Tenacity: plan the recovery before the setback

Most people already know how to be tenacious. They show it at work every week: the deal that falls through and gets rebuilt, the project that slips and gets rescued. Dr. Scott's original slide makes the point that many people who show that kind of resolve at work find it much harder to apply to their own health. It's a familiar pattern: one missed week of walking becomes a missed season, and one alarming reading gets explained away while the cuff goes back in the drawer.

High reliability science treats this as a design problem rather than a character flaw. The fifth of Karl Weick and Kathleen Sutcliffe's principles, commitment to resilience, starts from the assumption that failures will happen. As the AHRQ patient safety primer describes it, teams that practice it assume things can go wrong, assess problems fast and watch each other's work so they can respond before harm occurs. Dr. Scott's original slide describes it this way:

"High reliability organizations develop capabilities to detect, contain, and bounce back from inevitable errors. These organizations aren't error free; instead, they embrace processes to ensure that an error isn't disabling." Dr. Scott, from the original SCOTT Protocol

Read the verbs again: detect, contain, bounce back. None of them is "avoid." The step called Tenacity asks you to stop measuring yourself by whether you ever fall off a plan, and start measuring how fast you notice and how far you fall before you catch yourself.

The shape of a setback

One way to picture resilience is as a curve: performance runs along, takes a hit, dips, then recovers. The interesting part is the dip. How deep does it go, how long does it last, and does the system come back to where it was, or lower, or a little higher? Replay one hard month below and watch where the two versions part ways.

The two people in that drawing face the same bad month. What separates them is three decisions made in advance: what counts as slipping, what the smaller version of the routine looks like, and when to call for help. Each of those decisions is cheap on a calm Sunday and nearly impossible to make in the middle of a crisis.

The most common failure is looking away

The deepest dips usually don't start with a missed walk. They start with a decision not to look. Dr. Scott names the reason in her original slide, and it is honest about how people actually feel.

"Avoidance behaviors are often grounded in a mindset that acknowledging a health issue will rob you of the comforting normalcy of everyday life." Dr. Scott, from the original SCOTT Protocol

That's the bargain people strike when they skip the follow-up colonoscopy or never open the patient-portal message. If nobody says the word, life stays normal for a while longer. The trouble is that the body doesn't honor the bargain. According to the CDC, more than 115 million American adults have prediabetes and roughly 8 in 10 of them don't know it. Not knowing is not the same as being fine.

Her slide frames resilience as the opposite habit: the ability "to acknowledge and act on a potential health risk or threat, instead of ignoring it." Acknowledging a problem early is what keeps the dip shallow. A borderline blood sugar caught this year is a conversation about walking and dinner. The same number ignored for five years can become a prescription, a specialist and a much longer conversation.

A missed dose is a data point

Medicine has a word for following a treatment plan, adherence, and the numbers on it have been sobering for a long time. In its 2003 report on long-term therapies, the World Health Organization estimated that in developed countries, adherence among people with chronic diseases averages only about 50 percent. It's an old, rough figure, and nobody should treat it as precise. The point it makes has held up: half-followed plans are the normal case, not the shameful exception.

So treat a lapse the way a reliable organization treats a near miss. Not as proof that you lack discipline, and not as something to hide from your clinician, but as information about where the plan is weak. Did the pills run out because refills need a phone call you dread making? Did the walks stop because the only free time is after dark? Did you stop the new medicine because of a side effect you never mentioned? Each answer points at a fix, and most of the fixes are small. Tell your clinician or pharmacist what actually happened; a plan built on what you really do is safer than one built on what you said you'd do.

What the Diabetes Prevention Program asked of people

Some of the clearest evidence that ordinary people can bend a risk curve comes from a trial that asked them to do something modest and keep doing it. The Diabetes Prevention Program enrolled 3,234 adults whose blood sugar was raised but not yet in the diabetes range. One group got a lifestyle program with two goals: lose at least 7 percent of body weight, and get at least 150 minutes of physical activity a week. Another got the drug metformin, and a third got a placebo.

New cases of diabetes, per 100 people per year

3,234 adults with raised blood sugar who did not yet have diabetes, followed for an average of 2.8 years.

036912

• Placebo 11.0
• Metformin 7.8
• Lifestyle program 4.8

Show the numbers

Group	New cases per 100 person-years	Compared with placebo
Placebo	11.0	Reference
Metformin	7.8	31% lower
Lifestyle program	4.8	58% lower

Source: Diabetes Prevention Program Research Group, Knowler et al., New England Journal of Medicine, 2002.

Over an average of 2.8 years, the lifestyle group developed diabetes 58 percent less often than the placebo group, and the metformin group 31 percent less often (Knowler and colleagues, 2002). For every seven people or so who went through the lifestyle program for three years, one case of diabetes was prevented.

Notice what the goals were not. Nobody was asked to reach an ideal weight or train for a race. Seven percent for a 200-pound person is 14 pounds. A hundred and fifty minutes is a brisk half hour on five days. These are goals sized to survive a bad month, which is exactly why tenacity matters more than intensity. A plan you can restart after a setback beats a heroic plan you abandon.

When the setback is a diagnosis or a hospital stay

Some hits are bigger than a bad month. A new diagnosis, an operation or a hospital stay can flatten every routine at once, and the recovery period carries risks of its own. In a study of 400 patients sent home from the general medical service of one academic hospital, 19 percent had an injury from their medical care within about three weeks of discharge. Investigators judged roughly a third of those events preventable, and two-thirds of all the events involved medicines.

Dr. Scott's slide describes the kind of resilience these moments call for, and it is more practical than heroic. "True resilience comprises managing all aspects of the business of your wellness," she wrote. "It includes acceptance and self-education regarding diagnoses and treatment options available to you."

Acceptance comes first because you can't plan around something you won't name. Self-education comes next: what the diagnosis is, what the treatment options are, what recovery normally looks like week by week, and which warning signs mean you should call. Then the recovery plan gets the same treatment as any other routine. Know who to call and how. Get the medication list checked against what you actually have at home. Book the follow-up appointment before you leave. Our field note on going home from the hospital and the discharge checklist walk through it step by step.

Study your good weeks too

Safety science spent decades studying failures. Erik Hollnagel and his colleagues in the resilience engineering movement argued that this was only half the picture. In a 2015 white paper with Robert Wears and Jeffrey Braithwaite, they wrote that safety management "should therefore move from ensuring that 'as few things as possible go wrong' to ensuring that 'as many things as possible go right.'" They called it Safety-II, and their advice was to "look at what goes right as well as what goes wrong, and learn from what works as well as from what fails."

For one person, that is a practical instruction. Most people can list their failures in detail. Fewer can say why their good stretches worked. Take ten minutes and think about the last month your health habits held:

• What time of day did the walk happen, and who, if anyone, was with you?
• Where did the pills live, and what were they next to?
• What was in the refrigerator on Sunday night?
• What did you stop doing to make room?

Those answers are your working procedures. Write them down. They are what you rebuild first after the next hit, because you already know they work for you.

Write the drill before the fire

Dr. Scott's slide notes that high reliability organizations "imagine worst-case conditions and practice their own equivalent of fire drills." The personal version is a short list of if-then plans: if this specific thing happens, then I will do this specific thing. Psychologists call these implementation intentions. A 2006 meta-analysis by Peter Gollwitzer and Paschal Sheeran pooled 94 independent tests and found that forming them had a medium-to-large effect on whether people reached their goals. The plan works because the decision is already made when the moment arrives, so you don't have to make it under pressure.

Good if-then lines share a few traits. The "if" is concrete enough that you'll recognize it (not "if I get busy" but "if I'm working past seven"). The "then" is smaller than the original routine and can happen right away. And anything that involves a symptom, a reading or a medicine includes a call to someone on your crew.

Keep the list short. Three or four lines you remember will beat a page you never read. Put a copy where the routine happens: on the refrigerator, in the travel bag, next to the cuff. Read it on the first day of each month, and rewrite any line that failed you, because a plan that broke is telling you something.

Tenacity keeps a setback from becoming an outcome. The last step in the protocol turns to the work that should happen before any setback at all: doing the things you already know you should.

Last updated October 16, 2026. Guidance cited here was current on that date; clinical guidelines change, so check with your own clinician. See our editorial policy.