The sense of unease taught to me by a single pocket tissue—the importance of not ignoring that 'something feels off'

At our clinic, all staff members recite the following every morning.

This sentence may seem simple at first glance, but to me, it is packed with the essence of protecting an organization. And this is not just a slogan.
I believe that
it is meaningless unless I embody it more than anyone else.

Today, I would like to share an actual event where that 'attitude of not ignoring a sense of unease' prevented a major problem.

At the end of a workday, I was checking the daily medical reports as usual.
Suddenly, one number caught my eye.

We were operating with two examination rooms that day. The number of patients seen by the doctors in room 1 and room 2 was almost the same.
However, the 'number of pocket tissues handed to patients' was extremely different.

At our clinic, staff members hand out pocket tissues as a gesture of apology to patients who have been kept waiting for more than an hour.
Based on this rule, if the number of patients and the pace of examinations are about the same, the number of tissues handed out should not be significantly different.

Yet on this day, the doctor in room 1 had 'zero', while the doctor in room 2 had 'over 10'.

This is strange. Something is different here.

I asked the staff.
'Why is there such a difference?'
The response I got was something like, 'Hmm, I wonder why?' or 'I had never noticed that'.

However, it bothered me.
I was also concerned that the examinations by the doctor in room 1 had been finishing strangely quickly.

So I asked further:
'By any chance, is Dr. M in room 1 not performing fewer tests than the other doctors?'

The staff thought for a moment and replied:
'Come to think of it... Dr. M gives an unusually high number of instructions to delete diagnoses' to the staff assisting them.'

With that one remark, everything clicked for me.

At our clinic, 'necessary tests' are pre-set for each diagnosis for returning patients.
This was designed to 'prevent missed tests due to variations between doctors' and is an important mechanism to ensure the quality of patient care.

And, if a diagnosis is deleted, the tests linked to that diagnosis are automatically not performed.

In other words—
there is a high possibility that Dr. M was reducing tests by deleting diagnoses in order to increase clinical efficiency.

So I gave the staff an instruction:
'For the next few weeks, I want you to record the number of 'diagnosis deletion instructions' for all supporting doctors (about 10 people).'

The result was clear.

While other doctors had about 0 to 1 case, only Dr. M was issuing around 10 diagnosis deletion instructions each time.

I want to clarify one thing here.
This is by no means 'excessive testing'.
It is a 'standardization' to ensure necessary tests can be performed appropriately, and a safety design for the patient..

It is unclear whether Dr. M's actions were intentional.
However, the fact that, as a result, the patient was not provided with the necessary tests cannot be overlooked.

Doctors also have their own individual clinical styles.
But if that freedom leads to 'patient disadvantage,' it defeats the whole purpose.

Regarding this matter, I carefully explained the facts to Dr. M and strictly requested improvements for the future.

The origin of this series of facts was
**'the extreme difference in the number of pocket tissues distributed,'** which was
just a slight 'discrepancy in the numbers'.

However, if I had ignored that,
this problem might still have gone unnoticed.
Or perhaps,it might only have come to light after a patient raised a complaint.It is my responsibility as a manager to notice such things before that happens.

'Something is a bit off, it's different from usual'—
there is a reason why I have this perspective recited daily.
That is because,the ability to perceive such unease is the 'last line of defense' that protects the safety and trust of the workplace.

And above all, the one who must practice this first and foremost is
none other thanmyself, as the head of the organization.