After a retrospective, it’s a good idea to write down the learnings and share them widely. A team growing hardy from its own successes and missteps is great, but when they can also help others improve or avoid similar errors, that’s even better. At the end of the day, a resilient organization isn’t one that never makes mistakes but rather one whose mistakes make it stronger over time.

Resilient processes also try to create repeatable best practices. Most of the work needed to make something happen in today’s world is staggeringly complex. Just imagine the number of steps it takes to get a plane to take off—the cabin must be cleaned from the previous flight, the jet must be refueled, passengers must be checked in, luggage must be loaded, safety checks must be done, and so forth. It’s near impossible to remember all the steps in your head, let alone try to improvise them in the moment.

1. Onboard People to the Organization, Not Just the Job

Friction fixers who are intent on building a culture of coordination go beyond training newcomers to perform their narrow job responsibilities. They teach newbies how their work meshes with that of others, how the organization functions, and how to use the system to help them do their work. This saves a lot of trouble down the road....

2. Get Up Close and Personal with People Who Make the System Tick..

Yet, as Wired reported, they developed grudging respect for one another. Together, they patched HealthCare.gov by bringing “order to the site through careful monitoring, automated testing, and a collaborative, methodical, commonsense approach to bug fixing.” There is nothing sacred about L6. Elsewhere, traveling down three or four levels is plenty. The key is locating the people—such as employees, customers, or vendors—who understand how a system works and why it doesn’t...

3. Good Stories Stoke Coordination

Hubert believes the stories that he told strengthened connections between Best Buy employees and customers, and employees and management. Like the one about Jordan, a three-year-old in Florida who loved his T. rex toy and called it his “dino baby.” When dino’s head snapped off, Jordan was heartbroken. Jordan’s mother found the same T. rex at Best Buy, ordered it online, and drove Jordan to a store to pick it up. She told the Best Buy associate that they needed a “dinosaur doctor.” The associate, T, recruited a colleague, Stephanie, and they took Jordan’s headless dinosaur to “surgery” behind the counter out of Jordan’s view. “Just a few more stitches,” the pair said as they replaced the broken T. rex with the new one. When they handed Jordan the “cured” dinosaur, he squealed with joy...

4. Build Roles and Teams Dedicated to Integration...

5. Fix Handoffs...

One rule is “never hand over a fire in the heat of the day.” Firefighters learned this lesson from the Dude Fire in Payson, Arizona, in 1990. Six firefighters were burned to death after a botched handoff, which occurred at “1:00 P.M. on a hot, windy day with temperatures in the high nineties while the fire was making spectacular runs.” Crews now do handoffs at night, when it is easier to see fires and “low winds, high humidity, and cool temperatures stabilize the fire.

Crew chiefs use a briefing for such handoffs to help pass along the “big story,” steps that could by adopted by friction fixers in other settings. During a forest fire, the outgoing chief goes through five steps during a conversation with the incoming chief:

• Here’s what I think we face.

• Here’s what I think we should do.

• Here’s why.

• Here’s what I think we should keep an eye on.

• Now talk to me (i.e., tell me if you (a) don’t understand, (b) cannot do it, (c) see something that I do not).

That last step places responsibility on both chiefs to assure that messages are received and to resolve clashing perceptions...

6. Coordinate on the Fly...

Friction fixers are of two minds. First, they labor to prevent unpleasant surprises. To build workplaces where people aren’t exhausted by one emergency after another and don’t live in fear of system failure. Second, they know, as Beatle John Lennon put it, that “life is what happens to you while you’re busy making other plans...

These teams started with a provisional plan, the “sheet music.” Film crews had a detailed daily schedule. The SWAT team outlined a plan for each mission—which specified, for example, who would cover the exits of a house, where snipers would be stationed, and when officers would bust down the door. But when things didn’t go as expected, because people understood one another’s roles so well and how their roles fit together, teams were adept at revising their plan on the spot....

Role shifting helped them make such rapid adjustments. It happens when a surprise leaves a critical role empty and someone else fills in...

Reorganizing routines is another improvisational practice. It’s triggered when a surprise reveals that the planned sequence or methods aren’t working and something different ought to be done.

I [Jeff Killeen] found I had to be precise and resist my natural temptation to use too many superlatives when describing the accomplishments in the business. John would say, ‘You spin things all the time. You make everything sound good.’ I’d say, ‘John, that was good.’ And he would say, ‘But you make it sound like it’s even better than it is. We’re engineers. We don’t use words like terrific and outstanding. We say, “You did your job.” When you say that the team did a terrific job, they don’t believe you.’ We finally agreed that whenever he thought I was spinning, he would tell me. And whenever I thought he was underwhelming, I would tell him.”

Killeen elaborates on how he learned to communicate in an engineering culture. “The perspective from which John comes to the business is obsessive in a wonderful way. He harks back to the philosophy that he’s building a bridge and that a bridge cannot fail. I said, ‘John, but we’re not building a bridge, and failure is okay if we fail fast and incorporate that learning so that we can grow as fast as possible. It’s preferable to me to get eight things done well and fail a two versus doing three or four things to perfection.’ John said, ‘We’re not trained to accept a lot of failure or welcome it into the process.’ I said, ‘That’s a management concept we have to work on.

The problem with Perrow’s idea that organizations could not safely function with interactive complexity and tight coupling was that so many such organizations did in fact function without mishap for years, even decades. Nuclear power plants operated without incident nearly all the time. So did air traffic control systems, nuclear aircraft carriers, and a host of other inherently risky operations. A small group of researchers led by Karlene Roberts at the University of California, Berkeley, set out to study how they did it. What they discovered was more behavioral than technical. The term high reliability organization, or HRO, captures the essence of the theory. HROs are reliably safe because of how they make everyone in them feel accountable to one another for practices that consistently catch and correct

deviations to prevent major harm. Vigilance is one word for it. But it’s more than that. To me the most interesting part of HRO research is the observation that rather than downplaying failure, people in HROs are obsessed with failure. My colleagues Karl Weick, Kathie Sutcliffe, and David Obstfeld wrote a seminal paper highlighting the culture of HROs as preoccupied with failure, reluctant to simplify, acutely sensitive to ongoing operations (quick to detect subtle unexpected changes), committed to resilience (catching and correcting error,

rather than expecting error-free operations), and valuing expertise over rank. In other words, HROs are weird places. Rather than holding back to see what the boss is thinking, people there don’t hesitate to speak up immediately. A frontline associate, to avert a crisis, can tell the CEO what to do. Failure is clearly seen as an ever-present risk that can nonetheless be consistently averted.

“Use Systems Thinking to Change How We Think about Error …

Rely on inquiry

So Morath faced a challenge: How to help people to see and accept their hospital’s failures? Rather than doubling down on her logic—You work in a complex error-prone system, don’t you see? Things will go wrong!—she instead invited clinicians to reflect on their experiences that week with their patients, then prompted, “Was everything as safe as you would have liked it to have been?” Her aspirational question opened the floodgates. Most people had been in what Morath called “a health-care situation where something did not go well,” and

once they reflected on the many problems they had noticed, they became eager to talk about what had happened and how they might improve…

New language

Another element of the patient safety system was what Morath called Words to Work By—a roster of suggested terms designed to help shift mindsets from blaming to learning. Morath substituted neutral-sounding words such as study for the more threatening word investigation, which put people on the defensive…

Synergy…

As with the system at 3M that supported people’s intelligent failures in ways that encouraged product innovation, and the system at Toyota that made quality improvement second nature, Children’s Minnesota built a robust learning system that turned everyone into an active participant in patient safety. Morath’s approach reminds us that system design is more than simply coming into an organization and flipping a single switch. It’s flipping multiple switches understanding how they work as a system.