Process without governance can literally kill you

11048198_mThere is great power when strong processes meet solid governance practices. I had a recent real-life experience of the opposite, process without governance, which could have had grave results.

A group of us were at the movies and a couple sitting on the row in front of us got up in the middle of the movie and started making their way to the aisle. I could tell something was not right based on the timing (it was a pivotal point in the movie) and nature (he was walking in an odd posture; she was kind of dragging him by the arm) of the move. As they reached the end of the aisle, the man collapsed.

My wife and I immediately jumped up, she was at his feet, and I was at his head. I ask the lady next to me to call “911”. I start going through all the CPR training checklists I’ve stored in my brain, checked to see if he was conscious, check for breathing, etc. He was breathing, but wasn’t conscious. Within 10 seconds he woke up, was sweating, didn’t know where he was, and was very agitated.

Process Starts Kicking In

Within the first 30 seconds, it was up to the people watching the movie to care for the man. After that, employees of the movie theater began to arrive. You could tell they were the trained first responders. They had obviously been given specific roles, specific duties, and been through dedicated training exercises. They were young and flustered, but performed very well within their span of control. The issue was the manager hadn’t shown up yet, and when he did, he didn’t take control of the situation and bring governance to the process.

What a Lack of Governance Looks Like

The ungoverned situation unfolded through a series of very well trained 18-to-20 year-old employees showing up and announcing they were trained in a specific discipline. The first young lady jumped down on the floor with me and announced, “I’m trained in responding to strokes. Can you ask him to… wait, let me think… move the fingers on his right hand. OK, now ask him to wiggle the toes on his left foot. Now, ask him to say ‘she sells sea shells by the…”

About 15 seconds into her instructions, the second young lady jumps down on the floor with me and announced, “I’m trained to respond to heart attacks. Could you tell me if he is breathing? Is he sweating? Is he coherent and lucid? Is he…”

By this time, about a dozen movie patrons were on the line with emergency dispatchers, a guy hands me his cell phone with the flashlight turned on and asks me to check to see if the patient’s pupils react to light. I check, they react, and I report back. I’m speaking with the patient and he is very agitated at this point, embarrassed the movie has stopped, the lights have been turned up, and such a commotion has developed around his collapse. A manager of the theater showed up, is watching the situation, and asked the man to lie still until the emergency workers arrive.

The patient doesn’t. Against everyone’s advice, he and his wife got up and walked out of the theater after announcing he won’t sue anyone for letting him get up and leave. The manager follows the couple and the movie starts again.

How to Make It Better

I have to admit I had a tough time concentrating on the movie after that. It is a scary thing to see and be involved in, but, in my opinion, something we have to be able to handle as a part of being a member of society. We have to take care of each other.

However, that damn process “thing” in my head wouldn’t let me stop think about how that situation could have been improved. I realize in an extreme situation like that, managing the process is not the first thing that pops into most people’s minds. The young people that showed up gave me great faith in the future of our society. They were well trained and eager to jump in and apply their training. Not the lazy, good-for-nothing bums we hear about all the time. They could have benefited a great deal from a good leader and some governance. I’ve since suggested that to the movie theater. Aside from just training their staff in how to handle the different types of disorders (stroke, heart attack, etc.), they should have a well-trained responder that is there to manage the people, too.

What suggestions would you make?

(Aside: We did go check. The emergency workers did arrive, assessed the man outside the theater  and were taking him to the hospital. He wasn’t in good shape, but looked to be in the right hands).


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Categories: Continuous Improvement, Process Management

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2 Comments on “Process without governance can literally kill you”

  1. January 19, 2013 at 10:46 pm #

    Emergency response needs to be practiced until actions become instinctive for the team as a unit.

    As you have demonstrated, partial mastering of individual protocols can do more harm than good.

    The theater event could have ended very badly.for the theater had the patron died on the premises.

    Today, as BPM practitioners provide their clients with tools capable of handling any mix of ad hoc and structured work, governance becomes more difficult.

    It’s not clear to me how many BPMs have the functionality to process fail-safe rule sets at key process points along structured workflows.

    I expect many practitioners are just starting to consider how to address the problems of providing real time governance of ad hoc interventions at Cases.

    • January 20, 2013 at 7:20 am #


      Thanks for the note and I agree 100%. This could have ended very badly. Governance is hard in emergency situations, and practice drills are imperative.

      My experience has been that most BPM tools and the practitioners I work with build governance in from the beginning. At least the good ones do.

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