Essays

Essays November 2013

Why Is It So Hard To Admit a Mistake?

Don Ford and Hugh MacLeod

When we think about many of the conversations currently taking place on the “balcony of personal reflection,” we hear a common theme: why is it so difficult for us to admit that we have made a mistake? How do we move beyond a “name, blame and shame” mentality and embrace a “discover, understand and seek to improve” mentality?

How is it that other industries that impact the welfare of millions, such as aviation and the nuclear industry, have found ways to embrace the need, and the expectation for, its members to identify when a problem exists and how to bring it to the attention of those who can examine it. These industries have been successful in creating an environment where its members trust that problems can be found, analyzed and corrected before they result in a catastrophic outcome.

From the Ghost of Healthcare Consciousness comes the familiar refrain:

“Fear, fear, fear. The fear that if we admit we did something wrong we will be sued, or our professional status will be damaged, or our future ability to obtain privileges will be impacted, not to mention the adverse media attention which can be overwhelming. Why would anyone be willing to subject themselves to that? Furthermore, there are times when these wrongdoings are brought forward, only to be ignored or for the individuals to be labelled as a troublemaker.” 

To realize a culture of continual improvement demands we embrace the concepts espoused by Peter Senge, author of The Fifth Discipline, where he writes of a learning organization, which he defines as an organization “where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to learn together.”

If we sincerely believe we are employed in a learning environment, what can we gain from the industries mentioned above? Could the acquired knowledge be applied to our own affairs, allowing us to better our present circumstance? From what I have witnessed, those other industries started their journey by initially declaring, from the most senior levels of their organizations, in loud and overt ways, that the status quo was no longer acceptable. It was no longer acceptable for the aviation or nuclear industry to put passengers or citizens lives at risk due to an unreported incident or issue. Rather, they adopted a system to identify and report issues so they could be reviewed and corrected. The conclusions reached then went on to become the new learning tools that spread throughout the parts of the organization. 

Why should the healthcare industry be an exception? When undesirable behaviour is no longer accepted, processes must be established to support reporting, examine the issues raised, develop solutions and rollout the new discoveries to all parts of the system.

What will it take for the healthcare system to declare such a war on error, to develop a methodology whereby reporting becomes an obligation rather than a choice? Shouldn’t the patients expect the same commitment to safety from us as they do from airlines and nuclear plants? Don’t we owe it to them to provide such assurances?

There are pockets of such innovation in our midst that can serve as beacons of hope that we can achieve such a culture of correction. In April 2010, the Canadian Institute for Health Information launched the National System for Incident Reporting (NSIR), an initiative designed to allow for voluntary reporting of medication incidents so sharing and learning could occur. The NSIR is web-based, allows for simplified data submission, and provides tools for learning and analysis on an anonymous basis to enhance sharing. 

We ought to reverse our conversations so that the first questions asked by the media are: “How do you intend to recognize the person who identified this issue so that you were able to address this issue? How did you address the issue? When will the subsequent realizations from this become standard operating procedure?” 

Imagine a healthcare system where healthcare workers felt motivated to, and rewarded for, identifying how to improve care – workers actively stepping up to make a real and profound difference in what they do.

Three questions for your consideration:

  1. 1. Do existing processes of social proof encourage inappropriate behaviour?
  2. 2. When the top performers are singled out for public praise, yet they are known/perceived by peers to achieve questionable results, does this promote the political game behaviour?
  3. 3. What will it take to get a critical mass of leaders to be open to learning and finding new solutions to old ignored problems?

We close with this passage from the essay, “Shaping Canadian Healthcare Alignment”:

“A major obstacle to progress is the failure to ask ourselves wicked questions leading to a deep exploration of assumptions we hold and make. Without exploring our assumptions we will continue to be hostage to our indifference to failure and be unable to reach our improvement potential. Exposing these assumptions can be both uncomfortable and a relief. It is uncomfortable because the conclusions we draw and the beliefs we adopt based on our assumptions often seem to be “the truth” – obvious, acceptable and defensible. They guide us to do and say “the right things.” By engaging people in dialogue, wicked questions invite exploration into inconsistencies in thought that have held us back from achieving our purpose, and can be used to promote a search for local solutions to organizational challenges.”

Can we really change behaviours and mindsets?

Join the conversation posted today: Three Management Voices: A New Dynamic Wholeness – Both Our Minds and Our Hearts, Why Is It So Hard To Admit a Mistakeand Can We Achieve Wholeness in Healthcare?

 

Click here to see the First Series of Ghost Busting essays.
Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author

Don Ford … Son, Brother, Husband, Father, Grandfather … Eternal and Chronic Optimist.
Hugh MacLeod … Patient, Father, Husband, Brother, Grandfather … Concerned Citizen.

Acknowledgment

The Canadian Patient Safety Institute (CPSI) exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To address many of the challenges mentioned in the essay above, the Canadian Patient Safety Institute – with partners – has tools and resources, please contact www.patientsafetyinstitute.ca 

References

MacLeod, H. and J. Kitts. 2013. “Shaping Canadian Healthcare Alignment.” Longwoods Ghost Busting Essays.

Senge, P. 2006. The Fifth Discipline. Doubleday, New York. 

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