Episode 16 - Operating in Uncertainty

Summary

In this week’s podcast we explore what leaders can learn from the way surgical teams manage complexity.

 

TRANSCRIPT

Welcome to episode sixteen of the Leadership Today podcast. Each week we provide practical advice to address some of today’s biggest leadership challenges.

Last week we dipped our toes into the waters of complexity, looking at how the storming stage of team development is better thought of as an ongoing process to be managed.

This week we are extending on that theme of operating in uncertainty, seeing what leaders can learn from the way surgical teams manage complexity.

As leaders we operate in a complex world where we are constantly presented with opportunities and threats. Some describe it as a VUCA world - an acronym that characterises modern conditions as volatile, uncertain, complex and ambiguous. The term VUCA can be traced back to the 1980s where it was used in US Army War College training to describe the conditions faced by soldiers - where the enemy is not always clear and traditional approaches may not work.

In this VUCA world we still need to manage tasks, processes and people within our teams. But we also need strategies that look beyond our team if we are to survive and thrive.

The operating room where surgical teams work is a complex environment. The human body itself is complex and variable, and we’re still learning more every day about how our systems work and interrelate. There’s complex equipment being used, and emergency situations to be managed. There’s input from various specialties - surgeons, anaesthetists, nurses and doctors - people who are highly qualified and full of opinions. Often times there are new teams performing surgery that may not have worked together before. This can lead to a lack of consistency, assumptions and disagreements. From a group dynamics perspective, this sounds a lot like the conditions for storming - and you don’t want storming during an operation. As a consequence of this complexity, surprises occur, things are missed and mistakes are made. This leads to variable outcomes for patients.

A World Health Organisation initiative sought to address these concerns. They tracked the outcomes of thousands of operations across eight hospitals in eight countries, gaining an initial baseline. They then implemented a 19-item surgical safety checklist - just 19 items that the surgical team would work through a check off. It was an initiative inspired by how pilots and ground crews manage the complexity of air travel through checklists.

So how does a checklist help? One example is the risk of people not speaking up during a surgical procedure, even when they see something going wrong. After all, they may not know everyone in the room, and may not see it as their role to intervene. As a result, the checklist includes a step where all team members introduce themselves to each other by name and role. Further down the checklist, the surgeon flags how long the case will take, anticipated blood loss, and any non-routine steps. This all helps to bring everyone together, building clarity and helping to preempt issues that might emerge.

The results of implementing the checklist were dramatic - the rate of death was reduced by over 40%, and complications were reduced by over a third.

So it would be natural to assume that this 19 item check list would be mandated for use everywhere. However, the researchers stressed how Important it was for local hospitals to tailor the checklist to meet local needs. That could include adding or removing items from the list.  They recognised that risks, resources and cultures differ from hospital to hospital. Despite the dramatic results, they were quick to recognise that the true value of their findings was in the principle of having a checklist, rather than the exact checklist procedure itself.

And then there’s the people factor. Given how dramatic the results were, you would think people would be thrilled to use the checklist. However 20% of surgical staff thought even a 19 item check list took too long. Interestingly, of that same group, 93% indicated that they would want the checklist used if they were having surgery. As with any change, there’s always opportunities to streamline by engaging people in the process - helping to address their concerns and involving them in refinements. It’s important to help people to appreciate the principle, rather than being obsessed about the procedure.

There are a number of lessons for leaders from this study in how we navigate through a VUCA world:

Always improve - even in the world of modern surgery there was still an opportunity for dramatic change, and even 1% improvements add up over time Look outside your field - in the research surgical teams applied lessons learned from air travel - maybe there are similar lessons that apply in your industry Identify principles - these provide ways to operate in the grey, and should be developed by incorporating input and feedback Principles not procedures - rather than rolling out more and more procedures, we are usually better off communicating a principle that applies more broadly When communicating a principle, start with the reasons why it matters - if people don’t understand the reasons for a new way of working, they will often block the change or just avoid it

I hope you found that helpful. Let me know what you think via our website leadership.today, or feel free to leave a review wherever you get your podcasts.

 

Reference

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population - January 29, 2009 N Engl J Med 2009; 360:491-499 https://www.nejm.org/doi/full/10.1056/NEJMsa0810119