Platt Perspective on Business and Technology

Rethinking exit and entrance strategies 4: crisis as a transition demanding challenge 3

Posted in strategy and planning by Timothy Platt on November 14, 2015

This is my fourth installment to a series that offers a general discussion of business transitions, where an organization exits one developmental stage or period of relative strategic and operational stability, to enter a fundamentally different next one (see Business Strategy and Operations – 3, postings 559 and loosely following for Parts 1-3.)

I began to more formally discuss single points of failure, and certainly as that topic would be relevant to this series, in Part 3, where I conceptually divided those events into two categorical types:

• Operational single points of failure, and
• Strategic single points of failure.

I focused there on the first of those categories, and on the operational side to these fundamental chokepoints and how they arise. And I illustrated the more general points that I was making in Part 3, by briefly outlining a very real-world (non)working example that I have had to deal with in the course of my own work life. And at the end of that posting, I stated that I would follow it here with a second real-world example, of a type of operational single point of failure that arises at least in part because of corporate culture issues, and blind spots that they can enable and even compel.

My goal for adding in this second example is to highlight how in-retrospect blind spots that become single points of failure can arise, and from shared understandings and presumptions – and particularly when they are strongly and widely held in an organization, but where they are never actually thought through or considered there for their potential consequences.

And in anticipation of offering this example, I begin by stating that it represents a challenge that probably cannot be entirely prevented, and for legal reasons external to this organization itself, as much as from anything else. So this example represents what can become an overtly realized single point of failure, but of a type that cannot readily be learned from, at least in ways that can entirely prevent recurrences and even very consequential recurrences.

I was very actively involved in healthcare systems in 1997, working full time at the Bronx-Lebanon Hospital Center as their research director. And I was also an active member of the New York City Regional Emergency Medical Advisory Committee (REMAC), serving on two of their subcommittees – see the Regional Emergency Medical Services Council of New York City, and with a variety of other related matters. So when the US government began to actively develop and implement a nation-wide program of “domestic preparedness” in anticipation of possible terrorist events (or similar-nature accidental or natural disasters), I became involved in its New York City implementation (see the public release version of the US Department of Defense, May 1. 1997 report to Congress: Domestic Preparedness Program in the Defense Against Weapons of Mass Destruction.) I went through their Train the Trainer program, and served as an official on-site observer when this program and its training elements were tested, in what at the time was the largest simulated chemical weapons exposure exercise to have ever been publically carried out in the United States: the November, 1997 New York City Interagency Chemical Exercise (ICE). I functioned in this event, as just noted, as one of the observer participants in hospital emergency rooms that received chemical exposure “victims” from this event, and that is where this eighteen year old and by now largely out of date narrative becomes relevant here.

When members of the apocalyptic religious group Aum Shinrikyo launched a sarin nerve gas attack on the Tokyo subway system in March, 1995, nearby hospitals were flooded with people who were terrified that they had been exposed to this deadly chemical weapon, overwhelming their emergency rooms. And mixed in with this larger crowd were a much smaller number of actual exposure victims, some of whom were very dangerously chemically contaminated. Some of the people who died from this event were in fact hospital workers who had not been anywhere near the subway system when this happened, but who became chemically exposed to sarin from handling clothing and other possessions of people who were, and who were brought to their hospital.

This very real-world event significantly shaped both the thinking that went into the US DoD Train the Trainer program that I participated in, and the design of the Hospital Emergency Room phase of the ICE exercise.

I worked with a group of Emergency Room physicians and nurses, hospital administrators and others in preparation for this event, over a period of weeks leading up to it, and with much of that work taking place at one of these involved hospitals, in preparation for their participation in this exercise. And one of the key points that I came to stress was a detail that I saw as critically important, coming out of the Tokyo event – besides the fact that there were many hundreds of unexposed but frantically anxious people streaming into those nearby hospitals for every genuine contamination victim, and no one at those hospitals had any idea as to what they were actually facing when this first happened. With the ER flooded, and with people entering those hospitals through what to them seemed the easiest and most accessible entrances, the first hospital personnel to see an actual chemical contamination victim might very well be a member of hospital maintenance or a member of their cleaning staff – as they are always working and essentially everywhere in an active, and well run hospital. And heavily contaminated victims touch things and contaminate those surfaces too, making them very dangerous and even deadly to the next to touch them too. I stressed the importance of enlisting the eyes and ears of as wide a range of hospital personnel as possible, to look for people who appear disoriented and unsteady – and thinking forward, who have a chemical odor (I was also thinking in terms of accidental exposure, for example, to large concentrations of some of the more powerful insecticide products that are used to fumigate buildings that are supposed to be empty of people at the time, as sufficient exposure to them can cause the same symptoms as nerve gas exposure.)

In this exercise, some people who were “exposure victims” arrived by ambulance as expected by ER personnel, but some arrived on foot with help, or by cab or other private vehicle – with everyone else in those vehicles also considered exposure victims too. Even with pre-event training and with the hospitals involved knowing that this was going to happen, a significant percentage of the Emergency Rooms involved were declared dead – so heavily contaminated that in a real event, they would become non-functioning and with multiple casualties from among their own staffs.

Hospital house cleaners and maintenance staff do not have medical training or experience so they cannot provide medical services or support, and by law for their lack of training and certification, and from their not being licensed or covered under hospital insurance protection. They do their jobs and that makes sense and licensed and trained healthcare professionals do their jobs. And there is very little if any overlap, ever. But I keep going back in my thinking to the Tokyo event of 1995 and to this exercise with its (fortunately just on paper) dead Emergency Rooms and ER personnel – and with that including both healthcare providers and non-medical, support staff too.

I am writing here of a crisis event, and even one that did not arise as a completely unexpected surprise, at least in this 1997 instance. And I am writing of a single point of failure blind spot that would keep healthcare providers from listening to and seriously considering messages coming from the people who primarily push brooms and mops, or who refill paper towel dispensers. And I am writing about the cultural divide that would keep those people from speaking out anyway and even if they did see something. In principle, there are ways to resolve this dilemma, with for example variations of “if you see something, say something” and” if you are told something, listen.” Actually institutionalizing that type of approach is where this becomes a less that tractable problem.

The hospital that I directly worked with in this came out of this exercise with a very good report card – which is probably bad news as this means less was learned that might be applied to a real event: unannounced, and with real exposure victims and real panicked crowds that they would be mixed into.

There are possible lessons to learn from what happened. But when they come up against both corporate culture and its ongoing momentum, and legal requirements for containing medical services and support within one particular group of trained healthcare professional employees, and for good reasons, how would such a hospital prepare for this type of event or incident where everyone there needs to become more actively involved? And as indicated above, this might mean a chemical weapons attack with its victims, or it might mean an apartment house full of people who are accidently exposed to a deadly insecticide fumigation agent, by people who did not mean to cause harm but who were careless and untrained. That scenario has taken place and more than once.

• I refer to this as an example of an operational single point of failure, and note here that it sounds like more of a cascade of such failures, all occurring in rapid and overlapping succession when you consider its unfolding details.
• And in fact what begins with a single point of failure can and often does spread out, and with more such bottleneck points becoming involved as well, and certainly for more serious and consequential events.

I stated at the end of Part 3 that after discussing this second operational example, I would turn to consider strategic single points of failure, and with an example of that categorical type too. As part of that discussion, I will at least briefly reconsider this posting’s example and the issues of distinguishing between operational and strategic single points of failure. In anticipation of that, I add here that I will also at least briefly discuss timing, and concurrent and sequential causality. And I will discuss the differences in practice between event analysis while an event is still actively occurring, and event analysis as a post hoc, after the fact learning exercise. I am going to at least begin delving into this complex of issues in my next series installment. And then with this discussion of single points of failure laid out, I will return to reconsider growth and scalability, and business transitions again, and in both crisis and non-crisis contexts.

Meanwhile, you can find this and related postings and series at Business Strategy and Operations – 3 and also at Page 1 and Page 2 of that directory.


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