Lesson 11: Don’t blame the person--fix the system.

I attended a meeting in Chicago in March 2004 sponsored by the American Council on Graduate Medical Education. Both keynote speakers, former Secretary of the Treasury Paul O’Neill and physician/astronaut James Bagian, MD, spoke on patient safety in medical care1. Both had jobs in 2004 that involved making policy regarding patient safety: Mr. O’Neill was founder and CEO of the Pittsburgh Health Care Initiative and Dr. Bagian was director of the Department of Veterans Affairs’ National Center for Patient Safety.

Dr. Bagian in his address described the success of the airline industry with safety. In the 1930’s, aircraft crashes were a frequent event. A pilot delivering airmail had a life expectancy on the job of three to four years. In the 1950’s, the aviation industry realized that they could not continue to build airplanes only to crash them. At that time, the industry began to emphasize teamwork and standardization of procedures to prevent error.

The airline industry sought to develop an environment where the mechanics and other airline personnel felt safe to report errors or potential errors. Too many of these people were afraid to point out errors and problems because they felt that in doing so they would be reprimanded or fired. Over time, the culture and the attitudes began to change. Those in management encouraged their employees to report not only errors and problems but also any potential errors or near misses. Employees began to work with standardized protocols and were encouraged to report any deviations from protocol—by themselves or anyone else. Eventually, to this present day, airline travel has become safe. Now, major airline crashes are rare.

Such a culture, according to Dr. Bagian, does not exist in medical care—at least it did not in 2004. Although it has been years since I have been involved in direct patient care, I remember from my days in training the tongue-lashings we would receive. Too often, young doctors and nurses feared getting chewed out by attending physicians. Dr. Bagian was right to point out that this kind of environment is not conducive to optimal patient safety.

An environment of fear is also not conducive for good death investigation. I realized this intuitively many years ago, and Dr. Bagian’s comments served to reinforce my own ideas.

The chief medical examiner is responsible for a relatively large operation. As a chief, you must rely on the professionalism and the diligent, careful work of your staff. So many disastrous events have the potential to bring serious scandal to the office. Toxicology specimens can be mislabeled. Bodies can be misidentified. The wrong body can be released to the wrong funeral home. Specimens can be lost. Refrigeration of critical stored evidence can fail. I could go on and on and on. The chief must maintain an environment where the procedures are standardized and the reporting of potential problems is encouraged. To do this, the chief must not blame the person but fix the system.

The “system” consists of policies and procedures worked out over time that everyone in the office must follow. The National Association of Medical Examiner Inspection and Accreditation Checklist provides a useful place to start in writing those policies and procedures. They can be obtained at the NAME website: www.thename.org. Several of the checklist items require specific written procedures covering varying aspects of the running of the office. Additionally, any new procedure enacted in the office should be put into written form once all of the details have been worked out over time.

You as the chief do not form or write those procedures by yourself. The procedures require the professional input of the people who work for and with you. In order to ensure compliance, the people in your office need to understand the need for the procedures. They need to provide their valuable feedback on how the procedures will impact their work. They also need to sense that they are a valuable part of your team. You cannot think of everything by yourself; you need help. Your job as a leader is not only to persuade them of the need for policies and procedures but also to motivate them in the writing and development of the procedures.

Beyond procedures, there needs to be an open channel of communication between you and the people you employ. Most of the time while I was at work and not in a private meeting, I left the door to my office open, inviting anyone to stop by to talk with me. I was willing to speak to any of the people who worked for me about anything. I may not have been willing to settle all disputes among employees because many of these were referred back to their supervisor, but I always did what I could to make myself accessible and to listen. People in the office need to sense that you are fair and they can trust you. This will never happen if you do not keep communication open.

You need to encourage your employees to report to you any and all irregularities, problems and mistakes—whether or not they are involved or others are involved. The point of this is not to get people into trouble but to correct any problems. This should include you. I encouraged this for myself when I was a chief. If anyone in the office felt I was making a mistake, I encouraged him or her to tell me and I thanked this person for the input. On multiple occasions, my autopsy aide would point out something I was overlooking during an autopsy, and I would thank him for bringing it to my attention. As long as people spoke to me respectfully, they could tell me anything they wanted or needed to tell me. Often I would tell them, “If you see that I am about to step into a deep, dark hole, please…feel free to warn me!”

We all make mistakes. No one is perfect. The only one to blame for anything in reality is the chief. He or she is responsible for the system and for the work environment. If a mistake is made, the system needs to be adjusted to minimize human error. Often, this may mean introducing more double checks and redundancy into the system. This may mean more safeguards, more encouragement for the people you employ to catch things early and to report even slight irregularities. It is much easier to fix the slight irregularity than it is to deal with the aftermath of a major disaster.

Does that mean that no one will ever be disciplined? Not at all. If one of my employees deals poorly with the public or engages in activity that is illegal, immoral or wrong, that employee must be corrected or possibly removed. Still, the chief must be willing to listen to all viewpoints, particularly the viewpoint of the alleged offender. Although the discipline may be tough, it must be fair.

But what if you fail to keep lines of communication open? What if you are arbitrary? What might happen if you insisted on blaming people for their mistakes without any consideration or fairness? What might happen if you insisted on writing policies and procedures without receiving the vital feedback from the people doing the work?

This type of insensitivity might not work well for any type of manager, but for the chief medical examiner, it could be disastrous. It could even cost you your job.

The chief medical examiner is already under intense scrutiny. The media is quick to report on any failure or misstep. Often, the chief may make enemies in high places just simply by telling the truth and doing his or her job. If any horrible mistake happens, the chief will be blamed for it immediately in a very public and humiliating fashion. Unlike the elected politician who has the power and the luxury to be able to get away with blaming others for his or her failures, the appointed chief medical examiner is much more easily expendable. Even though a chief medical examiner is not easily replaced, this does not stop many politicians from getting rid of a chief. Usually, the politician has finished his term and moved on before the consequences of that choice become apparent.

The disgruntled employee—the one you treated disrespectfully for so long—can exact revenge in several different ways. One way is to simply let things slide. Errors of omission and neglect are not as easy to pin on someone as are errors of commission. One can allow things to happen without leaving fingerprints.

A disgruntled employee can also become a whistle-blower. I have seen several examples of this over the years. For example, one periodically may read in the news how an employee blew the whistle on a county-employed forensic pathologist for doing outside work on government time and with government resources. Not only should a chief or any pathologist be above reproach, the doctor should also keep his relationships with employees in good shape to prevent them from even having the desire to cause problems.

In conclusion, there is one sure-fire way of spotting a poor leader. The most distinct evidence of poor leadership is when the leader publicly blames employees for mistakes. A good leader will never do this. A good leader is more interested in a system that runs like a well-oiled machine, enhanced by the talents of trained individuals who are treated well.

1 http://www.acgme.org/acWebsite/newsReleases/newsRel_03_23_04.asp