Sunday, August 22, 2010

A Culture of Safety: Forgiving

“The day is committed to error and floundering; success and achievement are matters of long range” ~ Johann Wolfgang von Goethe

I've been thinking about the "Safety Incident Detection and Response System Optimization" efforts and our culture. In reading about cultures in ultra-safe industry (airlines, nuclear power, European railways), as opposed to health care which is not considered to be, I have found that a relentless focus on learning and moving beyond the need to blame and the need for redemption seems to be a system attribute in each these industries. I should add that many others are thinking about this as well.

Thankfully, courageous leaders such as Lucian Leape, Don Berwick, Jim Conway, Maureen Bisognano and many more have advanced the discussions about how we respond to medical error and system failures into mainstream discussions and media publications. Here is a recent article the NY Times on disclosing medical error and apology. The Executive Director of Chugachmiut, Inc., an Alaska Native Tribal consortium recently posted in his blog "Lean in Alaska" Pointing Fingers, where he discusses a "no blame, no shame" culture. He points to W Edwards Deming's System of Profound Knowledge and Deming's focus on pride and joy in work. A simple Google query will yield thousands of related links on error, just culture, culture of safety, apology, blame, bad apple versus system response etc. There is no dearth of reading if you're interested.

A request for help. How do we move from blaming to forgiving?

I am not trying to minimize how complicated this is. To the contrary, I believe that too often this complex socio/cultural concept is oversimplified. The term "transparency" is tossed about as if it comes easy and as if it will save us. Please don't misunderstand, I am in favor of transparency. Yet I do believe there is a tension between transparency and for lack of a better term, a "need to know." There is a tension between an inclusive and democratic process and an autocratic process. Leading the system and providing service within it is a complex and humbling undertaking. I look to the words of one of the greatest change agents who ever lived, W. Edwards Deming who said, "All transformation begins with the individual." If we are to create safe, fair and just culture; if we are to create a culture of continuous improvement, we must begin with ourselves. With each new day and each new challenge we will continue to discover that those who came before us carried heavy burdens for us all. It's our turn now. We are here to make a new world.

I am not asking anyone to be perfect. I ask that we help each other and provide service to our community in the most respectful way possible. I don't pretend to have all the answers. I ask that we work together to lead our system forward and to recognize that sometimes, like those people we are here to support in carrying out our shared mission, we will make mistakes.

It's important that we all work together. It's important that we all learn together. That means all of us. Those we are here to serve are depending on us getting this right. We must learn to work through system failures and to work through mistakes.

I am not suggesting we forget harm or look away from difficult situations. I am suggesting we learn to forgive and not let it divide us as looking for blame will. I am not suggesting we be complacent in any way. I am asking that we draw on courage. Drawing on the same humility we require as leaders of our great health system, we must not allow mistakes to create permanent barriers between us. There will be times we must look beyond the mistakes of others and remember to be grateful they are participating. To better understand what I am saying I offer the speech Victor H. Carpenter presented at Harvard when Nelson Mandela was honored there. Please take a moment to read his very brief but powerful remarks on "Forgiveness: The Mandela Principle" and I believe you will understand what I am trying to say to you.

Change is here. With that, all that is possible lies before us.

Now, we move forward.


  1. Bravo Anna. I have wrestled with this issue since day one of our Lean transformation. Employees must feel safe disclosing defective work in order for it to be corrected. We use phrases like "see a defect, fix a defect;" "problems are treasures;" and we refer to our "Treasure Chest" of problems to address if they can't be addressed immediately. By focusing on processes, and instilling pride of work in employees, we hope our employees will be willing to disclose defects. We are also moving quickly into training our employees using the Training Within Industry model.

  2. Dear Patrick,

    Thank you for your generous comments. It's quite humbling to read coming from such an esteemed leader. The work at Chugachmiut, Inc is inspirational. Your deep commitment to those you serve, tribal culture, self determination and to your employees demonstrates a clear and unyielding respect for all.

    I did note you now have two blogs. Impressive!

    I found your Restoration to Health Strategic Initiative quite a unique and powerful contract with your Tribal communities. I look forward to learning more as "Restoration to Health" progresses.