Alignment of the Lamps

We all know about James T Reason's 'Holes in the Cheese'.

But we never think about the flip side:

"Those rare sentinel events when the exactly right combination of people and circumstances line up to create unprecedented and tangentally new vectors for spontaneous and blindingly meaningful cultural change."

It happened yesterday.

What happened is easy to misinterpret if you stop thinking too soon.

A bunch of people exercised flexibility in normally didactic process.


Stop thinking, and look for someone to blame.

Better still, don't stop thinking.

Let's look a bit further, and look for someone and something to celebrate!

A bunch of clinicians trusted each other, that is to say: trusted the others' abilities, competence and judgement, implicitly.

What then happened was a sufficient alteration in expectations right across the team which allowed the amazing to happen.

It might not seem laced with potential from someone else's eyes.

But we had never done what we did before.

And the interesting thing is that the outcome, from my perspective, was the most affirmative experience I have had in the operating theatre in foreseeable memory!

A point at which you can put a mark in the fabric of time and potentially exclaim:

"Now THAT was the moment that changed EVERYTHING!"

There are many times when you are proud to be part of a team and the awesomeness of what you accomplished;

But rarely do you get to be stratospherically excited about it.

On one side you could look for the holes in the cheese.

It stands to reason.

But for me, I'm staring at an alignment of the lamps.

And being immensely proud of the unique opportunity to tweak how we go about business!

Who needs to search for intelligent life in the outer universe?

Hey! I think we've found some on Earth!


Disclaimer: if you think I can think this stuff up all by myself, you would be sadly mistaken. The inspiration for seeing the 'holes in the cheese' thing the other way

comes from John Gibbs, who,

after reading an executive summary of a project

a health care quality improvement company in the U.S. had invited us to review

replied: Quote:

"they seem to imply that health care is broken.

But that ain't the whole truth.

Clinicians do a phenomenal job under extreme conditions,

and we should be able to celebrate the fact that we get it,

so often,

so right."


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