Pattern-Matching Tripwires

Pattern-Matching Tripwires

A variation of the tripwire idea was used, to lifesaving effect, by Lucile Packard Children’s Hospital (LPCH), part of Stanford University’s hospital system. In this account, LPCH treated some of the most seriously ill children in the San Francisco Bay area. “The cases in our general-care wards are like the patients in other hospitals’ intensive care units,” said Kit Leong, a quality manager at LPCH.

At a conference on quality in medicine, Leong became convinced that some deaths at LPCH were preventable. The conference was sponsored by the Institute for Healthcare Improvement (IHI), which had launched a “100,000 Lives” campaign to stop patient deaths due to medical error and ineffective practices. The IHI observed that many patient emergencies could be prevented if early signs of trouble were addressed quickly, and to enable that quick response, it urged hospitals to create “rapid-response teams” (sometimes called RRTs). In a typical situation, a nurse who noticed something odd about a patient’s vitals could summon a rapid-response team, a diverse team of medical professionals who would convene quickly at the patient’s bedside to analyze the situation.

The idea appealed to Leong because she knew that, while adults tend to decline gradually and predictably, kids often crater suddenly. As an experienced cardiovascular ICU nurse, Karla Earnest, said, “They hold on and hold on for a long time, then boom, they hit a wall where they can’t hold on anymore.” Often, by the time a nurse “called a code”—sounding an emergency signal that the kid’s life was at stake—it was too late to save them.

The advantage of rapid-response teams, Leong knew, was that they encouraged action before it was too late, before it was necessary to call a code. She convinced her colleagues to give the idea a try.

In the training sessions, the instructor passed out cards listing six tripwires that warranted calling in the RRT. Five of the tripwires involved objective measures such as acute changes in heart rate, blood pressure, or oxygen saturation. The sixth tripwire, at the top of the card, was the most important: Call the rapid-response team if you are worried about a patient.

Some of the ICU staffers were skeptical about that provision, worrying that it turned over too much control to frontline nurses. What if nurses overused rapid-response teams, distracting doctors from their work in the ICU? Despite the skepticism, the hospital moved forward with a pilot of the rapid-response program.

Over the next 18 months, RRTs were summoned about twice a week, and the most common reason was the one at the top of the card: A nurse was worried about a patient. Karla Earnest, the ICU nurse, said that it was critical that nurses’ worries were legitimized as a tripwire. Earnest said, “As a bedside nurse, it doesn’t force you to be able to articulate, ‘I’m seeing this change in respiratory rate or that change in heart rate.’ … You can just ask for help: Come look at this kid, he doesn’t look good.”

When the doctors and nurses realized they were catching problems earlier than before, their confidence in the program grew. While “calling a code” had always been pretty rare—it only happened 2–3 times per 1,000 patients—it was clear that, thanks to rapid-response teams, the incidents were growing even rarer. Leong and Earnest said that during the first few weeks of the rollout, they kept hearing, “Why didn’t we think of this a long time ago?”

A 2007 article in the Journal of the American Medical Association summarized the results of the project over the first 18 months. The article reported that code calls outside the ICU had fallen by 71% and hospital mortality by 18%. It estimated that the 143 rapid-response team calls made over the 18-month period had saved 33 lives by allowing earlier intervention.

The fears that critical personnel would be drawn away from the ICU were misguided. In fact, the RRT actually freed up resources. “You’re spending 20 minutes turning around a kid in an RRT situation,” said Leong, “versus an hour or more in a code situation.”

The estimated thirty-three lives saved gave the team a compelling reason to continue the program.

Some tripwires use a clear threshold: a $1,000 offer at Zappos, a deadline for completing a survey, or a budget limit for a spouse’s topiary-sculpture business.

Notice that the children’s-hospital situation is a little different. The most important tripwire requires nurses to call for help when they are worried about a patient. It’s a little fuzzy, a little subjective. As a result, the rapid-response team members can’t predict when they’ll hit that tripwire or how many times they’ll trip it. These tripwires aren’t tripped by clear-cut measures like budgets or dates or partitions; they’re tripped by pattern recognition.

This is an important distinction, because in many organizations, pattern matching is the skill that leaders desperately want their employees to have. They want their employees to be alert for threats and opportunities in the environment. They would like employees to recognize the pattern when they see it pop up and to feel that they have permission to act when it does. That was a powerful feature of the rapid-response-team protocol—any time nurses spotted a kid who didn’t quite look right, the protocol made it socially acceptable for them to raise their voices and say, I think we’ve got a problem.

Of course, the same idea is applicable to opportunities as well as threats. Organizational leaders need people to be sensitive to changes in the environment and to be brave enough to speak up. Here’s something new. Here’s a great opportunity for us.

Peter Drucker challenged executives to capitalize on “unexpected success.” He wrote:

When a new venture does succeed, more often than not it is in a market other than the one it was originally intended to serve, with products or services not quite those with which it had set out, bought in large part by customers it did not even think of when it started, and used for a host of purposes besides the ones for which the products were first designed. If a new venture does not anticipate this, organizing itself to take advantage of the unexpected and unseen markets … then it will succeed only in creating an opportunity for a competitor.

One great story of “unexpected success” is Rogaine, the drug that helps bald men regrow some of their hair, which was discovered by accident. Rogaine’s active ingredient, minoxidil, is also the chief ingredient in a drug called Loniten, which was taken by many patients to lower their blood pressure. Loniten had a surprising side effect, though: Patients started sprouting new hair on their arms, back, and legs. (As you can imagine, this was not a popular side effect.) The scientists at Upjohn were clever enough to recognize the opportunity buried in the problem, and they reformulated the drug into the antibalding elixir that we know as Rogaine today.

The discovery of Viagra was a similar story. Initially, the drug had been tested as a treatment for chest pain (angina), and for that purpose it was a failure. Then patients started reporting a curious side effect. (Imagine those awkward conversations: “Doc, my chest still hurts … but, um, I’ve been noticing an effect somewhere else …”)

One journalist concluded from these stories and others like them that “the pharmaceutical industry is driven as much by luck as by design.” But that’s not quite right, because luck didn’t make Rogaine. It took discipline to spot and monetize the opportunities represented by these flukes. (Let’s be honest, it was not self-evident that unwanted back hair heralded a billion-dollar opportunity.)

This is the same kind of pattern-matching tripwire that allowed the rapid-response teams to succeed. While the nurses were sensitized to signs of trouble, the pharma scientists were sensitized to signs of opportunity.

Could you define a similar tripwire for your team members? Could you sensitize them to the kinds of opportunities that Drucker called “unexpected success”? A small-business owner might coach her employees, “If you see people using our product in a way we haven’t anticipated, let’s talk about it.” A high-school department chair might say, “If you try out a new assignment that really seems to get students motivated, let’s discuss it in our next meeting.”

By coaching people to recognize patterns of threat or opportunity, you can take advantage of a phenomenon we’ve all experienced, the “seeing it everywhere” effect: You learn a new concept or word and suddenly you start to notice it everywhere. The Web site 1000 Awesome Things identifies this phenomenon as Awesome Thing #523. Dozens of commenters have shared their experiences with the phenomenon:

• “This is such a very, very true awesome thing.… ‘Haberdashery’ was one of the most recent words I learned. Who knew it was even a real word? My prof mentioned that Harry Truman used to be a haberdasher and next thing you know, my grandma uses it, I spot it on little shop signs, it’s on the wall at East Side Mario’s.… Small world!”
• “I remember as a little kid coming across the world ‘feasible.’ Next day at chess club, one of the books we used to give us tips on the game used that word again … and again … and again. My game didn’t really improve that much but my vocabulary did. Awesome, indeed.”
• “‘Justin Bieber’ is what I learned and now can’t avoid. I’m pretty sure it’s made me dumber, though. And, I’ve started to contemplate suicide.”

By labeling a tripwire, you can make it easier to recognize, just as it’s easier to spot the word “haberdashery” when you’ve just learned it. Pilots, for example, are taught to pay careful attention to what are called “leemers”: the vague feeling that something isn’t right, even if it’s not clear why. Having a label for those feelings legitimizes them and makes pilots less likely to dismiss them. The flash of recognition—Oh, this is a leemer— prompts a shift from automatic routine to conscious attention.

That quick switch is what we need so often in life—a reminder that our current trajectory need not be permanent. Tripwires provide a sudden recognition that precedes our actions:

I have a choice.