It is my goal to get the cardiac surgery program at Downstate back on track by providing the safest possible care to our patients. We’ve now had several meetings where I have explained my plans outlining “how”. To perform at the highest possible level, we need a team that is uniquely motivated and focused. Team members must all row the boat together in the same direction, all the time. Team performance is optimized by adopting effective ways of communicating and working together. I’ve seen these strategies transform other programs, but it leads to success largely by tapping into unique insights and wisdom of those on the team. There is no blueprint that can merely be applied as “one size fits all”. To get the team to contribute, its members must feel free to speak up about their ideas, thoughts and concerns.
During one of our debriefings sessions after a dry run simulation, one our most experienced team members did just that. She spoke up and reminded me of an embarrassingly obvious point. The cardiac surgical program at Downstate, like too many other academic cardiac surgical programs across the country, has endured many changes in leadership. Several surgeons have come and gone, which makes it hard to trust that things are all the sudden going to be different now. In so many words, she was saying that credibility has been depleted. She (and probably everyone else in the room and the NYDOH) needed to be convinced of the “why” before they fully endorse my recommendations for “how”.
The degree of commitment required for a successful cardiac surgery team cannot not happen without a leader that has tremendous credibility. The point she made was greatly appreciated. I should not just assume that my new chief title entails credibility. This is built brick by brick by putting focus back on the “why”. Motivating any group of people is a marketing problem. The first and most critical step is to convince them of why. No patient or referring provider should trust me as their surgeon if my team doesn’t accept why things will change from a history of mediocre results at Downstate. More specifically, the first task is not to explain how I can make teamwork better, but make the case why I would want to do so.
The first “why” to explain is my belief in the concepts of a high reliability organization (HRO). HRO operate a nuclear power plant, coordinate the flight deck activities on an aircraft carrier or the cockpit crew on a military helicopter or commercial airline with a near zero rate of errors. I’ve become convinced about the HRO strategies after reading much of the extensive literature about how HROs operate and more importantly after several in depth discussions about what really goes on by people on the front lines of these organizations. My first source of information was a medical student who took a position in my lab at Univ of Arizona and was a former Staff Sargent involved with heroic flight rescue operations in Afghanistan. I’ve also had dinner with a Blackhawk helicopter pilot in the Airforce, Captain Bob Remey and many long discussions about this topic with my best friend from childhood, Kepley Stonestreet, a Captain in the Army who did 2 tours in Iraq. I met with the Director of Training at the Indian Point Nuclear Power plant, Nick Lizzo. I worked closely for 6 months with Robin Behl, who was a first responder in the fire service and as a paramedic. All of them told me essentially the same thing: the strategy that all HRO use for their extraordinary achievements is actually quite ordinary – excellent teamwork. Nothing more and nothing less is required. The commercial airlines in the US did not have a single fatal accident for all of 2017 and nuclear power plants have not had any accidents in the 40 years since Three Mile Island.
It seems like too simple of an explanation. Its not that excellent teamwork is easy to achieve, but its something that all of us have been familiar with starting from our first tee-ball games in elementary school. Players on the best performing teams know the point in the game they need to have a sense of urgency, a behavior known as situational awareness. They reduce unwanted variation, or standardize, because it allows them to better identify when improvisation is warranted for their mission. They foster a sense of psychological safety among team members so they will speak up about (and therefore correct) mistakes. They use cross checking to build redundancy and resilience after errors. I suggest that these simple behaviors are what make HRO teams perform close to flawlessly.
I have no specific knowledge of the leadership style of Downstate cardiac surgeons in the past, but my personal experience is that very few leaders of cardiac surgical teams are on the same page as an HRO. There has been widespread discussion about spreading the tenets of an HRO into healthcare. In my opinion, the most pressing area in need of change is the cardiac surgery operating room where the culture is often the most toxic. Many cardiac surgeons view teamwork as mere compliance with their demands. For a variety of reasons, the risks of cardiac surgery are higher than other fields, partly because elderly patients have more comorbidities than those who are younger. This is combined with an even more complex choreography of multiple disciplines needed for a successful outcome. Compliance with standards helps. But when it is overemphasized, the team’s ability to improvise, to be versatile and resourceful is hijacked and this fosters complacency. Team members afraid of getting punished often watch out for themselves in lieu of providing each other with mutual support.
Surgeons reading this picture of doom and gloom are quick to point to an inconvenient truth: most teams perform at a high level with this current, albeit flawed model of “teamwork”. The overall risks of cardiac surgery continue to improve every year as the result of better technology and shared best practices. However, the risk of preventable harm has not changed. I am suggesting that, despite the good outcomes in our field as a whole, we need a new model of teamwork to pursue the goal of zero preventable harm.
Why have hospitals allowed the culture in cardiac surgery to deviate so far away from an HRO? It is only possible because CEOs and other stakeholders in cardiac surgery drink the Kool-Aid that says heart surgeons are infallible. They too will point to outcomes that are deemed to be good enough. From the perspective of a hospital leader, if a technically gifted surgeon is all you need, then success is derived by the hiring and firing of surgeons. That is a psychologically satisfying explanation because it is something that can easily be controlled. In reality, this overly simple analysis creates a blindness to the ever present risks of preventable harm. The airline industry has changed after realizing that too many planes crashed due to preventable problems with communication or teamwork. Now, they hire and fire pilots on the basis of their leadership skills rather than just their technical skills. I suggest that hospital leadership will eventually adopt this view once the benefits of an HRO surgical team are driven from the “bottom-up”.
It may not make sense that a heart surgeon would want to give up the perks that come from being seen as infallible. For me personally, the fallacy of infallibility was exposed by several defeats in the pursuit of robotic heart surgery by myself and others. The problems with developing these programs were driven by what psychologists would describe as the classic “double bind”. On the one hand it was my drive for creativity and innovation that prompted my interest in robotic surgery. These personality characteristics are not common in heart surgery, which emphasizes standardization and conformity. This made me stick out from the crowd and, in turn, easier for my conservative colleagues to accuse as unsafe and at times reckless. On the other hand, what I needed was a safety culture that would make team learning of this complex new procedure as fast and safe as possible. Instead, I found a poor safety culture that likely dated long before the robot was ever introduced. My teamwork and communication skills were far too limited to allow me to know what I didn’t know. Without an expert coach, the early stage novice can’t be expected to know how or why to change.
Experiencing defeat was tough but drove me to take the first step towards meaningful change: to accept the reality of this double bind. This acceptance may have come as the last step in a series of bad decisions, but it was also the first and most crucial step towards fixing the problem. Defeat was a powerful driver for me to seek the help of my other team members. In the end, my past robotic programs weren’t a failure but a powerful lesson on why I needed the power of the team to achieve results only possible from an HRO. I sought out and fully accepted the principles of an HRO as the only way out of hell. By “fully accepted”, I mean the same type of acceptance that an alcoholic gets about quitting cold turkey after losing his job, family and freedom while sitting in a jail cell with a DUI. An acceptance to this extreme degree changes you. It illuminates a reality that things can never be the same way again.
Culture of safety surveys have consistently shown that surgeons and others in leadership positions perceive the safety culture as better than those lower in the hierarchy. That means that mainly those lower on the totem pole and less capable of initiating change are able to see the need for change. They compare the low risk of harm from a poor safety culture against the far more unpleasant idea of changing behaviors that are fixed in their ways. The benefits don’t seem to warrant the costs. Their calculus seems logical, but it leaves out the gravity of harming a patient in a way that was preventable. The OR team may not say it out loud, but they always know when a patient was harmed in a way that could have been avoided. When no one speaks up, it amounts to their tacit approval and the need to accept that things will not change, that “its the price of doing business”. The only way to resolve these conflicting thoughts is by making them conscious and speaking up at a forum such as a formal debriefing session. The trauma to the team caused by these events does not go away by ignoring it. In the end, conflicts persist and emerge later as fate. The fate is that they start to realize that everything is not being done to prevent bad things from happening to their patients.
Errors happen. We should learn from them rather than deny them. The paradox of choosing to be blind to facts is that it makes the team members feel better at the same time it increases their risk of being “second victims”. This realization is why there is an urgency to change and become an HRO team.
