Attending to weak signals: the leader's challenge.
Halverson and Isham (2003) quote sources that report the accidental death rate of simply being in a hospital is "...four hundred times more likely than your risk of death from traveling by train, forty times higher than driving a car, and twenty times higher than flying in a commercial aircraft" (p. 13). High-reliability organizations such as nuclear power plants and aircraft carriers have been pioneers in the business of recognizing weak signals. Weike and Sutcliffe (2001) note that high-reliability organizations distinguish themselves from others because of their mindfulness which enables them to see the significance of weak signals and to give strong interventions to weak signals. To act mindfully, these organizations have an underlying mental model of continually updating, anticipating, and focusing the possibility of failure using the intelligence that weak signals provides. Much of what happens is unexpected in health care. However, with a culture that is continually looking for weak signals, and intervenes and rescues when these signals are detected, the unexpected happens less often. This is the epitome of how leaders can build a culture of safety that focuses on recognizing the weak signals to manage the unforeseen.
Kerfoot
Karlene
K
Nursing and Patient Care Services, Clarian Health, Indianapolis, IN, USA.
D006801:Humans; D007857:Leadership; D015279:Organizational Culture; D010346:Patient Care Management / Q000458:organization & administration*; D017751:Safety Management / Q000458:organization & administration*