My story: As a seasoned executive with experience in hospital and academic administration, I have … Read More
What a great joy to work with leaders at major healthcare institutions from across the country! Recently I had the opportunity to work with Dr. Kimberly Carter and her team at Carilion Clinic, a seven-hospital system in Roanoke, Virginia. There was an electricity in the air and a clear focus on quality as over 200 nurses gathered for their nursing research conference. It was my privilege to begin the day as keynote, but also end the day as the endnote speaker. While this isn’t customary, it was fun to weave some of the key ideas together from the other speakers who were all formidable experts in their respective fields. Here is some of the feedback that was received:
- “The speaker, Dr. Michael Bleich, was outstanding. His presentation was exactly what I needed to hear to push me to the next step in my career. He was entertaining and motivating.”
- “Love the energy of the keynote speaker and him challenging us to think creatively.”
- “Excellent keynote speak. Nice that he stayed for the entire session and added valuable comments and started and ended the conference.”
- “Michael Bleich was a fantastic speaker – great/interesting topics – inspiring.”
- “Keynote Speaker, Dr. Bleich was amazing! He was very knowledgeable and funny. He kept pics interesting and funny.”
- “I am working on my DNP project. This conference has given a clean picture of the problem and idea. I enjoyed his afternoon talk about finding my own personal area of scholarship.”
- “Dr. Bleich was awesome. Bring back!”
So, to my friends in Roanoke: THANK YOU for being so gracious and I hope we meet again! It was great to inspire you but know that I left equally inspired. For delivering first-rate care, your patients are grateful. Check it out: https://www.carilionclinic.org/sites/default/files/2017-09/NursingResearchBrochure.pdf
I had a wonderful opportunity to speak to an international group of regulators, dedicated to protecting the public by ensuring quality and safe clinical care globally. Technology is shifting how we regulate and practice, and this was a unique dialogue to model emerging technologies. Please take the time to listen and be prepared to be stunned by what is unfolding in healthcare!
The book entitled Brilliant Mistakes by Paul J.H. Schoemaker has intrigued me. So many efforts in health care relate to AVOIDING mistakes — AT ALL COST — and these efforts serve to remind us of the dire consequences that medical errors can have on life and limb. In no way do I trivialize medical error; quite the opposite. Have we pushed the subject of making mistakes too far, though, discouraging the benefits that come when they occur? Can the lessons that are derived from making mistakes lead us to fewer of them in the long run? A closer look provided by Schoemaker reveals four types of mistakes:
- A tragic mistake – the kind that should be avoided when caring for others. The cost of life, limb, career, reputation and more is simply too detrimental to all involved, so are to be “wholly avoided.”
- A serious mistake – can also have a high cost, but can yield tremendous life lessons in retrospect.
- A trivial mistake – is one with low impact, but also low reward. When I don’t take enough change with me to plug the parking meter and end up with a ticket is an example of a trivial mistake.
- A brilliant mistake – are those mistakes that offer high benefits at a relatively low cost. Taking an exam and not passing it the first time around has enormous benefits — you now know what you should have known — and can correct your course for the future. In the short-term, it might appear catastrophic, but in the longer term, it provides critical reflective feedback!
Brilliant mistakes require that “something go wrong far beyond the range of prior expectation” and, “this allows for deep new insights to emerge whose benefits far exceed the cost of the original mistake.
I observe that educators really dislike letting their students make brilliant mistakes. Too often these educators try to teach to achieve perfection, thereby avoiding the resultant wisdom that comes from helping someone remediate the problem they got into, to begin with. Wisdom is the byproduct of new insights – what is sometimes called critical thinking. Doing something right the first time is great, but it doesn’t lead to profound knowing. So, too, leaders and managers want their programs and services to be flawless. It takes perspective and skill to lead a team away from tragic and serious mistakes, minimizing the managerial effort spent on trivial mistakes and then letting go so the team can make and learn from brilliant mistakes. As a consultant who is usually on a tight time frame to get things accomplished, I have to fight the urge to fix something NOW, rather than trusting the process and facilitating deep learning that is derived from brilliant mistakes.
Risk managers are well-intended professionals who do deep dives into organizational problems. Combining subjective and objective information, they study decision-making, the design and strength of processes in place and outcomes. These prevention specialists are critical, but their presence can also lead to an unintended consequence — risk aversion that is tied to professional pride. Professionals need to learn from their mistakes; it makes us aware of what we do and don’t know, giving us wisdom. The wise risk manager will help us learn what evidence was present or missing and give us a chance to learn through reliable feedback. This feedback is the foundation for true peer- and self-review.
Shoemaker offers in Appendix A the “23 Errors of Einstein.” Each error of judgment – even by Einstein – is documented and leads to . . . well, you know the rest of the story.
Paul J. H. Schoemaker (2011). Brilliant Mistakes: Finding Success on the Far Side of Failure. Philadelphia: Wharton Digital Press