Making smart mistakes.

Hospital A has decided to purchase an operating room documentation system to improve scheduling of operative cases and increase productivity. Hospital A follows a well-established procedure for selection of the system. The procurement team generates a request for proposals (RFP). Several vendors respond.

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A multi-disciplinary team is established, including the vice president for operative services, the nursing and medical directors of the operating rooms, the director of information systems, the chairs of anesthesia and surgery, a vice president of finance, and the chief medical officer.

After many meetings and vendor evaluations, they decide to purchase the system offered by their preferred corporate partner. Their reasoning is they can easily integrate the operating room documentation module into the existing system. In addition, as a preferred corporate partner the institution will receive a discount on the purchase, and can count on preferred technical support.

Hospital B, a competitor of Hospital A, is similar in size, patient population and services offered. It too, has decided to purchase an operating room documentation system to improve scheduling of operative cases and to increase productivity. However, unlike Hospital A, they decide to deliberately "make a mistake" in how they will select their operative system.

They decide to test the assumption that their well-established selection process procedure is the correct way to select a vendor. They bring together the anesthesiologists and operating room nurses and ask them to establish a process for selecting a vendor. The anesthesiologists and nurses put together a group of representatives including an anesthesiologist, certified registered nurse anesthetist, an operating room nurse, and operating room technician, an information system technician, the operating room scheduler, high-volume surgeons from the general and specialty services, and a member of the finance department.

Rather than creating a formal RFP, they develop criteria to define the "perfect" system. Believing ease of use and functionality for the end-user to be the most important elements in the decision process, they give the greatest weight to these criteria. They contact colleagues who are working in institutions who have purchased and implemented operative documentation systems and poll them for their opinions, as they relate to their established criteria.

They decide to examine the products of three vendors and invite the end users to test them. None of the vendors chosen to participate is a corporate partner of the institution. Ultimately, they choose a small, but financially stable vendor, who specializes in operative systems. The system is chosen because it meets the needs of the end-users, can be interfaced to the current systems, and is competitively priced.

Hospital A implements its documentation system. Administrative "superusers" and experts are trained to teach the end users. Online training modules are used to learn the system. The implementation is met with resistance.

The anesthesiologists, nurses and operating room schedulers find the system difficult to learn and use. Many steps are required to enter and analyze their documentation. Frustration and anger ensue, and ultimately productivity falls.

Hospital B also implements its new system. The members of the selection team, as end users in the operating room, teach their colleagues how to use the system during cases and the normal course of business in the operating room. Acceptance is very high and productivity increases.

Was Hospital B just lucky by making this "deliberate mistake," or is the process of carefully planned mistakes one that should be built into the strategies of hospitals and other health care institutions?

In their article, "The Wisdom of Deliberate Mistakes," (1) Paul Schoemaker and Robert Gunther argue there is a way to make carefully planned mistakes that can pay off. They argue that making mistakes by challenging our assumptions is necessary for four important reasons.

1. First, we tend to be overconfident in our knowledge of what works and what doesn't. (1) Early in our careers as medical students and residents, our supervising physicians continuously test our assumptions. We make mistakes, but learn from them. The more experienced we become, the less likely we are to question our clinical assumptions. The same is true in business, but it does not mean we should not continue to test our knowledge and learn from the process.

2. The second reason to make "mistakes" is because we are risk averse. (1) We don't want to be seen as failures in the eyes of our colleagues or employers. Most business cultures are not set up to reward us for making mistakes and being good learners.

3. Thirdly, we consistently seek confirmation of our decisions by favoring data and experimentation that supports our underlying beliefs. (1) Hospital A in our example above, favored data supporting the advantages of its corporate partnership over other factors, to support its belief that the product offered by their partner would be easier to integrate into their existing system.

4. Finally, we assume the feedback we receive is reliable and valid. (1) Feedback from individuals or groups that supports our underlying assumptions is considered to be valid. That which challenges our thinking often is dismissed.

Given that making planned mistakes may be a good thing, how and when should we make these "smart mistakes?"

Schoemaker and Gunther offer a step-by-step process. (1) First, you must analyze the trade-off between the cost of the "mistake" and the benefit of learning from it. Hospital B felt the benefit of challenging their traditional selection process and learning if there was a better way, outweighed the cost. This is because they were testing the process of how to select the system and not the purchase itself. The cost of the mistake would have been the time invested in trying a different process.

Next, you should identify assumptions underlying large numbers of routine decisions. Hospitals make equipment purchases on a daily basis, ranging from information technology to clinical supplies. The deliberate mistake instituted by Hospital B resulted in a new process for all purchases, allowing the end-users, with input from administration, to take the lead. The result was greater staff retention, increased productivity and eventual cost savings.

Once you identify these assumptions, they can be ranked based on whether you believe they are highly important and very accurate. The greater your belief in these attributes, the greater is your potential for learning by making a planned mistake.

Finally, after executing the mistake, whether the outcome is good or bad, you must analyze the process and determine if the results reinforced or changed your underlying assumptions.

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As toddlers, we learn to walk by testing our assumptions as to how the process works, by making planned mistakes, by falling down without really getting hurt, and eventually using these mistakes to learn the process that keeps us upright and balanced, as we step forward. We then use that learning to advance to running. So too in our business practices, we have to be willing to challenge our thinking and make "smart mistakes" along the way, to accept occasionally falling down, provided it's not too painful, to learn from those mistakes, and to ultimately make the most of that learning.

David P. Tarantino, MD, MBA, is executive medical director of Shock Trauma Associates, P.A., a 50+ physician, multispecialty practice associated with the University of Maryland School of Medicine. In addition, he is the chief executive officer of The MD Consulting Group, LLC, a health care management consulting firm in Baltimore. He can be reached by phone at 410-328-2036 or by e-mail at [e-mail].

Reference

1. Schoemaker PJH and Gunther RE. "The Wisdom of Deliberate Mistakes." Harvard Business Review. June 2006.

By David P. Tarantino, MD, MBA