A very painful example of the tragic results when an organization does not learn from its mistakes comes from a case study by the Harvard Business School of NASA.  The study examined the NASA chain of command following the 2003 destruction of the space shuttle Columbia during reentry. At that time, NASA was a very top-down organization. Bringing up problems was a career killer. In fact, many NASA employees felt that they had to prove that there was a problem, before it was safe to even raise questions. One might have assumed that NASA would go to great lengths to research any potential error, no matter how unlikely, and do everything possible to fix the situation, much like they did for Apollo 13.

But that was not the case at the time the Columbia was launched. There were two senior engineers who were extremely concerned that the heat tiles that were knocked off of Columbia just after lift off lead to a very dangerous situation. They reported their grave concerns up the chain of command, but were repeatedly over ruled.  In fact, they recommended getting help from the military to get pictures of the damage to make conclusive recommendations. This also was overruled. They had one final opportunity to raise their concerns in a joint meeting that might have lead to a different outcome, but neither said a word. The rest is history. 

UBTs: A new culture

As we travel through the regions, we spend a great deal of time thinking and learning about culture change. We have the opportunity to see first hand how some teams that have really changed the way they do things. These teams tend to be very successful in accomplishing their goals. They tend to reflect a deep trust which creates a safe environment in which to try out change. This environment allows issues to come to the surface. It allows people to learn from mistakes with out fear of retribution and for new and creative ideas to bubble up. It is clear that many of the best solutions come from the people doing the work.

How do we create this culture change? Does it come from someone writing a memo, or a manager or physician or a union leader?  Or does it come from each one of us challenging ourselves to be the best team member we can be?  

Frances Frei, a professor at the Harvard School of Business says that “successful organizations have a relentless pursuit of surfacing problems.” This can only happen in a culture that rewards and encourages this type of dialogue. It can only happen if people feel it is expected -- and safe to do.   

Does your team’s culture  allow a disaster in the making to happen? Or is every voice heard? Our member’s and our patient’s well being is in our hands. It’s time to spread culture change throughout Kaiser Permanente.