Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: To err is human, yet in healthcare and in critical care, we still have an unhealthy relationship with failure.
Speaker: In today's episode of the podcast, we will discuss the science behind learning to fail.
Speaker: In other words, failing well.
Speaker: We will discuss our flawed relationship to failure, how to better understand failure, and more importantly, how to move from a culture of blame, who did it, to a culture of learning what happened.
Speaker: Our guest is Amy Edmondson, the Novartis Professor of Leadership and Management at the Harvard Business School.
Speaker: For the last two and a half decades, she has studied the elements of high-performing teams in complex environments.
Speaker: She has coined the term psychological safety and has made critical insights into teaming, learning from failure, and innovation.
Speaker: She is the author of several books, multiple academic papers, and a regular contributor to the Harvard Business Review.
Speaker: Her latest book, Right Kind of Wrong, The Science of Failing Well, was released in September of this year on hardback.
Speaker: I am truly honored and grateful to have her back on the podcast.
Speaker: Amy, welcome back to Critical Matters.
Speaker: Thank you so much for having me back.
Speaker: So I would like to start with a rapid fire of just some terms that are often thrown around when we talk about failure and just get your reactions.
Speaker: One of them that we've heard over and over again in the business world and in the startup world is fail often and fail fast.
Speaker: My reaction is that is too indiscriminate.
Speaker: That is appropriate advice for some contexts, but not for most contexts.
Speaker: Failure is not an option.
Speaker: Again, failure is not an option is an interesting one because it's, I believe it's trying to convey the idea that we absolutely must do our very best because of what's at stake.
Speaker: But it can inadvertently drive truth telling underground.
Speaker: So it can backfire.
Speaker: So I think whenever we want to use that term, failure is not an option, which I think is our aspiration in very high stakes situations.
Speaker: We want to make sure we're crystal clear that we're saying because we don't want to fail, we need to hear from you.
Speaker: Perfect.
Speaker: And last, we don't fail.
Speaker: We are winners versus we don't fail.
Speaker: We are learners.
Speaker: Again, lovely sentiment, and it needs to be a bit more nuanced.
Speaker: There are times when we fail.
Speaker: There are times when we fail badly, and many of those are, as human beings, are preventable.
Speaker: So, yes, we should learn from all failures, and we should be quite discriminating about the kinds of failures that
Speaker: that we're proud to have experienced and those which we are really going to try very hard to never have happen again.
Speaker: Perfect.
Speaker: And before we go into our troubled relationship with failure, especially in healthcare, as a physician, I mean, obviously we deal with failure on a daily basis, yet we still deal with it in a very, I believe, unhealthy way.
Speaker: Could you define failure and how is it different from an error?
Speaker: Well, failure is a larger, broader term.
Speaker: Failure is an undesired result.
Speaker: An error is a deviation from a known practice, a known process.
Speaker: I often think of the easy way to talk about this.
Speaker: There is a recipe, but we messed it up, didn't use it properly.
Speaker: So a mistake, the concept of mistake is
Speaker: only exists when there is knowledge about how to get the result you want.
Speaker: So many failures are caused by mistakes, but many failures are not at all related to mistakes.
Speaker: There are undesired results in new territory.
Speaker: And I think that that's a very important distinction to get us started, especially when we're talking to healthcare providers, because we have been taught that all failures are wrong.
Speaker: And we talk about failure and error and mistake almost in the same context and are unable to talk about it with maybe a better framework, which I hope that you will provide us today.
Speaker: So why don't we go ahead, Amy?
Speaker: Sorry.
Speaker: Sorry.
Speaker: I just my initial reaction, my immediate reaction to that wonderful point about health care is that I think it's easy to lose track of the historical perspective.
Speaker: The remarkable work that you do today in medicine and health care.
Speaker: all exists because of a willingness to experiment, again, I think almost always in cautious, thoughtful ways throughout the history of medicine.
Speaker: If people had not been willing to experiment in the early days, for example, of cardiac surgery in the 50s, we would not have that medical miracle today.
Speaker: I agree.
Speaker: Now, can we talk about our troubled relationship with failure and maybe start with our aversion to failure?
Speaker: How does that impact our learning?
Speaker: You know, our aversion to failure as human beings is largely our aversion to our own failures, right?
Speaker: It turns out that we have less aversion to other people's failures.
Speaker: In fact, sometimes they give us an unhealthy experience.
Speaker: sort of sense of relief or worse.
Speaker: But our aversion to failure, I believe, is quite instinctive.
Speaker: It's an emotional reaction because we want to be successful.
Speaker: We don't want to fail.
Speaker: We want to look good, not bad.
Speaker: And so I think it's both somewhat automatic, but also well-learned through our childhood and our socialization that lead us to
Speaker: really want to distance ourselves from failure.
Speaker: And what do we commonly get wrong about failure, Amy?
Speaker: One of the things I think you clearly outlined already is that failure is not always bad.
Speaker: That's one of them.
Speaker: But what else do we get wrong about failure?
Speaker: Well, I think what we get wrong about failure is a sense that it has to be either or.
Speaker: Either we're embracing the fail fast rhetoric or we're saying, no, failure is off limits.
Speaker: Failure is not an option.
Speaker: And you sort of have to take sides.
Speaker: And then some people will say, well, there's a balance.
Speaker: I don't think it's a balance.
Speaker: I think it's a balance.
Speaker: very specific, you know, context-specific set of principles so that when you are in, say, a scientific laboratory, if you're experiencing no failures, you are not going to publish very well as a scientist.
Speaker: In other words, if you're on the leading edge of any field, you are experiencing very likely far more failures than successes because your experiments haven't been done before by anyone in the world.
Speaker: And so,
Speaker: You might have a very good hypothesis and Mother Nature doesn't agree with you.
Speaker: So in that context, that would be a context where you must be failing or you won't be succeeding.
Speaker: Similarly, let's say you're an elite gymnast.
Speaker: If you're only doing safe moves that you can do in your sleep, you're not going to make it to the Olympics.
Speaker: If you're trying harder and harder things, which involves failing along the way to getting them just right,
Speaker: you will have a better chance of ultimate success.
Speaker: So we have to be thoughtful about failure.
Speaker: We have to say, well, under what conditions is failure truly on the path toward success?
Speaker: And under what conditions are we going to do our very best individually and as groups to prevent them?
Speaker: And I think another aspect of failure that people might not appreciate is that it's not that easy to learn from failure.
Speaker: We think it is, but I think we'll talk about it more.
Speaker: It's a bit complicated.
Speaker: Yes, I agree.
Speaker: It's, you know, I think oftentimes our learnings are quite superficial.
Speaker: It's sort of, okay, I don't want to do that again.
Speaker: I just move forward and don't look back.
Speaker: We often don't take the time...
Speaker: to really look at what happened, what was my thinking, what were the actions, why were we wrong, and what does that tell us about what we should be doing going forward.
Speaker: So I don't mean to imply a lengthy, lengthy analysis, but a thoughtful one that is clear-eyed and willing to do a little bit of that hard work.
Speaker: In medicine, historically, we have examined failure through the very traditional and the toxic M&Ms, morbidity and mortalities.
Speaker: And I think some teams are moving in the right direction.
Speaker: But obviously, having trained before they were in our sets and in a different culture,
Speaker: it seemed that we had that hero mentality that we would just put our head down and say, I will do better next time.
Speaker: But there was really no learning there.
Speaker: Could you talk a little bit about the failure and the blame culture?
Speaker: Yes, I do think, you know, it's, it's, um, and Eminem is a good example of this.
Speaker: The, the, um, imagine the following, right?
Speaker: What, um,
Speaker: How many failures in, let's say, your medical center, and I would say that to any listener, are caused by people engaging in what we might call blameworthy acts, where they really woke up, came to work impaired, or just mailed it in, did sloppy work on purpose, or worse, deliberately set out to sabotage a case, right?
Speaker: And most people's answers will be, well,
Speaker: Virtually none.
Speaker: I mean, when something like that happens, it's very, very rare to say, OK, I'm with you on that.
Speaker: And then I'll say, well, what percent of.
Speaker: failures does your organization, your medical center treat as if they were caused by blameworthy acts?
Speaker: And then either, you know, a gasp or a laugh and people will say, well, most of them.
Speaker: And to me, the key to an effective M&M meeting is that we're making that thoughtful distinction.
Speaker: It's not a blame and shame meeting.
Speaker: It's a learning meeting.
Speaker: We recognize that tragically, sometimes things do go wrong.
Speaker: And our aspiration is simply to learn everything we can from it to prevent it from happening again.
Speaker: Not to accuse, blame, criticize, but to truly learn, as the scientists you all are, to really learn what happened and how to do better.
Speaker: And to realize that sometimes we have to take care of the clinicians as well as
Speaker: I mean, if you go through something like that, like, you know, a fatal event, especially, it can be quite traumatic.
Speaker: And so in our aspiration to prevent them again from happening, we have to take care of everybody involved as best we can.
Speaker: That is a great segue to talking about the types of failure.
Speaker: And then we can talk about that some of these types are, like you said, blameworthy and some are praiseworthy.
Speaker: But could you give us an overview of the three types of failure?
Speaker: So the three types of failure I identify are basic, complex and intelligent.
Speaker: And just to get out ahead of this, only intelligent is what I'll call the right kind of wrong, the praiseworthy kind.
Speaker: And basic failures are single cause failures.
Speaker: They're caused by human error.
Speaker: They're in familiar territory.
Speaker: We had knowledge about how to achieve a result, whether it's a chocolate cake or a medical procedure.
Speaker: The knowledge exists and error intervened and led to a failure.
Speaker: Those are obviously not celebratory moments.
Speaker: Those are learning moments to be sure.
Speaker: We can prevent all of those.
Speaker: And not because, I'm not saying we can prevent all human error.
Speaker: We cannot.
Speaker: Two errors human.
Speaker: But in medicine, usually there's at least a space between an error and an outcome.
Speaker: So when we're at our best, we can catch incorrect errors before anyone is harmed.
Speaker: We can not deliver the erroneous dose that was just written.
Speaker: We can quickly give an antidote if it gets that far.
Speaker: So that's basic failure.
Speaker: Single cause, bad mistake leads to a failure.
Speaker: Complex failures are, of course, the real beast in medicine and healthcare, which are the Swiss cheese kind of failure.
Speaker: And I define them as they're multi-causal,
Speaker: A handful of factors line up in just the wrong way to create the failure.
Speaker: And any one of those factors on their own would not lead to the bad outcome, right?
Speaker: It's the perfect storm.
Speaker: They had to come together in just the wrong way to make the failure, to allow the failure to slip through.
Speaker: Those two are preventable.
Speaker: And quite often, and to me quite tragically, many complex failures could have been prevented had people felt psychologically safe enough to speak up when they were
Speaker: you know, not convinced that something was wrong, but just curious about whether something was wrong.
Speaker: When they glimpse what I would call an ambiguous threat or an ambiguous moment and they just are afraid to ask for help or to question a dose or what have you.
Speaker: So complex failures are multi-causal.
Speaker: That makes them pernicious, but it also gives us many, many opportunities to catch incorrect.
Speaker: And then finally, intelligent failures are the still undesired results of novel forays into new territory.
Speaker: So technically, they're experiments, whether it's an experiment in your personal life or an experiment in a laboratory.
Speaker: Intelligent failure is the outcome that happens when your hypothesis was wrong in new territory.
Speaker: And I think that this framework is extremely important for our clinicians to understand because it gives them a better way of talking about failures among the team.
Speaker: And what I wanted just to comment from the clinical perspective, Amy, is that the names basic, complex, and intelligent work.
Speaker: are really based on the processes that are involved in terms of thinking and behaviors and not necessarily on the outcome or the stakes.
Speaker: Right.
Speaker: So I can think of a basic failure would be we amputated the wrong limb.
Speaker: Right.
Speaker: That is devastating for a patient, but it's a basic failure that should be prevented.
Speaker: Yes.
Speaker: I'll just interrupt and say yes.
Speaker: Basic doesn't mean small.
Speaker: Let's be clear about that, right?
Speaker: A basic failure can be very large and consequential indeed, but it's just that single cause.
Speaker: And complex failure, on the other hand, is what I live, I think, every day in the ICU, right?
Speaker: Because it's a complex environment with every action has so many parts to it.
Speaker: And a lot of complex failures that we experienced in the ICU might be, for example, they were about to give the wrong type of blood, but they did a check and they recognized it.
Speaker: So they didn't give the wrong type of blood.
Speaker: So no harm to the patient, but still was a failure of the process, right?
Speaker: Right, right.
Speaker: And that's the beauty of it is that so many of our process failures
Speaker: can be caught and corrected.
Speaker: And I think you're doing better at that nowadays.
Speaker: I think that like everything, right, talking about the problem is the first step.
Speaker: But I do agree.
Speaker: I think there are pockets of excellence in healthcare.
Speaker: But I think that if you were to take the average of the thousands of hospitals that we have in the United States, there's still a lot of room for opportunity.
Speaker: Oh, yes.
Speaker: Yes.
Speaker: I mean, better doesn't mean best.
Speaker: Yes, I agree.
Speaker: And intelligent failure, I just want to...
Speaker: Make the point that our audience in general, I think, is a very clinically oriented audience, Amy.
Speaker: I think it's very easy in the context of research to understand intelligent failure or in the context of development of new products.
Speaker: Right.
Speaker: However, I would say that a great example of intelligent failure is COVID.
Speaker: some teams organized the delivery of care with small pilots and were learning very fast and adapting very fast because they were psychologically safe teams where everybody could say, why don't we do this this way?
Speaker: Why don't we do this the other way?
Speaker: And I think that the delivery of care is a great example of how we can be smarter about intelligent failures.
Speaker: That's great.
Speaker: That's actually a beautiful example in my view because it was new territory for everybody.
Speaker: And these don't have to be formal experiments like in a laboratory, but there was a lot of experimenting and, oh, we discovered we could make an ICU in a tent.
Speaker: I mean, there was a lot of iteration that went on and the more thoughtful you were in that iteration, the better off you were in making progress in that new territory.
Speaker: The other thing I wanted to ask you, Amy, is I've seen you and I've seen in some of your previous papers, and I'm sure also in the book you talk about it, on a spectrum of this is blameworthy to this is praiseworthy, right?
Speaker: There is a context that goes, and I think it's important to recognize, even when somebody does something wrong, commits an error, it's not always their fault.
Speaker: And especially when I talk to our clinical leaders, I think it's important to talk about that.
Speaker: Could you talk about that, but overlap it with the process knowledge spectrum?
Speaker: Yes.
Speaker: So the process knowledge spectrum basically points to the reality that in our processes, whether in healthcare or any other industry, there's a spectrum from
Speaker: highly routine work that we know we're good at.
Speaker: We know exactly how we want things to unfold.
Speaker: This is, of course, an automotive assembly line or, you know, I think about an area of medicine that is more routine than other aspects.
Speaker: And then we move to the right in the spectrum toward variable work, where we have a lot of knowledge about how to get the result we want, and there's a high need for customization or variability of arrival times.
Speaker: All sorts of complexity is introduced into our process by that.
Speaker: And if we keep going to the right, we get to what I call novel contexts, where the knowledge is very undeveloped.
Speaker: And so we have no choice but to
Speaker: experiment and see what works to develop the knowledge that may make some activity routine in the future, but it's not routine today.
Speaker: So that's, that basically that's a spectrum from very, very low uncertainty to very, very high uncertainty.
Speaker: Now, I would argue in all three of those domains, you can have both praiseworthy and blameworthy actions.
Speaker: And I suppose I'm a little bit of a purist on blameworthy.
Speaker: I like to really only call things blameworthy where the person was deliberately intent on causing harm or at least intent on not really trying in a situation where their effort was needed.
Speaker: Yeah.
Speaker: And then we move to the right.
Speaker: And let's say someone is, you know, let's say the root cause of a failure is someone didn't pay attention.
Speaker: There's an airline accident in the book that happened 40 years ago, Air Florida Flight 90, that was just a single human error and not putting the anti-ice on led to this catastrophic fatal accident.
Speaker: Right.
Speaker: So, you know, that that's not paying attention to
Speaker: isn't always blameworthy, but it can be blameworthy if, I mean, it may even be the supervisor who puts someone in a position where they just wouldn't be able to be alert for that long a time that led to the outcome.
Speaker: Whereas praiseworthy is any attempt to try, you know, any attempt to try something new and being fully cognizant of what's at stake so that you don't unnecessarily create risk
Speaker: especially safety risks, can be thought of as praiseworthy.
Speaker: And I think a perfect example for healthcare, and just thinking of my own listening of errors, when I was a critical care fellow, after a 36-hour shift, I punctured myself with a needle, right?
Speaker: I mean, and that probably was...
Speaker: Inattention.
Speaker: Yeah.
Speaker: That's, I mean, you didn't follow protocol, but it's a needle stick.
Speaker: And yet the context, and we'll talk about that later, is very important, right?
Speaker: I mean, anybody who's fatigued, anybody who's overworked is more likely to make those errors, right?
Speaker: Right.
Speaker: And I remember that the shame of trying to get help for that.
Speaker: And I'm sure that this is a story that a lot of our listeners have experienced or know in different variations.
Speaker: And that's really why I think it's so important to talk about all this for health care.
Speaker: I agree.
Speaker: And 36 hours.
Speaker: I mean, the human being was not designed to work for 36 hours straight and then be just as good at the end of that time as you were at the beginning of that time.
Speaker: So that is a context factor that matters greatly.
Speaker: And this is why I say we have to learn from failures thoughtfully, because if you don't take into consideration in your analysis,
Speaker: the contributing factors such as that, you will get faulty answers to your analysis.
Speaker: So can we do a little bit of a deeper dive into the types of failure?
Speaker: So we talked about basic errors, which I think in the context of clinical medicine are well recognized today, right?
Speaker: Transfusing the wrong type of blood.
Speaker: and dosing somebody with 10x, right, which still happens, of a narcotic, amputating the wrong limb.
Speaker: These are all examples of basic failures which could have deadly consequences.
Speaker: And I think that, like everything in life, prevention, right, is worth a, what do they say, a ton of treatment.
Speaker: Could you talk about some of the strategies for preventing basic errors?
Speaker: Yes.
Speaker: You know, I often feel embarrassed to talk about this because it's so basic.
Speaker: And I'm going to be saying things that your listeners already know.
Speaker: But the fundamental preventions for basic failures are training.
Speaker: And so we don't want to short change training, whether we're in medicine or in manufacturing.
Speaker: We want to make sure people have what they need
Speaker: in being trained in procedures so that they have a good shot at doing them well.
Speaker: Failure proofing, right?
Speaker: You rarely leave instruments inside a patient anymore because you often have the instruments in nests that make it crystal clear.
Speaker: If something's missing, it's got to be somewhere you better find it before you sew up, for example, as just maybe a simple example of failure proofing.
Speaker: But you can think of all sorts of failure proofing techniques
Speaker: mechanisms that you build into your practice or build into your life.
Speaker: Sharing, psychological safety to help people speak up quickly and have blameless reporting of things that go wrong so that we can collect those data and be better informed about where the risks are is another strategy for preventing as many basic failures as possible.
Speaker: And and I guess that's you know, I guess those are the top ones that come to mind.
Speaker: But you can see how these aren't what I'll call rocket science.
Speaker: These are very basic, very fundamental.
Speaker: Examples of good practice.
Speaker: And I think that.
Speaker: It's important to talk about these and think about them because a lot of people know these things, but it doesn't mean that it happens every time for every patient.
Speaker: And even in academic centers, there's still basic failures going on.
Speaker: But one of the areas that I wanted to dig a little bit deeper is checklists or codifying prevention because...
Speaker: It seems that since Atul Gawande's wonderful book and Peter Pronovost, I mean, really, I think kind of a revolutionary study with central lines, something that we do every day in the ICU, checklists are everywhere in health care.
Speaker: And what fascinated me, Amy, reading the book was the transcript of the, I think, the Florida airplane that you mentioned, right?
Speaker: Yes.
Speaker: Can you just talk a little bit about that?
Speaker: Sure.
Speaker: So, you know, first of all, I erred in a sense that should have been the very top of my list of failure, basic failure prevention is checklists.
Speaker: And and yet and I do this deliberately in the book.
Speaker: I include this Air Florida flight in 1982 that that crashed because despite, I'll say, despite the checklist, because the checklist was used in a highly mindless process.
Speaker: routine, almost autopilot, forgive the parallel manner.
Speaker: So the first officer said anti-ice and then the captain said off.
Speaker: And the correct answer, it was a January wintry, icy day.
Speaker: The correct answer is, of course, on.
Speaker: And that led to this horrific crash.
Speaker: So the takeaway, as you all know well, is that checklists are a very powerful, you know, profound tool even.
Speaker: And they must be used while awake, right?
Speaker: They must be used deliberately, thoughtfully.
Speaker: If we don't take them seriously, we don't see them as the useful tool that they are, and we just sort of go through the motions, as it were, then they won't do their job.
Speaker: Excellent.
Speaker: And in terms of complex failures, we mentioned that these are also very, very prevalent in healthcare, especially in a setting like the one our listeners work in, which is the ICU.
Speaker: It's not only high complexity, but high stakes on a daily basis.
Speaker: You did mention the Swiss cheese theory a little bit earlier.
Speaker: Could you just explain that a little bit more for some of our listeners may not be as familiar?
Speaker: Absolutely.
Speaker: So Jim Reason, who is the...
Speaker: Error, he's an error theorist,
Speaker: in the UK is the one who came up with this metaphor.
Speaker: And I like to say, if you think about the holes in Swiss cheese, any hole in your cheese is not something that contributes to your nutrition.
Speaker: So it's a kind of error, those little air bubbles.
Speaker: And he used this metaphor to say, it's fine for your cheese to have holes, no harm done.
Speaker: But when the holes line up,
Speaker: they create a tunnel that lets the failure flow through.
Speaker: So the idea is many of our processes are slightly flawed in a variety of ways.
Speaker: There's deviations here, there's deviations there.
Speaker: But every now and then the deviations all line up in such a way that allows the failure to just slip on right through.
Speaker: And why this is a useful metaphor is that it points out that
Speaker: These kinds of failures aren't the norm, of course, but they are preventable if we're really paying attention because all you have to do is catch one bubble.
Speaker: The tunnel won't work to allow the failure through if there's even one of the factors that gets noticed and altered before the failure happens.
Speaker: So I think it's empowering.
Speaker: I think it's meant to say, speak up.
Speaker: Even if you have very low confidence that you've spotted a concern, speak up anyway.
Speaker: Your voice is welcome here.
Speaker: And I think that in healthcare, a lot of our listeners may have been part of root cause analysis of some sentinel event or some complex failure.
Speaker: And as you go backwards, so for example, a child received a overdose of a narcotic and went into respiratory distress.
Speaker: Right.
Speaker: If you go backwards, all the point to where the medication was prescribed, you might find...
Speaker: multiple opportunities for intervention that would have avoided that happening right I think you alluded to that I think the term that you use in your research is the recovery window and yes and I think that that's important because in retrospect it's easy to figure out right but right why doesn't it happen in real time
Speaker: And that's where, like you said, speaking up, psychological safety and paying attention is really important.
Speaker: I think a lot of times also people really, whether it's imposter syndrome or common knowledge effect, they assume that this doesn't feel right, but it's okay.
Speaker: Right.
Speaker: Somebody else must know better than me.
Speaker: And that's a big problem.
Speaker: They assume, oh, I probably just didn't read up on the latest literature or I'm new here or, or, or.
Speaker: And they make the assumption, which is fine in your social life.
Speaker: I don't think I'll speak up about that right here, right now.
Speaker: But in health care, and I would say in work environments more generally, we have to flip that script and say, no, no, no.
Speaker: Even when in very real doubt, we need to hear from you.
Speaker: And finally, we have intelligent failures.
Speaker: And one of the things I want to make sure our listeners understand is that we can always learn from failure.
Speaker: That doesn't make it the right kind of wrong, right?
Speaker: Maybe it's failing well is we can talk about that later, but intelligent failures specifically have a very precise definition and setting.
Speaker: Could you talk a little bit about that in the context of healthcare?
Speaker: Yes.
Speaker: Thank you.
Speaker: I, I, um,
Speaker: I think there's really four questions to ask.
Speaker: Is this new territory or is there existing available knowledge that I can look up and use?
Speaker: And do you glimpse an opportunity?
Speaker: So it's opportunity driven.
Speaker: There's a goal, taking care of patients, a new treatment, or even just getting better at a particular procedure, that you've got a goal in mind that makes it worth the
Speaker: Modest experimentation that's about to happen.
Speaker: Have you done your homework?
Speaker: Have you read the literature or talked to experts or found out what you could about what is known before you go off into this unknown territory to try something new?
Speaker: And then finally, and so importantly in health care especially, the experiment.
Speaker: should be as small as possible.
Speaker: You want to mitigate the risks that are inherent in new territory by keeping your experiments just large enough to learn, but not so large that you're actually wasting resources or putting undesirable risks in there.
Speaker: And I think that the pilot and the size of your pilot, for example, I think is very valuable.
Speaker: I often think of, I guess, in the tech world or in the startup world, we're talking about the minimum viable product, right?
Speaker: Yes.
Speaker: How much do you need to invest in effort, time, and money to get an idea if it's going to work or not, right?
Speaker: And this is very common in healthcare delivery as a mistake.
Speaker: People say, oh, we got to change this, and they change it across a large scale, and then it doesn't work.
Speaker: right that would be i think a great example of clinicians using intelligent failure to improve the way they run their office to when they would run their icus and that is outside of the context of research which a lot of our physicians and app's who listen to us don't do yes that's right and it's i mean i think this the size issue is quite subtle and quite important which is
Speaker: You always want to have I love the term minimum viable product or, you know, minimum viable process.
Speaker: Like if you can you must use your, you know, your brain to design the the experiment such that it's just big enough to be valid to learn from.
Speaker: But no bigger as to create waste.
Speaker: So if it's a new procedure in your office, test it out with a particular subset of patients or test it out on Mondays or whatever the appropriate move is.
Speaker: But don't roll things out before they're ready for prime time.
Speaker: So the way I process all this, Amy, is that failing well is understanding the different types of failure.
Speaker: It's putting every effort we have to prevent basic and complex failures.
Speaker: And when those occurs, it's trying to truly learn from them so we can improve our processes.
Speaker: And in the right context, it's applying intelligent failure.
Speaker: Yeah.
Speaker: Now, your audio expertise is the science behind that.
Speaker: Can we talk a little bit about that?
Speaker: Well, first of all, I just want to give you an A plus because that's exactly right.
Speaker: And I don't think everybody appreciates that.
Speaker: Maybe they're out there reading the sort of short digital articles on this topic and they decide that failing well is all about the fail fast break things.
Speaker: But to me, what you just said is exactly right.
Speaker: Failing well is about preventing as many
Speaker: bad failures, basic and complex, as humanly possible.
Speaker: And it's about increasing our willingness to engage in smart experimentation to make progress in new territory and welcoming the still undesired, but welcoming the failures that come our way.
Speaker: So that's exactly right.
Speaker: So being able to distinguish, but also being really good preventers and then really good experimenters.
Speaker: So one of the words that I hear a lot these days when we talk about failure in healthcare is high reliability organizations or HROs.
Speaker: Could you talk a little bit about those?
Speaker: And is that just a fancy name for a psychologically safe environment?
Speaker: Yes.
Speaker: And I think it's a fancy name for a psychologically safe environment, but that's not all it is.
Speaker: So I think HROs are,
Speaker: High reliability organizations are profoundly psychologically safe environments because one of the principles is that people at any level of a hierarchy will speak up immediately and forcefully if they see something wrong.
Speaker: So these are organizations that are really, really good at catching and correcting deviations.
Speaker: They understand that deviations will happen.
Speaker: And so they're not, I don't think they would ever use the term failure is not an option because what they understand is failure is
Speaker: Always a possibility.
Speaker: More than the rest of us, people in HROs truly appreciate that failure is always a possibility.
Speaker: So they don't want them to happen if they're preventable.
Speaker: So they're, you know, acutely sensitive and to, you know, to subtle changes and committed to speaking up about them.
Speaker: So what it has in addition to psychological safety, which is that permission for voice, is it has just a high level of sensitivity, that people have a mindset that says, yep, things could go wrong.
Speaker: And that they have a high level of just, what's the word I'm looking for?
Speaker: Carl Weick, who has written about this, calls it heedful interrelated.
Speaker: aware of what each other is doing.
Speaker: It's not just, okay, let me do my job, you do your job and all will be well.
Speaker: It's sort of, there's a lot of very thoughtful interactions.
Speaker: And so I think HROs really appreciate that failures in their context, whether it's nuclear power or an aircraft carrier, are so consequential that they really, really, really are committed to them not happening.
Speaker: And I think the interrelativeness awareness in healthcare is important because A, we're a team, but more, I think more significant, we live in silos.
Speaker: Yes.
Speaker: And I think historically in healthcare, you know, long, long ago when you had the horse and buggy doctors and, you know, you essentially had clinicians with their shingles and they couldn't do much for you, but you know, they were good people doing their best with the knowledge that was available at the time.
Speaker: And, you know,
Speaker: As medicine has gotten more and more complex and more and more subspecialties and interdisciplinarity, our mindsets, your mindsets, haven't always caught up, right?
Speaker: So there's still this idea, I'm a professional, I'm an expert, I should have what it takes and know what to do to care for my patients.
Speaker: And that's fine and good.
Speaker: And also one needs to be aware that
Speaker: in to care for my patients, especially the hospitalized ones, I am utterly dependent on so many others, you know, at the bedside and in other parts of the organization where, where back office things are happening, where, where drugs are being, you know, put into cartridges and all of the rest.
Speaker: So it's, it's just a profoundly interdependent system and, and,
Speaker: your mental models haven't always kept up with that interdependence.
Speaker: The other thing I wanted to ask you about, Amy, is the power of shame versus embracing vulnerability.
Speaker: Yeah, so to me, they're very different things, but I can see how people would
Speaker: confuse them or sort of think of them as highly related.
Speaker: So embracing vulnerability to me is simply embracing a fact, right?
Speaker: Each and every one of us is vulnerable.
Speaker: We're vulnerable because we can't see the future.
Speaker: We're vulnerable because we're fallible human beings and things both we will make mistakes and our systems will have little breakdowns.
Speaker: So we're vulnerable by fact.
Speaker: And
Speaker: the only real question mark, our only decision is whether we're willing to acknowledge that and sort of use that fact to shape our thinking and shape our behaving.
Speaker: So that's just, to me, it's a strength.
Speaker: Like vulnerability means I am strong enough to know that I'm vulnerable.
Speaker: Whereas shame is to believe really quite erroneously that
Speaker: That vulnerability is somehow wrong and indicates that I'm not a good person or I'm not a worthy person.
Speaker: And I think as a leader, it's important to be vulnerable at the right times.
Speaker: You also want to inspire confidence to your team.
Speaker: But like when somebody makes a mistake, we fail, we made a mistake, let's move forward and try to learn from this, right?
Speaker: It invites others to say the same thing.
Speaker: Exactly.
Speaker: I mean, first of all, if you're a leader in healthcare, you must go first.
Speaker: You must demonstrate the example of honesty, of speaking up, of acknowledging when you've come up short.
Speaker: It's just you must or else no one else will.
Speaker: But also, I think you can both acknowledge your individual vulnerability and acknowledge the vulnerability of, say, our ICU, because those are just facts, but
Speaker: while also express extreme confidence in our ability to deliver great care.
Speaker: When we are at our best, when we are working together, when we are honest, when we are asking for help, when we're in over our heads, we can really do almost anything.
Speaker: So it's not, you know, to acknowledge your individual vulnerability is not to give up on the strength of your teams or the strength of your organizations.
Speaker: I read that becoming is better than being, which I think is another way of saying learning over knowing.
Speaker: Yes.
Speaker: And can you talk a little bit about in this pursuit of learning from from from all failures, a little bit of how we can reframe failure and how can we play to win versus not to lose?
Speaker: Well, I think we reframe failure as a necessary or inevitable part of life, especially a full life, especially a life of achievement, even, that I have not met anyone who's achieved a lot, who hasn't experienced lots of failures along the way.
Speaker: And so the reframe has to be from failure is bad and shameful, and I don't want to have it, or I don't want to admit it if I do have it, to failure.
Speaker: Failure is on the path to successes and working together and at our very best, we can prevent the preventable ones, the basic and complex ones, and we can embrace
Speaker: the intelligent ones in new territory.
Speaker: So that is the reframe.
Speaker: And I believe that as I describe it that way, you begin to realize this is kind of a team sport.
Speaker: And I don't think you can do any teaming whatsoever if you're not willing to choose learning over knowing.
Speaker: And that has to be a kind of explicit override because our default state is to believe we know, you know, I believe I'm right, you're wrong, you know, when we disagree.
Speaker: And I have to kind of
Speaker: train myself to say, Oh, wait a minute, you know, maybe I'm missing something.
Speaker: And, and that's not a shameful thing.
Speaker: That's like just a fact of life.
Speaker: And now I'm curious.
Speaker: Now I want to know what you see that I miss, because it's going to help me.
Speaker: Perfect.
Speaker: And what about in the book, and some of your research, you talk about stop challenge choose?
Speaker: How do we incorporate that?
Speaker: Well, a stop, challenge, choose is a little kind of cognitive habit that I suggest our listeners practice.
Speaker: And that is the sort of the self-discipline to pause, right?
Speaker: If there's any uncertainty at all, which is often the case, just pause for a moment and check what you're thinking and then
Speaker: Challenge it.
Speaker: Like, I wonder what I'm missing.
Speaker: And then choose the path of learning.
Speaker: And that can be in a disagreement with your partner.
Speaker: That can be in a, you know, a clinical intervention you're about to make.
Speaker: Just pause, take a close look at what you're thinking and why.
Speaker: And then, you know, to see whether there could be any gaps that are important here.
Speaker: And then choose a learning path.
Speaker: path forward the last thing i wanted to ask you as we as we start closing amy is obviously um great people and bad systems will underperform and we don't think enough about systems in health care any any comments on how we incorporate that into everything we discussed
Speaker: Well, you know, in the book, I use the example of Children's Minnesota just because I have studied it.
Speaker: I studied it a while ago closely as part of the patient safety research.
Speaker: I use it as an example of an organization that I think any organization can do without any health care organization without a ton of cost or costs.
Speaker: new equipment or anything like that.
Speaker: It's just a kind of a mindful recognition of the way the different elements of a system, you know, your staffing systems, your training systems, your technology, your mindsets, your culture, your reporting systems, and all the rest, how they
Speaker: interact in ways that create more than the sum of the parts.
Speaker: I think we have a tendency, certainly in management, we have a tendency to look at elements and to analyze the heck out of elements.
Speaker: And we're less likely to look at how different elements of the system relate to each other and create unintended consequences or create mutually reinforcing strengths that we want to make sure we design on purpose.
Speaker: We covered, I think, a lot of ground.
Speaker: And as we move from understanding and theory to action, I think Herb Spencer said many, many centuries ago that the whole point of education is not knowledge, but action, right?
Speaker: Any tips and pearls for our ICUs and moving towards feeling better?
Speaker: Well, I think the most important action in the ICU is the action of speaking up.
Speaker: It is the action of asking for help.
Speaker: It's the action of, of,
Speaker: Asking good questions.
Speaker: If you're a clinician leader in an ICU environment, your best action is to pause and say, ah, what am I missing?
Speaker: Ask people, what did you see last night?
Speaker: What thoughts do you have?
Speaker: Maybe it'll only be one out of 10 times that you hear something that you didn't expect, but that one will be well worth it.
Speaker: So the crucial action, I would argue, is the action of inquiry.
Speaker: invite people to participate and listen to understand, right?
Speaker: Yes, indeed.
Speaker: So Amy, you've been on the podcast before.
Speaker: We'd like to close with a couple of questions unrelated, I guess, to the topic.
Speaker: Although in this case, they will be related to the topic.
Speaker: The first question is any book or books you would recommend for our readers after they've done with the right kind of wrong to expand their journey and learning about failing well?
Speaker: Yes, I'm going to recommend ADAPT by Tim Harford, which kind of takes, he's a beautiful writer and it takes on some of these issues in more of the management space.
Speaker: And then in this sort of psychological and sociological space is a beautiful book called Being Wrong by Katherine Schultz, which goes more deeply into our sense of shame and discomfort with being wrong and how, again, that's something we have to learn to welcome.
Speaker: Perfect.
Speaker: And we'll definitely link those in the show notes.
Speaker: And also we'll link our previous conversation on psychological safety, which I think, as you said, is the underpinning for all of what we discussed today.
Speaker: And the last question is, as we close, could you share with us your favorite failure?
Speaker: Well, my favorite failure, which is in the book, concerns Ray Dalio, who was a tremendously successful person in finance.
Speaker: His investment business, Bridgewater Associates, has been one of the most successful companies in history, and he's the entrepreneur who started it.
Speaker: But seven years into
Speaker: that company's existence, Dalio had made an absolutely wrong bet in new territory about the economy and lost everything he had.
Speaker: Now, I think our leaders will notice that is not an intelligent failure.
Speaker: Everything about it was fine, except the size, right?
Speaker: It was new territory.
Speaker: He had a hypothesis.
Speaker: He had a goal.
Speaker: And yet that experiment was much too big for uncertain territory.
Speaker: So the reason it's my favorite failure is not just because it misses being intelligent, but even more because he came away from it a changed man.
Speaker: He says, in retrospect, that failure was the best thing that ever happened to me.
Speaker: It taught me to temper my arrogance, my confidence, and replace it with a kind of humility that says,
Speaker: Instead of I'm right, I wonder why I think I'm right.
Speaker: That is the shift that I think great clinicians can and should make.
Speaker: It doesn't involve being insecure.
Speaker: It just involves being strong enough to say, I wonder why I think I'm right.
Speaker: And then you get curious.
Speaker: And so I think it was a profound insight for him and I think for others as well.
Speaker: And I think it speaks to the idea that it's not about having answers, but having great questions.
Speaker: Precisely.
Speaker: Amy, always a pleasure.
Speaker: Thank you for putting out such wonderful work, both in the research level, but also in framing it in a way that everybody can understand with your books.
Speaker: Like we were speaking beforehand, I think this is critical for all clinicians, especially in the ICU.
Speaker: And I look forward to more in the future.
Speaker: And again, thank you so much for sharing your time and expertise with us.
Speaker: Well, thank you for the work that you do.
Speaker: It really matters.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
