Important Lessons From Black Box Thinking

Transcript

1. IMPORTANT LESSONS FROM BLACK BOX THINKING BY MATTHEW SYED Today’s “black box” can be vulnerable to the individual but helpful overall to our society. Should we change our perception how we treat black boxes? *All images used are copyrighted CC by Bing search engine, educational sites, and articles in the sources of last slide, and are used in here under fair use. By Sokratis Anastasiadis*
2. Privacy? Norms? Individual Experiences? Actual Events? Self-interest? Hiding Bad Habits? WE USE THIS BOX FOR BOX INCLUDES Black Box Version of 21st Century: Pandora Box
3. Privacy? Norms? Individual Experiences? Actual Events? Self-interest? Hiding Bad Habits? WE USE THIS BOX FOR BOX INCLUDES Liabilities = Costs Credibility = Brand Depreciation for Organizations Less Career Opportunities for Individual Processes that we don’t want to face/analyze /improve we circumvent in such way to exclude liability. Working for Ideologies against Rival Organizations/Clients/Individuals Due to profit/recognition/pride They are only entertained. Actual events are twisted through their ideologies (= Cognitive Dissonance) Careers that expect Perfectionism/High Prodigy Due to long term experience/education (Examples: P.H.D. , C suite executives, Doctors, etc.) Are hidden with professionalism that it is beyond their “habits” (= bad luck?)
4. Brand Depreciation for Organizations Less Career Opportunities for Individual against Rival Organizations/Clients/Individuals Due to profit/recognition/pride Careers that expect Perfectionism/High Prodigy Due to long term experience/education THE MOTIVATIONS ALL SHARE A COMMON THREAD The ME is becoming threatened by the external environment And the easiest way for ME to not be threatened is to stuff them in a Black Box
5. Aviation Industry Shows us how to take use of Black Box Thinking The Story Of Plane: United Airline 173 Date: December 28 1978 Route: New York to Oregon Departure : 2:47 PM Est Arrival : 5:15 PM
6. Landing Gear Lights not on (5:10) Thud Sound (5:10) 5:10 PM: Near Arrival. landing gears not followed the usual pattern. (Risk landing with no landing gears: LOW) 5:10 PM: Placed plane onto “holding pattern” 5:10 PM: Captain worried about the Landing Gears. Could not identify problem. 5:46 PM: Engineer advised captain warning fuel reserves low (Risk increases from LOW to HIGH for every minute after 5:51PM for not doing a land attempt) Captain focused still on landing gears problem. 5:50 PM: Engineer advised captain warning fuel reserves 2nd time. Captain replied there were 15 minutes left. Captain focused still on landing gears while engineers already knew fuel reserves was the highest risk but could not disobey the captain orders. 6:06 PM: The plane was falling down 3,000 feet per minute. Captain was not aware of the cause until engineers told it was due to fuel. (The plane crashed with 10 people killed out of 189 passengers and crew) (Days after): Pilot in hospital wanted the investigator to check if there was any leaks on the fuel tank. Warning Fuel Reserves low (5:46) THE PROBLEM WAS THE LANDING GEAR?
7. Similar airplane accidents with more fatalities happened before 1. DC8: While flying to Chicago, had problem landing gear and ended crashing on a mountain 2. Eastern Airline 401: While flying to Miami, due to no landing gear lights, landed on everglades killing 101 people
8. Norms of the aviation industry was the problem Problem: 1. Pilot was too focused on the landing gear and not for any other arising problems, losing the sense of time. 2. Pilot did not got the sense of urgency from others because engineers couldn’t challenge the captain’s orders. Solution: 1. Have a checklist the pilot/crew would check every X minutes for the main components of the airplane 2. Assertiveness lessons must be addressed not only from engineers, but pilots too
9. Did the aviation industry said only sorry and forgot the problem?
10. Accidents reports are disclosed to everyone Independent investigators are allowed to examine the issue The black box is opened Airplane Industry gets less credibility, but addresses the problem so future similar events do not happen Answer: Aviation industry makes a black box become a white box
11. Healthcare industry Norms Current Situation 1. Under budget constraints. 2. Trying to cut as much costs as possible 3. Does not want in the short term to deal with liabilities 4. R&D: Improving procedures of better services not within the budget The story of Lucile Packard Children’s Hospital in Palo Alto vs Johns Hopkins Hospital
12. Meet Nora, the victim of 4 central line infections Children’s Hospital in Palo Alto Symptoms: Fainting episodes due to pulmonary hypertension October 2012 (Age 3): Admitted on hospital November 2013 (Age 4): Last day of her Life
13. Children’s Hospital in Palo Alto Had to be administered a drug through central line for her symptoms February 13 2013: Central line infection identified. February 14 2013: Doctors and surgeons had to "remove a lot of pus from the central line tunnel after the line was removed.“ April 2013: Another central line infection identified . Living in the hospital (Hearts and lungs become increasingly weak) November 2013: Another central line infection identified. Contacted parainfluenza 1, a respiratory virus Mother sent a letter to hospital investigate why her daughter died due to central line infections, with notes including, such as “We also observed nurses …touching bedrails after they put their gloves on and then not changing their gloves before accessing the line”
14. The hospital’s response? Unfortunately, the placement of central lines is associated with a risk of infection. There is a risk of infection — in the best of circumstances — which can never entirely be eliminated. Please be assured that multiple procedural protocols are in place to promote hand washing techniques. We understand and recognize your feelings regarding Nora's care, and we apologize that you were dissatisfied with your experience at LPCH They did not address the case The mother filed a lawsuit
15. Did the hospital address the issue after her mother filed a lawsuit in order to get more information about the case? Due to patient privacy issues, as well as the fact that the matter is now in litigation, we cannot comment on the specifics of the allegations. But we can say that our entire organization is committed to collaborating with families on ways to continuously improve, and we are proud of our commitment to quality and patient safety Could it be that the sorry letters are: Numerous studies show, somewhat counterintuitively, that patients who receive apologies from hospitals are less likely to pursue legal action.
16. Meet Johns Hopkins Hospital where “There is a risk of infection — in the best of circumstances — can entirely be eliminated.”
17. In summary, they found the problem like the airplane industry did, and added the following procedures to be done by using “a checklist” they had to explicitly check for every step done to every staff that inserted a central line (no exceptions) Results Central Line Infections -Decreased by 50% in 3 months -Decreased by 70% in 6 months
18. Old History Repeats Again Dr. Semmelweis Despite various publications of results where hand washing reduced mortality to below 1%, Semmelweis's observations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community In 1865, Semmelweis was committed to an asylum, where he died at age 47 of pyaemia, after being beaten by the guards, only 14 days after he was committed (Wikipedia) First Clinic: “No hand washing” Second Clinic: “Hand washing”
19. On April 1, 2016, the National Health Service of England has invited Matthew Syed, the author of "Black Box Thinking", by the Secretary of State for Health to help draft the proposals that come into force for addressing such issues. Health care may indeed be under-resourced, but it would save money by learning from mistakes. Cost of medical errors United States: $17 billion
20. Criminal Justice: Are lawyers seeking the truth? The story of: Juan Rivera Innocent man convicted for the rape murder Holly Staker 1992-2012
21. 1992: Juan Rivera, having psychological problems, at age 19, was pushed under grueling examination, became “psychotic”, confessed on the 3rd day of the examination that he was the murderer by signing a letter. With no witnesses and physical evidence matching the murder, he was convicted first-degree murder. 2005: DNA tests found no match with the semen of the murder case with Juan Rivera. Lawyers twisted the story that Juan Rivera murdered her after another person did intercourse and left. 2009: Re-trial of 2005 against DNA evidence. Prosecutors were able to wrap up a story Juan Rivera was still guilty. 2012: Re-trial of 2009 against DNA evidence. Juan Rivera found innocent and released from prison. The trial of Juan Rivera
22. Aftermath of Aviation, Healthcare, Criminal Justice Systems Template Evidence that I receive Locked, Theory Cannot Change “My theory” black box Others theory story “black box” Twist or warp the evidence to fit Actual Evidence Fits without altering the content Focus Only Ignore Motivation for suppressing this path
23. Aviation (Example 1) Landing Gear Locked, Theory Cannot Change My people rely on me fixing the landing gears Whatever is the highest priority, I should be attentive about it. The low fuel sounds critical. This is the most important thing right now is the landing gear. Landing Gear, Low Fuel Find the highest priority, Listen to crew (New Norms) Focus Only Ignore I am an expert at this. I cannot fail my people Would be embarrassing for my career If I land without gears (hiding bad habit)
24. Healthcare (Example 2) Central Line Infections Locked, Theory Cannot Change Central Line Infections, even at best circumstances, happens Central Line Infections are reduced with better Sanitary practices. It is impossible to avoid. Make sure to apologize customer to avoid Liabilities. Central Line Infections Admit mistakes. Give more strict rules For staff to follow For inserting a line. Focus Only Ignore We still need be the top hospital accredited (Privacy)
25. Criminal Justice System (Example 3) Testimony, DNA not matching results Locked, Theory Cannot Change All that matters is the guy testified It is reasonable that the suspect is less likely to Be the murder with decisive evidence The testimony is all that matters. The DNA is due to someone else doing Rape on her before he murdered her. Testimony, DNA not matching results The DNA confirms that the Victim is less likely to be the murderer, having less proof for the individual being guilty Focus Only Ignore I can’t lose face to my client (self-interest)
26. If a theory does not fit with the actual evidence And we are forced to adjust our evidence to such theories for otherwise it makes us get the “stick” Then we are doing a disservice to this society for not showing our correct methodology Can a theory “king” still retain its seat even when new evidence contests him? When our individuality is threatened, is it actually “rightfully” threatened? Or does the paradigm of society need to change for not punishing people who give a better theory? Both us as well society has to change in a way that we can deal personal matters in scientific way. Neurology, Neuroscience, and Human Behavior are the keys to unlocking the right formula how people should behave to make a better community. We should treat our personal matters in a scientific way and not as a mystery. Then we will be more on the correct path and less dealing our personal matters like cavemen.
27. Main Sources: http://www.bbc.com/news/health-35929557 (What can doctors learn from pilots and cyclists?) http://www.vox.com/2015/7/9/8905959/medical-harm-infection-prevention (Medical Harm Infection Prevention) http://www.amazon.com/Black-Box-Thinking-People-Mistakes-But/dp/1591848229 (Black Box Thinking, Matthew Syed) Other acknowledgements I want to thank also independent researcher Lorin Friesen. To read his research, go to www.mentalsymmetry.com About Me If you are interested, you can visit my blog http://softwaredeveloperlife.blogspot.sg/ for more info about my research and contributions. My Vision I am planning to bootstrap a company, I don’t know how long it will be, but it will be a social network website like Facebook, but its foundations will be based on neurology that focuses only on the personal, that will try to solve problems like black box thinking and common organizational cultural problems, in such a way, that we don’t need to re-invent these issues these days like throwing water out of fire. Neurology will have its own independent branch that will behave In the same format as science and will run in parallel with science, which its role is doing iterative abstractions that will improve the quality of relationship and communication of people instead of automating tasks in the physical world so the human can have more time on focusing on abstract stuff instead of concrete manual work.