I have been reading an interesting article entitled “the hard work of failure analysis”, which looks at the structures and processes people put in place to learn from failure – a difficult task for most organisations, and prone to cognitive bias. I thought that the following was a good example of ways to work around these issues
Julie Morath, the Chief Operating Officer at the Minneapolis Children's Hospital, implemented processes and forums for the effective analysis of failures, both large and small. She bolstered her own technical knowledge of how to probe more deeply into the causes of failure in hospitals by attending the Executive Sessions on Medical Errors and Patient Safety at Harvard University, which emphasized that, rather than being the fault of a single individual, medical errors tend to have multiple, systemic causes. In addition, she made structural changes within the organization to create a context in which failure could be identified, analyzed, and learned from.
To create a forum for learning from failure, Morath developed a Patient Safety Steering Committee (PSSC). Not only was the PSSC proactive in seeking to identify failures, it ensured that all failures were subject to analysis so that learning could take place. For example, the PSSC determined that "Focused Event Studies" would be conducted not only after serious medical accidents but even after much smaller scale errors or "near misses." These formal studies were forums designed explicitly for the purpose of learning from mistakes by probing deeply into their causes.
In addition, cross-functional teams, known as "Safety Action Teams," spontaneously formed in certain clinical areas to understand better how failures occurred, thereby proactively improving medical safety. One clinical group developed something they called a "Good Catch Log" to record information that might be useful in better understanding and reducing medical errors. Other teams in the hospital quickly followed their example, finding the idea compelling and practical.
Some good ideas there, and I really like the “Good Catch Log”