Paul did a lot more at Alcoa than use powerful words. He and fellow company leaders dismissed managers who didn’t turn knowledge about process improvements into action or, worse yet, covered up safety problems. As business author David Burkus argues, the genius of zeroing in on safety is “you can’t improve safety without understanding every step in the process— understanding each risk—and then eliminating it.” As a result, hundreds of process improvements “made the plants run more efficiently,” and Paul “gradually changed the systems and the culture” so that “executives began sharing other data and other ideas more rapidly as well.” Paul was effective not only because of the powerful language he used to fire up employees and focus their attention on the details of Alcoa’s production processes. What Paul didn’t say provides an equally important lesson for friction fixers: we can’t detect even a whiff of jargon monoxide in his words after reviewing numerous speeches, interviews, and written statements.

For example, meeting with senior executives in a large financial services firm in April

2020, I listened as they explained that the current business environment made failure temporarily “off-limits.” Understandably concerned about an economic climate increasingly challenged by a global pandemic, these business leaders wanted everything to go as well as possible. Generally speaking, they were sincere in their desire to learn from failure. But enthusiasm about failing was acceptable when times were good, they told me; now that the future looked uncertain, pursuing unerring success was more imperative than ever. These smart, well-intentioned people needed to rethink failure. First, they needed to appreciate the context. The need for fast learning from failure is most critical in times of uncertainty and upheaval, in part because failures are more likely! Second, while encouraging people to minimize basic and complex failures may help them focus, welcoming intelligent failures remains essential to progress in any industry. Third, they needed to recognize that the most likely outcome of their prohibition on failure wasn’t perfection but rather not hearing about the failures that do occur. When people don’t speak up about small failures—say, an accounting error—these can spiral into larger failures, such as massive banking losses.

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.

My engineering background had made me a fan of Perrow’s groundbreaking book Normal Accidents, first published in 1984, which had a lasting influence on experts’ thinking about safety and risk. Perrow focused on how systems, rather than individuals, produce consequential failures. The importance of that distinction cannot be underestimated. Understanding how systems produce failures—and especially which kinds of systems are especially failure-prone—helps take blame out of the equation. It also helps us to focus on reducing failure by changing the system rather than by changing or replacing an individual who works in a faulty system.

“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.