I want to talk about failure. How do you think about failure? To me, it is an inevitable part of caring for patients with “end-stage renal disease.” After all, if I am average my death rate will be 22-23% annually, and even if I am doing better than average, it will still be 20%. I say this to make it clear that I what I am going to say is witnessing, not preaching—I experience failure regularly, too.
I think most physicians respond to failure in one of several ways. The first, and in my view the most adaptive, is to focus on the process of care more than the outcomes. Did we make good decisions? Did we miss a signal of deteriorating condition we should have noticed? Did we have the right consultants in to help deal with the patient’s problem? Did the family say something like “It’s okay doctor, you did what you could?” A senior physician told me early in my training to accept that all practicing physicians acquire ghosts—the ghosts of patients who had bad outcomes or died because, in retrospect, the answer to these questions might be negative. I usually phrase this as “Doctors do what doctors do, and sometimes it works and sometimes it doesn’t. If we don’t take too much credit when it works, we don’t have to take quite as much blame and guilt when it doesn’t.”
A second response is heightened vigilance. “I’m not going to make that mistake again—I am always going to order that lab/radiology study or go back to the bedside to check one more time just to make sure.” The problem with heightened vigilance is that the psychic cost is enormous, and often leads to decision making paralysis. One of the most vivid lessons in my early training was being in the operating room when the surgeon encountered an unexpected difficulty during the case and froze instead of changing his plan. Neither the resident or I had anything useful to say, but the circulating nurse was wiser and asked the surgeon if she should call his partner. The junior partner made a “suggestion” that got the surgeon back on track and the case was finished satisfactorily.
A third response is avoidance—if I don’t make any decisions and defer everything to “consultants” then I will be okay, or I will stick to something simple, like outpatient acute minor illness, and send everything else to the ER. Of course it is not usually possible to arrange your practice quite so neatly. Another type of avoidance—seeking release through drugs and alcohol—has obvious drawbacks. The physician who denies that he has ever done anything wrong is also engaging in avoidance, not reality.
Thus far, we have considered failure at the individual level. How we respond is a combination of our training, experience, temperament, early life experience and everything that makes us who we are. However, it is also important to consider failure at the level of the group, in this case people in your department, and at the organizational level of the hospital.
The most challenging group failure is surely peer review. Since we all have ghosts and we are reluctant to talk about them, we tend to try and avoid the whole subject. However, avoidance is no longer permissible. So how do we get to a useful form of peer review? It seems to me we must admit that failure at the group level is inevitable, not avoidable. We already know that we are going to fail individually, and have developed (unconscious?) strategies for handling it. Yet when we gather in our groups, we act as though failure is the exception. Is this a form of scapegoat behavior designed to relieve our own anxiety?
It turns out all highly reliable groups accept failure as inevitable, and therefore attention is focused on trying to identify “little” errors and correct them before they become “big” errors. What if we took the view that most of our peer review activities should be focused on identifying failures that might be corrected for everyone’s patient? All of our departmental triggers for case review are focused on death and complication, and I am not suggesting these be replaced. I am suggesting, though, that looking at outliers only is not very helpful in improving care.
If this were easy, why aren’t we doing it already? I think the real barrier is emotional, not intellectual. Failure is unpleasant and associated with a lot of negative emotions including guilt and shame. It may be easy to admit that failure occurs at an intellectual level, but it is not easy to admit that I failed, and it is particularly difficult to be told by my colleagues that I failed. Yet if we are to reduce failures, we have to start there. Navy pilots grade each other on the quality of each and every carrier landing, not as a form of one-upsmanship, but as a way of trying to spot little errors in technique that, if not identified and corrected will lead to a crash. Can we change our culture to look at how we handle routine cases to see if we are heading for a crash?
The problem of handling failure is also an organizational challenge. Administrators, nurses, and everyone involved in the process of care have the same negative feelings about failure that we experience. Those in non-clinical areas, though, have even less training and experience in coping with this than do rookie nurses. If we are to improve the “way we do things around here” the first challenge is to overcome the alphabet soup of usual organizational response to failure—attack, blame, criticize, deny, evade, and filibuster. Individual failures occur, and those who fail more than average must be held accountable, but the greater challenge is to redesign the system so that the average failure rate goes down. Are you up to it?
Written 5 April 2011, revised 4 May 2014.
Why do people change? A consideration of the desirable future state.
On Institutional Failure - Part 1
On Institutional Failure - Part 2
A central question for healthcare organizations as they face the future is what is our goal? While taking care of patients might seem the obvious answer, it is the one that is usually not considered.