Tag Archives: Mayo Foundation for Medical Education and Research

I’m a licensed pilot, and I once managed to land a small plane on the wrong strip at a small airport. I could have gotten in pretty big trouble for it, so you might have thought my best move would have been to keep my mouth shut and hope the FAA wouldn’t find out. But I couldn’t wait to report my screwup to the government. I wish I could say it was because I’m such a conscientious fellow. But the truth is, I fessed up fast because the U.S. government rewards pilots for quickly owning up to their mistakes, agreeing to waive punitive action if they report themselves. In fact, most pilots carry the self-reporting form with them in their flight kit, just in case. Why the free ride for confessors? Because the government wants pilots to learn from one another’s mistakes in an effort to keep accident rates low. Indeed, the flood of self-reports–nearly 3,000 a month on average, including confessions from air traffic controllers, aircraft mechanics, and flight attendants–are gathered by NASA and selectively published in a monthly newsletter, “Callback,” that’s a must-read for 150,000 pilots and other aviation personnel each month. In the August issue, for example, a commercial airline pilot admitted that he failed to position the flaps at the back of the wings correctly at takeoff, nearly causing the plane to plunge. The pilot of a business jet described how he didn’t hit the right buttons for the cabin pressurization system, which could have left crew and passengers starved for oxygen at 22,000 feet. Neither pilot was fined or punished. You can’t stamp out mistakes at your company, no matter how good a manager you are or how brilliantly you hone your processes. Essentially, you can do one of two things: create an environment in which mistakes are seen as shameful and counterproductive; or create one in which each mistake becomes a collective learning experience. To me, the choice seems obvious. Do employees at your company point out their own screwups–even the ones that might not otherwise have been discovered by management? Probably not. But let me suggest an easy way to fix the situation: Blog it. We’ve heard a lot about blogs over the past few years, and it’s clear that corporate America is in on them. Many corporate blogs are sanitized, public-relations-oriented affairs intended to create bonds with existing and potential customers. Others serve as internal message boards to keep employees up to date. But I’m proposing something else: a blog that encourages employees and managers to tell their peers what they themselves have done wrong. It’s an easy step that could quickly effect a large, positive change in your corporate culture. Such blogs are rare. But they do exist. The Mayo Clinic in Rochester, Minnesota, for example, has set up a system in which medical residents electronically log their mistakes or any other problems they see so the hospital can analyze the errors and look for fixes. It’s more of a database than a blog, but any resident can post to it without fear of recrimination. (The residents identify themselves on their reports, but are only publicly named if they’re getting credit for coming up with a solution to a problem.) “The residents are in the trenches seeing what’s going on, and they pick up on things we may not be aware of,” says Furman McDonald, a faculty member in internal medicine. “We’re trying to get across that people can present their mistakes in a forum that won’t leave them feeling chastised.” Because residents are promised that what they confess to the Mayo stays at the Mayo, the clinic wouldn’t share an example of a confessed mistake. (We may be better off not knowing.) But feedback from residents has led to some significant changes at the clinic. It’s improved the gathering of information about different drugs prescribed by different doctors to the same patient to avoid problematic drug interactions. It has also enabled doctors to do a better job of picking up on obesity-related complications and created a safer way to deliver some medicines to diabetic patients. The U.S. Department of Energy, meanwhile, is pushing its contractors to gather and share goof-ups via so-called “lessons learned” databases accessible to employees at all of its contractors. Fluor Hanford, an engineering firm that is tackling one of the world’s toughest environmental cleanup sites in Hanford, Washington, has been particularly enthusiastic about getting its employees to fess up. Tony Umek, Fluor Hanford’s vice president for safety and health, says that the database led to the discovery that a number of employees were going around standard company purchase procedures to buy their own electrical equipment–and that some of the equipment was flawed. Everyone involved was thanked for their honesty. “The best people make mistakes, and that’s a fact of life,” says Umek. “We want our people to see the mistakes coming and report them, so we don’t have to lament a debilitating injury after the fact.” Of course, the culture of hiding error to avoid blame and punishment is ingrained in most of us from an early age and perpetuated in companies because managers tend to whack employees who mess up. Managers themselves don’t go around blabbing about their own errors because they want to be seen as role models for the highly effective. Some organizations, including the U.S. Marines and aerospace maverick Burt Rutan’s Scaled Composites, have created cultures that celebrate honest mistakes and confession, but they are exceptions and are not easily replicated. Deep down, people want to confess their mistakes. And that’s more true than ever in the Internet age. And this is where the specific appeal of piggybacking on new blogging technology comes in. It’s fine to include an error-confession session in meetings, on databases, and on suggestion slips. But blogs are tailor-made for sharing screwups because they’re conversational, intimate, low key, and usually easy to read or post to. It’s also a perfect format for small companies. A blog with, say, three or four posts a day is a lot easier to maintain than one with 60 posts a day. Blogs are cheap–many blogging tools are free–and can be set up in a few hours. A confessional blog can provide real benefits in a matter of weeks, if not days. As great as we are at learning from our own mistakes, you can learn almost as much from the mistakes of others. Don’t take my word for it. Research recently published in Nature Neuroscience by a team of Dutch scientists indicates that “similar neural mechanisms are involved in monitoring one’s own actions and the actions of others.” In other words, watching your colleague blow a sale has much the same effect on your brain as hearing yourself do it. Afraid someone will leak the contents of your confessional blog to the public? As the saying goes, just hope the blogger spells your company’s name right. Any customer of yours that stops doing business with you because it is shocked–shocked!–to learn your employees make mistakes on occasion probably was pretty precarious to begin with. More likely, your customers will admire you for your candor. (I’m assuming here that your employees do not regularly make mistakes of the criminal variety.) I also believe that deep down, people want to confess their mistakes. And that’s more true than ever in the Internet age. Sure, much of what you see in online forums is whining and blaming, but increasingly, personal bloggers are coming forward to talk about how they screwed up–and often in business situations. These what-I-did-wrong tales so far are disproportionately focused on software projects, Web businesses, and, fittingly, blog development because that’s where you find people who are most comfortable sharing information online. But why wouldn’t it work just as well for an insurance company or building contractor? My only specific recommendation: Encourage everyone to keep it breezy, even fun. Believe it or not, the NASA aviation reports are almost always framed in a humorous light, and they’re a blast to read. The hardest part, of course, will be sticking to your promise to not bring down the hammer on those who confess to good-faith mistakes. That’s not to say you need to let everything slide. Make it clear that confessions of malfeasance, real damage, and repeated offenses don’t merit get-out-of-jail-free cards. (The FAA gives pilots one freebie every five years, and there’s no amnesty if a crime is committed or something gets smashed up.) Not everyone will be happy about where you draw the line, but it’s easy enough to draw it and to make clear that anyone who doesn’t cross it will truly be appreciated for sharing. By the way, my flying mistake apparently wasn’t deemed instructive enough to make the newsletter. However, a warning was added a bit later to the aviation map for that airport to alert pilots to the very mistake I had made. I like to think of it as my contribution to aviation. Contributing editor David H. Freedman (whatsnext@inc.com) is a Boston-based author of several books about business and technology. His latest, A Perfect Mess, co-authored with Eric Abrahamson, will be published by Little, Brown in January.