By: DMKashmer MD MBA MBB FACS (@DavidKashmer)
Don’t Just Attribute Issues To One Cause
One of the things we do every day is attribute issues to their cause. We are, perhaps, programmed to notice items that seem to cause other events. Some evolutionary biologists believe that our notion of causality has helped us modify the world around us and evolve as no species has before. Yet another interesting take from evolutionary biologists is the idea that we are programmed coincidence machines. In our imagination, when lightning strikes a log, we imagine fire. Soon after the rain when the sun is out, we expect to see a rainbow.
In fact, some believe that we over-notice coincidence. After all, both the log on fire and rainbow immediately post-rain are special, unusual cases–yet these are top-of-mind when we consider the scenario. Reality is, often, much more mundane than what we imagine and more common than we are prone to notice: when a log is struck by lightning we generally don’t see fire unless the conditions are just so. This entry describes how our notions of causality are sometimes at odds with the process of statistical process control. It is this evolved, intuitive notion of causality that sometimes gets in the way of quality improvement. In the end, our over-simplified thoughts on causality may end up making us blame the victims of the lousy system that we own.
Consider, for example, the typical process improvement pathway at your hospital. Often, one service line blames another for trouble. I typically see this in trauma where trauma surgeons blame the emergency department for issues regarding notification of trauma activations etc. It’s a very standard story that one service blames another or one provider blames another for being wrong or somehow just not skilled enough. In fact, what’s really going on is not that simple.
Angry At One Another? Probably A Bad System Putting You At Odds
More often, the situation and events conspire to make a system that puts people’s interests at odds. People get mad and blame each other because the system is dysfunctional–and there’s more.
An expanded notion of causality lets us see the deeper truth regarding how people are setup to succeed or fail. For example, consider a trauma center that has issues with triaging its patients. It is over-simplified, often, to say that the emergency physicians do not “call traumas”. In fact, the truth is usually much more complex and requires a deeper dive with an take on causality which is very different than what we’re typically programmed to do. (Techniques like the “five why’s” may be used to get at these deeper root causes.)
It’s NOT Usually Just A People Problem
Deeper causes lay behind superficial takes on different issues. It’s rarely just “the ED docs are not calling the traumas”. Thought, and additional techniques, usually reveals that the reasons traumas are not called are multifactorial. The trouble is, perhaps, that we aren’t programmed to look beyond who acts upon us. We attribute their actions to “how they are”. (Maybe it’s related to the fundamental attribution error.)
In reality, perhaps the ED is slowed down by traumas and is measured on how long it takes to admit patients to the hospital. Perhaps trauma surgeons do not respond to trauma calls in a meaningful way and so the ED doctors do not activate the system. Perhaps the ED doctors feel like nothing different goes on for the patient when a trauma is activated. These are just a few of the common reasons why “traumas are not called” and notice that few of these are the result of ED provider judgement. Expanded takes on causality even include things like how the weather impacts what we see from a process. Further expansion allows us to see which causes are controllable (and how controllable) versus those that we are not able to influence.
Do You Blame The Person Who Is Drowning?
The notions of statistical causality, association, and our everyday notion of causality are clearly very different from each other. Consider, for example, a drowning man. Imagine this man in the middle of the Atlantic Ocean and he is alone. Eventually, and sadly, you watch him drown. An over-simplified, typical version of causality for the man’s drowning (like one we’d use in the hospital) is that, well, he wasn’t a strong enough swimmer. But does that really make sense? Although that may be true, it’s incredibly superficial and lacks recognition of the deeper reasons why this poor soul didn’t make it.
When healthcare providers aren’t performing (by the way, weren’t these some of the strongest, most apt, caring individuals coming out of college and high school–what happened?!), do we sometimes blame them as not being strong enough swimmers when the reality is much more complex? Perhaps the issue is not that these people somehow changed; some of it may be how they look through the lens of our current system.
Now, expand the situation. Consider that the man was in the middle of the Atlantic Ocean. Consider that he was alone. Consider that he had no safety equipment to indicate his location. Consider the reasons why his boat sank. Consider whether mother nature brewed up an unexpected storm. This expanded notion of causality, which focuses on the six M’s of statistical quality control and special cause variation, gives us a much more robust view of exactly why the man drowned. Bad hospital systems cause drowning people.
In truth, physicians and care givers who work in bad systems are also like drowning people. You can only swim against the wave for so long. And if the system conspires to have you drown rather than set you up for success, we see a recurrent group of problems. And, just as people beset by the ocean don’t want to disappear quietly, so too do these providers get angry.
In Healthcare, We Tend To Blame Ourselves
In fact, in healthcare, we typically look to ourselves first as the reason something went wrong. We abide by the illusion that, typically, if only we were stronger we could have swam to shore. This is sometimes true, and in many ways (especially for trainees) it helps us focus on learning to be as skilled as possible. However, there are many other causes listed in the six M’s for which things go wrong.
When we really want to rebuild a system to make things go right, we should look to this expanded notion of causality. We should attempt to set things up so that it’s easier to be successful (poka-yoke) than it is to have difficulty. In fact, building a system to make it easier to do the right thing usually leads to success. This starts with looking at causality that moves well beyond the person standing in front of us.
This can be very tricky, of course, as there are all sorts of reasons why dysfunctional hospital systems conspire to make people drown in work. Tampering with these systems often uncovers old resentments and deep history for the organisation. A careful balance is necessary when we go to adjust systems that are not functional.
…luckily for us there are pre-packaged toolboxes to help us do this. These advanced tools allow us to get beyond the frame of “whose fault it is” and look at that more robust view of causality. Next time you feel like you’re drowning at work, it’s worthwhile to ask yourself whether your swimming skills need improving or whether you can influence the water created by the system. Remember, when you see someone drowning, it’s worth spending time to look to the system rather than blaming the victim.