By Stewart Gandolf
Chief Executive Officer
Recently, I had the opportunity to see Richard Franzi, author of Killing Cats Leads to Rats, speak about his book. Essentially, the topic is the unintended consequences of our decisions. And in terms of healthcare, there are unintended consequences all over the place.
You can learn strategies to avoid unintended consequences in healthcare organizations from our podcast interview below, or keep reading for my insights.
And you can find this extraordinarily unique book on Amazon here.
Killing Cats Leads to Rats: The Premise
We’ll jump back to how this book relates to healthcare in the next sections. First, I wanted to touch on the topic that probably convinced you to read this article in the first place: that killer title.
Killing Cats Leads to Rats comes from the unintended consequences of decisions that lead to the Black Plague in the 1300s, which killed 17 million people in the 1300s. Unfortunately, the problem of the Plague was exacerbated by the unintended consequences of the decision to kill cats, which were believed to be spreading the disease. Of course, cats are the natural enemies to rats who were now able to roam freely—and whose fleas were a true source of the deadly disease.
In fact, Franzi says we can trace the Plague back to some unintended consequences of a much earlier decision. A hundred years earlier, the pope created a fear of cats with his edict that the black cat was the “vessel of satan on Earth.” This started the bias against black cats and cats in general that lead to a decision 100 years later which multiplied the death count.
Unintended Consequences in Healthcare
Franzi says the term “unintended consequnces” comes from Dr. Robert K. Merton, known as the Father of Modern Sociology, who lived from the 1920s to the early 2000s. He published a paper in 1936 about unintended consequences arising in large scale social systems.
Franzi says, “I started to think as I read his research, ‘What are hospitals if not a smaller version of a society?'” There’s an authority hierarchy as well as citizens—known in healthcare as patients, as well as the doctors and nurses who serve the patients.
Marten’s work, says Franzi, is directly applicable to healthcare organizations, hospitals, and service providers, and I agree. For example…
- CMS penalties for readmission rates may make hospitals focus more on that than improving mortality rates.
- Opiod laws (which are certainly a positive thing) may be causing doctors to under-prescribe, unintentionally sending addicts to heroin or other illegal sources.
- The Affordable Care Act is causing less charity care for uninsured, but more bad debt from people who can’t make their high deductible copay.
- Doctors may avoid the sickest patients due to concerns how it will impact success rates.
And from my own experience in marketing…
- One of our clients almost cut digital marketing due to cost, until we showed the team that 55% of their new patients were coming from digital marketing.
- Too often, organizations using physician liaisons to build referrals try to save money by giving double duty. These physician liaisons are given marketing tasks and end up confined to a desk, without being very useful at all.
5 Causes of Unintended Consequences
In his research, Marten determined 5 states that exist in the decision-making process that can lead to unintended consequences.
- Immediate interest
- Basic values
- Self-fulfilling prophecy
Ignorance, Franzi points out, is a common cause of unintended consequences in healthcare. Mistakes in healthcare often don’t necessarily come from the decisions leaders in a hospital or organization make. Rather, the doctors, nurses, or staff may take purposeful action to achieve the desired outcomes the leaders have set forth. Unfortunately, they are not prepared or knowledgeable about what they have to do—and the unintended consequences can be quite problematic for patients.
Immediate interest resonates the most with leaders Franzi speaks with. It shows up when we have a heavy focus on a subset of the total problem, trying to control for just one aspect of a much more complex problem (that requires a more complex solution).
And error shows up when facts are misrepresented or when people incorrectly analyze decisions and come up with erroneous decisions. For example, people may choose not to vaccinate their children for fear of side effects like autism, mistakenly interfering with their child’s health (and a possible spiraling problem for the community).
The 6-Step Process for Controlling and Mitigating Unintended Consequences
Finally, Franzi lays out his process for controlling unintended consequences, based on the acronym “SECURE,” which you can read more about in his book.
- S – Slow down the decision process. Often in the heat of the moment, we make decisions based largely on our past experience. Many times that’s colored heavily by the emotion associated with that experience. It’s important to step back, try to remove any emotion associated with a decision, and examine the facts.
- E – Expand your knowledge. Understand the latest research and access information available to you.
- C – Clarify the desired outcomes. Start with the end in mind. It’s very important, especially for leaders in healthcare organizations translating strategy into implementation, that they spend time with the individuals who are empowered to act on decisions.
- U – Unify the team. Don’t micromanage the implementation of a strategic decision. Build a collaborative culture where people are able to work together. Delegate responsibility.
- R – Retain control. Whenever there’s a new decision, it’s best if you can test/control it with simulation. The earlier you can adjust for unintended consequences, the less damage you’ll have to worry about in the long run.
- E – Ensure you stay on focus. When you roll out a new decision, there’s a change in behavior amongst doctors or staff. Many times, people want to go back to their previous behavior. It’s important to remind them why we’re changing our behavior or strategy and stay true to that overall goal.
Franzi’s final thoughts to our readers and listeners are to recognize, “There are unintended consequences to everything. When you’re planning a strategic decision and implementation, it is so powerful just to ask the people involved, ‘What is the craziest thing that could happen that we’re not expecting or intending to happen from this decision?’ And the more playful and open you are to ideas, the more brainstorming happens.
“Be open to the idea of the unintended consequences of your decisions and seek out people telling you what they might be. Sometimes in the team you’ve built, they have ideas of things that might happen and if you give them a chance to express it, you can figure out how to deal with it.”