Sweat the Small Stuff

A high-reliability EMS provider does more than just show up fast and treat patients appropriately. As the idea of reliability is defined in the world of operational theory, it entails particular qualities characteristic of organizations that operate successfully in complex environments where accidents are likely to happen. In these high-stakes areas--aviation, for instance, or hospital emergency departments--organizations operate under intense pressure, with multiple complex tasks occurring concurrently, consecutively and interrelatedly. High-reliability organizations can detect and respond to problems, crises and unexpected challenges with a flexibility and resilience that minimizes disruption and harm.

In their 2001 book Managing the Unexpected--Assuring High Performance in an Age of Complexity, organizational experts Karl Weick and Kathleen Sutcliffe articulated five traits of organizations with this kind of mindfulness:

• A preoccupation with failure;
• A reluctance to simplify interpretations;
• Sensitivity to operations;
• Commitment to resilience; 
• Deference to expertise.

Veteran consultant and educator Jay Fitch, PhD, founding partner of Fitch & Associates, examined these concepts in the context of EMS in an opening presentation at the 2010 Pinnacle EMS Leadership & Management Conference in July. Here he explains for EMS World.

What is the value of being preoccupied with failure?

The core element of it is trying to find issues early--understanding what the signs of failure are. It's not to experience a failure and then try to find a silver lining based on that; it's more looking for the potential for failure. The author Richard Carlson said "don't sweat the small stuff," but we really have to sweat things, because the signs are often weak and hard to detect. And the earlier you try to detect them, the weaker they are.

What's a good example of that for EMS?

Think about having a vehicle being checked out on the ramp that starts rolling and collides with something. A weak early warning sign of failure could be that the wheels weren't chocked, or that someone was interrupted as they went about their work out on the ramp. If you're not thinking about it, or get distracted by coworkers while you're doing it, or stop your vehicle checklist to answer an e-mail and then come back to it, that's when you can have issues. As a pilot, one of the things we're taught fairly early is that if you're checking out your airplane, it's not a time you let somebody come up and talk to you or distract you. Because then it's really easy to go back to your process and miss something, and that can lead to a bad outcome.

Everyone loves simple solutions. Are there areas where folks in our business commonly tend to overlook complexity?

Well, I think we try to simplify everything. And that can lead to complacency--ignoring facts and developing blind spots. A good example is restocking: If we've always caught our mistakes before when we've restocked something, I might become comfortable that my future mistakes will be noticed and fixed before they cause harm. That won't necessarily always be the case.

Is there a greater diversity of expertise within organizations these days? How can leaders identify and access that?

I think part of it is a cultural thing. Historically, leaders were viewed as the people who made the decisions. "That's a decision the chief should make." People almost had the attitude of, "I'm not an officer; I shouldn't have to deal with that. That's somebody else's job." Now, as our entire world has become more specialized and complex, I think we've begun to recognize there are specialists emerging at all levels, and we need to recognize that expertise.

People often think of resilience in terms of major events. But what are some of the little things that can really hamstring an organization?

It could be something as simple as scheduling. Say you're a medium-size organization and have lots of people call off because a wave of flu comes through town. The resilient organization has a plan for that, and has figured out what they're going to do ahead of time. This isn't so much about big disasters, because everybody will turn up for the building collapse or major incident. Sometimes it's incidents that aren't as "sexy" that are harder for organizations that aren't resilient to deal with--supplies, maintenance, those kinds of things. And that kind of ties back to the silo management concept. If your management structure is tied up in silos, it makes it a lot harder to get things done in the midst of trying to resolve something.