“Generals are Always Prepared to Fight the Last War”
I was a bit surprised to open Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making, a book by Gary Klein, and find a well-thought-out discussion of a conundrum that has been nagging me my entire career: how do we optimally balance critical thinking, experience, and independent judgment with standardized metrics, standard operating procedures (SOPs), checklists, and job aids? Within the highly regulated and structured environment that we live in today, it may be easy to conclude that SOPs, intensive methodical data gathering, and articulated logic are the ways to achieve optimal safety. While they are incredibly important, especially within transfusion medicine, real-life decision making is messy and often no amount of pre-planning or data gathering will eliminate all risk. Perhaps this is the lesson the precautionary principle is really trying to tell us.
According to the author, real-life decision-making relies on both explicit and tacit knowledge. Explicit knowledge is what is readily known: data, test results, and information that is readily codified. Much information within transfusion medicine falls into this category - for example, the Food and Drug Administration's layers of safety, guidelines and, rules and regulations on how to manufacture blood, and the quality control testing necessary to release our blood components. Our blood is safe largely because we train our staff to treat each donor, each donation, and each component in a safe and consistent manner.
Tacit knowledge, on the other hand, is experiential knowledge that cannot be readily transferred. It is gained through experience. It is tacit knowledge that the seasoned neonatal intensive care unit nurse uses when she starts looking for sources of respiratory distress in her patient, who has always been noisy until now. It is that gut instinct that tells you something is wrong when you cannot articulate why, or that which encourages you to continue a line of thinking that leads to a new idea or a discovery.
Using real-life extreme decision-makers, such as pilots, fire fighters, and nurses as examples, Mr. Klein walks us through 10 common claims about ways to improve performance. He shows us that most decisions in the real world are unreasonable - that it is not always possible to have a clear goal when starting a project, and that we cannot always reduce uncertainty by gathering more information. I recommend this surprisingly readable book as you think about how your blood center's management team will adapt to the evolution of healthcare.