Beyond the Blame Game

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If at first you don’t succeed, then go ahead and fail, but do it intelligently. Failure, in fact, not only should be dissected and analyzed, but should be planned for—and, if done well, celebrated. That’s because failure, according to Amy C. Edmondson, not only is inevitable in complex systems (such as a busy hospital emergency department), but is a key innovation tool. The tragedy occurs when organizations fail to learn from failure, and most of them do, she writes in the April 2011 issue of Harvard Business Review.¹ As health care embarks on a period of great experimentation, the lessons that Edmondson imparts are well timed for this market. The author reviews the role and spectrum of failure (from deviance to exploratory testing), but she also addresses ways to limit the liabilities associated with failure. Edmondson lays the responsibility for the inability to learn from failure squarely at the feet of leaders, who are invariably guilty of viewing failure as something bad (though not all failures are) and are unable to embrace the lessons of failure due to cultural beliefs and stereotypical notions of success. “In organizational life it is sometimes bad, sometimes inevitable, and sometimes even good,” she says. Begin by understanding how the blame game gets in the way of learning from mistakes. Executives Edmondson has interviewed in a range of organizations, including hospitals, worry that without the fear of blame, people will not do their best work. The author identifies a spectrum of reasons for failure to explain why a culture in which it is safe to admit blame can—and in some organizations, must—exist in an organization that adheres to the highest standards. On the blameworthy end of the spectrum, it begins with deviance, followed by inattention, lack of ability, and process inadequacy. Task challenge is at the center of the spectrum, followed by (and progressing toward the praiseworthy) process complexity, uncertainty, hypothesis testing, and exploratory testing, the most praiseworthy reason for failure. Very few of the reasons for failure on this spectrum are purely blameworthy, and in fact, most executives acknowledge that the percentage of blameworthy failures is in the low single digits. Because 70% to 90% are treated as blameworthy, however, many failures go unreported and therefore are likely to recur. Three Flavors Failures fall into three broad categories: preventable in predictable operations, unavoidable in complex systems, and intelligent at the frontier. Preventable failures are to be avoided and usually involve deviations from specified processes in high-volume or routine operations. Training, checklists, and systems that adapt processes (based on what is learned from small mistakes) are measures that are successful in preventing such failures. Unavoidable failures in complex systems can usually be attributed to an unpredictable combination of factors that might never have occurred simultaneously before in a complex environment, such as a hospital emergency room, a battlefield, or a fast-moving startup. Such failures are inevitable, Edmondson believes, and the best approach is to identify them rapidly, so that they do not trigger consequential, larger failures. “Most accidents in hospitals result from a series of small failures that went unnoticed and unfortunately lined up in just the wrong way,” she notes. Intelligent failures occur when experimentation is required, providing an organization with valuable new knowledge. At the frontier, managers hope for experiments that fail quickly, thereby preventing the failure of a larger-than-necessary experiment, which is what Edmondson calls an unintelligent failure. The Leader’s ROle Tolerating the failures that provide knowledge requires leadership that can shift the organization away from blame and toward a culture of learning—in which managers seek the reason for a failure, rather than the perpetrator. All organizations learn from failure through three activities: detection, analysis, and experimentation. Detection, however, can be tricky. Big failures are easy to spot, but the small failures that are unlikely to cause serious harm stay hidden, in many organizations. Edmondson relates an anecdote about Alan Mulally, president and CEO of Ford Motor Company (Dearborn, Michigan), who instituted a new system for detecting failure by color coding reports green for good, yellow for caution, and red for problems. Mulally grew increasingly frustrated during the first several meetings, as all reports were coded green. After one manager delivered a yellow-coded report about a problem that could delay a launch, Mulally broke into applause, and a greater openness ensued. The attitude of the manager plays a significant role in the willingness of nurses to discuss failures in hospitals, Edmondson writes. How midlevel managers respond to failures and whether they encourage open discussion, welcome questions, and display humility and curiosity were the differentiators. She also reports that failure analysis is frequently ineffective, even in hospitals. An exception to that rule is Intermountain Healthcare (Salt Lake City, Utah), where physicians’ deviations from care protocols are routinely analyzed. Allowing deviation and sharing the data on whether care is improved encourage physician buy-in; multidisciplinary teams can go beyond the superficial to root out second- and third-order causes of failure. The third activity necessary for learning from failure is experimentation—but only in the right place and at the right time. “Too often, managers in charge of pilots design optimal conditions rather than representative ones,” Edmondson writes. “Thus the pilot doesn’t produce knowledge about what won’t work.” In communicating the kinds of failures that can be expected in a particular work environment, it is important for leaders to craft the right message for a given work context. Most organizations engage in the kinds of work associated with all three categories of failure: routine, complex, and experimental. Building a Safe Environment Julie Morath, former COO of Children’s Hospitals and Clinics of Minnesota (St Paul), led a successful campaign to reduce medical error during her tenure (1999–2009), illustrating five practices that Edmondson identifies as critical to building a psychologically safe environment: Frame the work accurately, embrace the messengers, acknowledge limits, invite participation, and set boundaries and hold people accountable. Morath began by accurately framing the safety issues in the hospital environment through sharing US medical-error rates, building teams of influencers, and conducting discussion groups. She also implemented a system of blameless reporting, in which employees were encouraged to reveal medical errors and near misses anonymously. She encouraged employees to learn from failure and always assigned a team to analyze each incident, and the rate of reported failures spiked. By acknowledging her limited knowledge of how things worked and encouraging thoughtful discussions about the safety of the patient experience, she helped employees recognize that there was room for improvement, thus enlisting many willing helpers. When Morath launched blameless reporting, she held the staff accountable by specifying the behaviors that were not blameless—including reckless conduct, conscious violation of standards, and failing to ask for help when overwhelmed. Courage is required by those individuals and organizations intent on learning from their failures, but most managers are loath to move beyond the blame game, at the risk of creating a lax workplace. Edmondson believes that failure is inevitable in today’s complex work environments, and those who can learn from it are the ones who will succeed.