As mentioned, high reliability organizations (HROs) are built upon a state of mindfulness. The enemy of mindfulness is mindlessness, and in a dynamic environment like a hospital there are still many routine tasks that are done with every patient. The potential to perform the routine tasks mindlessly is something HROs successfully avoid. Instead, every task is approached with mindful questioning, “What’s the big picture here, and what is the worst thing that can happen?” As Weick & Sutcliffe point out in Managing the Unexpected:
…When operators execute operations mindfully, they tend to rework the routine to fit changed conditions and to update the routine when there is new learning. These small adjustments are the bane of a command-and-control system. But those same adjustments keep the system going even as they sustain the illusion that it is commands and rule compliance, not continuing
adjustments, that keep it going.
In the healthcare setting, checklists and surgical debriefs are two ways to introduce and incorporate mindful practice into daily routine. Ronald Epstein MD penned a must read article on Mindful Practice in JAMA in 1999, showing how mindfulness can further be applied to medicine. The table to the right itemizes characteristics of mindful practice, not currently taught in medical schools or tested on boards, but skills very necessary to complete a healthcare providers training in order to provide true patient-centered care. As Epstein writes:
…consider what a resident in a busy pediatric emergency department might do when he is unable to determine whether an ear examination is normal or abnormal and the attending physician is not immediately available…(s/he) weighs the consequences of misdiagnosis for the patient, the humiliation of having to call the otolaryngology resident…loss of self-esteem by having to admit incompetence…
…A mindful conscious approach would be to cultivate awareness not only of the correct course of action but also of the factors that cloud the decision-making process. The mindful practitioner is mentally and technically better prepared for the next situation.
Mindfulness shares a number of qualities embedded in emotional intelligence. Developed by Daniel Goleman, emotional intelligence embraces and draws from numerous branches of behavioral, emotional and communications theories. Forbes.com interviewed Goleman in September of last year, and provides an overview of his work in their piece, Daniel Goleman on Leadership and the Power of Emotional Intelligence. Key to his work are the identification of five emotional intelligence domains:
- Knowing your emotions.
- Managing your own emotions.
- Motivating yourself.
- Recognizing and understanding other people’s emotions.
- Managing the emotions of others in building strong relationships.
High emotional intelligence requires awareness and control of our own emotions, values, preferences and goals as well as those around us – for caregivers that includes not only our colleagues and peers, but most importantly our patients. Understanding and being mindful of a patient’s emotions, values, preferences and goals is critical to the provision of high quality, safe healthcare.
Throughout our series on High Reliability Organizations (HROs), we have been discussing the five defining principles Weick & Sutcliffe have described HROs to possess: 1) Sensitivity to Operations; 2) Preoccupation with Failure; 3) Deference to Expertise; 4) Resilience; and 5) Reluctance to Simplify. The five principles are interrelated and do not exist unless they are built upon an organizational “collective mindfulness,” which describes the way in which the scarce commodity of individual attention is applied to the health of the overall organization. They use Langer’s model of a mindful state at the individual level and then apply it to the group based on its application and interplay within the five principles above. According to Langer:
“…a mindful state is expressed at the individual level in at least three ways: active differentiation and refinement of existing categories and distinctions; creation of new discontinuous categories out of the continuous streams of events that flow through activities; and a more nuanced appreciation of context and of alternative ways to deal with it…”
But mindfulness for the sake of mindfulness will not transform an organization into a HRO. Awareness and vigilance without action will not keep patients safe in our hospitals. It is the ability of all within an organization to consistently focus awareness to that which has the potential to cause harm without losing the forest through the trees as they say, and then effectively act upon the data taken in that will effectively transform an organization. As Weick, et al share:
“…To grasp the role of collective mindfulness in HROs, it is important to recognize that awareness is more than simply an issue of “the way in which scarce attention is allocated” (March, 1994, p. 10). Mindfulness is as much about the quality of attention as it is about the conservation of attention. It is as much about what people do with what they notice as it is about the activity of noticing itself…”
Mindfulness empowers action that prevents potential harm, and can be appreciated with the high reliability mindset of crews on aircraft carriers. Stephen Muething, MD, Vice President of Safety at Cincinnati Children’s Hospital illustrated one such example of action in his post, Lessons From An Aircraft Carrier:
“A piece a paper floated up onto the deck. A young trainee raised his hand immediately, dozens of other hands went up on deck when they saw his, and the landing was aborted. During the commanding officer’s daily address that evening he called out the sailor by name and thanked him.“
The chart at the top of this post is adapted from Weick, Sutcliffe & Obstfeld, 1999 and was found in the AHRQ publication “Becoming a High Reliability Organization: Operational Advice for Hospital Leaders.” The visual further reinforces that without a constant state of mindfulness, an organization will not achieve high reliability, or if they do so, the accomplishment will be fleeting. How can organizations develop and institute a state of collective mindfulness within their organization? With practice, intention and a culture steeped in transparency and an openness to learning. More on mindfulness to follow. Please share your thoughts–
Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior. 1999;21:81-123.
Weick KE & Sutcliffe KM. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco: Jossey-Bass.