A fascinating interview in Slate magazine (sent to my by my brother) quotes James Bagian – once a NASA astronaut among other careers – as saying:
You can't change the culture by saying, 'Let's change the culture.' It's not like we're telling people, "Oh, think in a systems way." That doesn't mean anything to them. You change the culture by giving people new tools that actually work. The old culture has tools, too, but they're foolish: "Be more careful," "Be more diligent," "Do a double-check," "Read all the medical literature." Those kinds of tools don't really work.
So here's a man after my own heart. (He's also against scorecards – another plus in my view). In fact, I wondered if he'd read my book, but no it seems he had these ideas without any help from me.
In the interview Bagian talks about how people in organizations deal with errors, except that he doesn't like that term. He is of the opinion (he is talking of healthcare, but in my experience it could be any organization) that a common response to failure is to look for someone to demonize when things go wrong, "Let's figure out who screwed up and blame them and punish them and explain to them why they're stupid." Shades of the treatment of BP's CEO, Tony Hayward, spring to mind. His view of the word "error" is that "it distracts people from the real goal, which isn't reducing error but reducing harm. And it also feeds into precisely the cultural problem we're discussing. It has a punitive feel, and it suggests that the right answer was available at the time, which isn't always the case."
The same day I read this interview I read a report of an article on learning from failure in Science Daily. This notes that "While success is surely sweeter than failure, it seems failure is a far better teacher, and organizations that fail spectacularly often flourish more in the long run, according to a new study by Vinit Desai, assistant professor of management at the University of Colorado Denver Business School." Peter M. Madsen, Vinit M. Desai. Failing to Learn? The Effects of Failure and Success on Organizational Learning in the Global Orbital Launch Vehicle Industry. Academy of Management Journal, 2010.
Desai doesn't recommend seeking out failure in order to learn. Instead, he advised organizations to analyze small failures and near misses to glean useful information rather than wait for major failures. "The most significant implication of this study…is that organizational leaders should neither ignore failures nor stigmatize those involved with them," he concluded in the June edition of the Academy of Management Journal, "rather leaders should treat failures as invaluable learning opportunities, encouraging the open sharing of information about them."
What's interesting is that both Bagian and this article have roots in the 'orbital launch vehicle industry'. I wonder whether this industry is particularly open to learning from failure and whether other industries are not (and would they be more successful if they were?) But looking at another of Kathryn Schulz's interviews, this time with Victor Niederhoffer he takes a similar line to both Bagian and Desai people who make errors and mistakes "should think about the principles that led to their mistakes". Summing up the three pieces they all make the same three points: to learn from errors
1 Ask why mistakes occur and look at close calls – where mistakes nearly occur but are headed off (as in near mid-air collisions).
2 Encourage people to report errors and close calls – which they tend not to for fear of humiliation, punishment and retaliation. Bagian encourages reporting in a very specific way by framing what an error or close call is and why he is interested in it.
3 Be open about things that go wrong and be willing to discuss them, analyze the situation in which they occurred, and provide people with the information and tools to do things differently in the future.