How Unilateral Control Can Kill You

Roger Schwarz

This is not a headline from the sensationalist tabloid National Enquirer.

It is the conclusion of Dr. Peter Pronovost, an MD and a Ph.D. in hospital safety, who is medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, MD. Pronovost’s group is responsible for increasing safety and reducing iatrogenic illness and death – those caused inadvertently by physicians, surgeons or by medical treatment or diagnostic procedures.

Each year, a lot of people become ill or die in hospitals not despite health care, but because of it.

According to the Centers for Disease Control and Prevention, in American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year.

So, what does this have to do with unilateral control?

It turns out that some of these infections and deaths can easily be prevented, but unilateral control takes over. Pronovost says, “As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture. When confrontations occurred, the problem was rarely framed in terms of what was best for the patient. It was: ‘I’m right. I’m more senior than you. Don’t tell me what to do.’” This is the classic “I understand, you don’t; I’m right, you’re wrong” unilateral control mindset. The impact in healthcare is the same as it is anywhere: many, many people stop sharing relevant information when they are treated this way. The difference? If a nurse clams up you may die.

Take the case of doctors washing their hands. According to Pronovost, even with improving safety records, 30% of the time, doctors in hospitals were not washing their hands prior to surgery. So, at Johns Hopkins hospital, they made a number of changes, including empowering nurses to make sure the doctors washed their hands. If the doctors did not, the nurses were empowered to prevent a procedure from beginning. Initially the nurses said it wasn’t their job to monitor doctors; the doctors said that they would not allow nurses to prevent a procedure from moving forward. Yet, over four years, the hospital got their ICU infection rates down to nearly zero. What Pronovost doesn’t say is whether these medical teams changed their mindsets about hierarchy and unilateral control or used checklists and other simple structures that treated the symptoms but bypassed the fundamental causes of unilateral control.

As Pronovost points out, unilateral control also exists between doctors.

Once, during a surgery, he was administering anesthesia and saw that the patient was developing the classic signs of a life threatening allergic reaction. He told the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” the surgeon insisted, refusing. Pronovost responded, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.” When communication between the surgeon and Pronovost broke down, Pronovost asked the scrub nurse to phone the dean of the medical school, believing that the dean would support him. As the nurse was about to call, the surgeon cursed Pronovost and finally pulled off the latex gloves.

For most of us in organizations, the costs of unilateral control can be difficult to pinpoint.

We lose time, our commitment, innovative ideas, the organization’s money, our faith in leaders, and some of our mental health. Pronovost’s work reminds us that when the stakes are high, unilateral control can cost people their lives.

Originally published March 2010