s) purported to be responsible for an error towards one that views error as an invaluable opportunity to learn and improve.  This would improve the lines of communication with the front lines, granting the hospital a more accurate understanding of progress (or lack thereof) and enabling better decisions about how best to support (or stop) the program.

Another important step is to improve the financial accounting of innovation.  Most financial analysts in healthcare have been reluctant or unable to consider the dynamic changes associated with costs of the learning curve,inherent inefficiencies of training and the opportunity costs of sticking with the status quo.  CFO’s at innovative hospitals know that not everything important is on the balance sheet.  They understand that investments in the learning curve are worth their weight in gold because they are the driving force behind culture change.  The problem is there is no easy way to quantify the impact of culture change.  So it becomes the type of expense that is frowned upon for CFOs that only consider the numbers.

A third critical issue for hospitals is to get better at learning from mistakes.  There is an evidenced base way to do this: promote better teamwork.  Teamwork is fostered by getting those on the team to speak up about their errors.  The impact of a team on learning is illustrated by the Buddhist story of “The Blind Men and an Elephant” that describes several blind men feeling what an elephant was like for the first time.  One felt the ear and said an elephant was like a fan.  One felt the leg and said it was like tree trunk.  Others said whip, sword, hose, etc.  The disagreements over what they were heated.  The poem concludes that the men “were each partially in the right and all were in the wrong”.  The surgeon is unable to understand what their elephant looks like without help from the anesthesiologist, perfusionist, nurses, techs and anyone else that is paying attention and cares about the patient’s outcome.  Good outcomes in cardiac surgery come excellent situational awareness and sensemaking.  This happens when all the right information is put together at just the right time, which promotes good decisions when the case suddenly shifts course.  Improvisation can’t happen when surgeons don’t listen to or seek out others views, often because they are too distracted by a challenging technical task (i.e. cognitive tunneling).  The same thing is true for CEO’s.

Effective leaders know they need input, so they promote “psychological safety” in order for speaking up to be encouraged.  Evidence suggests this phenomenon is not happening as much as it should in cardiac surgical operating rooms. Social scientists investigating the communications within cardiac ORs have documented twice the amount of conflict than in the ORs of other high risk specialties like neurosurgery.  One hospital tried to implement team training adopted from the airline industry in their cardiac surgery and neurosurgery ORs.  There was far less success among cardiac surgeons.  It is estimated that half of all cardiac surgical mortalities in the US are preventable due to issues such as poor teamwork and communication. The fact that the culture of cardiac surgery tends to be more harsh and unforgiving than other high risk surgical fields provides a plausible mechanism for these preventable deaths.

In my experience, there are three reasons why OR team members don’t speak up: 1) they are in some way punished when they do so, 2) they speak up and nothing happens, and 3) they feel their don’t have enough expertise or knowledge of the situation to warrant speaking up.  Fostering psychological safety helps address each of these problems but seems to be harder to foster in cardiac surgery than it might otherwise appear.

The hospital CEO is in the best position to change the current dysfunctional culture into an HRO for two main reasons. First, they are the ones responsible for recruiting, training, and motivating members of high performance teams.  The most powerful message is how CEOs hire, evaluate and fire their employees.  Airlines became highly reliable in large part once they started hiring pilots for their ability to lead the team and not just their technical capabilities.  Take a look at the online job descriptions of pilots for United and American.  Making these selections of who’s on your team the right way is what Jim Collins, the author of Good to Great, describes as beginning with “who” rather than “what”.  If you have the wrong people, it doesn’t matter whether you’ve discover the perfect strategy for your hospital to become an HRO. You still won’t succeed. Great vision without great people is irrelevant.

Secondly, CEOs establish the training required of their employees.  At an HRO this training is called crew resource management.  It focuses on making the crew assertive and as responsible for safety as the person in charge.  For instance, if a pilot is having a bad day and doesn’t want to go through the safety checklist, the copilot and others on the plane are encouraged and even obligated to stop the flight from taking off.  Hospitals have no such training.  Looking at how poorly they have trained clinicians on the use of electronic health records, I don’t expect this advanced type of team training to be part of any hospital’s core competencies for a long time.

Healthcare has fundamental flaws outside the influence of even the most dedicated CEO that block the HRO mindset from taking root.  The culture of medicine jealously defends physician independence and fights for the right to make unfettered decisions on behalf of patients.  Surgeons aren’t aiming to become interdependent on a team made up of hospital staff over which they have no formal control and is often not dedicated or trained on their procedures.  A common response to staff that feel empowered to challenge a surgeon’s decisions is that they are a hindrance to good care.  Leading medical teams is as complex as performing a surgical procedure but training in leadership skills is notably lacking in most U.S. medical schools, business schools offer these courses as part of their core curricula.  Absent this training, we adopt a dysfunctional physician leadership style based on “giving orders”.  This default command and control physician leadership style – the same one used in the military – has its consequences. It turns your team into sheep.

There is one thing that – more than anything else – would most likely make the change that is needed happen.  Take away control from hospital leaders that have no clinical experience.  In their place, put expert physicians in charge.  Please – no short cuts here.  Don’t just pick some doctor who decided to go into administration because they didn’t succeed in medicine.  We physicians know who among us are the true technical experts, the masters of medicine and surgery.  It is this expertise that will be the root of all their effectiveness leading physicians.  Extensive evidence proves that leaders should have expert knowledge in the core-business of the organizations they are to lead.

There are a variety of reasons why this expertise is necessary.  First, the greater a CEOs expertise, the more credibility he/she will have with medical colleagues.  This increases the chance of influencing physicians.  They are the lifeblood of hospitals because they control the core business: diagnosis and treatment of patients.  Non-clinical administrators may be masters at managerial skill, but this gains them no credibility with physicians.  So nonclinical CEOs often give up on physicians and steer their leadership focus onto nurses and other employed staff that respond to command and control.  This shift makes a non-expert CEO a more efficient manager but his/her core business is left without leadership.  Second, being an expert means that the CEO shares the same values of those he/she is trying to lead.  Those that come from the same “in group” have an increased interpersonal attraction and greater odds that they will be able to influence each other’s decisions.  As Steve Covey has argued, the best way to influence someone is to be willing to be influenced by them.  A third issue important to a CEO’s job is the need to set standards.  At an HRO these standards are incredibly high – zero preventable harm – which is a feat no hospital has achieved.  The mere mention of this as a goal is laughable unless it comes from an technical expert who knows what it takes.  A standard bearer must first be able to bear the standards.  Finally, a hospital board that hires a true technical expert sends a strong message.  They are making it clear that they are willing to step outside their comfort zone of hiring CEOs that are nonclinical.  It shows their own willingness to hire someone that is not like them.  This willingness to take a risk and think outside the box would be a welcome signal to physicians.  They just might not have to be written off as a lost cause anymore.

Innovation would thrive in this type of a hospital.