Shooting for "Sensemaking" in Health Care

Despite my lackluster sports careers in tennis and Ultimate Frisbee, I am a huge sports enthusiast. In college, I was introduced to basketball. My hometown team, the Miami Heat had just fought their way to the 2006 NBA Finals. Like any good fan, my eyes were glued to the TV every game against the Dallas Mavericks. I gasped at every missed shot, held my breath during every free throw shot, and cheered for every point scored. The Miami Heat's journey to the championship was epic and I have been enamored with them ever since.

However, since winning the NBA Championship in 2006, the Miami Heat have really tried my devotion to them. In the 2006-2007 season, my team was riddled with injuries and inopportune player absences. Shaq had promised us a repeat championship, but the end result was far from that. The Miami Heat instead became the first defending champion since 1957 to get swept out of the playoffs in the first round following a championship season. Disaster only continued in the next season with major roster shake-ups. The Heat made history again by ending the season with the worst record in NBA history: 15 wins and 67 losses. When the Miami Heat came to Boston that year, they set another new record: the fewest made baskets in a game (17). I left the game with the feeling that I should have worn green and that it was time for me to switch my allegiance to the Boston Celtics, the team of my new home.

But, things began to turn around in the next year. The Miami Heat began rebuilding the team around superstar Dwyane Wade and the new talent joining the Heat gave them new energy. This year, they are seeded 5 in the Eastern Conference and face the Boston Celtics in the first round of the NBA Playoffs. However, their tumultuous journey to Game 5 (today) serves as a reminder of how unstable my beloved Miami Heat are. While watching Game 4 last Saturday, I could not help but think of the work of Karl Weick, Rensis Likert Distinguished University Professor of Organizational Behavior at the University of Michigan Business School. Thankfully, on Saturday, the Miami Heat, down 3-0 in the best of seven series against the Celtics, beat the Celtics 101-92 to force a Game 5 (today).

As much as I love the Miami Heat and have faith in Wade's athletic prowress, I am not hopeful about tonight's game. Using Weick's own words, the Miami Heat are not a high-reliability organization, an organization that operates under very trying conditions all the time and still manages to have fewer than their fair share of accidents, but should be.

The conventional way of thinking paints organizations as stable and secure structures or institutions. Referencing and extrapolating from the intelligent design movement and the watchmaker's analogy, the conventional organization is one that was carefully designed and left to operate and survive against all subtle and radical changes. However, Weick believes that organizations are alive and dynamic. At all times, they "chat, dissemble, disguise, mobilize, and galumph." In an ever-changing reality, these dynamic organizations possess the ability to change, anticipate, react and adapt to the unpredictable and unexpected.

It's not difficult to see the Miami Heat as such a dynamic organization. Each player is a member of the organization and in the game, they are acting, communicating, and reacting to whatever play the opponent team throws their way. So, why is the error rate or number of losses so great? How did the Miami Heat slump so low after winning the NBA Championship? Looking back at my abridged account of the Miami Heat's recent past, you will notice significant unpredictable changes made to the organization: injuries, roster changes, coaching changes...and those are just changes within the organization itself. Every opposing team experiences such changes and brings those with them to the game. These are external changes. For organizations like the Miami Heat, as Weick describes, "when the unpredictable happens, and the world as we know it unravels, we are all the more likely to become so paralyzed that we cannot survive the experience."

In my own unqualified opinion, the Miami Heat have been operating as a flawed and rigid organization. Its world-view relies heavily on Dwyane Wade and his ability to carry the entire team to victory. When the Miami Heat won the NBA championship in 2006, it was Wade who scored a series of clutch points to edge the Miami Heat past the Dallas Mavericks. The writing was on the wall, so to speak, in regards to Miami's rigid reliance on Wade. In the following season, Wade briefly injured his wrist and then seriously injured his shoulder. In the season where the Miami Heat dropped to its lowest point, Wade was obviously rusty from his injuries. Who charged the Miami Heat forward to win Game 4 and stay in the playoffs this season? Dwyane Wade. He scored 46 points alone. Of course, Wade has had the help and support of his teammates, but not enough since the NBA championship line-up to really call the Miami Heat a team. The Miami Heat since the 2006 championship has been a one man show. Taking a look at tonight's game, what do the Celtics have to do to overcome the Heat? Study and adapt to one man and according to news reports, they did just that. The Celtics spent three times more time than usual watching film to prep for tonight's game. If I was a betting woman, my money would not be on the Miami Heat to win tonight.

What can the Miami Heat do to become a high-reliability organization? It needs to develop its, as Karl Weick calls it, sensemaking abilities. Sensemaking is the process through which the complex and unpredictable world is given order, within which people can orient themselves, find purpose, and take effective action. This sensemaking is achieved through two other Weick concepts called mindfulness: the ability to react to even very weak signs that some kind of change or danger is approaching and the ability to take strong, decisive action based on these signals, and galumph: purposeful playfulness and innovation that provides organizations the opportunity to test different possibilities and scenarios. For the Miami Heat, the team's reliance on Wade immediately following the championship season was a weak signal that should have been corrected immediately, rather than seen as a sure-fire formula for success. New players and innovative starting line combinations were tried. Miami just needs to be even more creative. With this unflinching commitment to reliability coupled with increased innovation, the Miami Heat will see improvement. I am confident in my team.

Stepping back from my NBA playoffs fervor of excitement, what do basketball and sensemaking have to do with health care? Like the Miami Heat, health care is an organization that has yet to achieve the status of being a high-reliability organization. Health care has similar rigid organizational flaws. There is an over reliance on individual performance, weak signals of variation and danger are not taken seriously, and there is great need for innovation and system redesign. If health care can make improvements in sensemaking, it too can reach the season playoffs and become champions. Basketball fans hold their heads up high when their team becomes a high-reliability organization and performs well. But in health care, the stakes are higher. Our patients depend on us to make health care more reliable because it means they can live another day. The health care playoffs are happening right now, and it’s about time we all pitch in and start shooting for sensemaking in health care.

For a more eloquent explanation of sensemaking and its application to health care, read Don Berwick's IHI National Forum Speech, "Escape Fire".