bewitched by the binders

May 8, 2009

Nothing quite like finalizing plans for a flu pandemic to cast a light on biased approaches to planning and action.
We have 52 cases of swine flu in British Columbia as of this morning, but it looks like the first estimates on volume and severity are diminishing. I heard a reference the other day about “visions of Y2K and all that b-s planning and stress.” I have also heard others whisper about the Armageddon that is sure to come if not this spring then this coming fall for sure. Depends on who you talk to.
In such circumstances where our health care system prepares for sudden and extraordinary strain we make plans to convert our normal org chart to a scalable Emergency Response Management System (ERMS). The roots of this system, I believe, are military. Ominous 3-inch binders and bulging hard drives filled with planning templates, communication samples, and various processes prepared by earnest pre-planners are dusted off. These people are secretly thrilled that their hard work is finally getting the attention it deserves.

In part because I sit on our senior leadership and happened to be in the room at the right time, and in part because of my past life as a ski patrol director, I have landed in the planning department of our emergency team. All hands on deck.
And so the orders went out last week. Urgent – all managers across our health service area: read the condensed version of the pandemic planning document (196 pages), assemble your management team, and then plan what health care services you will cut should your staffing levels be reduced by 35, 50 or 65%. And where and how will you provide health care should the weekly inflow of patients rise 100, 200, or 500% above “normal” levels? Complete business continuity planning forms on pages 44-46. Have these in by Friday.
Meanwhile, in our recently opened Emergency Operations Center (EOC) with its phones, white boards, laptops, and fluorescent vests, one of the managers who worked in the same building happened by for some clarification and we got to talking.
Her comments: “Yes, there was some confusion about which forms to fill out, and given the 48-hour notice it would have been nice if they had just sent us the 3 pages they wanted. I spent 4 hours trying to read and absorb the plan. Some interesting stuff, but I got lost in it.”
Hmmmm. I ask more impromptu questions:
How long did it actually take you to complete the form? “Three of us had it done in less than an hour.”
On a scale of 1-10, what’s your level of confidence in your staffing plan? “About a 7. It was actually good to think this through. I’ll feel better once we communicate this to our staff.”
What’s your biggest worry about your readiness for a big event like this? (And here’s where it got interesting). “I’m having some real problems right now. I can’t get a hold of any XXXX and I am running out. I heard that YYYYY are hoarding them in case this is real.”
I have a confession to make. If that manager hadn’t walked in, I’m pretty sure I would have remained bewitched by the binders and the laptop, but this conversation woke me up.
I went on to phone six other people who had e-mailed their forms. In the space of an hour or so, these lightly structured questions quickly revealed the following patterns to the four of us planted in the EOC. 1) Half the managers had received directions from two different sources resulting in confusion, frustration and unnecessary work. 2) Almost everyone, while not exactly thrilled with having this work land on their desk, actually felt better having gone through a process which forced them to think through what they had been thinking about anyways. 3) The anonymized fragment above cropped up again.
This all resulted in some quick changes to the process and a somewhat urgent phone call from our director to the department head at the butt end of those stories. The stories were re-told, suitably embellished for impact, positions were then politely explained and justified, and some not-so-subtle shifts in policy were quickly made.
In very short order, we had learned some key insights into how this planning was being received, viewed, and what was going on in the system. Furthermore, these people felt like someone was interested in their experience.
As an old first aider, I tingle when I get near the vests and the binders and the stocks of emergency supplies and the radios and the crisp order of situation reports. I for one, am thankful of such things. But here’s my point, if it isn’t already obvious. Structured ordered planning processes, especially within systems under pressure, have a bias to view people as inputs to processes and outputs. Fill in these boxes and report back to me. What’s missing is what is going on in the spaces between those people and processes. What’s not in the binders (I’m being only somewhat facetious here) is a chapter on the importance of hidden knowledge and emotional status of these same players. How about a tab or two devoted to guidelines and templates for gathering stories, mining for metaphors, analysing the social network et al et al. Can you imagine?

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