I immediately saw that there was a significant correlation between the independently collected error rates and the measures of team effectiveness from my survey. But then I looked closely and noticed something wrong. The direction of the correlation was exactly the opposite of what I had predicted. Better teams were apparently making more – not fewer – mistakes than less strong teams. Worse, the correlation was statistically significant. I briefly wondered how I could tell my dissertation chair the bad news. This was a problem.

No, it was a puzzle.

Right Kind of Wrong: How the Best Teams Use Failure to Succeed - Amy Edmondson

Introduction:

“Intelligent failures provide valuable new knowledge. They bring discovery. They occur when experimentation is necessary simply because answers are not knowable in advance.

When a group is higher in psychological safety, it’s likely to be more innovative, do higher-quality work, and enjoy better performance, compared to a group that is low in psychological safety. One of the most important reasons for these different outcomes is that people in psychologically safe teams can admit their mistakes. These are teams where candor is expected. It’s not always fun, and certainly it’s not always comfortable, to work in such a team because of the difficult conversations you will sometimes experience. Psychological safety a team is virtually synonymous with a learning environment in a team. Everyone makes mistakes (we are all fallible), but not everyone is in a group where people feel comfortable speaking up about them. And it’s hard for teams to learn and perform well without psychological safety.

Owning our errors becomes easier when we accept human fallibility as a fact and put that acceptance to use in learning and improving. In the most successful teams in my research, people, especially team leaders, talk about the ever-present chance that things will go wrong. They are honest and good-humored about mistakes, which nurtures the psychological safety you need for people to speak up quickly about them. This is a best practice—in families, too, not just work teams—if you want to reduce basic failures.

“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.