Healthcare has no Red Teams - we need them

NHS has no red teams - we need them

Defence forces have red teams. The US defence has had red teams since the early 2000s, soon the UK defence forces followed with their own version with slight variation. A few private companies such as IBM use red teams.

An internet search did not reveal healthcare especially the NHS using Red Teams.

What is Red Team?

A red team is an 'independent' team within an organisation that is deliberately created by the organisation  to critically analyse from a variety of perspectives (especially from an opponent or competitors perspective) and challenge the organisations' strategies, assumptions, operations  and all other aspects with a view to helping the operational part of the organisation get to a better position.

Basically you hire and pay a team of people to stuff you so that when you get out in the big bad world you don't get stuffed real time.

Red Team is something  but not fully like the opposition in the parliament whose job is to oppose the ruling party yet work for the benefit of the country. The opposition in the parliament provides an alternate view of the issue in question which the government must consider but need not necessarily act upon. A good government would willingly adopt the opposition's ideas if it would benefit the country. Of course given the unsavory political overtones and entrenched positions of political parties these days, this may not be the best example in practice but I think you get the gist. A red team in your organisation is a paid opposition without the baggage of politics - the ability to thoroughly analyse and provide an alternative point of view to the powers that be but no inherent ability to act on their own views.

A Red Team is not................

Red Team is not about providing innovation or offering solutions. Red Teaming is not strategy formulation by the management or organisation. Red Teaming process runs either in parallel to the strategy formulation or immediately after the strategy formulation but before it is finalised, signed off for implementation.

Red Team is not made up of union reps, protestors, resistors, laggards, innovators, management cronies, enthusiasts and so on. Red team is not a group with representatives from any area. Red Teams are not the same as whistle-blowers. They are certainly not people from 'risk', 'clinical governance' or any other over used cliched terms. They are not part of management or operations.

Executives are not obliged to follow the red team's advice or recommendations; they are only obliged to listen carefully and consider if they are suitable for implementation. Post-implementation, executives will be obliged to review their operations in the light of the prior recommendations of the red teams so that better learning can happen and be captured for future operations. The red team does not do operations, it is not the boss. The executives are responsible for the operations and results. The red team provides feedback, reflections but has no power to implement, reward or punish. Red team never says 'I told you so' irrespective of whether things have gone right or wrong; they take no credit or flak for success or failure of operations - that belongs purely to the executives.

Red Teaming

Red Teaming are a large set of tools and techniques that take time to learn, taught to people with prior operational experience and high level of maturity. Red Teams are friends who are playing the role of the enemy. Red Teams will face resistance and hostility. Red Teams are people who will pick holes in your plans and shred your strategy during the day and yet party with you in the night. Their level of development is such that they will have to think and act like the enemy, be the enemy so that they can help their friends. Red Teams often do not have automatic rights on most things, they will have to engage and negotiate at every turn. They have to be nice to you to you before you will consider their help in tearing down your own plans - see the complexity in human interactions here? Red Team exists to falsify the organisations' and its executives' theory.

It is important to remember that Red Teams and Red Teaming is not 'process driven', it has been described as an art, something to help with intuitive decision making. To convert them into 'tick boxing' so that we can claim we have a Red Team who have done the Red Teaming is very tempting so that operations staff can move on with carrying out their high pressure functions on a day to day basis but would be an expensive same side goal.

Healthcare needs Red Teams

Essentially, one of the fundamentals of the army is the business of protecting lives and minimising loss of life; like healthcare I suppose. Evidence based healthcare has huge problems and still in its infancy. Even if enough good evidence was available the complexity of healthcare means that the decisions will still be very different from many other industries. While other industries will need Red Teaming to look at from the competition's perspective, healthcare especially the NHS, needs Red Teams to look at itself. That will be an even more specialised art. We need that art and those artists urgently.

Do we in healthcare have the guts or the maturity to have red teams?

© HEMADRI

Follow me on twitter @HemadriTweets

Further reading

UK version of Red Team https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142533/20130301_red_teaming_ed2.pdf

US version of Red Team http://usacac.army.mil/cac2/UFMCS/Repository/RT_Handbook_v6.pdf

Abilene Paradox: Watch out, it could hurt you

Abilene paradox - the importance of managing agreements and agreeable colleagues

Last month I wrote about the Bad Apple theory and argued for a slightly softer approach in understanding and dealing with clinical 'bad apples' in healthcare. In a subjective sense, bad apples (irrespective of whether they are actually right or wrong) are persons who tend to disagree with their group and use negative behaviors to show their disagreement.

The Abilene paradox is some what the opposite phenomenon. This is when we do not voice our concerns, do not speak up, do not disagree. In fact in this paradox we actively do something that we do not fully believe in or want to do, because we felt that is what our boss, our group, our organisation wanted. We agree with our colleagues and peers to please them, we think our agreement will make them happy, will vindicate their opinion. If you are the leader, manager or proposer of ideas you come up with ideas, projects, activities, etc with the intention to please your team; your team in return go with your idea not because they think it is a good idea or want to agree with you, they simply run with your idea as they do not want to displease you or dampen your enthusiasm.. They might agree due to fear of authority, lack of knowledge, loyalty, the desire to play the part of a cooperative team member or perhaps even with the hope of getting something from you in return in the future. Obviously these are all the wrong reasons to play along with an idea if it was bad in the first place.

Watch out. This is something which has the potential to take you well away from your mission and plunge you into problems despite everyone's support and agreement; well actually because of everyone's support and agreement. Some might consider this a version of what we know as 'group think'; perhaps. In my view, group think is when all members of the group are convinced that it is a good idea, whereas the Abiline paradox is when group members may not believe it is a good idea but push the idea along forward and ahead simply because they think it will please other members of the group. This is something you want to avoid at all costs.

The fairly old but very interesting article called the Abilene paradox can be found at http://www.rmastudies.org.nz/documents/AbileneParadoxJerryHarvey.pdf .

In summary, the author John Harvey says
‘’Organizations frequently take actions in contradiction to what they really want to do and therefore defeat the very purposes they are trying to achieve.’’

‘’.......a major corollary of the paradox, ... is that the inability to manage agreement is a major source of organization dysfunction.’’

This is the opposite of what many of us often assume that managing conflict is the usual big problem that frustrates us.

He suggests

‘’through the process of active confrontation with reality, we may take respite from pushing our rocks on their endless journeys’’

Abilene paradox is very relevant to healthcare. Just think, at your department level in MDT (multi disciplinary team) meetings and at national/international levels the unanimous decisions, at the consensus groups. Could the paradox be in play or could group think be in play? May be yes, may be no. But has the question been asked and answered if these phenomena could be affecting our decision making? I think we do not consciously explore this; we simply assume sometimes rightly, sometimes wrongly, that such ill effects did not afflict our decision making. In highly technical industries, in highly scientific industries and in highly evidence based industries adverse effects of the Abilene paradox will be negated pre-event by knowledge and post-event by data. In healthcare with its relatively poor evidence levels which results either in large variations in clinical practice or practice without improvement, the problems with group think and managing agreements are undoubtedly huge with its negative impact on patients.

Abilene paradox may turn out to be the bigger problem in recognition and management of healthcare's complexities.

You see the bad apples are easy since they are visible, audible and apparent. They make you uncomfortable or annoyed. You will be able to identify them and deal with them as early as you wish. Since we are all trained on how to deal with 'difficult colleagues' we at least imagine we can deal with people who disagree with us. Abilene paradox does not make you uncomfortable or annoyed till it might be really late. Since the intention of the group, who fall prey to the paradox is to cooperate and please, it will be really difficult to identify early and when identified we will be reluctant to deal with persons who have cooperated with us with good intentions. We have no knowledge or training on how to deal with easy colleagues who might pleasantly mislead. In organisations and teams peoples role is to cooperate appropriately and that can only happen when people support their team by critically questioning and vigorously analysing the issues. Only after a robust process should people offer their cooperation or agreement. 'Yes (wo)men' are probably more harmful to teams than bad apples in the longer run.

In old Jewish writings it is said that in a case subject to capital punishment if a guilty verdict was unanimous then the accused would walk free. This was generally thought to prevent group think, I feel their wisdom probably included concepts of the difficulty of managing agreements as in the Abilene paradox. It is said that good effective leaders surround themselves with a good team. Of course that is very important, but good leaders should make sure that the Abilene paradox does not frustrate them. Good leaders should demand that their team provide a genuine expression of opposing or divergent views so that higher quality decisions are made which would enable longer term success.

©M HEMADRI 

Follow me on twitter @HemadriTweets

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