HRO: (14) Leaders who subdue the earth

According to the 2013 article by Chassin and Loeb, there are three things which are necessary for an organization – specifically healthcare—to make headway toward the goal of zero patient harm, to approach the status of High Reliability Organization:  1) commitment by leadership to zero harm 2) thorough incorporation throughout the organization of the behaviors which lead to zero harm 3) adoption and use of effective process improvement methodology to enhance safe operations.  

Pardon me while I wander onto a tangent which—I promise—will bring us back to these elements.  

The Bible contains two commissions present as bookends in Genesis and the Gospels.  The first is found in Genesis 1, where mankind is told to both be fruitful and multiply and to “subdue the earth.”  The second is found most clearly in Matthew 28:19, 20 where Jesus tells His disciples “Therefore go and make disciples of all nations….”  The work of all of God’s people is some combination of these two commands:  a pastor will likely spend much more of his time making disciples, but is also called to be fruitful and subdue the earth.  By contrast, a farmer spends much of her time pursuing fruitfulness and control over the earth, but is also called to make disciples within her sphere of influence.  

I believe that these two sets of commands are deeply entwined.  Fruitfulness certainly speaks directly to the physical procreation of having children, but I believe it relates to other creative efforts: building, crafting, growing, composing music, creating art, developing computer programs or inventing cures for disease.  In our fruitfulness and creative efforts, we follow the lead of our Creator.  Our Creator also calls us to “subdue the earth.”  This phrase may for some connote an abusive, Machiavellian, rapacious relationship with the created world—but should not be so for those of us called upon to “Love the Lord your God with all your heart, with all your soul and with all your mind” (Matthew 22: 37) when we know that the God whom we love created this world and called it “very good (Genesis 1:31).  The call to fruitfulness and the call to subdue the earth are tied together:  all of our creative efforts should be in harmony with the goals of our Creator, directed at enhancing His perfect creation—and, post-Fall, to mitigate the impact of sin and evil on God’s world.  The actions supporting peace and civilization honor the command to “subdue the earth.”

Fruitfulness and subduing the earth are tied to and support the “great commission.”  When the earth is subdued—when crops are grown and people are fed, when just rules are enacted and enforced, when roads are safe and well paved, when civilization exists and families flourish—the proclamation of the Gospel message can go out unhindered.  (Side note:  I’m not glorifying peace on earth as the sole purpose of mankind; nor do I discount the role of suffering and conditions of persecution and diaspora in the spread of the Gospel message.  I simply say that God is a God of order and peace (1 Cor 14:33) and that disorder, war and suffering are a result of sin.  We are always to combat sin in all its forms.)  Those of us engaged in secular work are engaged for the majority of our workdays and probably also our home-life in “subduing the earth.”  (Second side note:  please also don’t misunderstand this as an excuse to neglect the call for us to make disciples).  

Subduing the earth is what we do.  Those efforts which bring order and discipline, which beat back chaos and the entropic forces of the Fall, which bring comfort and relief from suffering, which protect the weak and guide the wayward—this is what Christians are called to do, even more so those of us in leadership positions. Where else are the forces of the Fall so strong as within the walls of each hospital, clinic, cancer center, and emergency department?  When Chassin and Loeb challenge healthcare leaders to be fully committed to zero patient harm, to ensure solid integration of all known tools to enhance patient safety, and to commit to systematic, intentional, planned improvements to the patient-care environment toward the goal of zero harm—this is a challenge to “subdue the earth” on our home turf.  

One of my favorite quotes is from Space Balls, the 1987 movie parody of Star Wars.  In it, the villain Dark Helmet says “Now you see that evil will always triumph, because good is dumb.”  “Good is dumb”—this is probably an oversimplification, but my observations have been that “Good” is often some version of “dumb.”  Good is often exhausted by acts of compassion and caring, such that Good may appear lazy; Good may even actually be lazy, believing that “it’s the thought that counts” and real results don’t matter.  Good can be trusting, to the point of being gullible.  Good puts high value on good intentions, cheerfully forgetting how prone to sin and failure (and pride, sloth, and anger) we all are.  Good often forgets that love is not just kindness and compassion, but that love also entails correction and discipline; Good may confuse confrontation with fighting and behave with timidity.  Good is therefore too often ripe to be steam-rolled, intimidated and taken advantage of.

Jesus knew this was a risk and seems to speak directly to it in Matthew 10: 16, when He told His disciples “I am sending you out like sheep among wolves.  Therefore be as shrewd as snakes and as innocent as doves.”  If I dare to link Jesus with Dark Helmet, Jesus was telling His disciples and us:  don’t be good and dumb.  Don’t be gullible, ask clarifying questions; don’t let your compassion-fatigue exhaust you into complacency; don’t let good intentions be enough, look for meaningful results.  Be as shrewd and wily as a serpent, but be as innocent, compassionate, kind and gentle as a dove.  Be good AND wise.  

We as leaders (in medicine and elsewhere) are called on to motivate people to achieve success, to protect the weak in our care, and to leverage all of the tools available to us—process improvement, change management, data collection, Ishikawa diagrams and Pareto charts—toward safe, efficient operations. We are called on to be good and wise, compassionate and shrewd, innocent and wily.  This means giving people the training and tools they need; ensuring that they are resilient and protect themselves from compassion-fatigue and alarm fatigue; explaining clearly the “why” behind the changes and demands; mitigating forces that would derail us; and guiding people to prioritize efforts appropriately. We should not just want to do the right thing, but to do the right thing in the right way.   The goal is compassionate care that is safe, care that is safe because it is founded upon the best processes possible.  Care that is Good and not dumb.

1)      Have you found yourself behaving more like a serpent or more like a dove?  Do you place more value on shrewdness or on compassion?  How has one extreme or the other been a detriment to your work or relationships?  Consider how Jesus’ words call for a very delicate balance as both serpent and dove.

2)      Jesus sent His disciples out “as sheep among wolves.”  How does healthcare feel like being sent out “among wolves?”  Consider what we are up against—risk of infection and other complications; scarce resources; fast pace combined with time-sensitive tasks; physical fatigue and long hours; difficulties with communication and teamwork—and how those may be the wolves in healthcare.  Are there particular “wolves” which your organization, unit, or clinic is struggling against?

3)      Caring for the sick and diseased is part of “subduing the earth”—bringing peace and order where there is pain and chaos.  We are fighting the impacts of the Fall every day, combating the evil work of Satan who wants to make life on earth as close to hell as possible. Can our work in healthcare also be a fulfilment of the call to “make disciples?”  Why or why not or why both?  Consider 1 Peter 2: 12 in this context.

4)      Read Matthew 10, where Jesus sends His disciples out.  In verses 28 – 31, He promises protection and tells them they are worth more than the sparrows whom God knows and counts.

a.       Consider what it means to be God’s child through Christ Jesus:  you are redeemed and made new; God has called you His own and forgives and blesses you for Jesus’ sake.  You are worth more than many sparrows to Him. 

b.      Compassion fatigue is a real thing.  It is exacerbated by the daily reality of our own weakness and sin:  we get grouchy, we fail to be attentive to details, we snap and snarl at coworkers or even at patients, we make mistakes that could result in real and lasting harm, or at least defeat our efforts toward healing.    How can your status as forgiven child of God allow you to forgive—to be gracious—to both yourself and others?