"What a mistake-a to make-a!"

Upon rereading Pfeffer and Sutton’s opus on evidence-based management[1], let me pick Captain Alberto Bertorelli’s main catchphrase and go about a subject that keeps itching me: mistakes, errors, failures – or whatever you wish to call it – at work, and how difficult it is for most organizations to deal with.

Pfeffer and Sutton call it the best diagnostic question: What happens when people fail?

They say that a hallmark of good management is that when something goes wrong, people face the hard facts, learn what happened and why, and keep using those facts to improve the system.

The literature is also abundant on this one, particularly on the quality and organization learning realms.

But I’ve found a most interesting article, cited in Pfeffer and Sutton’s book that I’d like to discuss a bit here.

It’s from a study in a hospital setting – nine hospitals – dealing with nursing care processes, meant to investigate the conditions of response to failures in order to prevent its recurrence.[2]

The hospital setting is a delicate one. The consequences of failure can be serious, ranging from mere discomfort to life-threatening. One would expect, above all and in such a setting, sensible and acute management would be the norm.

But no, the authors say great doctors and nurses do the trick, not great organization or management.

Needless to say – the authors say it anyway – that the lessons learned from this study have implications for management in other services organizations.

They start by making a distinction between errors and problems.

Errors are usually one-offs, more attributable to individual action and more palatable to self-learning, but that can nevertheless be prevented with appropriated pre-existing information, which, according to the authors, also calls for management intervention to redesign the work systems in ways that make errors less likely to occur.

Errors, although typically less serious than problems, carry a little bit more stigma, at least for the feelings of embarrassment and schadenfreude they elicit.

On the other hand, a problem is said to be a disruption on one’s ability to execute a task because something needed is unavailable on time, place, condition, or with the required quality. Typically, most problems cross organizational boundaries, relate to other stakeholders (units, departments), and boil down to lack of effective coordination.

Therefore, the authors centered their analysis on problems and on its resolution approaches.

They say there’s first-order problem solving when the individual concocts a short-term remedy that just “patches” the problem, a workaround.

There are two strategies for this first-order problem-solving approach: 1) if you can, on your own, overcome the situation and get on with your task; 2) if you need help, ask it from people socially close to you, rather than from who’s best equipped to correct the problem.

That’s a sensible approach, and not difficult to see why, as it preserves your reputation and avoids unpleasant encounters.

Second-order problem solving occurs when one also takes action to address the underlying causes of the problem, which entails communication with the person of the unit or department responsible for the problem, bringing it to management attention, sharing ideas about what caused it and how to prevent it along with someone in a position to implement the necessary changes and verifying its desired effect.

You’re dead. "What a mistake-a to make-a!"

The point is: how counter-normative is such behavior?

But wait! Second-order problem solving is the way to go for real beneficial change – to attain organizational learning.

The authors also came with up with an insight they called the three positive human resources attributes that prevent learning, my favorite.

First, an emphasis on individual performance: when you raise the flag you can’t help being looked upon as someone who can’t do your thing and unable to overcome the situation. Stop whining!

Second, protection of your own turf: the unavoidable issue of questioning some other unit or department’s way of doing things. Next time you look, they might be building trenches.

Third, the perennial mantra of empowerment: empowerment has been plentifully cited as a solution for quality and productivity problems, but then, what are the managers supposed to do?

Besides, until you eventually burn out by keeping amending the same things on and on, you can feel a lot more comfortable with first-order problem solving: you’ve solved the problem, bothered no one – or just someone who was glad to have been there for you –, avoided “unnecessary” conflict, and best of all, can even look a lot more competent.

Well, the authors concluded second-order problem solving is better but calls for management intervention.

So, is this another management problem? "What a mistake-a to make-a!"

[1] Jeffrey Pfeffer and Robert I. Sutton. (2006). Hard Facts, Dangerous Half-Truths & Total Nonsense – Profiting from Evidence-Based Management. Boston, Massachusetts: Harvard Business School Press.

[2] Anita L. Tucker and Amy C. Edmonson. “Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change.” California Management Review 45 (2003): 55-72.