Changes stems from learning from mistakes

As we build quality culture we need to question our basic assumptions and build new principles of every day interactions. At the heart of this sits a culture where change is viewed as a good thing.

Willingness to change

To what extent are employees willing to continuously review and adapt their own behavior in response to a changing environment? The ideal scenario is for the entire workforce to be willing to change. This willingness to change should not be confined to situations where changes are already being implemented. It means that people should look at environment with open eyes, recognize when there is an opportunity or a need for change and initiate the relevant actions themselves. Willingness to change should be the first principle of culture and is a key enabler of the popular concept often called agility.

Learning Culture

To what extent do employees think that their actions should be guided by data- and fact-based knowledge? The term “knowledge” encompasses any knowledge acquired through targeted observation, by chance, through data-based analysis or from practical experience.

Willingness to make mistakes

Learning cultures attach great importance to mistakes. These organizations have understood that learning and change processes can only be triggered by mistakes. Mistakes provide an opportunity to gain a better understanding of the company’s processes and uncover previously unknown cause-and-effect relationships.

The way an organization deals with mistakes is therefore a key aspect of its culture. Two fundamentally different approaches to mistakes exist.

  • A negative attitude towards mistakes is reflected in a strategy based on the systematic avoidance of errors, strict penalties for making mistakes and the correction of errors as rapidly and unobtrusively as possible. Employees of companies where this culture prevails are not usually willing to disclose mistakes. This attitude inhibits their willingness to change.
  • On the other hand, a culture that recognizes the value of mistakes is characterized by open discussion of mistakes when they occur, systematic error documentation and a determination to find both the causes of the mistakes and their solutions. When investigating mistakes, it is critical to focus on understanding the causes rather than on finding out who is to blame.

Openness to Innovation

Openness to innovation and new ways of doing things is an important capability that is required in order to initiate change and adopt the right measures, even if they may sometimes be rather unconventional.

Social Collaboration

An environment characterized by trust and social relationships provides the basis for open, uninhibited knowledge sharing between employees. Social collaboration, helps to accelerate knowledge sharing within the organization. Good strong social networks build resilience and enable the ability to change.

Open Communication

In order for companies to respond rapidly and to be able to effectively change, employees need to have access to the necessary explicit and implicit knowledge. While explicit knowledge can be provided through the appropriate communication technology, the sharing of implicit knowledge calls for direct communication between the people who possess the knowledge and the people seeking it.

An effective organization needs to abandon the “us and them” mentality. Employees have acquired the capability of open communication if, having taken on board the fact that openly sharing knowledge and working together to achieve a vision increases the total sum of knowledge, they then also act
accordingly. Once the organization’s entire workforce is willing to share knowledge with everyone, it becomes possible to significantly accelerate learning processes within the company.

What Does This Look Like?

Social collaboration exists between employees and with customers and partners. Confidence in systems and processes results in high process stability. People are willing to document their acquired knowledge and share it with others. The democratic leadership style values people for the contribution they make and there is a culture of open communication. The workforce is both receptive and willing to change. They learn systematically from the captured data, are open to innovative approaches and participate in shaping change processes. Employees are also conscious of the need to continuously develop their skills and competencies. While mistakes are still made, people recognize that they are valuable because they have the potential to trigger improvements.

Where we need to be

What to Do When You Realize You’ve Made a Mistake

  1. Take responsibilitySay, “I was wrong.” (Don’t say “mistakes were made” or “it didn’t turn out the way I had anticipated” or any other version that deflects or minimizes your personal contribution). Offer a brief explanation, but do not make excuses. Acknowledge that your error had a negative impact on others, and be willing to really listen, without defensiveness, to others’ recounting of that impact. Do not interrupt. Apologize.
  2. Address what you need to do right now. Taking responsibility is critical, as is taking action. This is core to crisis communication, even if your mistake doesn’t constitute a major crisis. Tell others what you are doing right now to remedy the mistake, and distinguish between the parts that can be fixed, and those that can’t. Include what you are doing to address the substantive impact (money, time, processes, etc.) and well as the relational impact (feelings, reputation, trust, etc.) of having been wrong. Be open to feedback about what you’re doing. Over-communicate your plans.
  3. Share what you will do differently next time. Being wrong is messy. Being wrong without self-reflection is irresponsible, even if you hate self-reflection. Take some time to think about what your contribution was to this situation, and identify how others contributed as well. (Try to stay away from using words like “fault” or “blame” — which tend to put people on the defensive.) Then tell those impacted by your error what you’ve learned about yourself, and what you’re going to do differently in the future. For example, you might recognize that you tend to dismiss the input of someone you don’t see eye-to-eye with, and that in the future, you’re going to actively engage her, and consider her perspective. Ask for help where you need it. And ask others to give you frequent feedback down the road on the commitments you’re making.

Continual reminders to myself to do better.

Photo by George Becker on

Falsification and error

At the heart, data integrity is a lot about culture. There are technical requirements, but mostly we are returning to the same principles as quality culture and just keep coming back to Deming. A great example of this is the use of the fraud triangle and human error.

The fraud triangle was developed by Donald Cressey in the 1950s when investigating financial fraud and embezzlement. The principles Cressey identified are directly relevant to data integrity, and to quality culture as a whole.

Falsification Triangle
Element Exists When To Break
Incentive or Pressure Why commit falsification of data? Managerial pressure or financial gains are the two main drivers here to push people to commit fraud. Setting unrealistic objectives such as stretch goals, turnaround time or key performance indicators that are totally divorced from reality especially when these are linked to pay or advancement will only encourage staff to falsify data to receive rewards. These goals coupled with poor analytical instruments and methods will only ensure that corners will be cut to meet deadlines or targets. Management must lead by example – not through communication or establishing data governance structures but by ensuring the pressure to falsify data is removed. This means setting realistic expectations that are compatible with the organization’s capacity and process capability.
Rationalization or Incentive To commit fraud people must either have an incentive or can rationalize that this is an acceptable practice within an organization or department. Staff need to understand how their actions can impact the health of the patient. Ensure individuals know the importance of reliable and accurate data to the wellbeing of the patient as well as the business health of the company.
Opportunity The opportunity to falsify data can be due to encouragement by management as a means of keeping cost down or a combination of lax controls or poor oversight of activities that contribute to staff being able to commit fraud. Implement a process that is technically controlled so there is little, if any, opportunity to commit falsification of data.

Mistakes are human nature – we all have fat finger moments. This is why we build our processes and technologies to ensure we capture these errors and self-correct them. These errors should be tracked and trended, but only as a way to drive continuous improvement. It is important to have the capability in your quality systems to be able to evaluate mistakes up-to-and including fraud.

It helps to be able to classify issues and determine if there are changes to governance, management systems and behaviors necessary.

Events should be classified based on how intentional they are

Human error should be built into investigative systems. Yes, whenever possible we are looking for technical controls, but the human exists and needs to be fully taken into consideration.

The best way to ensure data integrity is the best way to build a quality culture.

System Model