They are also ….
Early in my career, I was tasked with reviewing the files of my employer’s biggest fails. What expertise/skills should the decision maker have had, what information was available, what information should have been available, and in real time what were the decision errors. In cases reconstructed there were several to dozens decisions made over a period from a few months up to two years. The experience level of the decision makers ranged from four years to twenty. The most common characteristic was that non-reversible decisions were made prior to receipt of standard complete information.
It was tempting and would have been easy to run with that and trash those decision makers. It would also have been a denial of reality. Industrywide, full and complete information before the first decision had to be made was the exception and not the rule. And more than 99% of the time, it works out just fine. On the other hand, conservative decision makers that “just said no” with incomplete data, were as likely to pass on a gem as a POS. A better observation of those fails is that the decision makers didn’t recognize the narrative gaps, the risk level of those gaps, and efforts to fill those gaps quickly before the next decision point. IOW managing the case. Containing and limiting the fail. Or managing it out of a fail.
The biggest fail, the largest in the industry up until that time, was different. There was information up the wazoo in that file. It was unique. Nothing like the decision makers (and there were several on this case) had ever seen before. They did all lack the higher level accounting/finance skills to grasp fully all the details because such skills hadn’t been all that necessary over the prior decades. Yet, as the “Monday morning quarterback” the conceptual fail was glaringly obvious to a rookie like me. All of the standard measures that had worked so well for so long were based on a particular operating model, and the proposed model was so different, that the decision makers didn’t appreciate that those measures didn’t apply and didn’t know what did. Never been tried before and never since. (Conceptually the payoff could be exceptional; unfortunately, the risk is huge.)
Years later A was deeply hurt when I chastised him for playing the perfect “Monday morning quarterback” in his review of a fail. He told a colleague, “Marie yelled at me.” Yes, I did. He’d trashed one of the principle decision makers, B, instead of looking at all the decision points based on the information known at that time and the multiple fails by multiple decision makers. Based on his review, firing B would have been appropriate. That wouldn’t have been totally fair nor instructive for that person and others. Objectively, the review task is to find the errors and omissions and how to prevent that fail from happening again. A, who I liked very much, had failed at his assignment, and B, who I didn’t much care for, wasn’t fired and improved his skills from my in-depth review of the fail.
Shinseki wouldn’t have been fired in a fair hearing. Unfortunately, his critics piled on without collecting, much less assessing, rudimentary information on the situation at VA hospitals. Same with Hillary Clinton on Benghazi (might be the only thing I haven’t/don’t criticize her for). The US public health system is weak today because the public doesn’t appreciate it’s vital role and has been underfunding it for decades in favor of privatized medicine. However, it’s still operational for infectious diseases and it’s the parents that refuse to have their children vaccinated that are responsible for most of the recent outbreaks of what were thought to be preventable infectious diseases.
Presby D may well be below the median in quality care and staffing. But who can say without qualification that most US hospitals would have done better when Mr. Duncan appeared in their emergency rooms and was later admitted, tested and cared for? Mr. Duncan denied both times during his ER interviews that he’d come in contact with anyone that had been seriously ill. He went further and denied that he could possibly have been exposed to Ebola and the hospital ran the test in spite of his denials. The same thing happened at the Lagos hospital that Mr. Sawyer was taken to after collapsing at the airport. And Sawyer had been under observation in Monrovia for Ebola.
There are likely many “should ofs” in the Duncan case. But “could ofs” in real time? Not so clear. With the exception of Nurse Vinson leaving the Dallas area while she was being monitored for development of Ebola. While the situation is still evolving, the US public health and medical community are performing and should soon be up to speed. (And apparently trashing both here is more popular than reading the data that I’ve been collecting and posting.)
