Yesterday, I tweeted a quote about patient safety that I've seen posted on the wall or bulletin board in many hospitals:
“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”
Could this quote be possibly misinterpreted?
Sir Liam Donaldson is the Chief Medical Officer of England.
In my reading of the Donaldson quote, I agreed that it's indeed human to make mistakes and errors. We're not robots or computers – we forget things and we get sloppy at times. That's why we have to design systems that prevent good people from making errors (as Dr. Atul Gawande writes about in his excellent books).
Toyota's philosophy, called “respect for people” recognizes this human frailty through the practice of “poka yoke” or mistake proofing. Toyota's approach was originally called “respect for humanity,” which as I've heard it explained, includes the idea that we have to respect our human nature that people aren't perfect and we can't have a workplace that expects them to be other than human.
In the healthcare realm, or any workplace, covering up errors and near misses means that we're doomed to repeat the same errors – causing more quality problems and harm to patients. To solve problems and proactively improve future safety problems, we have to be open and non-blaming in our behavior when people raise an issue or a risk. We have to be “hard on the process, soft on the people,” as my friend Pascal Dennis says.
If covering up problems leads to more harm, then that certainly could be considered unforgivable. Making one error, an honest human mistake, isn't as bad as making a conscious choice to cover up that problem (there's a different level of awareness involved).
In response to my tweet, @benjaminm raised an interesting point, saying:
#Argyris would say that “to cover up an error is highly likely especially if it is embarrassing or threatening”
and
And if #Argyris is right, then telling ppl their actions are “unforgivable” will make them less likely to be open.
Benjamin wondered if the quote could have the effect of “browbeating” people. He raises an excellent point.
In a traditional organizational culture, a “blame and shame” culture, people aren't going to be open and honest about risks and errors and near misses. I
t's well studied and shown that hospitals and their people underreport errors — arguably due to a culture of fear – shame and blame.
I think Benjamin and I would agree that we have to do more than just lecture and point fingers at people for not reporting problems. We can't just blame individuals for covering up problems — we have to work on the culture and management system that leads to that fear.
We have to ask, “why do people cover up problems?”
Everybody works as part of a system. We can hope some people will be heroic, risking punishment or their jobs. But not everybody can or will take that risk. If people cover up problems, that's a deep management and culture issue, not an individual issue.
That quote, if hung on the wall in the wrong organization or if hung on the wall without leadership, could shame people into not coming forward.
I think Benjamin is right on that and I appreciate him for moving the discussion forward. Who says Twitter is worthless?
Looking to the last part of the quote: To fail to learn how to improve our management system is indeed inexcusable.
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[…] Graban’s blog “Dangers of a Pithy Quote About Patient Safety?” where he reflects on some of these […]
Good discussion, Mark!
Perhaps the operational question is how to convert an organization of covering up to one where all errors are like “jewels to be mined.” That was a translated phrase I learned from the Japanese as applied to customer complaints, but I think it also applies to errors.
How do we create a culture where all errors are examined? These days the threat of litigation makes many extra paranoid. Yet we also have whistleblower laws that should protect employees when they bring forth safety concerns.
We know from studying Toyota and other Deming Prize winners that a culture of open examination of errors will help build the Engine of Improvement that is the core of a lean organization.
It’s interesting to contrast these concerns with the question at the heart of lean: How can we make problems more visible? That is what the tools and techniques of lean do, after all, so if you are pursuing lean, you better love finding problems! What a difference in culture!
One might take issue with the tone of the Donaldson quote. It’s pretty harsh and judgemental. Contrast with another teaching of Pascal Dennis, who you cite above, who taught us that “problems are treasures, because they show us what’s wrong with our managment system, and then we can fix it.” Problems not as something to hide, but something to treasure and learn from; and hard on the system not the people.
This is a rich area for discussion! At the recent North East Shingo conference, Ritsuo Shingo gave an awesome talk, the first half (roughly) of which was dedicated to the question “what is a problem?”
I can see where the quote could seem judgmental. I can also see where there might be frustration with the predominant healthcare management mindset that blames and shames….
Ironically, to those who practiced it “shame and blame” is probably intended to help. But, that mindset arguably harms untold numbers of people when that shame and blame culture forces people to hide problems, which prevents prevention and improvement.
It speaks to the importance of culture change over tools.
A while ago, I introduce similar lean idea to an organization.
All managements agree with the idea with pleasure. Unfortunately, I discovered later that they mis-interpret:
1. To err is human,
2. to cover up is unforgivable,
3. and to fail to learn is inexcusable
as:
1. Okay, I can forgive YOU some mistakes. I am a decent person.
2. But YOU’ll have to report me so that I know how much mistake YOU’ve made.
3. And … YOU can’t complain for what would YOU get if more of the same kind of mistake happen again, given that I once kindly forgive YOUR previous mistake.
I stop introduce any idea or comment on anything ever since until I recently quit from the organization.
Sakesun, I can understand your frustration. Thanks for sharing your example of how dysfunctional mindsets can interfere with improvement. It’s important to keep in mind the mental models of others, especially old habits about blame and control.
The other point I’ll make is that this goes to show slapping slogans and posters and quotes on the wall doesn’t easily change the culture (as Dr. Deming taught us).