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.

And because competencies are unmeasurable, it is impossible to prove or disprove the assertion that everyone who excels in a particular job possesses a particular set of competencies. It is equally impossible to show that people who acquired the competencies they lacked outperformed those who did not—that, in other words, well-rounded people are better. These two statements together are the foundation for most of what companies do to develop the talents of their people, yet each of them is unfalsifiable—you will find no academic papers in any peer-reviewed journal proving the necessity of possessing certain competencies, and no proof that acquiring the ones you lack nets you any increase in performance. Both of these assertions, despite the good intentions that created them, are conjured from thin air—and we can never know if they are correct.

What made Notes Day work? To me, it boils down to three factors. First, there was a clear and focused goal. This wasn’t a free-for-all but a wide-ranging discussion (organized around topics suggested not by Human Resources or by Pixar’s executives, but by the company’s employees) aimed at addressing a specific reality: the need to cut our costs by 10 percent. While the discussion topics were allowed - even encouraged - to stray into areas that might seem only vaguely related to this goal, the fact that it was there was key. It provided a framework - and it kept us from falling into confusion.

Second, this was an idea championed by those at the highest levels of the company. Had the enormous task of making Notes Day a reality been shunted off on someone who didn’t have the clout to throw muscle behind it - and not entrusted to Tom, who in turn recruited the most organized people in the company to help him - it would have been an entirely different experience. Employees wouldn’t have bought into the idea because they’d sense that management hadn’t, either. And that would have rendered Notes Day moot.

Third, and relatedly, Notes Day was led from within. Many companies hire outside consulting firms to organize their all-staff retreats, and I understand why: Doing them well is a monumental, enormously time-consuming undertaking. But that our own people made Notes Day happen was, I believe, key to its success. Not only did they drive the discussion in meaningful ways, but their involvement also paid its own dividends. Seeing themselves engage and cooperate, steering the agenda toward something that could make a real difference, they remembered why they worked at Pixar. Their commitment was contagious. Notes Day wasn’t an end point but a beginning - a way of making room for our employees to step forward and think about their role in our company’s future. I said before that problems are easy to identify, but finding the source of those problems is extraordinarily difficult. Notes brought problems to the surface - but we still had the hard work in front of us. Notes Day didn’t solve anything all by itself. But it shifted our culture - repaired it, even - in ways that will make us better as we go forward.

Eskreis-Winkler and Fishbach concluded that unawareness of failures’ useful information made learning from failure difficult. So they designed an experiment in which participants were helped to identify the useful information in their failures, and this made them more likely to share them.

“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.