The scenario plays out something like this: an organization pulls together a team of people to work in a stressful environment. The team coalesces and after some time a shared set of norms emerges. Everyone begins to do things the same way. When narratives outside this shared experience emerge, the group closes its ears and marginalizes the outside voice.
After some time, an unusual situation emerges that is different that what the group expects. Since there is nobody around to challenge the group’s instinctive response, a serious error is made. Rather than apologize, the organization defends its actions rather than admitting it has a serious cultural and leadership problem.
Exhibit 1: I’ve wanted to write about the GM whistleblower for some time. By now, everyone knows about the stunning failure of GM to address a lethal flaw in their ignition switches which disabled airbags in a crash. Businessweek had great coverage of this story a few weeks ago. The article makes clear that there were internal engineers who kept calling for the company to fix flaws, but that these requests were ignored by senior management for over a decade.
At some point in GM, all dissent regarding the ignition switch was squashed and independent thinkers were sent to outlying parts of the company. Businessweek notes:
GM professes contrition, promises change, and has ousted 15 individuals for misconduct or incompetence. Announcing the Valukas [external auditor] findings to an audience of employees on June 5, Barra [CEO] called the report “extremely thorough, brutally tough, and deeply troubling.” It describes a corporate bureaucracy fatally indifferent to mounting evidence its cars were killing people. “Group after group and committee after committee within GM that reviewed the issue failed to take action or acted too slowly,” Valukas writes. “Although everyone had responsibility to fix the problem, nobody took responsibility.” … Management wasn’t just distracted or confused; speaking up was actively discouraged, and workers saw that pointing out safety flaws could derail their careers. When a GM employee did blow the whistle, the nation’s largest automaker shut him down.
Is [the whistle-blower’s wife] surprised that more whistle-blowers didn’t emerge at GM? She laughs. “I’m surprised there aren’t more people who stand up for what they believe,” she says. “But am I surprised that they wouldn’t go against General Motors? I suppose not.”
Exhibit 2: Details of yesterday’s rocket attack on the Malaysian airliner over Ukraine are just beginning to emerge but already its beginning to look like an error on the part of rebels who had no idea they were targeting a civilian airliner, at least according to transcripts available on several newspapers.
Since detail are sketchy, I wanted to reflect on three better-investigated examples of civilian airliners being shot down: My knowledge of all events comes from Wikipedia. I’ll paraphrase their entries:
In 1978: On April 20 Soviets shot down Korean Air Lines Flight 902 (KAL 902) near Murmansk, Soviet Union, after the civilian aircraft strayed into Soviet airspace. Soviet air defense initially identified it as American. The pilot of the fighter that brought down the jet saw Asian characters and a logo on the tail of the Korean aircraft, and reported this to the ground control, but despite this conflicting information, he was convinced that it was a spy plane and opened fire, taking the jetliner down. The plane subsequently made an emergency landing on the frozen Korpijärvi lake near the Finnish border. Soviet helicopters rescued 107 survivors and transported them to the city of Kem in Karelia.
In lieu of any apology or introspection, Soviets held the flight crew was held for investigation. The Korean pilots were forced to acknowledge that they deliberately failed to obey the commands of Soviet pilots. They petitioned the Presidium of the Supreme Council of the USSR for pardon. Eventually, the passengers were deported from the Soviet Union back to Seoul. The Soviet Union invoiced South Korea $100,000 for rescue expenses while refusing to cooperate with international experts nor sharing any data mined from the plane’s “black box”.
Five years later, Korean Air Lines Flight 007, a scheduled Korean Air Lines flight from New York City to Seoul, was again shot down by a Soviet fighter in the Sea of Japan after accidentally entering Soviet airspace. The Soviet Union initially denied knowledge of the incident but later admitted the shooting suggesting that the aircraft was on a spy mission. In a 1991 interview Major Genadi Osipovich, pilot of the fighter, spoke about the conflicting information available to the Soviets. He recalled telling ground controllers that there were “blinking lights”. He continued, saying that “I saw two rows of windows and knew that this was a Boeing. I knew this was a civilian plane. But for me this meant nothing. It is easy to turn a civilian type of plane into one for military use…” He furthermore did not provide a detailed description of the aircraft to his ground controllers: “I did not tell the ground that it was a Boeing-type plane; they did not ask me.”
In 1992, Russian president Boris Yeltsin disclosed five top-secret memos. They noted:
In connection with all mentioned above it seems highly preferable not to transfer the flight recorders to the International Civil Aviation Organization (ICAO) or any third party willing to decipher their contents. The fact that the recorders are in possession of the U.S.S.R. shall be kept secret… We have made necessary efforts in order to prevent any disclosure of the information in future.
Five years later, Iran Air Flight 655 was shot down by the US Navy in the Persian Gulf. Again, this was a case of mistaken identity. The navy thought that it was targeting a rogue Iranian fighter jet, but instead launched a missile at a commercial flight from Iran to Dubai. There have been a number of books written on the event, and all note that there was little discord among the 18 members of the Navy who were on the bridge of the USS Vincennes the day of the shooting. The officer in charge offered no conflicting perspective.
Any student of healthcare quality will tell you that these sorts of errors, and their subsequent organizational responses, are not rare in medicine. Culturally, healthcare organizations share many parallels with multi-national companies like GM and the military. All are hierarchical, team-based and mission-driven organizations with an unfortunate tradition of separating “workers” from “thinkers”.
The danger to this type of setup is that once routines are established, it becomes hard for employees to manage situations that deviate from a pattern. Employees overlook conflicting sources of information (an airline logo on the tail of a plane, the fact that it is a passenger jet) and regress to the engrained and unchallenged way of doing things. There is great fear of “sticking ones head out” lest it be chopped off by superiors. When a mistake is made, the group becomes defensive. Wikipedia describes this psychological phenomenon of “groupthink”
Groupthink is a psychological phenomenon that occurs within a group of people, in which the desire for harmony or conformity in the group results in an irrational or dysfunctional decision-making outcome. Group members try to minimize conflict and reach a consensus decision without critical evaluation of alternative viewpoints, by actively suppressing dissenting viewpoints, and by isolating themselves from outside influences.
Loyalty to the group requires individuals to avoid raising controversial issues or alternative solutions, and there is loss of individual creativity, uniqueness and independent thinking. The dysfunctional group dynamics of the “ingroup” produces an “illusion of invulnerability” (an inflated certainty that the right decision has been made). Thus the “ingroup” significantly overrates its own abilities in decision-making, and significantly underrates the abilities of its opponents (the “outgroup”). Furthermore groupthink can produce dehumanizing actions against the “outgroup”.
I hope that the latest tragedy in Ukraine can remind us of how critical it is to develop critical thinking skills among employees at all levels of a healthcare organization. Leveraging a diversity of minds can help us avoid these sorts of catastrophes in our own business of healthcare.