The Race to the Top of the Mountain

Remember the old joke about the two men who were racing to the top of the mountain and when they got there, a third man asked them what took them so long? The guy at the top has been a rabbi, a priest, a woman, and a host of other things, depending on the point the comedian was trying to make.

I feel like that joke just became real after reading this article. Nurses, doctors, and health care researchers clamoring to the top of the mountain as they discuss how to interpret data from interventions in health care settings, and realizing that the organizational scientists have been there for some time.

I couldn’t agree more with the conclusions drawn in the article. Randomization is a great tool, but it loses power in quasi-experimental settings. Field studies trade realism for control, and while the ecological validity of a field study is very valuable, extraneous variance due to internal validity violations is always problematic.

Organizational scientists are in a unique position to help those involved in RCTs with the identification and modeling of these variance sources, both in terms of measurement AND with respect to the meaning that they provide. For example, the article states that “changes in the skill and confidence of practitioners” was observed (Results section, first paragraph). Of course, this is not surprising from a human performance perspective, but it also constitutes a history effect, which is an internal validity concern. How are these concerns being addressed? Psychologists have many ways to do so, but how well have we applied these ideas to health care practice?

I encourage health care practitioners to seek out partnerships with organizational science. We can help each other make patient experiences in care of even higher quality.

A Metaphor for Error: The Wet Parking Lot

It is difficult for some to fully grasp the concept of the error as “emergent property,” something that only exists potentially and “pops” into reality abruptly. I thought a metaphor based on an experience I had this morning might help.

I drove to work this morning on a brisk day with the roads wet from rain and condensation. I was a little later than normal as it took longer for my daughter to get ready for school. The parking lot outside my office is a dark asphalt color and the sun was set in a cloudless sky at a severe angle to the ground at 8am. I park on the west side of a lot that is shaped like a heart – the entry and exit points merge at one end, and a concrete center median creates one-way traffic. Since I like to park facing east, I have to drive through the east side of the lot, turn around at the north end, and drive up the west side to my spot. The lot is sloped slightly to the north, so water tends to gather at that end.

I behaved as I always do when navigating this area – same speed, same angle of approach to the corner at the north end. As I neared the turn, I perceived that I was alone in the lot.

Abruptly, a colleague appeared in front of my vehicle, seemingly out of nowhere. I applied the brakes with force and stopped before striking him. Upon quick reflection, I realized that the sun was creating a “washed-out” area in my visual field as it reflected off the standing water and wet asphalt. He was standing in that washed-out area as I approached, and only when he moved out of that area was he visible to me.

If I had struck him, accident investigators would be likely to say that I was driving too fast, was not paying attention, or was even negligent. But in actuality, I was behaving quite normally given my assessment of the environment. On any other morning (i.e., cloudy day, sun at a different angle, driving my wife’s car instead of my truck, arriving at a more typical time, parking lot facing different direction, decision to park elsewhere, etc.), I would have seen the colleague and easily avoided a near-collision.

The message here is that every morning that I navigate that lot, potential errors can emerge at any moment. They don’t actually exist yet – they are only observed when the components that construct them align in just the “right” way. I hope you will consider how my trip through the parking lot relates to the phenomenon of error in your workplaces.