Posted on July 13, 2015 in: Articles


One of our most basic principles is that organizations are organisms, not mechanisms, and as such require diversity and feedback to sustain life and achieve their purpose. A primary responsibility of effective leaders, then, is to create and sustain the kind of environment where diversity and feedback can flourish.

A review of operations at a prestigious hospital illustrates this point wonderfully — if tragically — and tells us that sometimes it really is brain surgery!

At Rhode Island Hospital, which an Associated Press story described as “the state’s most prestigious medical center and a teaching hospital for the Ivy League’s Brown University,” three critical mistakes were made in less than a year’s time:

  • An experienced brain surgeon told a nurse that he knew which side of the head to operate on — but he didn’t.
  • Another brain surgeon cut into the wrong side of a patient’s head after failing to refer to a pre-op checklist.
  • The chief resident at the hospital started brain surgery in the wrong place, and a nurse who knew he was making a mistake did not say anything to him.

One need not have been the patient in any of these cases to know that the consequences of each of these decisions were major — perhaps life altering or even life ending. Usually our decisions don’t have such serious consequences.

But if things can go wrong when situations are so critical — and many safeguards are put into the system to avoid such mistakes — how much more likely are they to go awry when the stakes are much lower and there are no safeguards?

Very likely, it turns out, because these mistakes had a common source that’s found in many working environments. The root cause was a combination of factors that impeded feedback:

  • Doctors, at the top of the operating room hierarchy, projected ego and overconfidence;
  • Nurses, as the bottom of the hierarchy, were afraid to speak up when they saw something about to go wrong. And even when one did, the doctor ignored the feedback.

“There’s a big cultural issue in most operating rooms where there’s a hierarchical culture there,” Diane Rydrych, an official with the Minnesota Health Department, told AP reporter Michelle R. Smith. “A surgeon is used to being the captain of the ship, and his or her word goes. If there’s a culture where people are afraid to say anything to the surgeon because they’re afraid they’re going to be yelled at, that’s a problem.”

How big of a problem? An official with the Joint Commission, an independent agency that accredits most hospitals, says the commission receives about eight reports a month of wrong-site surgery. But since hospitals are not required to report them, he thinks the number is probably 10 times higher. That’s almost 1,000 wrong-site surgeries a year in the nation’s hospitals.

Of course, organizations need hierarchy to function. Someone has to make decisions, especially in crisis when there is little time for consultation. But when leaders are so ego-driven that they impede or ignore feedback, the organization’s performance inevitably suffers.

When that happens, others who rely on the organization suffer too.

The solution is not to get rid of hierarchy and leaders. The solution is to make sure that leaders are focused on their mission — not their egos — and sufficiently humble to leverage the value of diversity and feedback in service to that mission.

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