secretary of state appointed a special investigator, Desmond Fennell, to study the incident. Fennell began by interviewing the Underground’s leadership, and quickly discovered that everyone had known-for years-that fire safety was a serious problem, and yet nothing had changed. Some administrators had proposed new hierarchies that would have clarified responsibility for fire prevention. Others had proposed giving station managers more power so that they could bridge departmental divides. None of those reforms had been implemented.
When Fennell began suggesting changes of his own, he saw the same kinds of roadblocks-department chiefs refusing to take responsibility or undercutting him with whispered threats to their subordinates-start to emerge.
So he decided to turn his inquiry into a media circus.
He called for public hearings that lasted ninety-one days and revealed an organization that had ignored multiple warnings of risks. He implied to newspaper reporters that commuters were in grave danger whenever they rode the subway. He cross-examined dozens of witnesses who described an organization where turf battles mattered more than commuter safety. His final report, released almost a year after the fire, was a scathing, 250-page indictment of the Underground portraying an organization crippled by bureaucratic ineptitude. “Having set out as an Investigation into the events of one night,” Fennell wrote, the report’s “scope was necessarily enlarged into the examination of a system.” He concluded with pages and pages of stinging criticisms and recommendations that, essentially, suggested much of the organization was either incompetent or corrupt.
The response was instantaneous and overwhelming. Commuters picketed the Underground’s offices. The organization’s leadership was fired. A slew of new laws were passed and the culture of the Underground was overhauled. Today, every station has a manager whose primary responsibility is passenger safety, and every employee has an obligation to communicate at the smallest hint of risk. All the trains still run on time. But the Underground’s habits and truces have adjusted just enough to make it clear who has ultimate responsibility for fire prevention, and everyone is empowered to act, regardless of whose toes they might step on.
The same kinds of shifts are possible at any company where institutional habits-through thoughtlessness or neglect-have created toxic truces. A company with dysfunctional habits can’t turn around simply because a leader orders it. Rather, wise executives seek out moments of crisis-or create the perception of crisis-and cultivate the sense that
“You never want a serious crisis to go to waste,” Rahm Emanuel told a conference of chief executives in the wake of the 2008 global financial meltdown, soon after he was appointed as President Obama’s chief of staff. “This crisis provides the opportunity for us to do things that you could not do before.” Soon afterward, the Obama administration convinced a once-reluctant Congress to pass the president’s $787 billion stimulus plan. Congress also passed Obama’s health care reform law, reworked consumer protection laws, and approved dozens of other statutes, from expanding children’s health insurance to giving women new opportunities to sue over wage discrimination. It was one of the biggest policy overhauls since the Great Society and the New Deal, and it happened because, in the aftermath of a financial catastrophe, lawmakers saw opportunity.
Something similar happened at Rhode Island Hospital in the wake of the eighty-six-year-old man’s death and the other surgical errors. Since the hospital’s new safety procedures were fully implemented in 2009, no wrong-site errors have occurred. The hospital recently earned a Beacon Award, the most prestigious recognition of critical care nursing, and honors from the American College of Surgeons for the quality of cancer care.
More important, say the nurses and doctors who work there, Rhode Island Hospital feels like a completely different place.
In 2010, a young nurse named Allison Ward walked into an operating room to assist on a routine surgery. She had started working in the OR a year earlier. She was the youngest and least experienced person in the room. Before the surgery began, the entire surgical team gathered over the unconscious patient for a time-out. The surgeon read from a checklist, posted on the wall, which detailed every step of the operation.
“Okay, final step,” he said before he picked up his scalpel. “Does anyone have any concerns before we start?”
The doctor had performed hundreds of these surgeries. He had an office full of degrees and awards.
“Doctor,” the twenty-seven-year-old Ward said, “I want to remind everyone that we have to pause before the first and second procedures. You didn’t mention that, and I just want to make sure we remember.”
It was the type of comment that, a few years ago, might have earned her a rebuke. Or ended her career.
“Thanks for adding that,” the surgeon said. “I’ll remember to mention it next time.
“Okay,” he said, “let’s start.”
“I know this hospital has gone through some hard periods,” Ward later told me. “But it’s really cooperative now. Our training, all the role models-the whole culture of the hospital is focused on teamwork. I feel like I can say anything. It’s an amazing place to work.”
1 The reporting in this chapter is based upon interviews with multiple people working at Rhode Island Hospital and involved in this incident some of whom provided different accounts of events. For details on responses from hospital representatives and the surgeon involved, please see the notes.
7
How Leaders Create Habits Through Accident and Design
I.
Andrew Pole had just started working as a data expert for Target when a few colleagues from the marketing department stopped by his desk one day and asked the kind of question Pole had been born to answer:
“Can your computers figure out which customers are pregnant, even if they don’t want us to know?”
Pole was a statistician. His entire life revolved around using data to understand people. He had grown up in a small North Dakota town, and while his friends were attending 4-H or building model rockets, Pole was playing with computers. After college, he got a graduate degree in statistics and then another in economics, and while most of his classmates in the econ program at the University of Missouri were headed to insurance companies or government bureaucracies, Pole was on a different track. He’d become obsessed with the ways economists were using pattern analysis to explain human behavior. Pole, in fact, had tried his hand at a few informal experiments himself. He once threw a party and polled everyone on their favorite jokes, and then attempted to create a mathematical model for the perfect one-liner. He had sought to calculate the exact amount of beer he needed to drink in order to work up the confidence to talk to women at parties, but not so much that he would make a fool of himself. (That particular study never seemed to come out right.)
But those experiments were child’s play, he knew, to how corporate America was using data to scrutinize people’s lives. Pole wanted in. So when he graduated and heard that Hallmark, the greeting card company, was looking to hire statisticians in Kansas City, he submitted an application and was soon spending his days scouring sales data to determine if pictures of pandas or elephants sold more birthday cards, and if “What Happens at Grandma’s Stays at Grandma’s” is funnier in red or blue ink. It was heaven.
Six years later, in 2002, when Pole learned that Target was looking for number crunchers, he made the jump. Target, he knew, was a whole other magnitude when it came to data collection. Every year, millions of shoppers walked into Target’s 1,147 stores and handed over terabytes of information about themselves. Most had no idea they were doing it. They used their customer loyalty cards, redeemed coupons they had received in the mail, or
