"Learning from Mistakes"

OD consultants like myself are very interested in organizational learning, building the capacity of teams and staff to learn from their experience in order to improve future performance.  We help organizations create the practices of ongoing reflection and learning, gleaning lessons from what worked and what didn’t work.  Learning from mistakes in high stakes situations is of paramount importance and interest, for example, in health care.

You’ve have probably heard stories about wrong-side surgeries, where patients wake up and wonder why the bandage is on the wrong side ;)  I was very interested in how Beth Israel Deaconess handled this 5 years ago, when then-CEO Paul Levy wrote about it in his blog, Running a Hospital.  Now I’m enjoying his new book, Goal Play, in which he connects leadership to lessons from the soccer field!  Levy talks about creating organizational cultures that “learn from mistakes”, which I think was a highlight of his tenure at Beth Israel.  There was a highly-publicized surgery mistake in his hospital, and the administration was very open about what happened.  They did not fire or punish the surgeon.  When challenged about that, Levy maintained that if you want people to disclose errors in the future, you can’t respond in a punitive manner.  Hence a learning organization – they were creating the conditions for people to be able to disclose and learn from their errors.  There were also other measures and tools that they implemented to improve the way people worked together.

One popular tool is a checklist, which was highlighted in Atul Gawande’s book, Checklist Manifesto.  I’ve been a fan of his since before he became famous. :)  He urges OR doctors to go over checklist of questions before every surgery in order to reduce errors.  Health care borrowed this from the aviation industry, which also uses checklists. The characteristics that both industries share is a hierarchy with a chief at the top – the pilot or the doctor, wherein the rest of the team defers to the chief, who may lead them down the wrong path – to a wrong-side surgery or to fly into a mountain.  The airline industry created CRM, crew resource management, to help crews have conversations that will help them prevent errors.   CRM includes 3 steps:  state the facts; verbally challenge the captain; take an action that impedes the ability of the captain to make a fatal error.  

The problem with CRM is that staff who are used to deferring to the chief, who is seen to have the ultimate power, are reluctant to raise questions or to provide negative information that would question a leader’s decision.  What teams need is time to practice the skills of speaking up, to break their habit of keeping silent, and to get over their fear, well in advance of stepping into an Operating room or a cockpit.  There is an  important role here for us to play:  to coach leaders on the need to be open to receiving this feedback and to not punish people for giving feedback – as well as coaching the team and the leader on how to give feedback to one another, in a respectful way that isn’t blaming or humiliating.  The ideal would be for us to help leaders create working cultures where people invite feedback.  As facilitators we are used to asking for feedback when we facilitate groups, and hopefully it’s a skill we practice with our clients.  When we ask for feedback we are modeling that which we’re asking leaders to do – which makes our ability to ask for feedback a real gift to our clients!

Do you have a story of helping a team to give one another feedback?  How did it go?