For Physicians

Lessons Learned — Creating a Health Care Culture That Accelerates Improvement

This Clinician's View is written by Raj Sawh-Martinez, MD, chief of craniomaxillofacial and pediatric plastic surgery at AdventHealth for Children.

A professional headshot of Dr. Raj Martinez
Raj Sawh-Martinez, MD

“If you’re afraid to fail, then you are probably going to fail.” — Kobe Bryant

In 1999, the Institute of Medicine Committee on Quality of Health Care in America released a pivotal report titled, “To Err is Human: Building a Safer Health System” in an effort to break the silence surrounding the topic of medical errors and to help set a national agenda for improving patient safety.

Their work concluded that the problem was not “bad apples” in health care, but good people in systems and environments that desperately needed improvement, posing the fundamental question, “How can we learn from our mistakes?”

Unfortunately, nearly 25 years later, that question still challenges many health care systems. Follow-up studies published in JAMA in 2005, BMJ in 2008 and the New England Journal of Medicine in 2010, among others, have all attempted to examine progress made since the release of “To Err is Human” but found little evidence of widespread improvement.

How then do we, as health care providers and leaders, move the needle?

I believe the answer lies in rethinking how we treat errors and embracing the concept of “failing up”—moving beyond blame, creating safe cultures focused on learning, using feedback to fuel improvement, breaking down processes to identify opportunities, and continually realigning with our personal passion and purpose.

Why Learning from Failure Matters

I am a huge Kobe Bryant fan. I always loved watching him play, but as I grew older, I also came to appreciate who he was as a person. By all accounts, Kobe is basketball legend—one of the greatest players to step foot on the court. He ranks amongst the top scorers in the history of the game. However, Kobe also holds the record for the most missed shots (over Lebron James by 5 as of this publication).

How did he achieve so much success despite this dichotomy? It was Kobe’s response to failure that made the difference—he used his defeats as motivation and his errors as opportunities to learn, work harder and improve.

By nature, and nurture, we don’t readily embrace failure.

As physicians, we tend to be hyper-focused on achievement and success, often reinforced from a very young age. The thought of failure comes with a lot of baggage—guilt, insecurity, identity, reputation and fear of retribution, to name a few.

I get it. As a pediatric craniofacial plastic surgeon, I live in a high-stakes, low-margin-of-error field where successful outcomes are expected—every day, every time.

My surgical work is visible on the outside, adding an extra layer of pressure—there is simply no hiding my mistakes. However, I have also grown to realize that perfection is unrealistic and acknowledging failures, no matter how small, is critical to avoid repeating them. In my practice, taking the time to work through challenges and creating a safe, collaborative environment in which to do so is essential to achieving the best possible outcomes for our patients.

To that end, Amy Edmonson, Professor of Leadership at Harvard Business School, wrote a thought-provoking article in the Harvard Business Review titled, “Strategies for Learning from Failure.” In it, she states that “… a culture that makes it safe to admit and report on failure can—and in some organizational contexts must—coexist with high standards for performance.”

So how do we acknowledge and unpack failures to stimulate success? It starts with exploring the different types of failure.

Categorizing Failure

In her piece, Edmonson breaks mistakes into three buckets that I think are especially relevant for health care professionals:

  • Preventable — These are the “bad errors”—the deviations in predictable operations that typically occur due to lack of attention or ability. They are easily identified and remedied. Surgical checklists are a prime example of how health care has aimed to reduce preventable errors.
  • Complex — Unlike the first category, these are often errors of uncertainty in multi-step processes, resulting from a series of small failures that go unnoticed and compound along the way. Avoiding them means rapidly identifying and remedying them at the earliest possible stage.
  • Intelligent — These are the “good” errors that are a natural part of discovery and conquering the unknown. They are the scientific method at work and how we advance medicine. Clinical trials and pilot projects are perfect examples.

As health care professionals, what we want to do is avoid the preventable errors and minimize the complex ones so that we can spend more time experimenting with the intelligent ones that will improve care for our patients. Let’s unpack how we can achieve this.

Lesson #1: Move Beyond Blame.

My parents are both physicians. When I was young, they were always supportive but held me to high standards. And like most kids do, I stumbled a few times along the way. When I was 16, my dad had a sporty Toyota Celica that was strictly off limits to me, and the keys were kept hidden in a “safe” place or so he thought. As a perceptive and determined teenager, I of course knew exactly where they were. One weekend, my parents went out of town for a conference. The temptation was too great—I secured the keys and took the car out for a joy ride. Upon his return, my dad knew immediately what I had done despite my feeble attempts at discretion. There were certainly some real consequences, but there was also compassion. From that experience and many others throughout my childhood, I learned that it was OK to make a mistake, but it was important to earn from it and improve. The car keys got improved security storage, and I developed greater responsibility and trust, having owned up to my rash decisions.

In health care, mistakes are rarely individualistic; they are typically systemic. Yet, too often, the focus in on “Who did it?” rather than “What happened?”

In Edmonson’s article, she talks about what percentage of failures in organizations were ‘truly blameworthy.’ She notes these typically ranged from 2-5%. However, when referencing how many failures were ‘treated’ as blameworthy, she shares that these percentages were as high as 70-90% in corporate culture.

When the culture is one of blame, it’s no wonder failures are swept under the rug. It’s human nature. The unfortunate outcome though, is that nothing improves given the reality of the numbers; a fact that is continually demonstrated in dedicated studies.

As health care providers, we can and must do better for our patients.

Lesson #2: Create a Safe, Supportive Culture Focused on Learning and Growing from Each Experience.

I love our service standards at AdventHealth:

  • Keep Me Safe
  • Love Me
  • Make It Easy
  • Own It

These simple but significant tenets apply to everyone touched by our organization—patients, physicians and staff alike. It is the heart of our collaborative ethos. If you love me and want to keep me safe as a health care provider, you must create a supportive culture. Fear has no place in this type of environment. We must work together as a team, learn together as a team and grow together as a team.

I believe this is especially critical in the operating room (OR). The stakes there are especially high, which means everyone—from the surgical tech to the resident who scrubbed in to observe the case—must feel empowered to speak up.

We’re all human, and we all have value. Most importantly, we all share a common goal to prevent errors and achieve the best possible outcome for every patient entrusted to our care.

Whether in the OR or in clinic, how we think and talk about failure is critical.

Physician leaders hold a responsibility to be as open, accessible and transparent as possible. It’s a culture, and it’s a constant—no easy task, but an essential one. For example, in my office, everyone on staff attends and contributes to clinical and administrative quality reviews. We hold each other accountable and help each other through quality improvements at every stage of the patient care experience. Our front desk team, administrators and clinicians—we all carry the ethos, “We succeed or fail as a team.”

Lesson #3: Use Feedback to Fuel Improvement.

In health care, we are continually surrounded by data—from clinical outcomes to patient satisfaction survey results. Using this intelligence wisely can help inform our path forward.

At AdventHealth, we use Press Ganey to gather patient feedback and multiple clinical databases to evaluate our surgical metrics. Our teams continually look for opportunities revealed in the data that could optimize how we are serving our patients. For example, in my office, as our practice grew, surveys revealed that patients felt our wait times were too long. As a result, we added staff, changed the way we scheduled patients, timed each step of the patient experience and improved how we communicate when we are running late, letting patients know right away. Changes like this, fueled by strategic data analysis, helped us to learn from our failures and ultimately, reach the top 1% globally in patient satisfaction according to Press Ganey. In addition, AdventHealth as a whole was recently recognized with Press Ganey’s “Guardian of Excellence” for consumer and patient experience.

While these accolades are certainly affirming, continually improving patient experience and clinical outcomes are the critical measures.

Lesson #4: Break Down Processes to Identify Opportunities.

No one typically looks forward to a debriefing. This part of dealing with failure is often avoided because it is uncomfortable and can be emotionally charged. However, if we want to improve, we cannot shy away from it.

In my practice, we routinely review every step of the patient experience—from the minute someone calls to schedule the initial consultation until the patient’s care is completed—to identify areas where we can improve. It is a collective and deliberative process involving our entire team—from medical assistants to the front desk. We analyze our bottlenecks or inefficiencies in workflow, identify challenges or frustrations for staff and patients, and compile the most common concerns or complaints our team may hear from patients and families. Then we explore together how we can make each one of those better. It is an open and frank discussion about our errors and weaknesses.

We have these difficult conversations regularly so that they become routine and without personalization, and so that ultimately, we can reach a level of improvement that enables us to focus more on the intelligent errors that will drive discovery and innovation.

Lesson #5: Continually Reflect and Realign with Your Passion and Purpose.

In his famous “Last Lecture,” Carnegie-Mellon professor Randy Pausch shared what he believed was the most valuable advice he gained from his childhood football coach, “You may not want to hear it, but your critics are often the ones telling you they still love you and care about you, and want to make you better.”

Everyone has a different coping mechanism, a unique perspective and their own history of experiences to help them move through and beyond failure. For me, the power, both individually and collectively, comes in reflecting and reconnecting. Daily, I review and think through the “why” of my failures, including both the technical and emotional aspects of our toughest surgical cases. I believe there is great power in acknowledgment, in calling out the elephant in the room. I also think it is important to provide the space and time to process, for all our team members. That is how we grow and gain the courage to take the next step forward.

Even at the end of my hardest days, I love what I do.

I was drawn to plastic and reconstructive surgery because it combined my love of science, technology and innovation with my passion for improving the lives of others. This drives me to embrace failure as opportunity as it is a critical element for success.

Failing Up

Once you know what failure feels like, determination chases success.” — Kobe Bryant

We will all fail. Repeatedly.

To err is indeed a human reality. However, as health care leaders, we have a unique opportunity and responsibility to recognize this reality and move beyond blame to create a culture that openly, collectively, proactively and purposefully processes failure so that we can quickly catch missteps, correct them, and ultimately, learn from each experience.

Then, and only then, can we create meaningful improvement and a better, safer health care system for us all.

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