We've never asked that question

I have spent more weekend hours than I would like building a spreadsheet that should not have needed building.

It goes the same way every time. Something in a report does not sit right. I ask for the number underneath it, and the number does not exist. Not because it would be hard to produce — the data is sitting in a data warehouse somewhere, and the pull is an hour’s work for somebody who knows where things live. What is missing is not the information. It is the decision that the information was worth having.

So I build it myself. A data pull, a pivot table, a chart. I bring it to the meeting and put it on the table, and often enough the conversation in the room changes direction. Then the next period arrives, the same number is missing again, and I build it again.

A number of people have asked me this month about a case that is on the mind of every anesthesia clinician, every hospital pharmacist, and every quality and safety professional I know. It sits now in a publicly posted regulatory finding that a great many of you have already read. I am not going to tell you what happened in it.

That is not modesty, and it is not caution dressed up as principle. It is the standard I hold in the seat I sit in. I lead an anesthesia company and I still work clinically a few shifts a month, and I do not judge the care in any case I have not reviewed in detail — where detail means two things and not one. A full review of the record. And conversations with the people who were actually there. Without both, any judgment I offered would be premature and would almost certainly be wrong on the facts. The record tells you what was documented. The people tell you what was happening. I have often found both to be incomplete by themselves.

I will leave that case to the people doing that work, and write instead about something I have seen from inside rooms I was actually in. If you have been reading the same document I have, you will do your own work with what follows.

Here is what I have come to understand about the way a problem reaches somebody in my role. It does not arrive as an event. It arrives as an event that has already been explained.

By the time a number, an outcome, or a person’s behavior gets to me, somebody closer to it has produced a reason for it, and the reason arrives fused to the thing itself. I am rarely in a position to receive one without the other. And the explanations that reach me are not lies. That is the part I misunderstood for a long time. They are almost always true, offered in good faith, by someone with no motive at all beyond answering the question they were asked.

Two of them come up often enough that I can now hear them coming.

The first is we don’t need it, we make good decisions without it. It cannot be disproven without the very data it is declining to produce, which makes it unfalsifiable by construction. It is not an argument. It is the shape of an argument, and it closes the conversation exactly as well as a real one would.

The second is we’ve never asked that question. That one is a statement about the past offered as a judgment about value. It is entirely accurate and it answers nothing. Nobody has asked. That tells you what has happened, and it tells you nothing whatsoever about whether the question is worth asking now.

The person who explains an anomaly to you almost always owns the function and not the decision, which is why the answer is honest, locally correct, and blind in the one direction that matters. They own the pipe. Somebody else carries the consequence. They are not protecting anything and they are not being evasive — the question simply does not feel urgent from where they sit, because the cost of being wrong about it will land somewhere they will never see it.

And this is where I want to be careful about my own part in this story, because I used to tell it as though the failure were curiosity. It is not. In almost every one of these moments I was not convinced. The answer did not pass the smell test when I heard it, and I accepted it anyway.

Not because I believed it. Because one reporting period and a plausible reason is not enough to spend real capital on. If I push on a service line’s numbers in a room full of people who have just been congratulated on those numbers, and I am wrong, I have burned something I will need later for a fight I have not picked yet. So I bank the doubt. I make a note I will not look at. I wait.

I want to be exact about what that calculus is for, because I have just described it in a paragraph about a service line. It is for a number. It is not for a patient. A doubt about someone on the table gets acted on in the moment, whatever it costs me in the room.

What I am waiting for is the same thing to happen twice. Which means the second instance is not the moment I notice. I noticed the first time. Some of what I noticed turned out to be exactly what I was told it was, and I do not get to count only the times I was right. The second instance is the moment I am finally allowed to act on what I already noticed — the moment a suspicion becomes a position I can hold in a room without being asked to prove more than I can prove.

The best example I have of this was a service line profitability report, and what makes it useful is that nothing about it was wrong.

The attributed profitability per case (the margin the finance model assigned down to each individual case in that line) ran far above every other service line in the organization, and the P&L line item did not explain why. When I pushed, the answer came back quickly and it was correct. That line’s costs were built on a different basis than every other line’s, and the difference was large enough to account for the whole gap. No one was hiding anything. The number was accurate.

But the basis was invisible, and the number kept being repeated. People made capital and recruiting decisions off that profitability figure without knowing what produced it, without knowing that it was not comparable to the figure printed beside it, and without pricing what would happen if the difference underneath it narrowed. Every one of those decisions was locally reasonable. Nobody was ever in a position to ask the aggregate question, which was how much of our strategy was resting on one line’s cost treatment — because each decision only ever touched the number, and never the basis.

That is the thing worth taking from all of this. A wrong number gets caught. A number that is correct and unexplained propagates, and everyone downstream quietly inherits a dependency they never agreed to take on.

The obvious objection is a fair one, and I have had it put to me directly. A leader who chases every anomaly is a leader nobody brings anything to. Investigate on suspicion alone and you will spend your organization’s patience on noise, and the next time something real surfaces the person holding it will decide it is not worth the meeting. Two data points, besides, are still only two data points.

All of that is true. But notice that the second instance is a cheaper trigger than the one most of us actually use, not a broader one. It fires far less often than investigate anything that looks odd, and it fires considerably earlier than investigate after something goes badly enough that nobody can explain it away. Most of us are running the second rule and telling ourselves we are running the first. And two instances are not evidence. I am not claiming they are. What the second one buys is standing — permission to ask a question I could not justify asking the first time. What the two-instance test asks for is not more scrutiny. It is a way to hold a suspicion across a reporting period without either acting on it prematurely or losing it entirely, which is the thing I have never had a good system for.

Which is the part that should embarrass those of us who work on the business side of a hospital, because medicine solved this a long time ago. Morbidity and mortality conference, peer review, event reporting, sentinel event review: every one of them exists so that a single instance lands somewhere other than one person’s memory, and the sentinel event review exists because sometimes one is already enough. They are imperfect and they are gamed and they are sometimes theater, but they are a system, and the whole point of the system is that no one clinician has to carry a suspicion alone across six months and remember to raise it. We built that apparatus for clinical care. On the business side we built it only for the number that misses. Nothing fires when a number is correct and unexplained, and I have spent most of my career in rooms where the equivalent question had no place to go.

Which brings me back to the spreadsheet, and to the part of this I like least.

Every time the information was missing, I built it. I brought it to the room, I made the case, and the decision usually got better for it. What I never did was treat the absence itself as the recurring event. Each one felt like a one-off, because each one produced something — a chart, a number, a decision that went differently. The series produced nothing at all. There was no artifact for the pattern, so the pattern never came up for review.

The loop never got fixed, and the reason it never got fixed is that I kept covering for it. My willingness to build the thing by hand is precisely what kept anyone from having to feel the cost of its absence. I was not exposed to that failure. I was the reason it survived.

So the question I would put to you is not whether you are curious enough. I suspect you are. It is narrower, and harder, and you can answer it this week: what is the thing you have now built by hand twice, and who in your organization is comfortable because you did?