Soaring with eagles or swimming with sharks? Aviation, banking and healthcare

"So, I should sell my shares in solar?"

When Steven Shorrock (@StevenShorrock),  Safety Development Project Leader at EUROCONTROL, spoke at ASPiH 2015, he mused aloud whether the conference organisers might have been better to invite a speaker from the banking sector than from air traffic control. He recommended reading "Swimming with sharks" for an insight into the former and these are my thoughts after reading it.

The book, "Swimming with sharks", published in 2015, is based on interviews with about 200 people who worked or recently worked in banking in London. The author, Joris Luyendijk, discusses the financial crash of 2008, which almost brought the developed world to its knees, as well as other scandals such as Libor trading, laundering of drugs money, assisting tax evasion and the fall of Lehman Brothers. The real substance of the book lies in the personal accounts of the people working in banking and their thoughts about the sector. There are definite similarities between healthcare and banking but also some important differences... 

Similarities

Safety

In banking, compliance officers are meant to keep an eye on the traders and ensure that trades did not expose the bank to too much risk. However, as Luyendijk states: "...it is very difficult to put a number on a loss you have averted by saying no..." A football analogy may be apt. The goalkeeper is remembered less for the many saves than for the single goal which lost her team the game. In healthcare a similar effect may be seen with those who work in "patient safety" including simulation-based training. Because safety is a "dynamic, non-event", interventions aimed at improving safety may be seen by both front-line staff and hospital board members as costly and time-consuming with little return on investment. 

Culture and sub-cultures

Although there is much talk in the NHS of changing "the culture". Shorrock suggested that healthcare may be more similar to banking in this respect too, with a plethora of "sub-cultures" rather than one over-arching culture. "Swimming with sharks" details a few of these sub-cultures. The  dog-eat-dog world of the front office traders compared to the investment bankers in asset management, who are encouraged to make slow, deliberate moves. Luyendijk says that banks like to portray themselves as organisations organised like an army or an airport, but in fact they are "clusters of islands in the fog, staffed by mercenaries" (p.145). It may be suggested that the culture(s) of hospitals can approximate those of aviation, although distinct in terms of values and behaviours the over-arching goal is the same. When hospitals fail, their cultures resemble those of banks, each sub-culture putting its own interests first resulting in a disconnect between frontline staff and the Board.

"Culture" is also high on the investigation list of a Holmes-like consultant who helps banks prevent and detect rogue trading (p.145). Luyendijk quotes him: "Is this a place where somebody can raise his hand and say I made a mistake?" In healthcare too the culture of a specific department or ward will give you an insight into how safe it is for patients. Dysfunctional teams are unlikely to be safe teams.

Lastly, one of the interviewees states: "It's not the people who are bad: it's the culture..." The same may be said of healthcare. Individuals are expected to adapt to, adopt and accept the given culture within a unit, department or ward. Luyendijk, in his recommendations at the end of the book, says: "One thing I believe does not help is to reduce the problems with global finance down to individual character flaws... if you blame all the scandals as well as the crash on individuals you imply that the system itself is fine, all we need to do is to smoke out the crooks..." This "bad apple" theory is well-addressed by Sidney Dekker and others. In fact the system/culture encourages certain types of behaviour and without changing the fundamental causes we are unlikely to see long-lasting change.

Hierarchies and silos

Luyendijk refers to Gillian Tett, a Financial Times journalist, who argues that "the number-one problem in investment and megabanks is that everyone works in 'silos'". A compliance officer Luyendijk interviewed says: "We need to get rid of the idea of "the bank". That term implies a unity of action and purpose, as if there's an all-encompassing view driving the bank. There is no such thing. What we have is a collection of individuals in positions of power. Each of them manages his or her own world." The same personalities can be found in healthcare, with the clinical lead or general manager who looks after "their world" without reference to the needs of the wider organisation.

Complexity

Some financial products have become so complex that very few people, even inside the bank, actually understand what they represent or how risky they are. "Even the risk and compliance people who were supposed to be our internal checks and balances... We had to teach them how to monitor us" (p.132). One of the causes of the crash of 2008 was that the complex financial products on offer, collateralised debt obligations (CDOs), although AAA-rated by ratings agencies, were filled with mortgages which people were not going to be able to repay. A similar level of complexity operates in healthcare. A Board which is not pro-active in understanding the everyday workings of the hospital risks thinking the place is much safer than it actually is. In addition, decisions made by the board (with the best of intentions) may have significant, unexpected implications on the shop floor.

Lack of funding in IT

Handwriting: Lantus 8 Units misread as 80 Units

"Your readers would be shocked if they realised just how crap the IT organisation is in many banks..." (p.141). The same is true in healthcare. Whether it is "the biggest IT failure ever seen" costing £10 billion of UK taxpayers' money or the fact that most hospital drug charts are still hand-written, IT investment in healthcare is lacking. This means that, as in banking, many systems don't "speak" to each other, multiple passwords are required for multiple systems and patients' notes are still folders where pages may go missing. The potential for errors is phenomenal.

Short-termism

In part because of the risk of instant dismissal (see below, under Differences) bankers often have a short-term outlook (p.154). In the NHS, acceptance of a post is often "for life", particularly at the patient-facing end. However there are perhaps similarities with NHS board members where turnover is much more rapid. This means that the long-term effects of some decisions are not made obvious to board members who have moved on.

Speaking up

A number of interviewees spoke of the futility of speaking up when witnessing poor practice. "I'd lose my job never to find a new one anywhere in the City. Meanwhile nothing would have changed" (p.188) The same can be said of healthcare, the fate of Stephen Bolsin, who spoke up about the Bristol heart surgery deaths, is not unique.

Differences

Focus

The focus of bankers and banks is to make money. Bankers want to make money for themselves and, in a meritocratic system, are rewarded for how much money they make for the bank. Public healthcare, as is generally found in the NHS (although the the English NHS seems to be on the road to privatisation) instead seems to be more focused on not losing money rather than trying to make a profit. This means that the majority of healthcare workers do not have a vested interest in increasing throughput or reducing costs.

Dismissal

In banking, dismissals are unexpected and immediate. To prevent the newly unemployed trader from damaging the bank, all network access is revoked and they are escorted from the building. In healthcare it is much more difficult to dismiss employees, even when their behaviour seems obviously unacceptable. Although at first glance it may seem preferable to be able to instantly dismiss "bad apples" or under performers, the effect this has on banking is not negligible. Bank employees may have much less loyalty to their bank and therefore may care little what effect their risk-taking has on "their" bank (e.g. Nick Leeson and Barings Bank)

Professionalism

The "professional" doctor vs the "professional" banker

In the City, the biggest compliment is 'professional'. "It means you do not let emotions get in the way of the work, let alone moral beliefs" (p.107). A recurring theme in Swimming with Sharks is that bankers are not immoral, but rather amoral. As long as an action is legal it is irrelevant whether it is "right" or "wrong". In healthcare the word "professional" may still mean a number of different things to different people, but what it most certainly does not mean is "amoral".

Final thoughts

Was Steven Shorrock right? Is healthcare more like banking than aviation? In effect it can be like both. At its best, healthcare resembles aviation with its focus on safety and a desire to ensure that the passenger/patient gets to his destination/home in one piece. At its worst, healthcare resembles banking, with a climate of fear (p. 95), amorality, back-stabbing and a focus on money and targets (cf. Mid-Staffs). It is up to all of us to decide what kind of ward, department and hospital we want to work in. In particular it is the job of hospital leadership to foster a safety culture and sell the idea of "the hospital" or "the healthcare centre" that staff can be loyal to and work together for. Hospital leaders must also speak truth to power by making it clear that the current cost-cutting across the NHS cannot be making the organisation safer. It is the job of politicians to provide the funding required and to protect the nascent safety culture against accusations of "blunders" as more adverse events are reported.

As for banking, Luyendijk makes a convincing argument that nothing substantial has changed. The basic weaknesses which almost brought the developed world to a standstill in 2008 remain in place. Unfortunately the political willpower to make the required root and branch reform is lacking.

Acknowledgments: 

"Swimming with sharks" does not make a single reference to healthcare or human factors. I am unlikely to have read it without Steven Shorrock's recommendation for which I am grateful.

Book of the month: Human Factors and Behavioural Safety by Jeremy Stranks

About the author

According to the book's blurb Jeremy Stranks "has 40 years' experience in occupational health and safety enforcement, management, consultancy and training." Stranks is the author of a number of books on health and safety, including "The Handbook of Health and Safety Practice" and "Stress at Work: Management and Prevention".

Who should read this book?

The book will be of use to simulation centre directors and managers. Specific chapters may be interesting for others involved in simulation-based medical education.

In summary

The book consists of 19 chapters:

1. Human behaviour and safety
2. Human sensory and perceptual processes
3. Organizations and groups
4. People factors
5. Perception of risk and human error
6. Organizational control and human reliability
7. Improving human reliability
8. Ergonomic principles
9. Ergonomics and human reliability
10. Principles of communication
11. Verbal and nonverbal communication
12. Written communication
13. Interpersonal skills
14. Systematic training
15. Presentation skills
16. Health and safety culture
17. Change and change management
18. Stress and stress management
19. The behavioural safety approach

What’s good about this book?

How many criteria does your sim centre/programme meet?

Stranks provides good descriptions of theories which may be unfamiliar to healthcare professionals. Herzberg's two-factor theory of job (dis)satisfaction (p.10) argues that the basic needs of employees, "hygiene factors", need to be met before job satisfaction can be improved through "motivators". For example, an employee is unlikely to be satisfied with having a challenging job if her supervision  and working environment are poor.

McGregor's Theory X and Theory Y (p.73) are also explored. Theory X says that people don't like to work and will not work unless coerced. Theory Y says that people will work if they are provided with the right environment in which their inherent motivation will emerge. Stranks also provides an overview of other concepts more familiar to simulation and human factors personnel such as Rasmussen's model of behaviour (p.123), error classification (p.127), the Swiss cheese model (p.130) and others.

Stranks provides a good overview of the elements and implementation of a behavioural safety programme including significant workforce participation, a data-driven decision process and peer-to-peer monitoring (p.28-29). He also drives home the need for "clear and evident commitment from the most senior management downwards, which promotes a climate for safety..." (p. 93) A need which is evident (and largely unmet) in healthcare.

Hale and Hale (1970)

Stranks describes accident prevention strategies and classifies them according to whether they are pro-active or reactive. Proactive strategies include "safe place" and "safe person" (p. 43). This concept may also be applied to healthcare. The safe place aims to ensure that the the premises, the equipment, the processes, etc. are safe. The safe person refers to behaviour, vulnerable people (e.g. those lacking in experience) and personal hygiene (e.g. hand washing).

A number of chapters are of interest to simulation faculty and those involved in research, including the chapter on risk perception. Simulation faculty may find that Hale and Hale's model of human performance in relation to accident causation (p. 112) could provide a structure to a debrief analysis.

What’s bad about this book?

The lack of referral to references makes the book more difficult to read than it need be. For example, on page 15 Stranks states: "Most people can only take in and retain 3.1 'bits' of information at any one time." This is probably a reference to Miller's seminal "The magical number seven, plus or minus two: Some limits on our capacity for processing information". However Miller's paper refers to 3.1 bits only for some types of data, such as "hue" and "pitch and loudness". A similar problem occurs on p.26 when Stranks provides a (long-winded) definition of human factors. It is unclear if it is his own or from elsewhere.

Stranks talks about some concepts (e.g. task fixation, alarm fatigue) without referring to their titles. This makes it more difficult for the novice to link Stranks' writing with prior knowledge. Some of the concepts are poorly explained (such as fault tree analysis (p.40) and the total working system (p.213)) and occasionally the Figures are unclear (e.g. Figure 7.1, p.169). Some concepts are superficially covered but then not linked to anything else (e.g. Learning styles, p.174) and the chapters could generally have better introductions to show the logical flow of argument/idea. 

Stranks uses human factors in the plural: "What are human factors?" (p.90) and singular: "Human factors has an important role..." (p.100). He uses the term "ergonomics" to mean the scientific discipline. While this may be purely semantic, it would probably be clearer to define the terms and then stick to those definitions.

Stranks states that "The ultimate objective (for engineers) is to design equipment which requires the least physical and mental effort on the part of the operator" (p.208). One could argue that this is not true. The equipment should probably require just enough mental effort to keep the operator "in the loop" and engaged.

Stranks argues that "The use of posters... repeating a specific message are important features of the safety communication process" (p.275). This is argued against by a number of human factors experts including Terry Fairbanks (see urinal pic).

Lastly, the entire chapter on Presentation skills (chapter 15) should be skipped. If this is a problem then there are much better books out there such as "Talk Like Ted".

Final thoughts

The entire contents of Stranks' book will not be of interest (or use) to the majority of people working in simulation-based medical education. However it may be of use to managers and directors and to people involved in clinical human factors. In addition, some chapters may be of interest to a wider audience and therefore a glance at the chapter headings may be worthwhile. Reading it with a "clinical" mindset, one can appreciate that the progression in safety management systems, the changes in culture required, and the elements and implementation of a behavioural safety programme are, with minor modifications, relevant to the healthcare environment.

Breakfast at Auchrannie’s (Or: How bad systems can make good people perform poorly) (by M Moneypenny)

Recently the family and I were lucky enough to be able to spend a few days at Auchrannie Spa and Resort on the isle of Arran. I would recommend both Arran and the resort to anyone. It has won a slew of awards and, according to trip advisor, is the #2 hotel in Brodick. However, goings-on during breakfast compelled me to write a blogpost…

A small selection of the awards

The problem with vegans

We are vegan which I had informed the hotel of weeks before, during the booking process. I received a lovely email in response which stated: “I have emailed the restaurant manager with regards to your request for vegan sausages.” On arrival at the breakfast buffet we were greeted by a very pleasant maître d’ who made sure we hadn’t just wandered in off the street, found us a table, and told me to talk to the waitering staff about the dietary requirement.

So we availed ourselves of the continental breakfast and then had chat with Sean who was looking after the hot food part of the buffet. Sean told me that they did have vegetarian sausages but that he thought they weren’t vegan. He said that he seemed to remember asking the chefs a while ago and that they had told him this, but that he would enquire.

Sean then went through to the kitchen and had a chat with one of the chefs. After a little while he came back and told us that the sausages were in fact vegan. Great, we said, we’ll have three breakfasts please. Sean said: “Two?” And we said: “No, three, one for each of the adults and one to share between the kids.” It would take a wee while to make he informed us, as they would cook everything fresh.

We sat back down and waited. And waited. And waited a little bit more. Then a friendly waiter called Will caught my eye and asked if we were okay. I told him we were waiting for our vegan breakfasts. Will said he would see what was happening. Unfortunately for him the swinging door into the corridor next to the kitchen has a clear glass window in it. This allowed me to see what happened next. Will walked through the door, looked into the kitchen, waited a little bit without speaking to anybody then turned around and came back to tell us that they were almost ready.

Great. So we waited. And waited. And waited a little bit more. I took the kids over to the play area while my other half went to find Sean. Sean was very apologetic. He went into the kitchen to find out what was happening. He came back and informed us that the breakfasts hadn’t even been started yet. He had only talked to and asked (he said) one of the chefs to make the breakfasts and because he hadn’t written the order down they hadn’t done anything. Sean apologised profusely and said he would be back with our breakfasts. About 5 minutes later there he was with 2 plates which we gave to my better half (it was her birthday after all) and the kids. Sean wandered off. He didn’t come back. A few minutes later we managed to call him over and ask him about my breakfast and he said he thought we’d only wanted two and we said, no, three. Sean then came back a few minutes later with a single sausage on a plate…

The following day things went much smoother, there was no maître d’ but Sean welcomed us, sat us down and brought us three breakfasts.

Good people in a bad system

Other than being a somewhat boring story from my holiday (at least I’m not making you sit through holiday photos) what is the point of this blogpost? One major learning point for me is that even very caring people, who want to do the right thing, can be let down by the system. What improvements could be made?

• There were more than enough waiting staff to allocate them specific tables. This would mean that “our” waiter/waitress would know we had been waiting longer than we should have been. The current system was chaotic with tables cleared ad hoc, sometimes one waiter would get the cleaning spray out, leave it on the table to do something else then another waiter would clean the table.
• If you take on a “problem” (and I’m using that term to describe us) then you own it until you have passed it on to someone else. We were Sean’s problem and he should’ve kept an eye on us.
• Empower your staff. I have no idea why Will didn’t actually speak to anybody in the kitchen, but he did recognise that something was amiss and he could have flagged up with the chefs that a table was awaiting a vegan breakfast.

The final give home message is that the staff at Auchrannie are some of the most pleasant and courteous I have ever met. However, they were let down by the lack of coordination at breakfast. The same can be true of healthcare, excellent staff working in a faulty system can still result in disappointed patients. (Names have been changed to protect the innocent) 

"They did too well"

When observing a new faculty member it is not unusual to see a look of relief on his/her face when the participants in a scenario (finally) make a mistake. The faculty member may believe that if no mistakes are made then the facilitator will have nothing to talk about in the debrief. Below are a few tips on how to deal with the participants who "did too well".

Don't create a special crisis

Some may be tempted to throw a curveball into the scenario. "They're doing great, okay... Your patient has now arrested and he's also aspirated." Try and avoid this. Your scenario should be running to your learning objectives. Creating a special crisis in order to have something to talk about in the debrief, means they're going to be talking about the crisis and not your learning objectives.

It's not you, it's them

The introductory paragraph contains an obvious mistake: "the facilitator will have nothing to talk about in the debrief". The debrief is not an opportunity for the facilitator to talk. The debrief allows the facilitator to facilitate the discussion the group is having. This means that the faculty member should concentrate on how to make sure the learning objectives get discussed, not on whether the participants did or didn't do well.

Good scenarios are not designed to create mistakes

Good scenarios are designed to explore performance based on the learning objectives of your course, some will do well, others less well. All performance can be discussed. The words of Peter Dieckmann and Charlotte Ringsted are worth remembering:

"Learners' errors should not be seen as a personal victory in scenario design and implementation." (p.55 - Essential Simulation in Clinical Education (Forrest, McKimm and Edgar (eds)))

Be enthusiastic and explore

Although "advocacy and inquiry debriefing" may have its faults (see blogpost here), its appeal to the facilitator to display genuine curiosity is a valid point. When the participants "did too well", why did that happen? What was their communication, leadership, teamwork, etc. like? How can we ensure that the next group of participants will do just as well?

Final thoughts

The desire to see participants make mistakes is a phase in the evolution of the facilitator. Most move beyond it, happy in the knowledge that good performance is a fertile ground for discussion as much as poor performance is.