Part 1: Introduction and normalization of the deviation

Introduction

The Challenger launch disaster on January 28, 1986, and the Columbia re-entry catastrophe were the result of a sociological phenomenon called Normalization of Deviation (NoD). Dianne Vaughan, PhD, a professor of sociology at Columbia University, decided that the root causes of these failures are more than the result of human or technological error, but are, in fact, part of a systemic failure where practices or unacceptable standards become acceptable. (Hall, 2003). As deviations are repeated without catastrophic results, it becomes the organizational norm that is impervious to challenge, and those who challenge it are treated as horseflies or threats. Typically, NoD is a gradual drift into unacceptable organizational practices that are accepted as long as there are no negative consequences. It is further reinforced by a hermetic and insular culture more concerned with its public reputation than its security. However, I want to posit that NoD can occur as a step function, with poor managerial decision making, often in a vacuum, and can formalize NoD from the standards of professional practice that govern a particular discipline.

With the trend toward more corporatized healthcare delivery through HMOs owned by insurance companies, hospital-owned multispecialty medical practices, and ever-larger multispecialty medical practices, the risks to patients are likely to increase. The example I will provide is the risky decision making and practices implemented at a large Health Care Maintenance Organization (HMO) based in Rockville, Maryland. This is the first in a three-part series of articles addressing risks seen through the lens of NoD. The first part will provide background on NoD; the second part will address how NoD occurs in a particular HMO and the risks to patients. The third article will focus on the lack of focus on health care risks and outcomes and the excessive focus on patient satisfaction scores, which have been shown to increase the risks of morbidity, mortality, overuse of medical services, and significantly higher costs.

What is deviation normalization?

In the case of the Challenger, it was well documented as early as 1977, four years before the shuttle’s first flight, that the O-ring and flange design of the solid rocket motors were faulty. Even a design correction did not correct the problem of leaking hot gases from the engines, but the shuttle flew successfully anyway, normalizing the design flaw. NASA’s assessment was that failure would not endanger a mission or crew, and that assessment was reinforced as NASA racked up more and more successful missions. It wasn’t until January 28, 1986, when the shuttle experienced an unusually cold morning, that the O-rings failed, resulting in the total loss of the vehicle and crew. Roger Boisjoly, Morton Thiokol’s engineer and expert troubleshooter, and Allan MacDonald, another Morton engineer, who tried to halt the launch due to the hazard that morning, were treated as troublemakers and whistleblowers by management and colleagues, with Boisjoly’s career in aerospace ruined (Martin, 2012).

Similarly, the Columbia re-entry disaster was a repeat of the same mindset: the external tank had a long history of shedding foam insulation during the launch phase, and several shuttles returned with their tiles damaged, some significantly and in areas high temperature reviews. releasing foam. But, because so many shuttle missions flew successfully on foam-damaged tiles, NASA management considered it an acceptable risk—until a briefcase-sized piece of foam punched a hole in the foam at the edge. Columbia’s left wing attack group. During re-entry, superheated plasma infiltrated the wing, destroying it and ultimately the shuttle, along with the crew. Again, NoD, where an unacceptable risk or practice becomes normalized, was the primary cause of the disaster.

NoD in enforcing Shuttle flight requirements was masked by the extensive public relations campaign for the Shuttle, with NASA attempting to make spaceflight appear as safe as air travel. This manifested itself through efforts such as the Teacher in Space program and foreign dignitaries and US politicians being able to fly missions, often to the detriment of crews’ ability to perform scheduled tasks.

Medicine also has a problem with NoD. As with NASA, this can be masked through public relations campaigns that emphasize patient satisfaction over quality of care. For example, lax attitudes about handwashing among patients became normalized in hospitals and clinics, and while no patient appeared to suffer adverse consequences, this practice became the norm in many medical settings. Furthermore, the inability to track actual infection rates for many years due to this practice made attribution essentially impossible, so the practice continued. This only began to change when it became clear that poor hygiene practices were, in fact, increasing infection rates in hospitals.

Today, aggressive cost reduction and financial incentives by large groups to maximize profits on a lean reimbursement regimen have led to clinical decisions that present greater risks to patients. This is reinforced by patient satisfaction surveys that often show that patients are very happy with the care they received; however, they were completely unaware of the risks they were exposed to during treatment. The next article will discuss how this plays out in the HMO topic.

References

Hall, JL (2003). Columbia and Challenger: organizational failure at NASA. space policy 19 (4), 239-247.

Martin, D. (February 4, 2012). Roger Boisjoly, 73, Dies; Warned of the danger of the shuttle. New York Times, p. A18.