Sunday, June 5, 2016

Follow-Up to Previous Post

I felt like I should follow up on my previous post, but I couldn't think of a good way to start.  I didn't want to double down on attacking the decision makers (i.e. you are incompetent, and here's why).  Nor did I want to be an apologist (i.e. it's okay, you did the best anybody could have done in your position).  I also didn't want to turn this so meta that it was useless (i.e. what is it about human nature that makes us repeat the same mistakes, over and over again?)

I found myself thinking about something I learned regarding how to manage healthcare organizations.  Healthcare involves life and death type situations.  And yet the people who manage that care are human, and fallible, and can make disastrous mistakes.  Like giving a patient the wrong medicine, or cutting off the wrong limb in surgery.  A good organization realizes that creating a zero-tolerance environment is actually counter-productive.  People try harder to hide it when they screw up, and you can't actually fix the root causes. 

You can't go pointing fingers, or punishing people too badly.  Not if you're serious about creating the best healthcare system.  You need to know if color coding pills (as one example) will help prevent future mistakes.

So that's what I wanted to do.  I don't want to point fingers, not really.  Sometimes I let my anger get the better of me, of course, and I think it comes out in my writing.  But I don't actually want to go back and figure out who carries how much blame for the current situation in the middle east (or other things).  At the same time, I think it's pretty obvious that our policies have not had the results we had hoped for.

So that's what I want to explore.  Why didn't we get where we wanted to be?  What can we do better? 

The first step, of course, is admitting that we didn't get the results we wanted.  Tied in with that is 'but we could have, if we had handled things differently'.

As usual, I'll continue this later.  Right now I need to go mow the lawn before it gets too much hotter.

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