Tuesday, November 15, 2011

Let’s All Feel Superior: Individual Failures Require Leadership, Systems, and Culture to Bind

I read this op-ed piece from David Brooks in the New York Times with great interest. While talking about the Penn State scandal, Brooks identifies several fascinating psychological constructs that we use as individuals to avoid taking the "right action":
  • Normalcy Bias - "shut down and pretend everything is normal" 
  • Motivated Blindness - "don't see what is not in their interest to see" 
  • Bystander Effect - "the more people are around to witness the crime, the less likely they are to intervene" 
  • Self Deception - "we attend to the facts we like, and suppress the ones we don't" 
  • Blind Spots - "when it comes time to make a decision, our thoughts are dominated by thoughts about how we want to behave; thoughts of how we should behave disappear" 
His key point is that we're in denial of "the underside of our own nature", which I would have to believe is likely true. However, as Brooks also points out "in centuries past people built moral systems that acknowledged this weakness .. they helped people make moral judgments and hold people responsible amidst our frailties." I would argue that this is the real weakness. Human nature has not changed, but society has evolved into such a complex organism such that the systems to keep "human nature in check" are not functional.

But this is ultimately what is means to be a leader - whether spiritual, political, or organizational - and to create an organizational culture: help to guide human nature - despite its many failings, blind spots, self deception, and biases - to achieve a purpose and pursue actions that no individual would undertake on his/ her own.

Many of us see these individual failings consistently in our healthcare organizations, which have largely been build around the notion that failure of behavior is an individual failing. Sometimes these individual failings are just as egregious as the examples used by Brooks when staff, managers, and executives "stand by" and allow for actions to be taken that lead to patient harm in the guise of "its just the way things work around here".

However, as many industry leaders have been pointing out - particularly the stalwarts for patient safety - individual behavior may contribute to a failing, but it is not the cause. The system (i.e., culture or society) that allows that behavior to be manifest is the cause. If we want better behavior, decisions, actions or ultimately the outcomes which result from these behaviors, then we have to work with greater diligence to build the leadership, systems, and culture that will allow individual failings to be overcome or at least held in check. The likelihood of harm is just as great, and not at all excused because the victims are sometimes unknown, or because it happens within a building and not on the street.


  1. Well said. Are there not parallels between protecting known bad actors within the medical profession (who go on to harm others and betray the public trust), and failing to report child abuse?

  2. Hi Pat, I think that's certainly an added dimension to this discussion. In my post above, I was mostly thinking of the "failings of human nature" described by David Brooks about why others witnessing wrong actions don't act, and not so much about the "moral depravity of specific bad actors". But that certainly exists as well, and unfortunately also tends to go on without adequate supervision, reporting, and remediation. I think that a properly functioning "healthcare system" needs to be able to deal with this level of behavior as well. As your statement implies, we need more action from the regulators and overseers (e.g., Board of Registration of Medicine, Department of Public Health, The Joint Commission) to ensure that this type of reporting is robust and fair.

  3. Great post. The culture of secrecy in medicine/hospitals deserves this comparison. How do we reduce pt. harm, co-worker bullying, hubris,or secrecy if we don't have honest leaders who value an open, transparent culture? Maybe more awareness, tighter oversight and accountability? How about ensuring the accuracy of death certificates? If we ensure that true causes/contributing factors of death are legally documented, non- disclosure of serious medical errors would become a non-issue...and families would no longer have to suffer the burden of life-long grief from never knowing what happened.

  4. Thanks Lori, Hadn't contemplated the death certificates angle that you are suggesting. Certainly it could help in improving transparency. Have to ponder this one a bit more.