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Lessons from "never" events: Mental model shifts

Posted Oct 21 2008 12:50am
In a post below, I mention some lessons from Tom Botts at Royal Dutch Shell that he and his senior team learned after a serious accident on one of their drilling rigs, lessons that made them rethink their approach to safety. Since then, I've had a chance to exchange a few emails with Tom, and he was very kind to send me an annotated version of major insights resulting from his experience. I post it below. I think there are lessons for all of us here at BIDMC and in other hospitals, as well. They are especially pertinent here as we follow up from our " never event", the wrong-side surgery, and as other hospitals watch and learn from our experience.

As we work through how to improve ourselves, Tom's insights offer guidance and warnings. They are quite potent. I am particularly attuned, though, to Number 5, as that is the usual response when something goes wrong; i.e., "bolting on" a new rule or procedure, which then creates a new layer of error-producing problems of its own.

Tom’s mental model shifts as a result of the Brent Bravo fatalities

1. Good results may not reflect underlying performance
Just before the incident, the Brent Bravo platform’s safety and operating performance was very good, as measured by our normal key performance indicators. The operating performance dashboard which listed ‘traffic lights’ for all of our key performance indicators was mostly green, which gave the appearance of an operation in control and performing well. Key question: Do the metrics I am looking at really indicate the underlying performance? Or are they giving me false comfort?

2. Challenge the green, and support the red
Related to 1. above. If on measurement dashboards, we focus on challenging red lights and praising green lights, pretty soon all the traffic lights will be green. Key question: Are the green lights really green? Am I in too much of a hurry to ‘fix’ the red lights, instead of really trying to understand what they are telling me?

3. At the level of rhetoric, there are no dilemmas
It’s easy for senior leaders to stand up and claim “safety is our most important priority—I do not want you to compromise safety”. And then we leave the people on the shop floor to deal with all the dilemmas of cost, schedule, production, etc. Key question: How do I acknowledge and help people work through the dilemmas they face every day? Or do I leave it up to them to grapple with the tough choices?

4. Lurking in the wall of noise are critical messages
During times of change, there will inevitably be a lot of feedback expressing concern over the change. A key for senior leaders is to resist the urge to dismiss the “noise” and chalk it up to “they just don’t want to change”. Key question: How do I really try to understand the concerns that people have and use that to deliver an even better product? Do I effectively play back the concern so people feel they have been heard?

5. Bolting on best practices may make the system worse

We love to identify and apply best practices. We tell our people to stop reinventing the wheel and find someone who has already solved the problem. Nothing wrong with that, but adding stuff onto the system without fully understanding the system impacts can result in worse performance, not better. Key question: Have I fully considered the unintended impact of applying this “best practice” change to my system?

6. The operations professionals may not see it either
As a senior leader, I assumed the professionals on the shop floor would have the knowledge and the empowerment to stop operations if they felt it was unsafe. We have developed incredibly complex systems, and it’s hard for even the experienced professionals to know if they are operating “outside the envelope” or not. Key question: Do the people at the shop floor making the day to day decisions have the competences and deep understanding of the system they are operating to know when to say ‘STOP’?

7. I’m enrolling somebody in something every minute
We know, as senior leaders, that all eyes are on us and it’s especially important our messages are consistent and well thought through. But we aren’t enrolling people only when we are giving speeches or making presentations. We enrol people with every word and action. Key question: What do I do at the coffee pot, or in idle chatter with staff, or when I think I’m having a private conversation that may enrol people in something different than my “public” messages?

8. A system full of well intended, competent people working world class systems trying their best to meet expectations can produce fatalities
Probably the most profound learning for me. In the Brent Bravo story, there were no obvious ‘villains’, but rather a number of causal patterns that came together to produce a tragedy. The whole point of Deep Learning for each of my senior leaders and me was to be able to see ourselves in the system and what causal patterns we could have been able to break (if we had a better appreciation for the unintended consequences of our many well intended decisions). Key questions: Am I asking the right questions? Am I curious enough?
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