Thursday, January 4, 2024

Talk About Mistakes, or Near-Mistakes

 At many companies, I've had to remind staff and employees, "I can't help fix problems if I don't know about them." Sometimes I got the response, "I would tell you...but I don't want to get into trouble." My followup was always, "You'd only get in trouble with me, if you don't talk about them." This was in contrast with one of my early-career assignments: I had a VP tell me he'd never admit making a mistake like I had just done.

Recently reported on a Hidden Brain podcast, a researcher was surprised when her findings showed that the best, collaborative, communicative healthcare teams had poorer results: more errors. Then she had the insight that perhaps the best teams report their errors consistently whereas poorer operating teams don't. She then correlated her results to a survey question regarding the impact of reporting errors. The worse teams were more fearful to report errors whereas the better teams freely reported errors.

We not only need to talk about the errors and mistakes and problems, but also the near-mistakes taking a tool from the safety handbooks of reporting near-accidents. For example, I almost bumped my head on a projecting piece of steel sitting on a rack shelf. I paid attention and got the piece of steel either repositioned or flagged so that others would see it and avoid injury. One of the situations mentioned in the research was a less-experienced nurse resetting an unfamiliar device in a dimly lit corner of the patient's room. If the person had reported it, the team could make sure all devices are in well-lit places or there's a mechanism to illuminate the device when needed.

In one company, we had thirty percent (30%) of the employees on internal audit teams. [Honestly, we didn't have enough to audit to keep them experienced as auditors; we had too many volunteers.] Two reasons for this: we framed the program not as "gotcha" mentality but as learning about other departments and what they do--to reduce the thoughts "they don't do anything all day" or "why can't they avoid these problems?"; we also wanted to learn how people avoided errors and mistakes through deviations from the written procedures and incorporate those best practices in the documentation. 

If your company doesn't like talking about mistakes, your company is not on the path of improvement. It's not a learning organization as Senge taught us decades ago. Learning organizations get better and have better results.

Good judgment comes from experience and experience comes from bad judgment, an old saying advises us.

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