Drinks, Pizza, and a Little Basketball

Nostalgic for the hours I used to spend in college dining halls debriefing a long organic chemistry lab session, planning the next Chinese Students Association event or discussing the misuse of Murphy's Law when describing catastrophic global events, I take great comfort in studying in cafes or catching a casual drink at low-key bars. Food and drinks are within reach and conversations are aplenty. However, it seemed just too perfect that I would find myself at a Wolverine friendly bar and pizza joint called the Brown Dog in the middle of Telluride to catch Game 3 of the NBA finals with my new patient safety friends.

In between sips (true sips because alcohol and high altitude could turn into a physiologic disaster), we would seamlessly transition from discussing the patient harm that results from unstandardized hand-offs to watching the Miami Heat claw their way towards a lead in the series against the Thunder. The true cherry on top was the mouth-watering smells of Detroit deep dish pizza that surrounded us. Because the University of Michigan atmosphere mixed with good pizza and beer seemed to be a winning combination for stimulating patient safety conversations and Miami Heat success, we recreated the magic for the rest of Miami's journey to become the 2012 NBA Champions. As I wistfully look back on my week in Telluride, especially as I suffer in the inhumane heat wave that has metaphorically encircled Southeast Michigan in an inescapable head-lock, I can’t help but intertwine patient safety and health care quality improvement with basketball.

Since becoming a basketball fan when the Miami Heat won the NBA Championship in 2006, my home team has really tried my patience. Like any health care quality nerd, I began to see health care connections in sports. The Miami Heat represented all of the negative characteristics of a poor performing health care system, primarily an organization that had seemingly lost its way (click here to read more about the Miami Heat and its failures as an HRO).

2010 represented a turning point. In a politically unwise and arrogantly publicized event, LeBron James was recruited to join Dwyane Wade and play for the Miami Heat. Chris Bosh of the Toronto Raptors also decided to move to warmer climates. Before I knew it, amidst the global antagonism directed towards Miami, a new sense of purpose had been injected into my home team: The Big Three had promised to fill their fingers with championship rings. While the rest of the world derided the team for its bombastic promises, I bought into the dream. With three superstars on the same team, as the Boston Celtics had proven in 2007, how could the Miami Heat fail?

Did the Miami Heat succeed in the 2011 NBA Finals? No. The Big Three was simply that, three basketball superstars who all happened to play on the same team. An optimist would say that The Big Three’s first season together was a string of small experiments (PDSA cycles) on how LeBron James, Dwyane Wade, and Chris Bosh would share the court together. But, what this looked like on TV was confusion and a total lack of coordination. The Big Three had their moments when they would each individually live up to their All-Star reputations, but these occurred in unpredictable and unreliable spurts. The Miami Heat haphazardly played its way into the 2011 NBA Finals and an entire season’s worth of bewilderment became obvious to the world as it was blown out by the Dallas Mavericks. I distinctly remember watching the team disintegrate into a group of headless chickens that did not seem to know what to do even when it possessed the ball.

In retrospect, the 2010-2011 season should not have come as a surprise to me. In assembling The Big Three, the Miami Heat committed the same mistake that many health care organizations make: attempting to achieve greatness through cultivating great parts. In a thought experiment to build the world’s greatest car by assembling the world’s greatest car parts, Dr. Don Berwick, former CMS Administrator and CEO of IHI, describes:

“Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence”… We’d connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”

The basketball teams that want success to become an intrinsic characteristic of the team, invest and develop not just individual talent, but also create a reliable system of teamwork.

Examining the Miami Heat’s run for the 2012 NBA Championship, the Miami Heat has done just that: built on the talents of The Big Three and transformed into a high-functioning team. For those that continue to carry Miami Heat antagonism (I realize I am in the great minority being a Miami Heat fan), I’m not claiming perfection, but improvement. Although an abbreviated season, the Miami Heat discovered a rhythm of teamwork that allowed The Big Three to play together as a more unified front. The Miami Heat faced one of its first great tests in the second round of the playoffs against the Pacers. Chris Bosh was injured and out of the picture and the Miami Heat was shut out of Game 3, falling behind in the series 1-2. The Miami Heat of 2011 probably would have been knocked out of the NBA Finals running. But, the Miami Heat of 2012 readjusted and Udonis Haslem stepped up to the plate to fill in the gap that Chris Bosh left. The Miami Heat beat the Pacers 4-2.

Improved teamwork was even seen off of the court. In the wake of the Miami Heat taking the lead in Game 3 against the Thunder, the drama that erupted in the media was when Kevin Durant of the Thunder was caught telling Dwyane Wade, "You're too small." Although the statistics of the team do back-up Kevin Durant's statement, LeBron James' response that the actual size of the players doesn't matter as long as they're fundamentally sound and play with the effort that helps that makes up that difference, rang true of the 2012 Miami Heat teamwork mantra. Just looking at the media coverage of the Miami Heat's journey to the championships, the words "we" and "team" are being used more frequently and coverage of the last game sings the praises of not just the Big Three, but also Mike Miller, Shane Battier, and Mario Chalmers--critical teammates who all contributed to the win.

So, what does this all mean for health care? The theme of the week at the Telluride Roundtable was communication. While we spent the day discussing the importance of communication facilitating successful teamwork, what we had in front of us in our after hours was an example of the incredible transformation of a basketball team that truly took teamwork to heart. So, as many of us are getting ready to apply for residency and are looking for residency programs and institutions that value patient safety, don't fall into the trap of optimizing health care by just optimizing individual parts, also consider what programs and institutions do to facilitate excellent interdisciplinary teamwork.

While the IHI Open School facilitates interdisciplinary communication by bringing health professions students of all disciplines out of their isolated silos together to discuss quality improvement and patient safety, what else can be done to improve interdisciplinary communication and hence create a reliable system of teamwork? I'd love to hear what you are doing at your institutions, so comment below and share your successes and challenges--perhaps some drinks and pizza will spark some health care quality improvement magic.

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".