One Reason we Fail: Our Nemesis, the “UNs”

Jul 23

This question drives my work:

“How is it that despite good intentions, great plans, safety programs, and highly trained and dedicated people, organizations keep experiencing failures and unexpected events, many of which result in severe harm or death?”

This problem of repeating failures prompts large amounts of time, energy, and money to be spent fixing policies, procedures, and improving processes in hopes of reducing failure and increasing success. And lots of people and budgets are exhausted from the endeavor.

Does it work? It hasn’t in health care, what about your industry?

Oddly, it seems we have more data and plans than ever before, yet, failure persists.

So we ask:

“Who is to blame?”

“What are we doing wrong?”

“What new rules should we make?”

These are common questions to probe the problem, yet I believe they are the wrong ones. They haven’t produced solutions.

A better question might be “what are we missing?”

Could it be that at the individual, group and organizational level, we are missing the types of strategies needed when much is UNcertain, or the UNexpected surprises us?

I think so.

I believe that increasing our capabilities in terms of the challenges related to the UNknown and UNexpected holds the most promise as the next step towards increasing consistent success and safety.

Here’s why:

Our volatile, uncertain, complex, and ambiguous (VUCA) world is just our foundation. On top of this unpredictable planet, fabulous, free-willed, yet fallible people build complex systems filled with technology where people engage in work that involves solving problems.

These layers combine and become what I call “the wonderful, wild world we work in.” Embedded in this complex world are natural challenges such as variability, ambiguity, limitations of plans, and power dynamics that occur in organizations.

These challenges create limitless possibilities. Some possibilities are wonderful, some dangerous, and many or most UNknown to us (or some of us) as we work. It is because of this universal, inescapable reality of the UNknown and the possibilities it holds as we live and work, that I propose that we should not envision that we are battling ourselves or each other, but instead, we are contending with a nemesis: “...a person or thing that is very difficult to defeat.” Cambridge Dictionary

However, while we will never fully defeat the UNknown, the UNexpected, and the UNcertainty it creates for us in our work worlds, we don’t have to be victims of it.

There is much we can do to increase our capability to become aware of and navigate possibilities as we work.

First, we need a way to start talking more specifically about the UNknowns in a way that helps us to get a handle on them.

I suggest we start by calling them the “UNs.”

Five years ago, I collaborated with a former hospital CEO who had served on many cases as an expert witness for corporate liability during malpractice cases. He was sure that there were important things to learn from looking at the cases in total.

It was a very dark and painful winter when we reviewed 353 cases of severe patient harm. But I noticed a pattern. It didn’t matter where the case was or what type of harm was endured…

When I looked back at these events where safety was absent, I found that what was present in almost every failure was one or more factor that was:

UNknown
UNseen
UNclear
UNstable
UNcontrollable
UNspoken
UNheard

Most often I would say under my breath “oh...they just didn’t see it” believing that if they did, they would have done something.

I wondered “What can help people see more as they work?.”

Next, I saw staff, or even the system struggling with ambiguity. They saw something but its meaning was UNclear. In retrospect, they mistook the world in front of them, and the label they applied did not align with what was actually going on. Patients did not receive what they needed, and because of this, harm occurred.

I wondered, “Is there something you can do to make the meaning of situations more clear?”

So, I set out to find out what individuals, teams, and organizations could do to meet the challenge of the UNs.

What I found out is that you CAN increase your capability to become more aware of the possibilities in your work world by using specific strategies that move possibilities from the UNknown to the known.

Some of these strategies I had instinctively used as an ED nurse, off-shift hospital supervisor, and mom of an undiagnosed child (over 7 year period).

I found that High Reliability Organizing theory and science addressed these challenges and the culture you need to overcome them (although Resilience Engineering overlaps and adds to the concepts and holds much promise if embraced).

It’s exciting to think that once you understand the dynamics that create and keep things in the UN category you can start to increase awareness and effective action to bring things into the “known.”

For example, once you understand the limitations of plans and how they can cause events to go UNseen, you gain an edge on your nemesis.

When you gain strategies for what to do when things are UNclear, by “acting to learn,” you can greatly improve your outcomes.

When people feel capable of doing something safe to probe the situation, you can gain useful information which makes things clearer.

I like the baby example. The baby is crying. You pick her up, check the diaper...dry, ok, hungry...no. Hmmm, a gas bubble? You burp the baby and have success. All is well, yet you had to ACT to uncover information and solve the problem.

Another strategy that is helpful for the UN of UNclear is to seek diverse perspectives as others possess unique viewpoints and experiences that you may not. Ask others, “what do you see?”

There are 2 particular UN’s that create all kinds of suffering in the world. I believe, if we applied the evidence uncovered by researchers, to these UNs, we could really create a huge wave of engagement, safety, and innovation.

These challenges are what is UNspoken and UNheard.

I call the UN of UNspoken the “elephant in the road,” as it is a major block to any organization’s journey to consistent success and safety.

A culture where people feel free to voice questions, concerns, and ideas created by leaders who invite and appreciate this communication must be present for success and safety in any uncertain work environment.

We have paid, and will continue to pay, dearly for its absence.

In a world, and work world filled with uncertainty, why not take the time to learn the strategies that will transform your relationship with the UNknown from confusion to calm confidence, and increase your chances of achieving your important mission, safely.

Kinsey Horneck