Top Five Indicators Your Hospital is Siloed (and What to Do About It)
Silos are helpful for storage of things like grain, cement, missiles or anything else that needs to be separated from outside influences (heat, moisture, pests, etc). A silo in a hospital, on the other hand, refers to a dysfunctional mentality that separates staff that work in one department from the influence of others. These symbolic ‘silos’ have no benefit. Their only role is to inhibit the alignment of those that work in a hospital from achieving its overarching goals. The most important and challenging goals – like improving patient satisfaction, safety, quality and even profitability – require systems thinking and wholehearted contributions from everyone for any chance of success. Human instinct focuses one’s work within small teams that think and act homogenously. It is an unnatural act to work with those that think differently. Based on these intrinsic truths, even the most severe case of silo mentality appears normal and would not raise red flags to those in charge. Identifying the silo mentality requires a proactive effort to seek out the signs. Here are the classic indicators that your hospital suffers from silos:
1) Patients: “the care here is so fragmented, the left hand doesn’t know what the right hand is doing” (the ‘right/left hands’ are the departments not working together)
2) CFO “our physicians cause too much waste” (often the CFO has not pinpointed what constitutes waste and explained that view to the responsible physicians directly: evidence of two departments not sharing information)
3) Nurses: “why do we need to use so many workarounds without ever fixing the problem” (workarounds are required to address problems that happen between different departments that lack accountability)
4) Managers: “meetings to solve the problem are great but my staff are too busy to attend” (systems thinking requires getting all stakeholders together in order to share their unique view of ‘the elephant‘)
5) Leaders: “staff don’t understand how their role influences our overall organization”. (the inevitable result of indicators #1-4)
Silos are a fixture in hospitals. There are a variety of reasons this happens, but most important is the insidious cultural incompetence of those in charge. Healthcare is by necessity a complicated mix of technical and managerial expertise that needs close collaboration between a wide array of stakeholders. Collaboration among the different specialties is not the default path. Instead, ingrown habits of technical and managerial experts lead them to focus only on their unique area of expertise. When such habits are left unchecked, a form of tribalism develops that is every bit as fierce as the cultural clashes seen between different religions, races, sexual orientations, political parties, etc. The deeper problem illustrated from this clash is that it is based on widespread unchallenged assumptions. For example, physicians, administrators and other hospital staff often use phrases like “us vs. them” and “not my job”. When they do, they provide clear evidence of the silo mentality (and therefore cultural incompetence), yet these types of comments remain commonplace and seem unremarkable. Imagine how different the reaction would be if the same staff used a racial slur or denigrated the religion of a colleague. Most of us are completely unaware of our silo mentality and how it causes certain data, counterevidence and other points of view to be ignored or discarded.
A excellent recent TED talk by Middleton introduced concepts important to cultural competency that help explain why silos have been so hard to solve. At the same time, her ideas point to the optimal solution for this dilemma. Her model is that each of us have core beliefs that are absolutely crucial to the identities of clinicians and managers. The more they demonstrate how loyal they are to these core beliefs, the more trust they gain from their in-group colleagues. Each group also has beliefs that are flexible, that are based in part on listening and learning from each other. The more they demonstrate this flexibility, the more the two groups gain the trust of each other. There are also what she calls “knots”, which are the unchallenged assumptions that each group has about the other that limit our flexibility. In hospitals, both physicians and administrators feel they need to protect the hospital from each other: administrators “don’t care about safety” and doctors “don’t understand finance”. It is important to understand when these assumptions cause us to miss opportunities. We will unlearn our false knots by engaging in multidisciplinary and cross functional teams to bring forward more innovative solution. The power of diversity on teamwork is well documented. It creates the necessity and collaboration needed to generate change.
Turning Safety vs. Profits Into a Fair Fight
Heart surgery is a complicated procedure done on unhealthy patients. Occasional bad outcomes are easy to understand. On the other hand, a bad outcome that was preventable is less acceptable. Examples of harm from preventable mistakes include giving a wrong medication because a verbal order was misunderstood, failure to correct an overlooked but important lab value, failing to intervene on a patient that is rapidly deteriorating, forgetting an important step in procedure. Oftentimes, other clinicians recognize missteps by their colleagues but fail to speak up in time. Even more disheartening is how rare it is for hospitals to learn from these errors so they can prevent them from happening again. These types of process and system flaws used to be common culprits of harm in other hazardous fields such as aviation, nuclear power and the military. But 40 years ago these fields all began to adopt the basic tenets of a high reliability organization (HRO). Once its rigorous methods of communication and teamwork were learned, it virtually eliminated preventable errors. It is impossible to find a plane, power plant or military team that does not lean on HRO tenets as its #1 guiding principle. Yet most hospitals –equally hazardous to these other fields – are a long way from becoming an HRO. Most fail to even acknowledge that errors in patient care are common within their walls. They do not have a blame free environment for reporting problems, so the most severe errors tend to remain hidden. They have been unwilling to commit resources to uncover and address system defects. They do not rank becoming an HRO anywhere near their #1 priority. The interesting question is why? Understanding how powerful concepts like this fail to spread in hospital is an often overlooked first step towards improving safety.
A major roadblock for becoming an HRO is tension between two fundamentally opposed ideas – whether the #1 priority should be finance or safety. For the late Paul O’Neil, former CEO of Alcoa, the answer was simple: safety. When you get safety right, the profits follow. This mainly happens because of the magic of engaged employees. Like workers in the aluminum industry, the hearts and minds of those in healthcare are won over when their leaders focus wholeheartedly on safety. That’s because it is a natural rallying point for teams. Full engagement in safety builds a wide array of habits in team members that cross-over to help drive profitability – clear communication, consistent accountability, follow-through, and a deep understanding of processes and system issues. A company full of engaged employees with all these skills led Alcoa to become the most profitable company in the industry.
As I’ve prosthelytized the HRO/O’Neill vision among others in healthcare, I’ve noted a surprising amount of resistance, particularly from hospital administration. Their main opposition is that safety as #1 is just not pragmatic. Hospitals must (at least at times) prioritize profits to pay bills and keep their doors open. An often-recited mantra of any business is “no margin, no mission”. They do not mean to ignore safety, but see it mainly as a tool to stay compliant with a myriad of regulations. Errors that are actually preventable are rare so going the extra mile to pursue a systems based analysis is unlikely to yield a good ROI. Instead, physicians are trusted to self-police those adverse events that are due to performance issues. A much more important priority for hospital leaders is to optimize the utilization of resources during routine care (e.g., control costs, avoid waste). Safety initiatives are reserved for when hospitals have finished making nursing and physician practices standardized and more productive. In a profit first culture, workers that are the most valuable do not report systems issues (e.g. poor staffing ratio, lack of supplies, lack of training). Instead, they become masters at using “workarounds” to get around chronic problems. Those that do report hazards to their supervisor are criticized as “complainers” and “not team players”.
Much of this debate centers on whether a safety culture can be sufficiently strong even if safety is not the #1 priority above all else. Isn’t it reasonable that there would be times where the hospital must first consider finances? To understand this debate, we need to consider what influences a safety culture. A culture of an organization is the sum of all the prevailing ideas of formal and informal leaders within an organization that address “how things are done here”. It is unimportant what the leaders say on this topic. Unspoken rules penetrate far deeper and influence the culture far more. It is precisely because these rules are unspoken that makes them so hard to challenge and change. Such rules emerge from a Darwinian struggle between conflicting priorities. Based on their training and experience, nurses, doctors and other medical personnel are the ones fighting for safety. In contrast, hospital executives are not clinicians, but businesspeople whose acumen lies in finance, fundraising, development, and politics. They advocate for cost control and/or profits. Since we know that all hospitals have a track record of safety far more mediocre than other HRO, it is fair conclude that the executives and their ideas won the battle of natural selection. Many assume that proves the pragmatic financial approach was the fittest in battle of ideas and that O’Neill’s vision (i.e. safety is the best way to a profit) is just not applicable to hospitals.
A medical culture that emphasizes perfectionism is another hang-up exploited by profit advocates. Physicians have been trained to view the common culprit of safety hazards as the one standing at the front lines. From this frame of mind, the best response to an adverse event is to eliminate that “bad apple” or provide remedial instruction. Blame and shame of the culprit is viewed as an effective intervention while efforts to learn from errors and seek out the underlying system defects are viewed suspiciously as trying to avoid individual accountability. The legal system benefits from pinning the blame on a single individual, reinforcing this “bad apple” theory. This idea allows administration to wash its hands of the system defects that cause harm, mitigating a potential driver of costs. Therefore, it is coadopted in lock-step with the idea of profits as #1 priority. This constellation of thoughts may be at odds with the modern understanding of errors, but it continues to be rapidly adopted because of its roots within the culture of both medicine and corporations.
On closer inspection, there flaws in the reasoning of these last two assumptions. For one, surviving a battle of the fittest is not proof that an idea was best. Sometimes wrong ideas win. Many people have the idea to consume alcohol, junk food and even illicit drugs even though it clearly is not healthy in the long run. History is replete with wrong but prevalent ideas rapidly infecting a culture like a virus of the mind. Second, the success of an idea is heavily influenced by the political power of its advocate. The hallways of hospitals are filled with the ghosts of physicians, nurses or other clinical staff that have been fired for being overzealous about safety. Being fired this way means that the advocate (and others watching in fear) no longer contributes to the development of a culture. The administrator lives on and gets to select a more compatible nurse or physician. This battle is not a fair fight of ideas between equals but better characterized as one between predator and prey.
Now turn to the relevance of O’Neill’s vision about safety in hospitals. His safety-first idea was fiercely advocated by Alcoa leaders, not just followers. Hospital leaders can’t do that because most would not know where to begin. They have a chasmic gap in their knowledge about how safety could improve the bottom line. If executive and clinicians were willing to learn from each other, their separate priorities might coevolve, merging into O’Neill’s view. However, coevolution requires two competitors that start out on equal footing, which is rarely the case in hospitals. In predator-prey interactions, the need to change and adapt is asymmetric with prey having to change more. Consider the Rabbit and the fox. The laws of natural selection guarantee that over time the average rabbit evolves to become faster than a fox, yet the fox doesn’t have to change at all. This is because their stakes are different: a rabbit that is slower loses its life while the slower fox merely loses its dinner. Physicians that push too hard on the safety agenda are like the occasional a slow rabbit – they become the prey that get eaten. This leads to a culture that may not ignore safety completely, but achieves the same lackluster levels of success seen in the aviation and nuclear power industries prior to their transformation into an HRO in the 1980’s. It certainly does not see safety as a key to profits like Alcoa. Mr O’Neill himself resigned from his position on the governing board of a major hospital in Pittsburgh after it showed no incentive to listen to their rabbits.
One thing changes the dynamic with predators – dangerous prey. The ability of prey to fight back forces natural selection onto predators, causing coevolution. Physicians will counterattack executives from time to time, mostly with poor results. The politically savvy and successful clinicians often employ the stealth tactics of a virus. Under conditions when the host is healthy, a virus is content to spread at a low enough rate to avoid provoking an immune response. However, once the host starts to shows signs of deterioration, it rapidly attacks and overwhelms the host. Likewise, wise clinicians lay dormant until a crisis occurs, like a sentinel event (e.g. wrong site surgery, accidental overdose, death of a low risk case). These events are most often caused by system errors/defects like poor communication, ineffective leadership and/or bad planning, thus providing a ripe opportunity to make the case for safety. They are also a rare chance to point fingers at the executives who are responsible for keeping these system defects in check.
The ultimate irony is that profits and safety are never mutually exclusive in any business. Once safety is prioritized, profits inevitably follow. Hospitals have twice as many reasons as Alcoa to be concerned about safety. Preventable errors cause harm to both their employees and customers (patients), which make O’Neill’s vision and its potential to drive engagement/profits twice as applicable to hospitals. In addition, a strong culture of safety prevents the wide array of hidden costs. Less preventable harm translates into reduced hospital costs, less risk for legal or regulatory sanction, higher staff morale/lower turnover and improved reputation in the community. The problem is that hospital leaders without a clinical background have no way of measuring costs that are hidden. The ease of measuring profits is why finances are the top priority. However, choosing to prioritize profits just because its easier to measure is called the “lamppost error” and causes neither profits or safety to be realized.
Constructive discussions over how a hospital ranks its most important priorities could not be more important. It is in the interests of the hospital community as a whole for this debate to be seen as credible. The tendency to use political discourse as the platform has most definitely been seen as unfair, unbecoming and lacking in legitimacy, mainly because the opposing sides do not enjoy equal political power. When governing board ranks safety as its number #1 priority, that dynamic changes immediately. That one decision would force hospital executives to stop paying lip service and find a real way to collaborate with clinicians and others who are the best position to create an HRO. Safety is not about motivation but about priorities: what is ranked at #1 is what gets done and only one idea can be #1. There will be plenty of ideas about safety that don’t work out, but the key is to develop dyad relationships across the divide that are able to quickly figure out the ideas that do. We don’t need Darwin to tell us which side wins in the long run once the fight is fair.
Why Do We Need a Checklist for Cardiac Surgical Cases Lasting More Than 6 Hours?
I am writing this post so that circulating nurses in the cardiac surgical OR understand the rationale behind my idea for “yet another checklist”, a proposed timeout at 6 hrs after starting a case. I recognize that this is a change in our routine practice. Such changes can be met with resistance. I welcome your feedback, particularly your thoughts on how my ideas outlined below are off-track.
Let’s start with the obvious. Standard operating times for cardiac surgery are 3-5 hours. More technically complex cardiac surgery cases, something other than a CABG or low risk isolated valve surgery, might require longer times in but rarely exceed >6 hrs. Excessively long cases demand levels of physical and mental exertion from the surgeon and anesthesiologist that can lead to fatigue and frustration, eventually taxing the patience and temperment of the whole team. Once this happens, the team can lose situational awareness, meaning they are lost. A variety of things can be done well beforehand to reduce this risk. Complex cases should be planned out appropriately – scheduled electively well in advance and not after hours or the weekend and a team should be provided that has extensive experience working together. A multidisciplinary discussion among a preoperative Heart Team committee is often useful to optimize the preoperative work-up and fine-tune the intraoperative strategy. In some cases, a short period of preoperative hospitalization for medical optimization and respiratory and/or physical therapy reduces the risks of surgery (known as prehabilitation). All this proactive planning undoubtably helps.
However, the best laid plans often go awry, particularly during prolonged complex cases. Such cases illustrate the wisdom of Mike Tyson who once said: “everyone has a plan until they get punched in the mouth”. Nothing punches the team in the mouth and renders its preop plans more useless than cases violating all expectations by lasting >6 hrs. Yet many teams fail to recognize the hazards of this 6 hr threshold in real time; its signals are often ambiguous – the patient’s blood pressure, extent of bleeding and acidosis and even the degree of tension among the team are abnormal but not so off-track as to provoke obvious alarm. The surgeon, who is best equipped to recognize how problemmatic the case has become, often fail to communicate that fact to others on the team that could help. This happens because everyone, even an expert surgeon, demonstrate a paradoxical response to increasing levels of stress. Moderate stress improves performance. While optimal stress can lead to “flow”, a state that absorbs one’s full attention and makes one lose track of time, further increase in stress absorbs even more attention in a way that causes cognitive tunneling. This hyperfocus steals both technical abilities and clinical judgment by making the surgeon blind to issues readily apparent to others in the room. OR team members hesitate to speak up to the surgeon because it is difficult to discriminate whether he/she is engrossed in a state of flow or completely lost in the weeds.
All this can lead to wide array of hazards that are often overlooked by the increasingly distracted surgeon and other members of the surgical team:
- Leg ischemia – Cardiac surgery often uses a perfusion cannula placed into the femoral artery. Because this cannula can obstruct the femoral artery, it is placed here under the assumption that the case will not be prolonged beyond a time in which ischemia might become a problem (i.e >6 hrs). When the case unexpectedly prolonged, the chance of clinically significant ischemia in the leg downstream of that obstruction rises significantly. An unexplained lactic acidosis or red discoloration of the urine (myoglobinuria) are often the telltale signs of that happening.
- Leg reperfusion syndrome – If the perfusion cannula is removed from the femoral artery and the blood flow into the leg dramatically increases after a prolonged period, a dangerous reperfusion syndrome can occur and is associated with acidosis, myoglobenemia, and hypotension.
- Life threatening blood loss – Prolonged surgery is often associated with excess bleeding. This can deteriorate into the lethal triad of acidosis, hypothermia and coagulopathy. Safe surgery requires a proactive effort to anticipate these reversible problems, which includes the surgeon taking a step back from the task absorbing their attention and taking care of bleeding sites.
- Need for a copilot – A long, complex case is like flying a jumbo jet across the Atlantic in turbulent weather. Attempting that flight with just a single pilot and no copilot is an unnecessary risk. Asking for a second surgeon to serve as a copilot during a long case can help take team’s eyes off the problem and put them on the solution. The power of a fresh set of eyes was illustrated by the famous video entitled the “invisible gorilla”. Many observers of the video asked to watch a basketball being passed between players end up blind to the fact that a gorilla walks through the middle of the scene. It often takes a second surgeon to see the gorilla in the room.
- Infection control – The risk of infection correlates with the length of the procedure. Hyperglycemia becomes more common. Antibiotics may need to be redosed to maintain therapeutic levels. A reduction in skin temperature can lead to tissue desiccation and increase the probability of wound contamination. Breaks in sterile technique often add up and become more common as the case continues to drag on.
- Patient positioning – The positioning of legs and arms during surgery can be appropriate for short cases but need to be reassessed once the case is unexpectedly prolonged. Pressure injury on nerves and stretch injury to joints are common problems in these prolonged cases that need to be anticipated.
- Limited resources – Having to do a case after hours is tough under any circumstance. It is possible that necessary equipment, supplies and staff might become unavailable when the case time extends beyond the expected window of normal working hours. Introducing this inconsistency of resources into to the case at the 6 hr time point can lead to case interruptions and further prolong OR times
As these issues accumulate, the case veers off in unanticipated directions. Losing situational awareness, while rare and unpredictable, is always dysfunctional and dangerous. In aviation, it is known as a pilot that does not stay ahead of the airplane. Whether happening in the OR or cockpit, this risk serves as a brutal audit of the team’s capabilities. The high performing team responds by rising to the occasion. Team members cross-check and cross-cover each other more than under standard conditions. They respond to fatigue by deliberately modulating their level of alertness. Knowing that their exhaustion increases the risk of deviating from or missing important details, they are extra careful to pay attention and stay mindful. I have had the honor of working within these types of teams. The results they produce can be outstanding. They are wise enough to know that sometimes complex cases don’t go well despite doing everything right, an insight that improves their resilience.
There is a simple tool that helps the team avoid the dysfunction associated with a long OR time: a checklist. Once a case extends beyond 6 hrs, the circulating nurse looks for an appropriate break in the action and initiates a predefined checklist. Obviously, the checklist should systematically inquire about the seven commonly overlooked hazards associated with a long case that are listed above. However, the most important goal of this timeout is for the team to regain full situational awareness: where have we been, where are we now, what caused us to get here? Sometimes accurate insight in a complex case requires the patience to piece together insights from several different team members. The team struggling through these cases often feels like blind men trying to describe an elephant by touch. Only when everyone seeks out and understands each other’s perspective (their “part of the elephant”) can any conclusion adequately reflect the truth.
Crossing the 6 hr timeline signals a “threat”. Aviation terminology calls this an “unintended state”. The checklists and the discussion it entails empowers the team to detect—and act on—that threat and the errors it can trigger. Like Mr. Tyson, General Eisenhower famously recognized that “plans are useless but planning is indispensable.” A battlefield can feel like the OR in a tough and prolonged case. Sticking with our original plan creates an illusion of control. We naturally do this based on inherent cognitive shortcuts known as the confirmation bias and escalation of commitment. We must trust the checklist at 6 hrs to combat this tendency and rethink whether we are on the correct course. Our patients are depending on it.
Beware of Automatic Decisions
In 1990, the Society of Thoracic Surgery developed a national cardiac surgical database as an effort to improve surgical quality. For the past 2 decades, extensive data has entered this database from >95% of cardiac surgical procedures all across the US. As a result of its size, the STS database provides a powerful way to measure the quality of a surgeon or surgical program by comparing their average patient outcomes against national averages. More recently, this database has also been used to predict the risk that a given patient will experience a bad outcome. This prediction uses statistical models to add up the impact of a variety of different risk factors on the risk of death. Death after heart surgery is mostly caused by the trauma of the procedure leading to the failure of important organs like the lungs, liver or kidneys. That means that the strongest predictors of operative death are those that signal that these organ systems are vulnerable. Any surgeon asked to operate on a patient whose only problem is severe lung dysfunction immediately recognizes the risk. However, it is a more challenging task to recognize the risk of death caused by a variety of modest risk factors, such as mild dysfunction in 3 or 4 organ systems in an elderly diabetic. Humans don’t have enough cognitive bandwidth in our working memory to consider the impact of multiple variables at once. A computer armed with the right statistical models is far more capable than the human mind of considering how these multiple variables influences surgical mortality. The risk score it provides augments the surgical team’s ability to select appropriate cases that are not too high risk for a successful outcome.
Despite its strengths, there are also important weaknesses of the STS risk calculator. First, it is highly accurate at predicting that a surgeon operating on 100 patients with similar risk is likely to have 5 patients die, but much less precise in discriminating exactly who are those 5 patients. Second, it is not good at the extremes of a population, i.e., very high-risk patients. The tail of the bell-shaped curve often has too few patients on which to build a statistically valid model with a high level of discrimination. Third, several important risk factors are not included in the STS risk calculation, such as severe calcification of the aorta, a history of chest radiation, liver dysfunction, cognitive impairment, nutrition level, frailty, pulmonary hypertension and severe CHF as illustrated by B-type natriuretic peptide. Because these factors independently increase surgical risk, the models often assume these “unmeasured confounders” are present in a high risk group even when they are not. Finally, the risk of mortality improves over time, particularly for high risk patients, and the database models must be recalibrated to reflect this change. However, the STS online risk calculator used by clinicians for a bedside risk estimate is still based on the 2008 STS models with no recalibration since that time. Evidence has shown that all these issues cause the STS tool to overestimate risk for mortality in high-risk cases.
Based on the above, it is logical to conclude that the strengths of the STS database for risk predictions outweigh its weakness except perhaps for one clinical scenario – using the STS online risk calculator tool to try to discriminate a patient that is above a high-risk score cutoff. When a patient has a score deemed to be low-risk, our confidence in this estimate can be high and the patient can be confidently reassured. However, a score that comes back as high risk for surgery should be viewed skeptically, at least initially. Such an adverse assessment may very well be accurate and provide us with useful information. However, the known inaccuracies of the model within this patient subset obliges us to exercise due diligence, particularly when it leads to a conclusion that a patient is too high risk for surgery. We demonstrate this by asking the following:
- Are the general impressions of the clinical team of the patient’s risk favorable (i.e. the patient “passes the eyeball test”)?
- Is the patient free from any important unmeasured risk factors?
- Can the typical approach to surgery be modified to reduce mortality risk?
- Are the patient and family highly motivated to accept risk?
When the answers to these questions are all “yes”, it is likely that the risk score is overestimated. It is unfair to use an overestimate as a sole reason to exclude a patient from the benefit of a life-saving operation. Unfortunately, this is the exact protocol of the Heart Team committee at our hospital – to exclude patients from surgical consideration if there is a single machine generated estimate of risk for mortality that exceeds 8.0%. There is no opportunity for even a discussion of these cases, the exact ones which benefit the most from the judgments and experience of the multidisciplinary members of the cardiac program. According to our hospital CEO, a score >8.0% puts the final decision on autopilot with no opportunity for change.
I recognize the tremendous value of using computerized risk assessment as an aide to choose high risk cases wisely. But “the devil is in the details”. The damning problem with the rigid protocol employed by our hospital is not that it is based on a childlike understanding of how databases work. More importantly, it needlessly pits the risk assessments of the STS calculator against human judgment, creating an imaginary conflict of machine vs. man like in Terminator or The Matrix. One envisions our administrators preparing for the day when clinicians eventually band together behind Schwarzenegger or Reeves to stop the STS machine from oppressing our judgment.
Instead of that comic book scenario, maybe we can learn from another high reliability field struggling with their own man v. machine dilemma: airline pilots and their use of autopilot. Autopilot improves overall airline safety, but some pilots cancel out its benefits by misusing it. Many crash investigations have documented the problems that come from when a pilot’s attitude about autopilot is “set it and forget it”. The pilots of Korean Airlines 214, Continental 3407 and Aeroflot 593 all put their blind trust in this tool, causing them to idly stand by as it led to a crash. If the machine says its so, it must be true. (are you starting to see the analogy with STS risk score?)
Both medicine and aviation would be better served by reframing their challenges to automation not as man vs. machine but instead as man plus machine. A high performing team views the STS score and autopilot as key teammates. Like any teammate, the point of their automated outputs is to challenge our judgments. However, it is also our job to challenge theirs. Everyone, even the most brilliant teammate on earth, is fallible. We are not being good teammates if we accept anything on blind faith.
Most important and above all else, humans (not machines) get the final say. The many problems that arise when that rule is not followed are bizarre and tragic. Boeing designed an autopilot software program (MCAS) that was able to intervene on the flight of its 737 MAX jets without pilot input. Seemingly out of the blue, that MCAS software thrust two separate jets downward directly into the earth, killing everyone on board, based on faulty input signals suggesting an abnormal angle of those two planes that was obviously incorrect to both pilots. Likewise, a recent risk score of >8% triggered an autopilot decision to exclude a salvageable patient from surgical consideration. Like a 737 MAX jet, our patient soon crashed from untreated coronary artery disease while our Heart Team remained willfully blind to the clear inaccuracies of the patient’s risk score.
If we recognize that all team members have their limitations, we will use the automated risk scores when they are likely to be accurate and engage in multidisciplinary debate about the best course of action when they aren’t.
The Robot Will See You Now (NY Times, 4/30/21)
Since da vinci’s robot was introduced in the 15th century, humans have been fascinated by the topic of robotics and respond with a mix of curiosity and skepticism, as illustrated by Ms Metz’s New York Times article about the use of robotic to aid in surgery. Emotional reactions like this, when kept under control, can be healthy and promote steady improvements in how this technology is used to help patients. When out of control, it can also become pathologic and halt progress. The key to keeping things under control is to honestly assess the strengths and weaknesses of the idea.
Spaceflight has also stirred similar emotions that have gotten out of control at times. NASA had meetings to discuss the Space Shuttle for many years prior to the explosion of the Challenger in 1986. Each meeting had engineers in attendance that knew about the problems with the O-rings but failed to speak up. Every time these meetings avoided the O-ring issue, it had the unintended effect of normalizing this latent hazard and sealing the fate that a rocket would sooner or later come crashing down to earth. The lesson our nascent field of robotic surgery must learn from this tragic case is not just that it is important to speak up about the real problems, but that we must constantly be aware of what can and will happen if we don’t.
The risk of preventable injury to a patient during robotic surgery is much higher than astronauts face during space flight. The actual hazards are almost never the technical issues mentioned in the NY Times article. A time lag between command and execution or the precision of a robotic arm being off a half centimeter are fascinating topics for cocktail parties, but not relevant to patient safety. The problem is far more fundamental and hiding in plain sight: poor communication. Excellent technical skills are necessary but not sufficient for good surgery; there are also a wide array of nontechnical skills involved. Medicine in general and surgery in particular is a team sport. Anyone that has ever been part of a team knows that all its members must be on the same page. In surgery, it is called having a shared mental model. The most important thing a teammate does is communicate effectively. Communication skills are critically important for a successful outcome.
A robot in the operating room changes communication in a dramatic fashion. There are new ways to communicate – the surgeon sits in a corner and is no longer standing at the operative field, which makes implicit communication less useful. There are new things to communicate – small incisions take away the surgeon’s direct vision of the operative site; video cameras and/or echocardiography are needed to explain what is going on. There are new dangers to watch out for– there is a risk for injury during a conversion from robotic to open surgery and new challenges in handling bleeding. The communication skills and mental models of surgeons have been honed for open surgery but not robotics. We demand a myriad of new technical skills to grant credentials for robotic surgery, yet we accept the same old nontechnical skills of open surgery. This false assumption ultimately impacts team resilience by inviting communication breakdowns. That turns a “near-miss” into a bad outcome.
Regardless of how good our technology becomes, we will never prevent all bad surgical outcomes. However, publications inadvertently perpetuate harm when they fail to speak up about real problems. To a news outlet like the New York Times, the nuance of how a team communicates during robotic surgery is not as compelling of a topic as autonomous robots. However, the focus on technical aspects to the detriment of nontechnical makes it seem like the field does not even recognize it has a problem. Atul Gawande improved the safety of open surgery with a low tech solution – checklists. Once robotic surgeons tailor their communication skills to the unique issues they face, they will do the same for robotic surgery.
The Value of Comfort with Discomfort
In the 1950’s, a psychologist named Leon Festinger studied the bizarre behavior of a doomsday cult called the Seekers that strongly believed in an imminent apocalypse. Once the date they predicted for destruction of the world came and went, Festinger noted that few cult members openly acknowledged the obvious failure of their prophecy. Instead, they doubled down on their idea and acted in a variety of irrational ways that reaffirmed their original beliefs. This famous research led to the theory of cognitive dissonance to explain the aversion caused by two opposing ideas and the strong motivations that we all feel to resolve this discomfort. It illustrated the immense grip that core beliefs have on us all – even the persistence of the world was not enough evidence to shake the unbroken unity of those cult members.
There has been a gradual paradigm shift in cardiac surgery, called the Heart Team committee, that also causes cognitive dissonance for those accustomed to the status quo. The purpose of this committee – as it has been described in the literature – is for experts in the management of cardiovascular disease to proactively discuss cases that are being considered for high-risk surgeries. In the past, case selection has been the sole domain of the surgeon with little input provided or requested from others. However, there has been a growing recognition of the value of teamwork in complex surgery – not just in the actual performance of the cases but also in the selection of candidates. Evidence suggests that using the Heart Team approach for case selection builds communication and trust among stakeholders, breaks down silos between the departments involved in the care of these patients, and helps shift the culture away from individualism and autonomy and towards better teamwork.
Our hospital administration reacted to the potential of a new Heart Team in a way that made me think about Festinger’s research. The personal interest of our administration in this type of Team is most likely based on the reality that case selection it not just important for optimal clinical outcomes, it also influences the bottom line. Cases that are too high risk for a given facility can strain its available resources, an issue that has come under the spotlight with COVID surges and the widespread cancellation of elective surgery to preserve resources. Increased need for resources also makes high risk cases less profitable, an issue that is not irrelevant at a for-profit hospital like Mt View Regional. Since profits were at stake, one opposing idea was that those with fiduciary responsibility – members of the hospital administration – should drive the Heart Team process.
The other opposing idea is that only experts in cardiovascular disease are intellectually equipped to improve case selection and resulting quality. It is axiomatic that the Heart Team that focuses first on quality will see profits inevitably follow but the one that instead prioritizes profits will end up with neither quality nor profits. Assigning hospital administrators like the CEO, CNO, chief of staff with no past expertise in cardiovascular disease as voting members of the Heart Team raises many red flags about the legitimacy of the case selection process used by the committee.
One rational way to solve the dissonance between these two opposing ideas is to learn what other Heart Teams have done. (Spoiler Alert: None has included hospital administrators on their teams.) The University of Ottawa Heart Institute recently published the protocol for their Heart Team. They presented the results of activities and expenditures to the senior management team semi-annually as an acknowledgement that this idea was in development and not yet fully evaluated/vetted. Discussion with management allowed the team to consider changes in direction, undertake new initiatives, or see changes to their financial support. However, including administrators as part of the team to select which patients should undergo high risk surgery breaks new ground.
All of this leads us to the following question: What does it hurt to include hospital administrators on the team? It is fair to acknowledge that most quality improvement projects need the skillsets and the input of both physicians and administrators to be solved. However, selecting the best cases for surgery is decidedly not one of those projects. To elucidate what makes this “collaboration” so unholy, we should start by articulating its underlying assumptions. The main unspoken assumption is that the goals of the Heart Team – to improve quality and profitability – are equal and that both these goals cannot be achieved by focusing on quality alone. If this is true, it leads to the second assumption that physicians cannot be trusted on the issues of hospital costs or profitability. Administrators resolve their discomfort from granting power to a new committee by holding fast to a comforting old idea: physicians do not care about finance. If this new committee has any hope of guiding more responsible resource use, it must come under the control of hospital administration. It’s a pattern of flawed thinking as old as Aesop’s Fables –we feel the need to micromanage and be suspicious of the goose if we want to get more golden eggs. Pointing out that other Heart Team committees do not have administrators in attendance is no more convincing than realizing the world survived the day after the Seekers predicted its demise.
The solution to cognitive dissonance is not to seek out ways to become more comfortable in our thinking. In fact, it is the opposite. The Heart Teams that are the most effective are those that learn to become comfortable with the uncomfortable. The Heart Team asks surgeons to give up their autonomy to select cases and to be willing to hear negative feedback on their proposed choices. That has the potential to cause anger and conflict. An important point is that this meeting should not be expected to reach its peak immediately. The process requires patience. In the beginning, it can feel like we are children – lashing out criticisms that come across more like personality conflicts and acting defensively. Passion to present your ideas in the best light can spill over to being pushy and unconvincing.
Eventually, the child gains experience and grows into adulthood, granting the wisdom to recognize the difference between a critique that is reasonable compared to an unfair blanket criticism of one’s personality. One of the most important skills in medicine is learning to navigate a difficult conversation with just the right amount of assertiveness and minimal defensiveness. To accomplish this, we must learn to balance advocacy of our position and inquiry into what reality looks like from others’ points of view. This is not a skill that can be mastered intellectually or individually. It requires sitting in a room with your peers, going about things in the wrong way, and reflecting honestly on what went wrong so that it can be done better the next time.
So now the final question: Why do really smart people rely on flawed assumptions? The root cause of this shortcut is a failure of trust. It is hard to rethink assumptions about those we do not really trust. It is far better for patients if we deal with the cognitive dissonance caused by bad decisions by taking time to seek out the correct facts. That’s what good decisions are made of.
On Becoming a Female Cardiac Surgeon
Since day 1 of cardiac surgery residency training, I have curiously noted that the personality of women interested in this specialty seemed a bit off compared to those with career interests in other less ‘masculinised’ specialties. They seem “hard-core” in a way that can be seen as inauthentic; like the overcompensation of a male actor trying to play the role of a woman (although not as hilarious). My first explanation was problems inherent to the woman surgeon. After all, our country is the land of “rugged individualism”. If you can’t assign one full responsibility for their actions here, where can you? This founding principle of America reflects a natural psychological tendency to see others as internally motivated and responsible for their own behavior regardless of other possible external causes of that behavior.
On further analysis, we must remember that many women pursued their goal of becoming cardiac surgeons despite external circumstances that would crack most people. They got where they are after enduring decades of microaggressions: processes of exclusion, sexual harassment, gaps in pay and being given less autonomy than men. The subtle (and sometimes not so subtle) hostility toward women in cardiac surgery is not just the result of few one-off chauvinistic surgeons or divergent OR team members. It is deeply rooted in a culture that continues to favor and reward masculine and resist feminine styles. Thinking about female surgeons from this perspective, my finger pointing becomes more like victim blaming.
According to linguistics expert Deborah Tannin, play groups that boys vs. girls entered at any early age taught them how to communicate. Girls were socialized not to be “bossy”, so they learned to use language to establish rapport and downplay their certainty. They say “sorry” more often which, in the workplace, can have the disadvantage of making them appear more blameworthy for mishaps. On the other side of the playground, boys learned to speak to establish dominance and demonstrate their skills. They downplay their doubts and are more comfortable with disagreements and conflict. The “superheros” that all cardiac surgeons idolize and seek to emulate (Cooley, Debakey, Senning, Harken) spoke in a way to epitomizes the boyhood model of dominance and certainty.
Here is the dilemma: all aspiring surgeons are taught to act the way those in charge want. Like the first day at Parris Island for a Marine recruit, there is never any request the CT resident to bring their “natural strengths” to the table. They just adopt to the blueprint or die. The case for changing this time-tested approach to training safe CT surgeons has not yet been persuasive. It is not enough to tell the male program director that he is wrong for requiring females to take on a masculine style in order to be accepted. Decades of change management literature proves this approach won’t work. Most likely, he will publicly agree and privately sabotage. The avenue forward is to prove that surgical outcomes will benefit from leadership styles that are more feminine. Once this case is made, we will achieve a critical mass of females in the lead and the field will change for the better.
A recurring theme of this blog is better teamwork in cardiac surgical operating rooms. It is an interesting and clearly testable hypothesis whether these gender related differences in communication style alter the effectiveness of teamwork. Unfortunately, this question has been poorly investigated. Until this knowledge gap is addressed, there remains a regrettable double bind for women in surgery – damned if they act natural or damned if they don’t. They can maintain their natural feminine communication strategies and be rejected by male surgeons, thus reinforcing the stereotype of women as inadequate in this role. Alternatively, they can adopt a masculine style in order to be accepted by men as “one of them”. This might increase their chance of success but perpetuates the isolation of women trying to succeed in the field based on using their natural strengths. The double bind arises because of a strict hierarchy that does not encourage junior staff to speak up about issues such as being damned either way.
Training and then developing a career in cardiac surgery is notoriously tough. At first glance, adding more pain on top of that appears tragic and unreasonable. However, sometimes adding additional hurdles into the learning process improves long term retention of information and technical proficiency of both individuals and teams. These are called “desirable difficulties” because they lead to a deeper processing of material than trainees would normally engage in without explicit instruction to do so. This insight uncovers a possible resolution in the double bind facing the female cardiac surgeon. Our field must promote a modernized workplace that learns to celebrate and take advantage of diversity while working to minimize its potential for disruption. Such a solution would not just lead to more successful women surgeons, but better surgery!
The Downside of Hospitals Becoming “Highly Reliable”
Imagine you are a student watching a cardiac surgical case that went very smoothly with the exception of a few random episodes of sudden drop in the blood pressure. Each time those ‘episodes’ resolved by the anesthesiologist manipulating the arterial catheter, suggesting that it was a false pressure reading. The surgeon just left the room to make a phone call and another episode happens. This time, the blood pressure reading – 50/20 – did not get better after flushing the arterial line. The circulating nurse notices other parameters are abnormal that weren’t before and calls this out. The anesthesiologist now understands the low pressure is real. Two things then happen simultaneously: the perfusionist calls the surgeon and anesthesiologist gives epinephrine. The OR tech, who still has on sterile attire, gets all the instruments ready to reopen the chest. The surgeon arrives quickly and after opening the chest, notices blood clots pressing on the heart causing the low pressure. A small bleeding point is sutured and the chest is reclosed. The patient has an otherwise uneventful recovery.
Episodes like this happen very frequently in a dangerous field like cardiac surgery. What distinguishes a high performing team is their expert use of teamwork to resolve things quickly. Team members are free to speak up honestly and openly and others listen and act. This is a powerful combination that yields a treasure trove of information. It enables teams to dig deeper than others in detecting problems before they cause harm using a proactive strategy called feedforward. This is different than basic feedback model used by most teams in the OR and throughout the hospital. The standard, status quo approach is to develop corrective action based on feedback about what caused an adverse event. The outcome this approach strives for is far from high performance. It reacts to evidence of malpractice – a hospital infection that should have been prevented, an operation on the wrong patient or the death of a patient that was very low risk. It looks for compliance with mandatory processes like handwashing, checklists, and adequate staffing with ICU specialists.
Monitoring for malpractice is a start, but it does not measure whether teams are performing at a high level. We are acting like the person who realizes he has lost his keys after spending a few too many hours at the bar. Looking up and down the dark street, he decides to focus his search under the single lamppost. His friends ask why he is just looking in this one place. He replies: “It’s where the light is.” Great teamwork might happen from time to time, but scaling it up at a hospital level won’t happen by choosing metrics just because they are near the lamppost. If we don’t get our measurements right, we don’t improve.
We want to measure how well our teams apply feedforward in order to improve the reactive mindset. Here’s an example of how I do that in my practice. During a heart operation, I often give a cold, high potassium solution into the heart so that it stops beating and is protected from harm. Using standard techniques, the solution goes into the coronary circulation and then into the heart muscle as long as the aortic valve closes normally while it is given. If the aortic valve does not close normally, the solution does not go in properly and the heart is inadequately protected. This causes the patient’s heart to suffer during the surgery and I would be blamed for using a poor technique. While this is all happening, others in the OR – the anesthesiologist and the perfusionist – have tools to monitor aortic valve closure. When they see a problem, I explicitly request them to advise me when another, non-standard technique for heart protection would be better. It is my primary responsibility to make sure the proper technique is used. But I don’t just wait for a problem and then react. Instead, I build in redundancy of teamwork to protect the patient if I miss something. The culture in most cardiac ORs is that no one ever dares to suggest to a surgeon how to do surgery, just like they tolerate surgeons that don’t participate in the time out OR checklist. HRO look for opportunities to use redundancy to minimize risk and use debriefing to identify these opportunities. They feedforward these ideas to correct any deviance until their processes work every time.
High performing teams thrive within a highly reliable organization (HRO). These are organizations with systems and processes that enable consistently low harm despite having to work under hazardous conditions. Patients and surgical teams would benefit greatly if hospitals were on the list of HRO. Unfortunately, none currently meet its basic tenets. A wide array of healthcare agencies, such as the Joint Commission, Leapfrog Group, the Institute for Safe Medication Practices, the National Quality Forum, the National Patient Safety Foundation, CMS, IHI, and AHRQ, are all calling for hospitals to dedicate themselves to high reliability. There is a growing cottage industry of advisors on how that transformation should happen.
HRO use feedforward because their teams have the freedom to speak up. This requires a level of trust that doesn’t currently exist between clinicians and hospitals. The fundamental hurdle is a culture in modern hospitals that often borders on being called “toxic”. Here is proof of the problem. A 2018 survey of physicians in the US that showed that the majority have an adversarial relationship with hospital administration and 65% feel they have little influence on how hospitals are run. Also, an AHRQ culture of safety survey has repeatedly shown over the past decade that the vast majority of nurses feel that hospitals have a punitive response to error and a tendency to blame the person involved. Bad culture permeates even the most prestigious hospitals. Johns Hopkins – a top 5 hospital ever since US News started publishing its rankings – performed an internal investigation and found “fear at every level” due to bullying. The investigation ended up disciplining 55 physicians and removing 9 from positions of power. Even patients perceive what is going on – a survey showed that 50% feel that hospitals do not provide compassionate care.
To understand what happens to teamwork in a toxic organization, let’s reconsider the opening case right after the OR nurse calls out the problem with the blood pressure. This time, the anesthesiologist is too focused on the arterial line to hear the nurse. The perfusionist assumes the anesthesiologist doesn’t agree with the nurse’s interpretation so he doesn’t call the surgeon. This delays surgeon’s arrival several minutes before the chest is opened so now the fibrillating heart does not recover. The death is investigated and records only a technical error of bleeding. The circulating nurse feels it was a preventable death due to a teamwork error so she speaks up and suggests that some of the blame is on the anesthesiologist. This comment is not accepted warmly by hospital administration who only get the physician’s side of the story. In the name of “teamwork”, the nurse is asked to resign from the cardiac team. Those that remain have learned their lesson.
Many of the published HRO initiatives start with the idea that culture change is needed but then show surprisingly little ambition on creating any real change. An inconvenient truth for most CEOs is that the majority of their employees and customers don’t trust them. Asking to become an HRO in a toxic culture is like trying to harvest crops before tilling the soil and discovering it is covered with asphalt. A CEO who has contributed to this culture and is really ambitious about creating real change should offer to resign. At the very least, sincerely apologize and then resign later if the culture doesn’t improve. Since there is no trust, an apology would never be enough to prove that they were really sorry.
A CEO that offers to resign would get my attention, but not my trust. That builds slowly by consistently and honestly walking the talk. We can talk about admitting mistakes as the best way to learn, but walking the talk is when the CEO is honest and candid about his/her own mistakes. Then, be humble and ask clinicians for feedback on how the executive team’s decisions could improve. It is easy to talk about deferring decisions to those on the front lines. It is much harder to walk around long-standing hierarchies that mandate all major decisions to be made by those with authority (CEO, department chairs, etc). An articulated vision for creating better culture must permeate every leadership action – ideas for new projects or investments, how investigations are handled, and who is interviewed for jobs. The closer things get to real change, the closer the staff will start watching. Its not just about creating a better culture for others, but with others so they know their decisions will be supported when a patient is in trouble.
Physicians and nurses know what George Orwell understood “no one ever seizes power with the intention of relinquishing it.” If collaboration with followers is unlikely, leaders focus on acquiring and maintaining power. It is curious that not even those most passionate about hospitals becoming an HRO have put the topic of toxic leadership on the table for discussion. If avoiding this topic was a ploy to make the idea of HROs more palatable to those in charge, the effort has failed before it started. It isn’t any more likely to work than the idea that electronic records were going to improve hospital costs by cutting out middlemen (e.g. unit clerks). How gullible are we to these impossible ideas?
So its not likely to happen, but is there any harm trying? Yes. As staff are being recruited into a futile effort like this, they are given a series of mixed messages that amount to what psychologists call a double bind. This has three basic components – damned if you do; damned if you don’t; damned if you notice that you’re damned either way. When it comes to the topic of HRO, staff are told it is important to speak up about safety concerns, but they know the culture doesn’t really allow them to be honest. Investigations have shown that speaking up is unusual in nurses. In part, this is because those that speak up about the many systems problems are labeled as complainers while those that are quiet, develop clever workarounds and don’t complain are promoted. Staff hear administrators say “we want you to speak up” but know the unspoken message is “if you do, you will be punished and if you call me out as hypocritical, then you’re not a team player and disqualified to speak.” In the name of speaking up, staff are barred from even pointing out that the very idea of an HRO puts them in an unsolvable double bind.
The more the topic of HRO comes up, the more double bind communication happens. Over time, this takes an emotional and mental toll. In the end, staff develop learned helplessness, like the research dog that doesn’t try to escape after being shocked too many times. They might end up with depression, anxiety and burnout, making them even less likely to speak up. Those that speak up are usually those most hopeful about an HRO and the most angry its not going to happen. Being outspoken is never celebrated, but sometimes tolerated, at least until the criticisms are directed towards hospital leadership. The small fraction of comments that might provide valuable feedback to hospital leaders are quickly discounted as naïve and lacking in “organizational savvy”. (do you get a sense that I’ve heard phrase before?)
Someone more savvy than me would be able to decipher what a hospital administrator really wants when they talk about the wholesale reprioritization of patient safety of an HRO while also demanding lower costs and higher productivity at the same time. That they don’t want to spend too much time training the principles of safety science because staff might quit and take their knowledge to competitive institutions. They engage in superficial executive walk-arounds to “give staff voice”, but don’t have the time or interest to become an executive member of patient care teams as described by Peter Pronovost’s CUSP program.
I work at a hospital that is part of a large corporate chain, called CHS. Their website describes a series of tools they’ve used to “adopt a High Reliability culture”. I have talked about this with nurses and staff that work at CHS. I came away from these discussions sensing an initiative devoid of the passion that characterizes those on the front lines I’ve met from HROs outside healthcare. In addition, CHS has not been transparent with their safety results as one of only a few that refused to provide safety data to Leapfrog Group. A lack of transparency and passion leaves them with a series of well packaged ideas that end up looking like high reliability but never able to operate like one. CHS executives can dress up with a mask of a duck’s bill, put on webbed feet and stick on feathers, but that doesn’t make them a duck.
Admittedly, this is hospital HRO 1.0. We have to start somewhere. However, the fatal flaws of these initial efforts are so obvious that it seems like the idea was meant to be an illusion. It is appropriate that hospitals want to climb out of the deep hole they are in regarding patient safety but even more important that they stop digging. The unintended result of the half-hearted initiatives like that at CHS has been double bind messages that aggravate distrust and create an even deeper hole. Real culture change comes with a hefty price. That price is the need to consider how well the command and control philosophy is serving patients. An overhaul of our mental models, not just our business models, is necessary to realize a future where nurses can speak up and protect patients better. I will analyze those tough considerations in my next post.
Learning From Other’s Mistakes
The purpose of this report to our team is to extract lessons from a recent safety concern at UNC-Chapel Hill that could be useful for improving our new hospital. UNC-Chapel Hill Medical Center has been ranked for many years by US News as “high performing” in heart surgery. However, several physicians and other staff recently became concerned about a high mortality rate and poor teamwork in cardiac surgery. They raised these concerns on several occasions but were ignored by hospital administration. With no other avenue available to enact change, two dozen UNC physicians and nurses spoke anonymously about their concerns to a NY Times reporter (Gabler 2018). To gather evidence for the reporter, several cardiologists secretly tape-recorded conversations they had with hospital administrators about their lack of confidence in the cardiac surgery program. These conversations documented that it was implied by the hospital that those making the complaints would be fired if they referred surgical patients to other local programs.
This issue put the whole hospital in a crisis. Bad publicity in a program like cardiac surgery that is critical to the financial well being and reputation of a hospital, amplified by the inability to cope with its impact, are triggers for a crisis (Keown‐McMullan 1997). Similar high profile disasters have triggered crises in the airlines (Tenerife crash, 1978), nuclear power (Three Mile Island, 1979), the environment (Deepwater Horizon, 2010) and the financial industry (Enron 2001, subprime mortgage crisis 2007). Investigations of these catastrophes in all fields reveal remarkably common themes. First and foremost is an acute failure of leadership when it was needed the most. In times of crisis, everyone naturally looks to the CEO and the administrative team to navigate its treacherous waters (Boin 2010). The fundamental failing of the leadership at UNC was that their response was reactive and not proactive. It was evident that problems in the CT program were known about for years at the hospital, but those in charge only responded when were forced to do so by a few whistleblowers who were forced to go to the press.
Another leadership problem at UNC and elsewhere has been a failure of accountability. Hospital leaders often have strong political instincts but limited clinical knowledge, a combination of attributes that afford them “plausible deniability” about the bad clinical programs at their hospital. This creates a disconnect between leadership and problems with clinical quality that plays out even in the best hospitals. Johns Hopkins – a top 5 hospital ever since US News started publishing its rankings – performed a broad internal investigation of its clinical services and found a culture of “fear at every level” (Dixon-Woods 2019) Top level administrators were afraid to act against senior surgeons that were disruptive. These surgeons were called “chronic untouchables” due to their long-established system of hierarchy and associated political power. They followed-up on reports of bullying and ended up disciplining 55 physicians and removing 9 from positions of power. I have seen no other hospital take such a courageous look into the collateral damage of failed accountability. Clearly, the heart surgeon at UNC-Chapel Hill established himself as an ‘untouchable’.
Another common theme is poor treatment of informants. At best, the dissenters from these adverse safety stories were ignored and treated like the skunk at the garden party. At worst, they were fired or themselves blamed for the problem. The culture of hospitals is often highly political. The most politically expedient solution is always simplest answer to the problem (e.g. “get rid of the bad apple”). This dreaded “bad apple” label creates a chilling effect on staff, which makes them unwilling to speak up about errors. This culture of silence is often tacitly fostered by those in charge because it creates an illusion of control, stability and security. Even when staff at UNC courageously spoke up about poor or dangerous practices, there was a strong tendency for the hospital to initially respond by criticizing the way they spoke up (e.g. a “disruptive physician” label is often used on whistleblowers). The result was staff that were disempowered and silent, which is what set the stage for the crisis.
A final theme is evidence of a poor culture of patient safety. A safe culture has a proactive, unwavering commitment to safety, which starts with open communication. Everyone on the team (not just the surgeons) must feel obligated to raise any and all concerns and those in charge must listen. This process comes to a halt the first time a credible allegation is not investigated. Leaders that fail in this duty cross the line from plausible deniability into the arena of “willful blindness”. At that point, they are no more innocent than I would be if I was stopped by the police while delivering a package of illegal drugs and claimed I never looked inside. Failure to acknowledge a duty does not make it cease to exist.
A hospital CEOs and other leaders typically deflect blame using two common defenses. First, the crisis was not their fault. Not every problem that happens in a hospital as the result of poor decisions or inaction by the CEO. The leadership team at UNC-Chapel Hill appropriately trusted and deferred the clinical decisions to their clinical experts. At UNC, the surgeon involved was Dr. Michael Mills, who is not a run-of-the-mill doctor with no talent. He was highly respected in the field of cardiac surgery and had been at his institution for decades. A CEO with no specialized knowledge of cardiac surgery is not expected to quickly challenge or overrule this powerful authority even after the crisis started to emerge.
The second defense is that we can’t hold hospital leaders (the baby) accountable for a crisis (the bathwater) that was not foreseeable. This amounts to “throwing the baby out with the bathwater”. A crisis is never as predictable at the time it unfolds as it appears in retrospect. When a bad outcome happens, it is natural for nurses, patients and others complain about those in leadership positions (including surgeons). That comes with the job of being a leader. Trying to separate “signal from noise” so that we uncover those complaints that are legitimate is easy only in retrospect, after the details of the crisis become clear to everyone. Leaders guide learning from these errors and help avoid overreacting to these rare events, which can aggravate the harm done to the hospital. If we fire the CEO every time a bad event happens, no one will be around to implement the lessons learned.
The take home lesson for our team is that we need to be prepared for this type of event to happen at our institution. ALL hospitals will eventually face a Black Swan Event – which is an incident so traumatic that it threatens the hospital’s future and its highest priority goals. Its par for the course for any high-profile, high-risk business (Fraher 2011). We prepare for this by creating a vision for what strong leadership looks like during a crisis. This starts with developing a strong culture of safety well beforehand. This emphasizes treating those that speak up with the respect they deserve, thereby creating the trust and excellent communication necessary to survive a crisis. Unfortunately, few hospitals have this type of culture, which leaves them doomed to respond to their next crisis with the same mismanagement errors. The time to change this is now. To paraphrase candidate Barak Obama in 2007, we are entering a defining moment in the history of healthcare where much of the public has lost the faith that our leaders can or will do anything about these repeated errors. We should start by understanding the fundamental principle of being a leader: take accountability for your mistakes. Those that don’t are the bathwater, not the baby.
Hospital Mismanagement of a Crisis: Common Themes
Most hospital administrators are not physicians and have no clinical background. They are selected as leaders due to expertise in management or finance. As a result, they don’t know how to respond to concerns about poor clinical care. They “stay in their lane” and focus on the overall business strategy and how to maintain a fiscally sound budget, protect the reputation of the institution and acquire and retain talented people. They avoid getting “into the weeds” of direct patient care. However, an event always happens that, at least temporarily, changes the demands on those in charge. Like it or not, any hospital in business long enough inevitably endures a crisis in the way its clinical care is perceived. Even the best hospitals in the country – particularly those with prestigious heart surgery programs – face harrowing moments such as these (I recommend following the links to read the details about these events, its heartbreaking):
- Consider Duke University in 2003 when a donor heart was transplanted that was the wrong blood type. Federal regulators cited Duke University Hospital (US News hospital ranking 19th) for multiple deficiencies in its organ transplant procedures and the hospital CEO admitted they hadn’t developed systems to be able to catch and prevent errors.
- Then there was a navy veteran that received a heart transplant in 2018 at Newark Beth Israel Medical Center (US News heart surgery ranking 32) and suffered a devastating stroke. His poor prognosis was evident to all the medical team but the family was kept unaware so that he could be kept alive artificially for a year in a vegetative state. This was done to improve the program’s mortality statistics and avoid federal scrutiny.
- Heart transplant at St Luke’s/Texas Heart Institute – arguably the most prestigious program in the country (home of Dr. Cooley and the first heart transplant, US News heart surgery ranking 22) – was closed down in 2018 after an investigation by Medicare. Two years after Dr. Cooley’s death, a CMS review revealed a high mortality rate and multiple problems including the lack of properly functioning defibrillators in the OR. The review was triggered when it was reported that their most famous surgeon – Bud Frasier – was accused by their cardiologists of implanting LVADs into patients that did not need them and other research violations.
- Then there is UNC-Chapel Hill (US News ranked as “high performing” in heart surgery) where a high mortality rate and poor team work in cardiac surgery was ignored by hospital administration. Two dozen UNC physicians and nurses spoke about their concerns to a NY Times reporter, usually on the condition of anonymity, for fear of retribution from UNC. Several cardiologists released secretly recorded conversations they had with hospital administrators who implied they would be fired if they referred surgical patients to other local programs.
- The pediatric heart surgery program at Johns Hopkins All Children’s Hospital had a sudden increase in mortality and complications after their lead cardiac surgeon was demoted in 2016. A newspaper report described multiple complaints from staff and cardiologists about the problem that administration appeared to ignore. Once the program was shut down by outside regulators, their response was “We are currently reviewing the program and recruiting senior surgical talent”. They did not acknowledge a more fundamental problem: their failure to be proactive in response to concerns.
- A high-volume cardiac surgery program at Redding Medical Center in California repeatedly performed inappropriate and unnecessary procedures on largely healthy patients. After investigation, it became evident that many hospital staff had been aware of what was going on for many years. Tenet Corporation paid $300 million in reparations for this scandal.
- At a hospital in Chattanooga, the Medical Executive Committee gave their hospital administration a vote of no confidence in 2019 due to chronic operational issues (inefficiency, understaffing, poor morale and policies that cause overcrowding). The Board chairman of the hospital dismissed concerns and claimed the issue was merely due to “challenges with relations between the medical staff and administration”.
- The best-known international example was the failure in pediatric cardiac surgery at the Bristol Royal Infirmary in England. It took 5 years and 35 preventable deaths between the first complaint and when authorities eventually shut down the program. Only the persistence of whistleblower, a cardiac anesthesiologist (Stephen Bolsin), was able to overcome the inertia trying to prevent this result.
- Winnipeg, Manitoba, 1994: a series of systems flaws – including poor team building and problems with risk management and quality assurance – were responsible for the failure of their pediatric cardiac surgery program. Specifically, the investigation cited that concerns of the nurses participating in the cardiac surgery program were systematically ignored.
These are only some of the most high profile cases of the recent past. However, ALL hospitals will eventually face incidents that are so traumatic that they threaten the hospital’s future and its highest priority goals. It is “par for the course” for any high-profile, high-risk business. Similar crises have occurred in the airlines (Tenerife crash, 1978), nuclear power (Three Mile Island, 1979), the environment (Deepwater Horizon, 2010) and the financial industry (Enron 2001, subprime mortgage crisis 2007).
We rarely hear about a crisis that resolves OK. Reports from when things go bad reveal remarkably common themes. First and foremost: a catastrophic failure of leadership. It is in times of crisis that leaders are needed the most. Everyone looks to the CEO to navigate the treacherous waters. Yet each of the cases listed revealed fundamental flaws in basic leadership. Leaders were reactive and not proactive. Problems were known about for years, but those in charge only reacted when were forced to do so. The only people that never seem to know the truth are the families.
Hospital CEOs typically defend inaction by clinging to the most well-proven defense against culpability: “plausible deniability”. Its application to a crisis is supported by two underlying premises. First is the problem of hindsight bias – the impending crisis was not as predictable at the time as it appears to everyone in retrospect. In other words, it was what Nassim Taleb defines as a “Black Swan Event“. Bad outcomes happen and nurses, patients and others complain about surgeons all the time. Separating signal from noise is only easy in retrospect, after the crisis unfolds and becomes clear to everyone. It is the job of leadership to guide learning and avoid overreacting to these rare but high impact events. Overreacting and blaming the administration can result in further institutional harm, i.e. “throwing the baby out with the bathwater”.
The second defense of hospital leaders is that they trusted their surgeons that told them nothing was wrong. The surgeons involved in the cases listed above– Jeff Jaggers, Mark Zucker, Bud Frasier, Michael Mills and those in Redding, Bristol and Winnipeg – were not run-of-the-mill surgeons with no talent. They were all highly respected in the field and had been at their institutions for decades. It is believable that a CEO that has no specialized knowledge of cardiac surgery would not challenge or overrule these powerful authorities. This tactic turns a disadvantage (no clinical knowledge) into a political advantage. Once a crisis starts to emerge, it is even more reasonable to think that a CEO would trust the experts to its management, at least as a default position. They see their role as stepping in at the end of the crisis and employing the politically expedient solution: hiring and firing the lead surgeons.
There is a major downside to plausible deniability: failure of accountability. It is best in the crisis to act early when the problems are treatable. Hospital leaders have a disincentive to do so because it limits their ability to claim deniability. This scenario plays out even in the best hospitals. Johns Hopkins – a top 5 hospital ever since US News started publishing its rankings – performed an internal investigation and found “fear at every level”. This included top level administrators afraid to act against senior surgeons that they called “chronic untouchables” due to their long-established system of hierarchy and associated political power. They followed-up on reports of bullying and ended up disciplining 55 physicians and removing 9 from positions of power. I have seen no other hospital take such a courageous look into the collateral damage of failed accountability, must less publish an article to let others know about it. But the story behind the story is that it took a brave “bottom-up” investigation triggered by anesthesiologist Peter Pronovost to get administrators to act.
This leads to the second theme of bad management of crisis: poor treatment of informants. At best, dissenters from these stories were ignored and treated like the skunk at the garden party. At worst, they were fired or themselves blamed for the problem. Even when staff were genuinely exposed to poor or dangerous practice there was a strong tendency to criticize the way they spoke up. This leads to staff that are disempowered and silent. I’ve written about this dilemma in the past (see past posts about Sophie’s choice, Why the Cardiac Team Fails to Speak Up). If you still don’t think speaking up is a serious problem, you aren’t paying attention. It is all so tragic because those that speak up should be celebrated, not punished.
A third theme is a poor culture of patient safety. Hospitals always seem to be reacting to problems, well after the horse has left the barn. The right culture requires a proactive, unwavering commitment to safety, which starts with open communication. Everyone on the team (not just the surgeons) must feel obligated to raise any and all concerns and those in charge must listen. This process comes to a halt the first time a credible allegation is not investigated. Leaders that fail in this duty cross the line from plausible deniability into the arena of “willful blindness”. At that point, they are no more innocent than I would be if I delivered a package of illegal drugs and claimed I never looked inside. Failure to acknowledge a duty does not make it cease to exist.
According to Taleb, organizations do not prepare for their next Black Swan Event by trying to predict exactly what and when it will be. By definition, they are unpredictable and inevitable. The core competency is an ability to mitigate its negative effects. There is one thing that – more than anything else – hospitals can do to facilitate this: take away control from leaders with no clinical experience. I expand on this point in a prior post. The bottom line is that the only one qualified to lead in a crisis is a physician. They have credibility and legitimacy with other physicians, which are precious commodities during the most harrowing times. No credibility/legitimacy = no trust. Hospitals with nonclinicians in charge are usually able to work around this equation when the times are stable, but ultimately discover its impact during a crisis.
Leaders that accept a future crisis as inevitable gain a better appreciation of the business case for safety. The downside risk of a Black Swan Event is that years of profitability, growth and goodwill are instantly wiped out. Building redundancy in safety systems appears far more profitable within this broader context. The best example of taking a hyperconservative approach to safety are the high reliability organizations, teams that have minimized the risk and impact of errors despite working in hazardous environments. They are characterized by complete transparency, deferring to expertise, showing resilience and a reluctance to simplify answers to complex problems. The above cases studies of crisis events shows that hospitals today often act the exact opposite way. They are places of secrecy, that defer to authority (not experts). Their leaders focus on avoiding blame via politically expedient and oversimplified answers.
I will close by addressing the “baby out with bathwater defense”. Hospital leaders (the baby) claim they should not be held accountable for a crisis (the bathwater) because that would be an overreaction to an unpredictable event. If we fire the CEO everytime a bad event happens, we will have no one around to implement the lessons that were learned. This defense requires hospital leaders to present evidence that they have actually learned from their mistakes. Unfortunately, that does not appear to be the case. As a cardiac surgeon, the result of every decision I make on behalf of patients is fully available for the world to see. Hospital administrators are virtually never transparent about their decisions, particularly those that go wrong. The crisis events over the last two decades show the same repeated mismanagement errors. When your instinct after making a bad decision that hurts patients is to skirt accountability, you are the bathwater and not the baby. The time for us to recognize that difference is now. To paraphrase candidate Barak Obama in 2007, we are entering a defining moment in history where we’ve lost the faith that our leaders can or will do anything about it.