As a leader, how will create a learning culture in your organization?
In 2002, Dr. Gary S. Kaplan, CEO of Virginia Mason Health System in Seattle, WA, visited Toyota in Japan. While in a Toyota plant, he noticed that a worker pulled a cord when a problem occurs. When the cord is pulled a production is stopped and executives and engineers would come to help the worker. They assess the error, learn the lesson, and adapt the system to prevent the error from recurring. In Kaplan’s words,
“The system was about cars, which are very different from people, but the underlying principle is transferable. If a culture is open and honest about mistakes, the entire system can learn from them. That is the way you gain improvements. We knew that medical errors cost thousands of lives across America and we were determined to reduce them.”
Kaplan encouraged his staff to make a report when they spotted an error that could harm the patients, which they call Patient Safety Alerts, which is similar to the reporting systems used in Toyota and in aviation.
It was not easy in the beginning. The prevalent culture at that time, not just in Virginia Mason but in the healthcare industry, was one of blame and steep hierarchy. Mistakes were frowned upon by staff, and they are fearful to report to senior executives. It was a case of a great innovation that was stifled by an underlying culture.
Things changed dramatically when in 2004, a 69-year old mother died when she was injected with a toxic antiseptic instead of a harmless marker die. It was a case of human error when the two substances were placed side by side in identical containers, and the syringe had drawn from the wrong container. Dr, Kaplan publicly apologized, and the relatives of the victim welcomed the apology. He said,
“We just can’t say how appalled we are at ourselves. You can’t understand something you hide.”
It was a wake-up call. Kaplan continued,
“It was a tough time, but the death was like a rallying cry. It gave us the cultural push we needed to recognize how serious an issue this is.”
Virginia Mason has since received accolades and improved in performance.
Distinguished Hospital Award for Clinical Excellence
Outstanding Patient Experience Award
Named a Top Hospital by Leapfrog group for 8 successive years
74 percent reduction in liability insurance premiums
Leaders, as exemplified by Dr. Kaplan, thus create a learning culture by creating transparency among employees and leaders, with everyone committed to drive fear out of the workplace and committing to solving problems as they are spotted.
This story was adapted from Matthew Syed's book, "Blackbox Thinking."
