Friday, June 6, 2014

Saving Lives: Expecting Problems or Burying Them

By Alexander Laufer and Jeff Russell
In our current blog we will use metaphors from hospital life to highlight two different approaches for dealing with problems. The first is a story told by Terry Little:

Life in the E.R.1

Contrary to what my wife would say, I don't watch much television. I do, however, regularly watch one show on the Learning Channel—the reality series Trauma: Life in the E.R.

While watching the last episode, I recognized parallels between what was going on in the emergency room, with its host of accident and gunshot wound victims, and what goes on in successful project management.

First, there was a sense of urgency, but not haste. As an ambulance or helicopter brought in patients, the physicians, nurses and technicians did some quick planning, anticipating the likely condition and needs of the patient. They moved to get the necessary tools and equipment in place before the patient arrived.

Once the victim appeared, there was no wasted motion. With time as the chief resource, no one did anything that didn't directly address the ultimate objective—saving the victim. The medical team shared a clear set of priorities: deal with life threatening issues first, possible long-term consequences second and ignore everything else.

Each person in the room had an active role. No one was in the emergency room as an observer or overseer. Someone was clearly in charge, but typically no one waited to be told what to do. Interestingly enough, no one ever seemed paralyzed by fear of doing the wrong thing. Through training and experience the entire team operated in harmony. When there wasn't enough information to make a decision about a course of treatment, the staff moved quickly to get more information using x-rays, magnetic resonance imaging and similar diagnostics. People spent little time debating or pondering what to do next. They decided on what to do and got on with it.

Sometimes the unexpected happened and a situation that seemed to be in control suddenly went out-of-control. In those cases, there was no hand wringing or fault finding—just a measured, adapted response to the new situation. Sometimes there were mistakes; mostly they were acts of omission rather than commission. There was concern and open discussion about the mistakes, but learning was the chief consequence.

I also noted that there was a general acceptance that not everything affecting the patient was totally within the control of those in the emergency room. The staff spent their time dealing with what was in their control and not complaining about what wasn't.

The second lifesaving story is an abridged version of a bizarre episode taken from the novel Doctors,2 as it appeared in Breaking the Code of Project Management.3

It was to be a routine removal of a gallbladder. However, some problems were anticipated since the patient, Mr. A, had a somewhat complex medical history and was allergic to almost everything one could imagine.

It was my first week as an intern on Surgery. I was eager and proud to be in the operating room with the chief surgeon, Dr. Aubrey, and the anesthesiologist, Dr. Nagy, who were considered to be the top specialists in their fields.

Everything seemed to be going smoothly until Dr. Nagy started reporting some problems. From then on, it seems that things deteriorated faster than lightning. One moment the blood pressure was dropping and the next, the ECG was going crazy. In spite of all their emergency procedures, within a few minutes the ECG was flat and Dr. Nagy pronounced the patient dead.

Suddenly there was silence. No one dared speak until Dr. Aubrey decided on a course of action. He ordered Dr. Nagy to continue aerating the lungs. I wondered what was going on. After all, the poor man was dead! Then, with growing disbelief, I watched as Dr. Aubrey took over from his assistant and carefully started suturing and closing the opening. When the last suture was in place, Dr. Aubrey quietly ordered, “Take him to the recovery room. I’ll be there in a few moments.”

I was stunned. Only after I recovered my speech did I dare ask Dr. Aubrey’s assistant why they continued pumping air into the dead man’s lungs. He seemed to think the answer was obvious: “That way, Mr. A will be pronounced dead after the operation by somebody in the recovery room. This explains why no patient of Dr. Aubrey’s ever dies on his operating table….”

The intern in the Doctors story explained that another reason for Dr. Aubrey’s aberrant practice was to avoid the massive paperwork required by the hospital and the insurance companies. Thus, in addition to maintaining his perfect operating record, the surgeon was able to pass a time-consuming bureaucratic job on to the recovery room staff.

The two lifesaving cases were affected by their unique contexts and the operating assumptions of their relevant leaders. In the ER series the assumption was that they operated in a “living order” environment, thus problems were expected and were addressed swiftly which was followed by an effort to learn from them. On the other hand, in Doctors, the environment was assumed to be in “geometric order”: major problems were not expected, and if unfortunately did occur they were quickly buried.
1Life in the E.R. appears in an article that was written by Terry Little and published in the NASA Magazine, Academy Sharing Knowledge, under the title: “Project Management: The Television Show.”
Terry Little served as a project manager in the US Air Force where he was regarded as one of the most successful project managers. He then served as the executive director of the Missile Defense Agency, the senior civilian in an organization of approximately 8,000 employees. Earlier, he was the first director of the Air Force Acquisition Center of Excellence. Currently, Terry is a member of a research team at the Consortium for Project Leadership at the University of Wisconsin. 
2E. Segal. 1988. Doctors.  New York, NY: Bantam Books, 303-6.
3A. Laufer. 1999. Breaking the Code of Project Management. New York, NY: Palgrave, 189-190.