Part 1: Introduction And The Normalization of Deviance
The Challenger launch disaster in on 28 Jan1986 and the Columbia re-entry catastrophe in were the result of a sociological phenomenon called the Normalization of Deviance (NoD). Dianne Vaughan, PhD, a professor of sociology at Columbia University, decided that the root causes of these failures are more than the result of human or technological error, but are, in fact, part of a systemic failure where unacceptable practices or standards become acceptable (Hall, 2003). As the deviations are repeated without catastrophic results, it becomes the organizational norm that is impervious to challenge, and those who do challenge it are treated as gadflies or threats. Typically, NoD is a gradual drift to unacceptable organizational practices that become accepted as long as there are no negative consequences. It is further reinforced through a secretive and insular culture more concerned with its public reputation than safety. However, I want to posit that NoD can occur as a step function, with bad management decision making, often in a vacuum, and can formalize NoD from the standards of professional practice that govern a particular discipline.
With the trend to more corporatized healthcare delivery through insurance company owned HMOs, hospital-owned multispecialty medical practices, and increasingly large multispecialty medical practices, the risks to patients are likely to increase. The example I will provide is the decision-making and risky practices being implemented at a major Healthcare Maintenance Organization (HMO) based in Rockville, Maryland. This is the first in a three-part series of articles addressing what the risks are viewed through the lens of NoD. The first part will provide background on NoD; the second part will address how NoD is occurring in a particular HMO and the risks to patients. The third article will focus on the lack of focus on healthcare risks and outcomes and the excessive focus on patient satisfaction scores, which has shown to increase the risks morbidity, mortality, overuse of medical services, and significantly higher costs.
What is the Normalization of Deviance?
In the case of Challenger, it was well documented as far back as 1977-four years before the first shuttle flight–that the O-ring and flange design on the solid rocket motors, were defective. Even a fix to the design did not correct the problem of hot gases leaking from the motors, but the shuttle flew successfully anyway, normalizing the design flaw. The NASA assessment was the flaw would not jeopardize a mission or crew, and that assessment was reinforced as NASA accumulated more and more successful missions. It was not until 28 Jan 1986, with the shuttle experiencing an unusually cold morning, that the O-rings failed, resulting in a total loss of the vehicle and crew. Roger Boisjoly, the Morton Thiokol engineer and expert trouble-shooter, and Allan MacDonald, another Morton engineer, that tried to stop the launch because of the risk that morning, were treated as a troublemakers and whistleblowers by management and colleagues, with Boisjoly’s career in aerospace ruined (Martin, 2012).
Similarly, the Columbia re-entry disaster was a replay of the same mindset: the external tank had a long history of shedding insulating foam during the launch phase, and several shuttles returned with tiles damaged-some significantly and in critical high-heat areas-by shedding foam. But, because so many shuttle missions flew successfully with tiles damaged by foam, it was considered an acceptable risk by NASA management-until a briefcase-sized piece of foam punched a hole in the foam on the leading edge of Columbia’s left wing. During re-entry, super-heated plasma infiltrated the wing, destroying it and ultimately, the shuttle, along with the crew. Again, NoD-where an unacceptable risk or practice becomes normalized-was the root cause of the disaster.
NoD in meeting flight requirements of the Shuttle were masked by the extensive public relations campaign for the Shuttle, with NASA attempting to make space flight appear to be as safe as airline travel. This was manifested through such efforts as the Teacher in Space Program, and foreign dignitaries and US politicians getting to fly on missions, often to the detriment of the crews’ abilities to perform scheduled tasks.
Medicine also has a problem with NoD. As with NASA, this can be masked through public relations campaigns that emphasize patient satisfaction over quality of care. For example, lax attitudes about hand washing between patients became normalized in hospitals and clinics, and as long as no patients seemed to suffer adverse consequences, this practice became the norm in many medical settings. Further, the failure to track actual infection rates for many years because of this practice made attribution essentially impossible, so the practice continued. This only began to change when it became apparent that poor hygiene practices were, in fact, increasing infection rates in hospitals.
Today, aggressive cost cutting and financial incentives of large groups to maximize profit in a reimbursement-austere regime has led to clinical decisions that present higher risks to patients. This is reinforced with patient satisfaction surveys that often show that patients are very happy with the care they received; yet completely unaware of the risks they were exposed to during treatment. The next article will discuss how this plays out at the subject HMO.
Hall, J. L. (2003). Columbia and Challenger: organizational failure at NASA. Space Policy , 19 (4), 239-247.
Martin, D. (2012, February 4). Roger Boisjoly, 73, Dies; Warned of Shuttle Danger. New York Times, p. A18.