How Great Leaders Prevent Problems Before They Happen: Go from Problem-Solving to Problem-Finding
- "It isn't that they can't see the solution. It's that they can't see the problem."
- —G. K. Chesterton
Code blue! Code blue! Mary's heart has stopped, and her nurse has called for help. A team rushes to the patient's room. No one expected this crisis. Mary had come to the hospital for routine knee-replacement surgery, and she had been in fairly good health prior to the procedure. Now, she isn't breathing. Working from a "crash cart" full of key equipment and supplies, the expert team begins trying to resuscitate the patient. Working at lightning speed, yet with incredible calm and precision, they get Mary's heart beating again. They move her to the intensive care unit (ICU), where she remains for two weeks. In total, she spends one month more than expected in the hospital after her surgery. Her recovery, even after she returns home, is much slower than she anticipated. Still, Mary proved rather lucky, because the survival rate after a code blue typically does not exceed 15%.
After Mary begins breathing regularly again, the patient's family praises the team that saved her life. Everyone expresses relief that the team responded so quickly and effectively. Then, the team members return to their normal work in various areas of the hospital. Mary's nurse attends to her other patients. However, as she goes about her normal work, she wonders: Could this cardiac arrest have been foreseen? Did I miss the warning signs? She recalls noticing that Mary's speech and breathing had become slightly labored roughly six hours before the arrest. She checked her vitals. While her respiratory rate had declined a bit, her other vital signs—blood pressure, heart rate, oxygen saturation, and body temperature—remained normal. Two hours later, the nurse noticed that Mary appeared a bit uncomfortable. She asked her how she was feeling, and Mary responded, "I'm OK. I'm just a little more tired than usual." Mary's oxygen saturation had dipped slightly, but otherwise, her vitals remained unchanged. The nurse considered calling Mary's doctor, but she didn't feel comfortable calling a physician without more tangible evidence of an urgent problem. She didn't want to issue a false alarm, and she knew that a physician's assistant would come by in approximately one hour to check on each patient in the unit.1
This scenario, unfortunately, has transpired in many hospitals over the years. Research shows that hospitalized patients often display subtle—and not-so-subtle—warning signs six to eight hours before a cardiac arrest. During this time, small problems begin to arise, such as changes in heart rate, blood pressure, and mental status. However, hospital personnel do not necessarily notice the symptoms. If they notice a problem, they often try to address it on their own, rather than bringing their concerns to the attention of others. One study found that two-thirds of patients exhibited warning signs, such as an abnormally high or low heart rate, within six hours of a cardiac arrest, yet nurses and other staff members brought these problems to the attention of a doctor in only 25% of those situations.2 In short, staff members wait too long to bring these small problems to the attention of others. Meanwhile, the patient's health continues to deteriorate during this window of opportunity when an intervention could perhaps prevent a crisis.
Several years ago, Australian hospitals set out to save lives by acting sooner to head off emerging crises. They devised a mechanism whereby caregivers could intervene more quickly to address the small problems that typically portend larger troubles. The hospitals invented Rapid Response Teams (RRTs). These teams respond to calls for assistance, typically from a floor nurse who notices an early warning sign associated with cardiac arrest. The team typically consists of an experienced critical-care nurse and a respiratory therapist; in some cases, it also includes a physician and/or physician's assistant. When the nurse pages an RRT, the team arrives at the patient's bedside within a few minutes and begins its diagnosis and possible intervention. These teams quickly assess whether a particular warning sign merits further testing or treatment to prevent a cardiac arrest.
To help the nurses and other staff members spot problems in advance of a crisis, the hospitals created a list of the "triggers" that may foreshadow a cardiac arrest and posted them in all the units. Researchers identified these triggers by examining many past cases of cardiac arrest. Most triggers involved a quantitative variable such as the patient's heart rate. For instance, many hospitals instructed staff members that the RRT should be summoned if a patient's heart rate fell below 40 beats per minute or rose above 130 beats per minute. However, hospitals found that nurses often noticed trouble even before vital signs began to deteriorate. Thus, they empowered nurses to call an RRT if they felt concerned or worried about a patient, even if the vital signs appeared relatively normal.3
The invention of RRTs yielded remarkable results in Australia. The innovation soon spread to the United States. Early adopters included four sites at which my colleagues (Jason Park, Amy Edmondson, and David Ager) and I conducted research: Baptist Memorial Hospital in Memphis, St. Joseph's Hospital in Peoria, Missouri Baptist Medical Center in St. Louis, and Beth Israel Deaconess Medical Center in Boston. Nurses reported to us that they felt much more comfortable calling for assistance, especially given that the RRTs were trained not to criticize or punish anyone for a "false alarm." As one said to us, "It's about the permission the nurses have to call now that they didn't have before the RRT process was established." Another nurse commented, "There is nothing better than knowing you can call an RRT when a patient is going bad." With the implementation of this proactive process for spotting problems, each of these pioneering hospitals reported substantial declines in cardiac arrests, transfers to the intensive care unit, and deaths. A physician explained why RRTs proved successful: "The key to this process is time. The sooner you identify a problem, the more likely you are to avert a dangerous situation."
Academic research confirms the effectiveness of RRTs. For instance, a recent Stanford study, published in the Journal of the American Medical Association, found a 71% reduction in "code blue" incidences and an 18% reduction in mortality rate after implementation of an RRT in a pediatric hospital.4 With these kinds of promising results, the innovation has spread like wildfire. The Institute for Healthcare Improvement has championed the idea. Now, more than 1,600 hospitals around the country have implemented the RRT model. Many lives have been saved.
What is the moral of this remarkable story? Small problems often precede catastrophes. In fact, most large-scale failures result from a series of small errors and failures, rather than a single root cause. These small problems often cascade to create a catastrophe. Accident investigators in fields such as commercial aviation, the military, and medicine have shown that a chain of events and errors typically leads to a particular disaster.5 Thus, minor failures may signal big trouble ahead; treated appropriately, they can serve as early warning signs. Many large-scale failures have long incubation periods, meaning that managers have ample time to intervene when small problems arise, thereby avoiding a catastrophic outcome.6 Yet these small problems often do not surface. They occur at the local level but remain invisible to the broader organization. These hospitals used to expend enormous resources trying to save lives after a catastrophe. They engaged in heroic efforts to resuscitate patients after a cardiac arrest. Now, they have devised a mechanism for spotting and surfacing small problems before they escalate to create a catastrophic outcome. Code Blue Teams are in the business of fighting fires. The Rapid Response Team process is all about detecting smoke (see Figure 1.1).7
Figure 1.1 Fighting fires versus detecting smoke
This book uses the terms problem and failure interchangeably; they are defined as a condition in which the expected outcome has not been achieved. In other words, we do not witness desired positive results, or we experience negative results. These problems may entail breakdowns of a technical, cognitive, and/or interpersonal nature. Technical problems consist of breakdowns in the functioning of equipment, technology, natural systems, and the like. Cognitive problems entail judgment or analytical errors on the part of individuals or groups. Interpersonal problems involve breakdowns in communication, information transfer, knowledge sharing, and conflict resolution.8
Many organizations devote a great deal of attention to improving the problem-solving capabilities of employees at all levels. Do they spend as much time thinking about how to discover problems before they mushroom into large-scale failures? One cannot solve a problem that remains invisible—unidentified and undisclosed. Unfortunately, for a variety of reasons, problems remain hidden in organizations for far too long. We must find a problem before it can be addressed appropriately. Great leaders do not simply know how to solve problems. They know how to find them. They can detect smoke, rather than simply trying to fight raging fires. This book aims to help leaders at all levels become more effective problem-finders.
Most individuals and organizations do not view problems in a positive light. They perceive problems as abnormal conditions, as situations that one must avoid at all costs. After all, fewer problems mean a greater likelihood of achieving the organization's goals and objectives. Most managers do not enjoy discussing problems, and they certainly do not cherish the opportunity to disclose problems in their own units. They worry that others will view them as incompetent for allowing the problem to occur, or incapable of resolving the problem on their own. In short, many people hold the view that the best managers do not share their problems with others; they solve them quietly and efficiently. When it comes to small failures in their units, most managers believe first and foremost in the practice of discretion.
Some organizations, however, perceive problems quite differently. They view small failures as quite ordinary and normal. They recognize that problems happen, even in very successful organizations, despite the best managerial talent and most sophisticated management techniques. These organizations actually embrace problems. Toyota Motor Corporation exemplifies this very different attitude toward the small failures that occur every day in most companies. Toyota views problems as opportunities to learn and improve. Thus, it seeks out problems, rather than sweeping them under the rug.9
Toyota also does not treat small problems in isolation; it always tries to connect them to the bigger picture. Toyota asks: Is this small failure symptomatic of a larger problem? Do we have a systemic failure here?10 In this way, Toyota resembles organizations such as nuclear power plants and U.S. Navy aircraft carriers—entities that operate quite reliably in a high-risk environment. Scholars Karl Weick and Kathleen Sutcliffe point out that those organizations have a unique view of small problems:
- "They tend to view any failure, no matter how small, as a window on the system as a whole. They view any lapse as a signal of possible weakness in other portions of the system. This is a very different approach from most organizations, which tend to localize failures and view them as specific, independent problems... [They act] as though there is no such thing as a confined failure and suspect, instead, that the causal chains that produced the failure are long and wind deep inside the system."11
With this type of approach, Toyota maintained a stellar reputation for quality in the automobile industry for many years. Experts attributed it to the vaunted Toyota Production System, with its emphasis on continuous improvement. As many people now know, Toyota empowers each frontline worker to "pull the Andon cord" if they see a problem, thereby alerting a supervisor of a potential product defect or process breakdown. If the problem cannot be solved in a timely manner, this process actually leads to a stoppage of the assembly line. This system essentially empowered everyone in a Toyota manufacturing plant to become a problem-finder. Quality soared as Toyota detected problems far earlier in the manufacturing process than other automakers typically did.12 Like the hospitals that deployed Rapid Response Teams, Toyota discovered that the likelihood of a serious failure increases dramatically if one reduces the time gap between problem detection and problem occurrence. Both the hospitals and Toyota learned that acting early to address a small potential problem may lead to some false alarms, but it proves far less costly than trying to resolve problems that have mushroomed over time.
This attitude about problems permeates the organization, and it does not confine itself to quality problems on the production line. It applies to senior management and strategic issues as well. In a 2006 Fast Company article, an American executive describes how he learned that Toyota did not operate like the typical organization. He reported attending a senior management meeting soon after his hire at Toyota's Georgetown, Kentucky plant in the 1990s. As he began reporting on several successful initiatives taking place in his unit, the chief executive interrupted him. He said, "Jim-san. We all know you are a good manager. Otherwise, we would not have hired you. But please talk to us about your problems so we can work on them together."13
More recently, though, Toyota's quality has slipped by some measures. In a recent interview with Harvard Business Review, Toyota CEO Katsuaki Watanabe addressed this issue, noting that the firm's explosive growth may have strained its production system. His answer speaks volumes about the company's attitude toward problems:
- "I realize that our system may be overstretched. We must make that issue visible. Hidden problems are the ones that become serious threats eventually. If problems are revealed for everybody to see, I will feel reassured. Because once problems have been visualized, even if our people didn't notice them earlier, they will rack their brains to find solutions to them."14
Most executives would not be so candid about the shortcomings of the organization they lead. In contrast, Watanabe told the magazine that he felt a responsibility to "surface problems" in the organization. By speaking candidly about Toyota's recent quality troubles, rather than trying to minimize or downplay them, Watanabe models the attitude that he wants all managers at the firm to embrace. For Watanabe and the Toyota organization he leads, problems are not the enemy; hidden problems are.