Dr. E.J. Caterson and Dr. Matthew Carty are members of one of the world’s finest reconstructive plastic surgery teams, working out of Boston’s Brigham and Women’s Hospital. They have reattached faces, salvaged legs, and saved lives. Seven years ago, they worked on a patient whose face had been torn off when she was mauled by a pit bull. The team opened up the dog’s stomach, removed the face, and reattached it. Today, if you saw this patient on the street, you wouldn’t bat an eye. At 3 p.m. on April 15, 2013, Caterson and Carty had just successfully completed a 10-hour operation on a teenager with an extreme facial fracture. They were about to head home to their families when their resident physician came in and said, “Hey, a bomb just went off.”
A few minutes earlier, two pressure-cooker bombs had ripped through the finish line of the Boston Marathon, killing three people and seriously injuring more than 200.
“[The team] just walked right from the OR to the emergency room,” Caterson says, where other operating teams converged. Casualties started rolling into the ER but, as Carty remembers, “No one had any sense of what the scope of the event was. As far as we knew, this could be 3,000 people.”
Working with trauma surgeons, orthopedic surgeons, and vascular surgeons, Caterson’s group helped devise treatment plans for the stream of injured patients, before triaging them to the operating room. These surgeons had all collaborated in the past and now made decisions as a collective, Caterson explains. One of the injured patients came in with a badly mangled leg that looked like it would have to be amputated above the knee. But the surgeons were determined to avoid that route, since an above-knee amputation means up to a 70% increase in energy expenditure to walk for the rest of one’s life, leading to cardiovascular and pulmonary issues and often triggering early joint failure. The team went to work, taking skin grafts from the victim’s leg and back, threading them with a single 2 millimeter-thick blood vessel, and removing and replacing the bone in his leg in an attempt to salvage and reconstruct his knee. Eight surgeries later, he had recovered with a functioning knee—the result of a meticulously rebuilt mechanism in the absence of the anatomic stump that is normally necessary for a below-knee amputation. “That was a complete deviation from normal practices,” Caterson says. “But as a result, that person will be able to run a marathon again.”
Brigham and Women’s had never simulated a mass-casualty situation across multiple trauma services. There was no real plan, and certainly no rehearsal. Their response was simply an extension of what they do every day—adapt. A unit functioning as a command, with members waiting for instruction from authority, would have been too hidebound to respond effectively. There is no medical school course on removing a human face from a dog’s stomach, and in time-critical situations, no time to conduct a study or draw up a blueprint. The human body is a complex and interdependent system, and surgeries can diverge from a plan. “Every patient is different. Nobody has an identical fracture,” Carty says. “Operations are unpredictable. You always have to adapt.”
If the Brigham and Women’s surgical teams’ response to crisis illustrates the virtues of adaptability, the GM ignition-switch scandal that erupted nearly a year later illustrates the sometimes fatal risks of organizational rigidity.
On April 1, 2014, Mary Barra, the CEO of General Motors, stepped into a somber, wood-paneled room full of cameras and congressional representatives. Tim Murphy, Republican representative of Pennsylvania, initiated the proceedings: “I now convene this hearing of the Oversight and Investigation Subcommittee, titled ‘The GM Ignition Switch Recall: Why Did It Take So Long?’”
This question had been on the public’s mind since GM had issued a recall of 800,000 vehicles two months earlier. A faulty ignition switch had been used in the Chevy Cobalt and the Pontiac G5; a weak spring meant that small amounts of force applied to the key when in the ignition—a bump by a knee or the tug of a heavy key chain—could cause the engine to turn off. The ignition shutoff also disabled airbag deployment, significantly increasing the danger of the fault.
“As soon as the Chevy Cobalt rolled off of production lines in 2004,” Representative Murphy read to the packed hearing room, “customers began filing complaints about the ignition switch. In 2004 and 2005, GM engineers twice considered the problem, but it wasn’t until December 2013 that the company finally put the pieces together . . . almost 10 years after customers first told GM the Cobalt ignition switch didn’t work.” In those 10 years, at least 13 people died.
GM appeared to be the ultimate evil corporation. For four hours, righteously indignant politicians alternately questioned and berated Barra. Press coverage highlighted GM’s greed. The reality, however, was more complex. What seemed like a cold calculation that privileged profits over lives was also an example of institutional ignorance that had as much to do with management as it did with values. It was a perfect and tragic case study of the consequences of information silos and internal mistrust. At GM, internal rivalries—the consequence of separate divisions and a competitive culture—inhibited communication. The air bags and ignition systems were overseen by two different teams, which explains how the relatively easy-to-fix ignition issue “passed through an astonishing number of committees” without ever being addressed. GM’s byzantine organizational structure meant that nobody—venal or kindly—had the information to make the crucial decision.
Why was GM unable to adapt to a challenge that many in the organization saw coming for years, when a team of surgeons was able to improvise around an unpredictable crisis on the fly? What fundamental structures led to the inertia and ossification of one of America’s great companies?
The answer to that question tells us a lot about the kind of organization that thrives in a climate of uncertainty.
Sandy Pentland is an MIT professor who studies the effects of information flow on organizations and communities. Looking at very large data sets, Pentland has found that sharing information and creating strong horizontal relationships improves the effectiveness of everything from businesses to governments to cities. His research suggests that the collective intelligence of groups and communities has little to do with the intelligence of their individual members and much more to do with the connections between them. Pentland writes about “idea flow,” the ease with which new thoughts can permeate a group. The two major determinants of idea flow, Pentland has found, are “engagement” within a small group, like a team, department, or neighborhood, and “exploration”—frequent contact with other units. In other words, a team of teams.
Pentland has conducted studies at a number of companies, outfitting employees with badges that produce detailed, quantitative measures of how people interact. At a Chicago-area IT consultancy, he collected a billion measurements in one month—1,900 hours of data—and found that engagement was the central predictor of productivity, exceeding individual intelligence, personality, and skill. The teams that had the highest levels of internal engagement and external exploration had much higher levels of creative output.
Whether in the medical world or the manufacturing world, the organization as a rigidly reductionist mechanical beast is an endangered species. Armed with unprecedented amounts of data, leaders can peer into what is happening almost as it occurs, and this information can seduce them into thinking that they can predict complex situations. But the speed and interdependence of our current environment means that what we cannot know has grown even faster than what we can know. Leaders must find a way to empower their teams to find the way.