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.

A great deal of strategy work is trying to figure out what is going on. Not just deciding what to do, but the more fundamental problem of comprehending the situation.

Here, as in so many situations, the required actions were not mysterious. The impediment was the hope that the pain of those actions could, somehow, be avoided. Indeed, we always hope that a brilliant insight or very clever design will allow us to accomplish several apparently conflicting objectives with a single stroke, and occasionally we are vouchsafed this kind of deliverance.

“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.

What this means is that when you have to think about connections between parts, rather than just counting the individual parts of a system, the number of possibilities grows very rapidly; the potential combinations multiply, rather than just adding up. Very quickly, they multiply up to astronomically huge numbers, spelling absolute death to any hope of knowing the entire state of the system.

In fact, knowing only a few of the feedback circuits can be actively misleading, if you rely too greatly on your partial information. It is a sobering thought, for example, that despite employing some of the best and brightest* analysts in the world, the advice given by the US State Department over the last fifty years could comfortably have been outperformed by a parrot that had been trained to repeat the phrase, ‘Don’t start a war.’ The repeated failures of the State Department are not the consequence of ignorance; they are the consequence of having very good and deep — but not total — knowledge of an extremely complicated situation, in which facts outside of that information set turned out to be crucial. Knowing a great deal of detail about a subset of a system has a habit of increasing your confidence in your opinions disproportionately from their reliability.

*The phrase ‘the best and brightest’ is often used by people who don’t know that its original context was ironic. It entered the language as the title of David Halberstam’s book about the policy mistakes of the Vietnam War.