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Defeating General von Clausewitz

Even though he’s been dead for over a century and a half, Prussian military General Carl von Clausewitz still enjoys a well deserved reputation as one of history’s most important military strategic thinkers.   His overall premise was crystallized in his theories of “the fog of war” meaning that 18th and 19th century battles were basically a mass of confusion and randomness uncontrolled by battle plans, generals and military discipline.  Although he advocated planning for battles he lamented that “no battle plan survives its first encounter with the enemy”.  Meaning when the swords fell, the best laid plans of the generals fell with them.

The modern era is really not a lot different.  General Dwight D. Eisenhower, who planned and executed Operation Overlord, the most massively complex movement of men and materiáls in history, agreed with our Prussian friend.  He said “in preparing for battle I have always found that plans quickly become useless, but planning is indispensable.”  Obviously planning for battles and planning complex surgical procedures anticipate polar opposite outcomes.  But battle plans and operative plans have similarities and we can learn from these generals to plan our surgery with an expectation that things can and usually do change.  Both generals saw battles as complex interactions of multiple moving pieces; similar to the way we view a complex surgical procedure in the operating room.  There are always imponderable events and twists and turns that might not mesh with our previous experiences that can rarely be accurately scripted in advance.

So then what does this have to do with patient safety and how can we learn from this as practitioners of the high reliability mindsetThe take-away message for us in healthcare is that we have to understand the value of plans and make careful and complete plans but not depend on things going exactly according to plans in order to assure safe outcomes.  We also can never accept an excuse like “things just haven’t gone as I planned” as a reason for a bad outcome.   It is critical to make plans that will account for that “fog of war” and anticipate every possible problem, additionally imagining new ways that things can go wrong and plan for that.  We need to thoroughly brief and communicate all these plans with the team but still always be nimble and anticipate things will go wrong.

If we drill down into von Clausewitz’ theories a little more we see that he understood and stressed how opposite factors interact, especially how sudden and unexpected developments unfolding beneath the “fog of war” called for rapid and correct decisions by alert commanders.  Planning in advance and getting enough things ready for contingency efforts if, NO WHEN, the unexpected occurs, gives us more mental bandwidth to process data and information related to any new twists and turns.  This makes it more likely that we will react correctly with urgent accurate decisions even in time-compressed situations to assure good outcomes in emergencies.

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