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Learning from Mistakes

by Paul F. Levy, author and patient-driven care advocate

As a leader, you must do everything you can to encourage people to admit mistakes they have made and to call out problems they have found in the organization. (As Amy Edmondson of Harvard Business School similarly suggested in an earlier post). If people think they will get in trouble for having erred, or for having brought up a systemic problem in the organization, those errors and problems will go unreported. The person and the organization will thereby lose an opportunity to grow and improve. Accordingly, a strong commitment not only to transparency but to a just culture is essential to achieve continuous improvement.

Leadership’s role in such matters is determinative of process improvement in the organization. Equally important, it also empowers the personal and professional growth of people in the firm.

MIT Management Professor Edgar H. Schein has described the communications ethic inherent in such an environment as follows: “Team members have to learn how to analyze and critique their own and each other’s task performance without threatening each other’s face or humiliating each other. That means that subordinates have to learn how to tell potentially negative things to their superiors, and superiors have to learn how to not punish their subordinates for telling the truth if that truth is inconvenient. That, in turn, requires the ability to give and receive feedback in a constructive manner.”1

But true process improvement also requires leaders to go one step further, to take ownership of flaws in their organization. Paul Wiles, former President and CEO of Novant Health in Winston-Salem, NC, once told me and a group of hospital CEOs a heart-wrenching story about an infant’s death from sepsis in his hospital, which was tracked to an MRSA (antibiotic-resistant staph) infection. The infection was part of a spread of a bug in his neonatal intensive care unit (NICU) that reached 18 infants in all and may have contributed to the deaths of two others.

“This was a direct result of staff not washing their hands appropriately,” he said. Since that event, “We have been on a relentless hand hygiene campaign.”

The crux of his entire presentation was this comment: “My objective today is to confess. ‘I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties,’ ” he noted, by focusing instead on the traditional set of executive duties (financial, planning, and such). Wiles ended his talk to the CEOs in the audience, saying, “If you cannot see the face of your own relative in a patient, or if you cannot see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.”

But it is not just leaders in the hospital world who have come to these conclusions. Let’s head to an oil rig in the North Sea.

A number of years ago, Tom Botts was involved in a tragedy aboard an oil rig in which he personally had to call off the search for men missing at sea. Deeply shaken, when he later moved on to be Executive Vice President for Shell Oil Company’s exploration and production activities in Europe, he decided that he would implement the most comprehensive program possible to protect workers’ safety at these remote outposts in the ocean. Notwithstanding that new program—the best in the industry—two men lost their lives on a North Sea oil rig when they mistakenly went into a portion of the facility that should have been off-limits. It would have been easy to blame the two men who, after all, entered a prohibited area. Instead, Tom launched a thorough, top-to-bottom review of the organization.

He explained, “We decided to be as open and transparent about the incident as possible and went through a ‘Deep Learning’ journey involving hundreds of people that examined in detail all the root causes that contributed to the accident to get a clear picture of the system that produced the fatalities. Even though the two men who were killed could have made better decisions, my senior leadership team and I could find places where we ‘owned’ the system that led to the tragedy.”

“It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organization to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.”

Tom continued, “Once you take that step of committing to transparency and learning, it sets a high bar and it is very hard (probably impossible) to take it back. This approach has helped make us stronger and more aware of the impact of our daily decisions.”

Turning back to health care, Dr. Charles Denham wrote an article in which he related the practice of nursing chief Jeannette Ives-Erickson, Senior Vice President For Patient Care and Chief Nurse at Massachusetts General Hospital.2 When a nurse makes an error in caring for a patient, Jeanette calls the involved nurse into her office and asks one question: “Did you do this on purpose?” When the nurse answers, “No,” then Jeannette says, “Well then it is my fault… errors stem from system flaws … I am responsible for creating safe systems.”

Chuck notes, “In a few short moments with a caregiver after an accident, the leader declares ownership of the systems envelope, and the performance envelope of her caregivers, and creates a healing constructive opportunity to prevent a repeat occurrence.”

Chuck properly warns us that it is easy to “automatically fall in a name-blame-shame cycle, citing violated policies, and ignore the laws of human performance and our responsibility as leaders.” It is up to us as leaders to be mindful of the results of such behavior on our part. The bad example we set cascades through the organizations. Mistakes and near-misses go underground, as people fear that reporting will just get them into trouble. Opportunities to improve our systems are lost, along with the potential for personal and professional growth on the part of our staff.

In contrast, behaving like Wiles, Botts, or Ives-Erickson empowers those working with us. People evolve individually and collectively into a learning organization. Each person feels that he or she is valued, understands his or her place in the firm, and goes home able to say, “I accomplished something worthwhile today.”

This post originally appeared on the athenahealth Leadership Forum.

1 Schein, Edgar H., Helping, How to Offer, Give, and Receive Help, Barrett-Kohler Publishers, Inc. San Francisco. 2009. Page 118.

2 Dr. Charles Denham, “May I have the envelope please.” Journal of Patient Safety. 2008 Jun;4(2):119–123.

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