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 MORE P RAISE FOR

The Moment You Can’t Ignore

“The authors bring to life the importance of culture: how very different it is from other elements of change
management and how critical it is to take advantage of ‘un-ignorable moments.’ Their stories are compelling
and memorable.”—Jon Katzenbach, Senior Executive Advisor, the Katzenbach Center, coauthor of The
Wisdom of Team, and coauthor (with Zia Khan) of Leading Outside the Lines
“The Moment You Can’t Ignore brings us something we have not seen in a long time—a new set of ideas
for leaders managing complex and continually changing organizations. This book provides vivid examples of
how leaders can create ‘superconducting organizations’ capable of successfully managing the rip tides of
change that threaten organizational identity, clarity about who is charge, and confidence that they can both
adapt to and shape their future. Doing so requires the ability to know and leverage the moments in your
organization you can’t ignore. This book is a roadmap to being able to identify and leverage those
moments.”—David Thomas, Dean and William R. Berkley Chair of Georgetown University’s McDonough
School of Business, and coauthor of Breaking Through: The Making of Minority Executives in
Corporate America
The Moment You Can’t Ignore
 The Moment
You Can’t Ignore
WHEN BIG TROUBLE LEADS
TO A GREAT FUTURE
____________________
How Culture Drives Strategic Change
Malachi O’Connor and Barry Dornfeld

PublicAffairs • New York

Copy right © 2014 by Malachi O’Connor and Barry Dornfeld.

Published in the United States by PublicAffairs™, a Member of the Perseus Books Group

All rights reserved.

Printed in the United States of America.

No part of this book may be reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles and reviews. For information, address
PublicAffairs, 250 West 57th Street, 15th Floor, New York, NY 10107.

PublicAffairs books are available at special discounts for bulk purchases in the U.S. by corporations, institutions, and other organizations. For more information, please contact the Special Markets Department
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Book Design by Pauline Brown

Library of Congress Cataloging-in-Publication Data O’Connor, Malachi.The moment y ou can’t ignore : when big trouble leads to a great future / Malachi O’Connor and Barry Dornfeld.pages cm Includes
bibliographical references and index.ISBN 978-1-61039-465-9 (hardback)—ISBN 978-1-61039-466–6 (ebook) 1. Corporate culture. 2. Organizational behavior. 3. Organizational change. 4. Leadership. I.
Dornfeld, Barry , 1958-II. Title.HD58.7.O244 2014 658.4'06—dc23 2014023886

First Edition

10 9 8 7 6 5 4 3 2 1
 To each of our wives, Bonnie O’Connor and Carole
Boughter—thank you for thirty years of love, inspiration,
partnership, and for helping us through our own un-
ignorable moments.
 CONTENTS
Introduction: The Many Ways to Attend a Funeral

ONE A Case of Conflicting Authority

TWO The Un-ignorable Moment

THREE A Case of Adaptive Identity

FOUR Finding the Future Inside

FIVE Sweeping People In

SIX The Case of a Leader Who Finds a New Kind of Power

SEVEN Leading Leaders

Conclusion: What Is Our Future?

Acknowledgments
Notes
Index
 Introduction
The Many Ways to Attend a Funeral

W we could not ignore almost thirty years ago—at the funeral of a

E FIRST ENCOUNTERED A MOMENT

Hmong friend named Bee Lor. We weren’t in the highlands of southern China where
the Hmong originated, or in Laos where they lived in refugee camps after fighting for
the United States during the Vietnam War. We were in Philadelphia, Pennsylvania,
where the Hmong had immigrated in the 1970s—a place as familiar to us as it was
unfamiliar to the Hmong.
At the time, we knew the funeral was an important moment but had no idea how
important it would become for us today as we work with company after company
facing challenges that are cultural at their core. In those Philadelphia days, we were
training as ethnographers and just beginning to explore how culture works. Today,
when we listen to people talk about the problems they are having with “culture,” we
know what they really mean: Our organization is stuck. We’re not quite sure how or
why. Or what to do about it.
The problem of organizations getting stuck has intensified in the past decade. As
continuous change became the new normal, addressing cultural challenges became
more difficult. Each wave of change was followed by another, bringing with it a
demand for new capabilities, new ways of working, new behaviors. People had no
time to catch their breath, reflect, and assess where they were.
As organizational change came crashing in, it encountered resistance. Increasing
friction brought issues of culture to the attention of business leaders and challenged
their ability to move their companies forward. While working with our clients, we
began hearing phrases like “culture eats strategy for lunch,” an aphorism often
attributed to management thinker Peter Drucker. It means that no matter how sharp or
differentiated your strategy, if you do not have an organizational culture that can put
this strategy into action it will likely fail.
When the stress of change becomes too much for an organization, the situation
often erupts into an “un-ignorable moment”—an event or action, or even a comment,
that stops you and your organization in its tracks, a moment when it becomes
blindingly clear that new ways of working are clashing with existing ones.
Paradoxically perhaps, the way to reduce the friction caused by these new ways of
working can usually be found somewhere in the existing culture, which has the
potential to be the most useful, resilient, and adaptable resource you have. But
understanding that can take time. We’ve been learning about how culture works for
some thirty years—ever since Bee Lor’s funeral.
The un-ignorable moment that day provided an important lesson for us. At the
time, we were working toward our doctoral degrees at the University of Pennsylvania
—Barry at the Annenberg School for Communication and Mal in the Department of
Folklore and Folklife. Not far from the Penn campus, a few thousand Hmong people
lived in a refugee community, a cluster of rental homes in West Philadelphia. We met
many of them, including Bee Lor, while working on a project to document the
experiences of the Hmong.1 They had migrated to the United States in the aftermath of
the Vietnam War, settled in Philadelphia and other American cities, and gradually
established a community. As a result of our work together, the Hmong came to know
us as “American friends.”
When we first worked with Bee, he was in his late teens. In his mid-twenties he
was diagnosed with hepatitis B but led a pretty normal life for many years. He
completed his education, got married, and started a family. In his late thirties,
however, he suffered complications and, after a protracted illness, died.2
We were invited to a gathering that turned out to be similar to a Catholic wake.
Bee had been laid out in a casket in the auditorium of the local high school. He was
smartly dressed in a suit and his head rested on beautifully embroidered “sun
pillows.” There were hundreds of people there and we got in line to approach the
casket and pay our respects.
That’s when the un-ignorable moment arrived. The first mourner stepped
forward, looked at Bee, and erupted in a wild outburst of emotion. She screamed.
Threw up her hands. Fell across the casket. Sobbed uncontrollably. Then, just as
suddenly as the outburst began, it stopped. She composed herself and moved on to the
reception. Surely this was an anomaly? No. The next mourner stepped forward and did
the same thing. And on it went. When our turn came, our somber looks and quiet
demeanor seemed inappropriate and we felt awkward and weird.
What we had witnessed, of course, was an example of ritual mourning, a long-
standing tradition in most cultures, but a version of mourning very different from what
we had grown up with. At that funeral gathering, we saw that culture was not
something that “others” who are “different” have. We understood that what seems
natural and normal is largely defined by culture, by the perspectives we learn and
bring to the world.
Now, when working with organizations, we encourage people to explore this
point of view. When trying to make an organizational change, we are challenged to see
our own culture clearly. And to do so, we have to find a way to “make the familiar
strange” as the well-known anthropologist Ray Birdwhistell put it.3 Only then can we
identify what’s causing big trouble and determine where our successful future lies.
__________________
E provides a superb opportunity to learn from that experience
XPERIENCING AN UN-IGNORABLE MOMENT

and take action, and that’s where the method we were trained in, ethnography, can play
a useful role. Ethnography studies culture by observing it in action. You can use what
you learn to understand how your culture best adapts to change, without abandoning or
violating its identity.
By using the ethnographic approach (“ethno” means “people or culture”) you can
understand the world in which a group of people live by seeing things through their
eyes—or, as anthropologist Bronislaw Malinowski described it, taking “the native’s
point of view.” 4 “Participant observation,” a way of working at the heart of the
ethnographic method, is particularly effective in organizations. It involves working
and sometimes living with the people being studied. You engage with them in their
own environment, participate in their activities, and ask them questions to strengthen
your understanding.5
Ethnographic methods work as well on the front line, or in the boardroom, of a
Fortune 500 company as they do with a refugee community in a city, if a little
differently.6 As social scientists, we seek understanding to deepen our knowledge
about society or aid social change, while in business our goal is to improve
performance by solving a specific problem that will lead to a positive change for the
organization. For example, a software company might look at the work flow of its
engineers to help them improve their efficiency. Retailers might study how consumers
use their products in order to improve their offerings. We are not the only ones who
have harnessed the power of ethnographic methods for improving business
performance. Large companies such as 3M, Intel, and IBM, as well as smaller
businesses and nonprofit organizations, have incorporated elements of the
ethnographic approach in their quest for innovation.
When you observe people’s behaviors in getting work done, you see that many of
them are not formally defined but are tacit: not openly spoken about, although
generally understood. Others are explicit: openly stated, shared, and discussed. An
ethnographic perspective on organizational culture focuses on both:

• Systemic agreements about how work gets done. Work is conducted in

organizations by following tacit as well as explicit agreements about how to
divide tasks, how decisions should be made, and how to allocate and
consume resources. When you are trying to make a change, these
agreements, especially when they have become tacit and assumed to be “the
 way things get done around here,” may become invalid. When that happens,
people will no longer understand how to get their work done and
productivity will plunge.

• Rules for how individuals interact with one another. There are many
unspoken rules that pertain to human interaction. How to act in a meeting.
How to communicate with a boss. How to work in teams. Again, when you
are seeking change, these rules for interaction may no longer make sense. As
a result, people will be unsure how to interact with others. They may be
confused and hesitant. Conflicts may erupt and productivity will suffer.
Together, these two dimensions of culture play out in workplaces every day.
F Q
OUR UESTIONS T
HAT AN U
NDERSTANDING OF C
ULTURE C A
AN NSWER

When you seek to make a change or accomplish a transformation in your business, you
need to pay attention to your organizational culture, understand it, and, very
importantly, trust it. When you understand culture, you can answer four questions that
are fundamental to any change effort:

• What is our identity as an organization? If you have gone through

multiple shifts in strategy or a number of restructurings, your people may no
longer be sure about the identity of the company. Who are we? What do we
stand for? What’s the connection between our identity and our strategy?
These questions are as fundamental to your success as strategy-related
questions, like, what business are we really in? When your people are
uncertain about the company’s identity, they will find it difficult to execute
on any strategy with passion or commitment.

• Who’s in charge? Sometimes people are not clear about who’s in charge
of any given initiative at any given time. Is it the person with the title or the
one with the expertise? Is it the maverick team leader or the unit executive?
When people don’t know who’s in charge or how to determine who is in
charge or should be, they may become paralyzed and unable to take action.

• How do I lead? People with formal authority may find themselves unable
to lead effectively. Simply ordering others to follow them doesn’t work—
they don’t know how to generate energy and spark enthusiasm for an idea or
initiative. Although people in senior positions in traditional command-and-
control hierarchies may realize they have to think about leadership
differently, they may find it difficult to adjust to the emerging approach that
we call “command and collaboration.”
 • What is our future? When people are unsure of what their company
identity is, don’t know who’s in charge, and can’t get behind their leaders,
they have little capacity to innovate, make changes, and propel their
organization forward. Old ideas get rehashed. New ideas get squashed or
lost. Consequently, people are unable to navigate through the turbulent
waters of the constantly changing business environment.
In this book, we take you on a journey that will help you answer these questions
for your own organization. Why are these questions so important? Because they are the
ones that always come up as a company struggles with change. Your problem may
look unique to you but is likely a manifestation of the overarching issue that so many
organizations are dealing with today: the organization as we have known it for
decades is just not equipped to meet the challenges of working amid rapid and
continuous change.
In the following chapters we present a method, developed over a period of years
with companies of many kinds, that enables you to remove the barriers to success and
make room for the capabilities needed to thrive and even transform a business. The
ultimate goal is to become what we call a “superconducting” organization, in which:

• Strategy and culture fuel each other. Leaders continually translate

strategy into specific, well-defined, on-the-ground actions and behaviors.

• Hidden assets are leveraged. Leaders value the courage of people

throughout the organization, so hidden or underused assets are
acknowledged, brought forward, and can be used effectively by others.

• Interests are negotiated openly . People hold honest, challenging

conversations, negotiate their interests openly, and are supported in doing
so. Agendas are made explicit, and people can see when and how their
contributions have power.

• Decision-making takes behavior into account. When people make

difficult decisions, they consider the impact of those decisions on behavior,
so that people are clear about what to do and have the ability to learn from
errors and make adjustments quickly.
These organizational features may sound simple and straightforward, but can be
quite difficult to achieve and sustain.
P REVIEW OF THE BOOK
The book unfolds in seven chapters. Three of them take the form of extended case
narratives. They are based on real companies and their challenges, but we have
synthesized their issues, changed names and other details, and dramatized the action so
the lessons are clear and applicable across many fields of endeavor. Four chapters
describe our framework for creating change by applying the ethnographic approach, by
analyzing the case narratives and bringing in other cases and examples.
Chapter 1, A Case of Conflicting Authority, tells the story of “University Hospital,” a
health care provider that faces an un-ignorable moment when long-standing
agreements about how work gets done in the operating room come into conflict with
newer agreements that are part of a change initiative to improve patient safety.
Chapter 2, The Un-ignorable Moment, describes those potent cultural moments (such
as our experience at Bee Lor’s funeral) that contain a huge quantity of information and
potential for catalyzing change. Every company that tries to transform or reinvent itself
in some way comes up against such moments, and must learn how to understand them
and unleash the positive energy that is contained within them.
Chapter 3, A Case of Adaptive Identity, explores the challenges facing Quire, a global
software company that has grown through acquisition and has built up considerable
debt. To avoid becoming an acquisition target itself, the company has to make a
strategic transition from cost-cutting and efficiency to double-digit organic growth
within three years.
Chapter 4, Finding the Future Inside, describes how to locate the elements of your
culture that you can build on for future success. We call these “found pilots”—people,
places, and projects where the desired cultural practices are already happening. By
harnessing the success of these found pilots, you can make a smoother transition from
old to new.
Chapter 5, Sweeping People In, looks at how you can mobilize people’s energy in
service of the new cultural agreements your company needs to fulfill its strategic
commitments—especially in organizations that are complex and resistant to change.
The ability to mobilize people’s energy is enhanced when you use social networking
tools to engage those who may not agree with you.
Chapter 6, The Case of the Leader Who Finds a New Kind of Power, relates the
difficulties of the newly appointed president of Moncrieff University, who devises a
brilliant plan to bring the institution out of its financial troubles and into the
international spotlight. Unfortunately, he fails to engage important leaders on and off
campus and finds himself facing a powerful wave of resistance from the faculty and
the board of trustees.
Chapter 7, Leading Leaders, describes the challenges of leading when your followers
are, in effect, volunteers—people who manage their own careers and have multiple
affiliations. Leaders can no longer “command and control” but must learn to
“command and collaborate.” Leaders can no longer push for results but must create
pull for achieving them by mobilizing the passion, interests, and energy of others.
__________________
O . As you begin to tap into your culture to enable change,
NE FINAL THOUGHT BEFORE YOU READ FURTHER

you’ll find others within the organization right there with you. But there will be some
who show little interest in participating in the new cultural agreements. You may find
yourself thinking that such people are acting in a resistant, inauthentic, or artificial
way. When that happens, remember the “native’s point of view.” Behavior is
culturally prescribed. Those resisters are likely acting in ways that are culturally
considered to be the normal and natural way to do things. Having at your disposal a
variety of ways to form cultural agreements provides you with the flexibility you need
to create change in turbulent times.
As it turns out, there are many ways to attend a funeral.7
 CHAPTER 1

A Case of Conflicting Authority

W HENI University Hospital at 7:52 am that wintry morning, everything looked
ARRIVED AT

normal. Nothing about the place suggested that it was on the brink of becoming
dysfunctional, as Andrea Crowley had remarked when she called me the night before.
But then organizations that are coming apart at the seams don’t necessarily show it.
And what organizations aren’t coming apart at the seams these days, I thought.
Andrea Crowley was the chief nursing officer at UH, the person responsible for
the nursing staff and nursing support personnel, as well as their training and
performance. She had called me just after 11:00 pm the evening before to say there
had been an “incident” at the hospital just two days earlier. Now it had escalated into
a “situation.” She had been charged with managing the issue. She didn’t have time to
look for a consultant and wasn’t even sure UH needed one, or if so, what kind, but was
sure she needed help. Our firm—a small consultancy that focuses on strategic,
organizational, and cultural issues—had worked successfully with University Hospital
on several assignments over the years, so Crowley’s boss thought of us. Crowley,
however, was new in her position and we had never met. She sounded concerned on
the phone. I agreed to come in and talk.
As I drove in that morning, the word “incident” kept running through my mind.
Interesting. What kind of incident was she talking about? What might be going on at
UH that required such immediate attention that an experienced executive would call in
a consultant she didn’t know? Clearly it was not a minor operational issue or an
organizational design problem. An incident sounded like a word used in international
diplomacy. The incident involved an unidentified aircraft flying over restricted
airspace.
What could it possibly be? How could a single incident escalate in two days to
push an organization to the brink of dysfunction? I didn’t know the details, but I had an
idea about the nature of the incident—one of those troubling but ultimately revealing
events that we call an “un-ignorable moment.” And, as it turned out, I was right.
Andrea Crowley met me at the elevator on the tenth floor, led me into her office,
and closed the door firmly behind us. “Thank you for coming in, Mr. O’Connor,” she
said. We sat at a small conference table next to a window overlooking the hospital
atrium where wheelchairs and gurneys and white coats moved about.
After asking Andrea to please call me Mal, I asked, “What happened?”
Crowley took a deep breath. “Tuesday morning, a patient came in to the ER in
distress. Severe diverticulitis. Suspected rupture of the large intestine. Risk of
abdominal infection. Miraculously, one of our best surgeons was available. Surgery
was tougher than expected. There were complications. Near the end, there was a
sudden increase in bleeding. The surgery lasted eight hours.”
“The team must have been pretty beat.”
Crowley nodded. “As the surgeon was preparing to close up, the scrub tech
conducted the post-op count.”
“That’s mandatory, of course.”
“Yes, to ensure all instruments and sponges are accounted for.”
“A forgotten sponge can prove fatal, I know.”
“And provoke a lawsuit.”
“Yes. Something went wrong?”
“The scrub tech came up one sponge short.”
“Not unusual.”
“Not at all. That’s why we do the count. The scrub tech informed the surgeon. But
the surgeon ignored the information and started to close up the incision.”
“I see.”
“As I understand it, the scrub tech spoke up again, more forcefully. Still the
doctor ignored the scrub. This is where it gets confusing. There were strong words.
The scrub tech somehow came between the patient and the doctor. He may have
reached for, even grabbed, the stapler. Somehow it came out of the doctor’s hands.
The surgeon stumbled toward the patient. Maybe fell across him. Maybe it was the
scrub tech who shielded the patient with his own body. Anyway, for a moment, things
were seriously out of control.”
“Wow.” This was all very odd.
“Fortunately,” Crowley continued, “the nurse was able to get the situation under
control. I don’t quite know how or what she did. But the missing sponge was located.
The incision was closed. The operation was completed successfully.” Crowley
looked at me very deliberately. “I want to stress that the patient’s safety was never in
jeopardy.”
“I understand.” We paused for a moment. It was certainly not unusual for a
sponge to go missing. But for a scrub tech to challenge a surgeon? And for there to be
some kind of physical interaction, if not altercation, in an operating room—that indeed
amounted to an incident. However, Crowley hadn’t been there. It had been a long
surgery. Everyone was tired. Who knows what “really” happened.
“What does the scrub tech say about it?” I asked.
“I haven’t talked with him. Yet. I suppose I should.” The prospect did not seem to
appeal to her very much.
“What about the surgeon?”
“I haven’t talked with him either. There’s been no time. And . . .” She didn’t say
it, but I had the sense that she wasn’t sure what she should do.
“Who have you talked with?”
“Only the nurse’s supervisor.”
“But nobody who was actually in the room?”
“No. I wasn’t sure what I should do. I thought it might just blow over. After all,
the patient is fine. Nobody was hurt. There seemed to be no lasting effects.”
We sat in silence for a moment. Why, I wondered, would a surgeon choose to
ignore the scrub tech’s information? What would cause a scrub tech to be so
assertive? Why would harsh words be necessary, if indeed they were used? What was
really going on between these two? It was an incident, for sure. And such moments
often are manifestations of some deeper issue.
“How are things going generally at the hospital?” I asked.
“I’ve only been here a year. There’s been a lot of . . . turmoil.”
“Of what kind?”
“About six months ago, we started a new initiative to improve patient safety. It’s
called Putting Patients First. Zero preventable errors. That’s our goal.”
“How’s it going?”
“It’s been difficult. Many people don’t like it. Some have refused to participate.
Some actively badmouth the approach.”
“Sounds like the incident in the OR might be connected to this initiative?”
“Well, possibly. The surgeon is not a fan of Putting Patients First.”
“I see.” I thought for a moment. “You said that the incident has escalated and it’s
now a situation. What do you mean by that?”
Crowley sighed. “Everyone’s on edge. Dr. Piersen has demanded the scrub tech
be fired. Other OR personnel are refusing to work with Piersen. We’ve had to
postpone some nonessential surgeries. In-patients are hearing all kinds of rumors and
some are getting nervous. Prospective patients are asking lots of questions before they
commit to us. Even the board of trustees has gotten wind of the incident and they are
expecting a report from our CEO.”
She shrugged and attempted a smile. “I need help. It feels like the place is flying
apart. My assignment is to find out what happened and make some recommendations
about what to do next. But I have no idea what really happened. And I’m certainly not
sure what we should do next. That’s why I called you.”
“Okay. I’ll do my best to help. The first thing to do is talk with the people who
were directly involved. Starting with the surgeon.”
Crowley twitched. “You want to talk with Dr. Piersen?”
“Yes, I do.”
“Okay,” she said. “I’ll set it up.” She reached for the phone and looked at me
with what I read as sympathy. “This should be interesting.”
__________________
W ,
ITH THAT FIRST , I had begun a process at University Hospital that we call
BRIEF CONVERSATION

“listening in.” Barry and I had learned about listening in during our early days as
ethnographers, working in various cultural communities. I would sit and listen,
observing, taking notes, occasionally asking a question as people went about their
daily lives—as Barry and I had done with the Hmong community in Philadelphia. At
University Hospital, I would not have that much time, but I did have the advantage of
experience since I had been in situations like this before with other hospital clients.
Listening in involves deliberately taking a pause, listening to individuals and
groups about what’s going on—often as they go about their daily lives—asking
questions, and recognizing signals when your own assumptions are getting in the way.
After hearing a great deal, thinking about causes, and talking about courses of action,
you are ready to explain how you have incorporated what you’ve heard from people
into your strategies and initiatives.
Far too few people spend time listening in, especially when they’re under
tremendous pressure, and instead take hasty action that throws the company into an
even messier state than the one they tried to fix. Listening in takes practice but pays
off. Slowing down helps you to speed up.
But slowing down to listen in is hard when things are coming apart at the seams,
as they seemed to be at UH.
 __________________
T with Andrea Crowley, I was slotted into Dr. Piersen’s schedule for a
HE DAY AFTER MY MEETING

twenty-three-minute interview. Not thirty minutes or an hour. Not a fifteen-minute call.

Twenty-three minutes. As I was walking from the parking garage to the main entrance
of the hospital, I got a call from the chief medical officer at University Hospital, Dr.
Darren Davidian. He was the man responsible for the medical staff and procedures at
the institution. A big job. He was the one who had asked Andrea Crowley to find out
what was going on, and also the one who had recommended that she call us. We had
worked together, tangentially, on a couple of earlier projects. He was no doubt taking
heat from people above, below, and all around him.
“Mr. O’Connor,” he said. “Thanks for jumping on this issue so quickly.”
“Of course.”
“I just wanted to catch you before your conversation with Leonard. Dr. Piersen. I
expect you’re headed there now?”
“That’s right. I’m glad you called. The more information I have the better.”
“Well, as you undoubtedly know, Dr. Piersen is an incredibly important player
here. He’s our chief of gastroenterology. President of the medical staff. I’m sure you
know of him, if you don’t know him directly.”
Oh yes. Everybody knew of Piersen. A major name in the medical community.
Involved in politics, philanthropy, and the arts, both in the metro region and on the
national level.
“Leonard runs the most successful group practice in the city, possibly the region.
He attracts patients to UH from all over the world. Residents kill, as it were, to work
with him. He’s our rock star. Our franchise player.”
“I understand.”
“All of that is not to say, however, that Leonard is a perfect guy. He is what you
might expect of a top-ranked, incredibly busy surgeon. He does not suffer fools gladly.
He worships precision. He can be prickly. But he is a top surgeon and a thoroughgoing
professional.”
“I understand. I have twenty-three minutes scheduled with him.”
Davidian chuckled. “Is there anything further you need to know before you talk
with him?”
“Yes. What can you tell me about the status of your new patient safety program?
Putting Patients First. Zero preventable errors.”
 “It’s largely about following protocols and procedures.”
“The sponge count being one of them.”
“Yes, that one isn’t particularly new or controversial. But we have introduced
many of them, some mandated by various professional and governmental oversight
bodies, some we have developed ourselves. In addition to these very specific and
detailed protocols, there is a set of recommended practices for professional conduct,
team behavior, that extend into every area of activity. Operating room. Clinical and
nonclinical activities. It’s quite extensive and we’re proud to be leading the way in
this regard.”
“I see. And what connection do you identify between the initiative and what
happened in the operating room the other day?”
“That’s easy. One of the key tenets of Putting Patients First is that everybody in
the hospital has a responsibility for patient safety. Everybody, whatever their role or
function, has a responsibility to speak up about any issue in that regard. If you see
something, say something. That’s the mantra.”
“What was the impetus for the program? Do you have a patient safety issue?”
“Absolutely not.”
“I assume you have data to support that.”
“Of course we do. Just let me know what you need.”
My phone buzzed—time for my appointment with Dr. Piersen. “I’ll be in touch,” I
said.
__________________
D L
R. P
EONARD was not as imperious as I had been expecting. He was gracious and
IERSEN

charming, greeting me with a warm handshake and even a light pat on the shoulder. He
was lean and fit, in his early sixties, with silver-white hair and slim, strong surgeon’s
hands. We sat across from each other in leather chairs around a low, round table with
nothing on it except a small carved figure of a downhill skier.
Piersen wasted no time. “You are some kind of consultant, I’m told. And you are
investigating the case of the missing sponge.”
“Yes. I’m just trying to understand what happened in the OR that day.”
“Of course you are.” Dr. Piersen leaned forward. “The surgery was complex.
Acute diverticulitis. The patient came close to bleeding out. I’m told you have a PhD
in folklore. You may understand what it’s like to be responsible for bringing a person
back from the dead.” He looked at me with a faint smile. “Isn’t that what shamans
do?”
“Shamans operate in high-risk environments. They have a lot of responsibility.
They have to earn the trust of their patients. Of course, there is a critical difference
between shamans and surgeons.”
Piersen raised an eyebrow. “Which is?”
“No one questions a shaman’s authority.”
Piersen looked at me deadpan, then returned to the story. “As I was getting ready
to set the first staple, the scrub tech yelled at me. I have never worked with this guy
before. He has a rather distinct accent, so I couldn’t understand exactly what he said,
but it was something about sponges. I knew there were no sponges in the patient.”
“You counted them?”
“Yes. I have performed hundreds of surgeries. Never once have I left anything
inside a patient that wasn’t supposed to be there.”
“I see.”
“But that’s not the point. The proper procedure is for the nurse to do the sponge
count, not the scrub tech. This nurse, Sheri McGlynn, has been with me in countless
surgeries. I trust her completely. I can’t be talking to every scrub tech in the middle of
surgery. It’s distracting. Indeed it’s dangerous.”
“I see.”
“There’s a clear chain of command in the operating room for one very good
reason. Patient safety. That’s the only way to ensure the best outcome for the patient.”
“But, as I understand it, there was a missing sponge.”
Piersen looked sharply at me. “It wasn’t missing.”
“What do you mean?”
Piersen spoke almost off-handedly. “The scrub tech put it there.”
“Wait a minute. You’re saying that the scrub tech deliberately put a sponge inside
the patient?”
“Yes, when he yelled at me the second time he threw himself across the operating
table and tried to grab the stapler. I lost a bit of balance. Stepped back. Turned away
for a second. Sheri was attending to me. It was a perfect opportunity. The scrub tech
could easily have popped in a sponge.”
“Why would he do that?”
 “To be a hero, of course. I’m sure you’ve learned about this program called
Putting Patients First. Zero preventable errors.”
“Surely the program does not encourage people to plant sponges in patients.”
“No, but the program does offer incentives and rewards and recognition for those
who supposedly advance the cause. This guy might have benefited or at least thought
he could benefit. He may also have just been trying to keep his job. In addition to the
safety program, we’re also in the middle of a cost-cutting initiative. Head count
reduction. I don’t know what was going on inside that guy’s head.”
“The Putting Patients First program involves a number of new protocols and
standard operating room routines, as I understand it.”
“Yes, soon the surgeon will be like the airline pilot. With no authority to do
anything that does not adhere to some guideline dreamed up by a government
bureaucrat or an insurance company underwriter who has never been inside an
operating theater. That, I assure you, will not improve the quality of patient care in this
hospital. Or this country.”
He smiled. “What else can I tell you?”
Not much, as it turned out. Due to a scheduling issue, Piersen’s time for me had
been cut from twenty-three minutes to thirteen. The listening in was out, at least as far
as Dr. Piersen was concerned.
__________________
O , I did a good deal more “listening in” elsewhere at the hospital. I
VER THE NEXT SEVERAL DAYS

talked with several senior people as well as nurses and midlevel staffers. I also spent
a fair amount of time just hanging out, listening in on lunch conversations and hallway
talk, chatting with anyone I could connect with. It didn’t take long for people to learn
that I was “some kind of consultant” trying to learn what was going on. As a result,
some people gave me a wide berth. Others wanted to tell me everything.
What did I learn through the listening in? That the sponge incident was not an
anomaly at University Hospital. It was only the latest, most disruptive, most visible,
and most worrisome of many such conflicts, large and small, that had erupted
throughout the hospital in the past several months, coinciding exactly with the
introduction of the Putting Patients First program.
I also came to understand that the program itself was a manifestation of pressure
the hospital was feeling from outside forces. There was the surgical safety checklist,
which had recently been issued by the World Health Organization (WHO). And the
Medicare Quality Reporting program, which mandated use of the checklist as part of
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