out for warning signs of fire-existed because, years earlier, the Underground had problems with understaffed kiosks. Clerks kept leaving their posts to pick up trash or point tourists toward their trains, and as a result, long lines would form. So clerks were ordered to stay in their booths, sell tickets, and not worry about anything else. It worked. Lines disappeared. If clerks saw something amiss outside their kiosks-beyond their scope of responsibility-they minded their own business.
And the fire brigade’s habit of insisting on their own equipment? That was a result of an incident, a decade earlier, when a fire had raged in another station as firemen wasted precious minutes trying to hook up their hoses to unfamiliar pipes. Afterward, everyone decided it was best to stick with what they knew.
None of these routines, in other words, were arbitrary. Each was designed for a reason. The Underground was so vast and complicated that it could operate smoothly only if truces smoothed over potential obstacles. Unlike at Rhode Island Hospital, each truce created a genuine balance of power. No department had the upper hand.
Yet thirty-one people died.
The London Underground’s routines and truces all seemed logical until a fire erupted. At which point, an awful truth emerged: No one person, department, or baron had ultimate responsibility for passengers’ safety. [182]
Sometimes, one priority-or one department or one person or one goal-
There’s a paradox in this observation, of course. How can an organization implement habits that balance authority and, at the same time, choose a person or goal that rises above everyone else? How do nurses and doctors share authority while still making it clear who is in charge? How does a subway system avoid becoming bogged down in turf battles while making sure safety is still a priority, even if that means lines of authority must be redrawn?
The answer lies in seizing the same advantage that Tony Dungy encountered when he took over the woeful Bucs and Paul O’Neill discovered when he became CEO of flailing Alcoa. It’s the same opportunity Howard Schultz exploited when he returned to a flagging Starbucks in 2007. All those leaders seized the possibilities created by a crisis. During turmoil, organizational habits become malleable enough to both assign responsibility and create a more equitable balance of power. Crises are so valuable, in fact, that sometimes it’s worth stirring up a sense of looming catastrophe rather than letting it die down.
IV.
Four months after the elderly man with the botched skull surgery died at Rhode Island Hospital, another surgeon at the hospital committed a similar error, operating on the wrong section of another patient’s head. The state’s health department reprimanded the facility and fined it $50,000. Eighteen months later, a surgeon operated on the wrong part of a child’s mouth during a cleft palate surgery. Five months after that, a surgeon operated on a patient’s wrong finger. Ten months after that, a drill bit was left inside a man’s head. For these transgressions, the hospital was fined another $450,000. [183]
Rhode Island Hospital is not the only medical institution where such accidents happen, of course, but they were unlucky enough to become the poster child for such mistakes. Local newspapers printed detailed stories of each incident. Television stations set up camp outside the hospital. The national media joined in, too. “The problem’s not going away,” a vice president of the national hospital accreditation organization told an Associated Press reporter. [184] Rhode Island Hospital, the state’s medical authorities declared to reporters, was a facility in chaos.
“It felt like working in a war zone,” a nurse told me. “There were TV reporters ambushing doctors as they walked to their cars. One little boy asked me to make sure the doctor wouldn’t accidentally cut off his arm during surgery. It felt like everything was out of control.” [185]
As critics and the media piled on, a sense of crisis emerged within the hospital. [186] Some administrators started worrying that the facility would lose its accreditation. Others became defensive, attacking the television stations for singling them out. “I found a button that said ‘Scapegoat’ that I was going to wear to work,” one doctor told me. “My wife said that was a bad idea.”
Then an administrator, Dr. Mary Reich Cooper, who had become chief quality officer a few weeks before the eighty-six-year-old man’s death, spoke up. In meetings with the hospital’s administrators and staff, Cooper said that they were looking at the situation all wrong.
All this criticism wasn’t a bad thing, she said. In fact, the hospital had been given an opportunity that few organizations ever received.
“I saw this as an opening,” Dr. Cooper told me. “There’s a long history of hospitals trying to attack these problems and failing. Sometimes people need a jolt, and all the bad publicity was a
Rhode Island Hospital shut down all elective surgery units for an entire day-a huge expense-and put the entire staff through an intensive training program that emphasized teamwork and stressed the importance of empowering nurses and medical staff. The chief of neurosurgery resigned and a new leader was selected. The hospital invited the Center for Transforming Healthcare-a coalition of leading medical institutions-to help redesign its surgical safeguards. Administrators installed video cameras in operating rooms to make sure time-outs occurred and checklists were mandated for every surgery. [187] A computerized system allowed any hospital employee to anonymously report problems that endangered patient health. [188]
Some of those initiatives had been proposed at Rhode Island Hospital in previous years, but they had always been struck down. Doctors and nurses didn’t want people recording their surgeries or other hospitals telling them how to do their jobs.
But once a sense of crisis gripped Rhode Island Hospital, everyone became more open to change. [189]
Other hospitals have made similar shifts in the wake of mistakes and have brought down error rates that just years earlier had seemed immune to improvement. [190] Like Rhode Island Hospital, these institutions have found that reform is usually possible only once a sense of crisis takes hold. For instance, one of Harvard University’s teaching hospitals, Beth Israel Deaconess Medical Center, went through a spate of errors and internal battles in the late 1990s that spilled into newspaper articles and ugly shouting matches between nurses and administrators at public meetings. There was talk among some state officials of forcing the hospital to close departments until they could prove the mistakes would stop. Then the hospital, under attack, coalesced around solutions to change its culture. Part of the answer was “safety rounds,” in which, every three months, a senior physician discussed a particular surgery or diagnosis and described, in painstaking detail, a mistake or near miss to an audience of hundreds of her or his peers.
“It’s excruciating to admit a mistake publicly,” said Dr. Donald Moorman, until recently Beth Israel Deaconess’s associate surgeon in chief. “Twenty years ago, doctors wouldn’t do it. But a real sense of panic has spread through hospitals now, and even the best surgeons are willing to talk about how close they came to a big error. The culture of medicine is changing.”
Good leaders seize crises to remake organizational habits. NASA administrators, for instance, tried for years to improve the agency’s safety habits, but those efforts were unsuccessful until the space shuttle
In fact, crises are such valuable opportunities that a wise leader often prolongs a sense of emergency on purpose. That’s exactly what occurred after the King’s Cross station fire. Five days after the blaze, the British
