Brian Kenny: In 1961, Phil Crosby, an engineer at the Martin Company, was given a seemingly impossible task. Phil was the chief of quality control on the Pershing Missile Program, a critically important field weapon in the US arsenal, but one that had been fraught with quality control issues throughout its development.
With the conflict looming in Vietnam, the Army demanded the missile be delivered ahead of schedule, and Phil's bosses challenged him to drive down defects. Phil marshaled his resources, and in spring of 1962, Martin Company delivered the missile program a month ahead of schedule, with no discrepancies in hardware or documentation. In effect, perfect. And from this arose the concept of Zero Defects, a management approach aimed at preventing mistakes through motivational techniques and tools. It's been the subject of articles and books ever since. Mistakes happen, and fortunately for most of us, a mistake at work isn't the difference between life and death. But in some jobs, the consequences can be tragic.
So, can a concept that originated in the defense industry be applied to saving the lives of children? Today we'll hear from Professor Amy Edmondson about her case entitled, Children's Hospital and Clinics. I'm your host, Brian Kenny, and you're listening to Cold Call, recorded live in Klarmen Hall Studio at Harvard Business School.
Amy Edmondson's areas of expertise include leadership, teams, innovation, and organizational learning. She's the author of a recent book called, The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. And we're going to talk about all of that today.
Amy, thanks for joining me.
Amy Edmondson: Delighted to be here.
Brian Kenny: It's a fabulous case, and I think one that many people will be able to relate to, many people have probably experienced some sort of a scare in a healthcare setting, and we know that as much as it is a science, it's also a management practice. And the ideas that the case brings to the surface, I think, will be eye-opening for a lot of people. How does the case begin? Who's the protagonist and what's on her mind?
Amy Edmondson: The protagonist is Julie Morath, and she is the chief operating officer of Children's Hospital and Clinics. And in fact, she's just joined the organization. She was hired from the outside when they needed a new COO, and she had a pretty good reputation in the Minneapolis area. She was a former nurse, she had been working in Allina Healthcare System, and they asked her to come in. She, in fact, negotiated on her way in, that she was interested in the job, but only if they would allow her to lead something called the Patient Safety Initiative. I think they didn't really think about it one way or another, they wanted Julie, and they hired her.
Brian Kenny: They didn't realize what they were signing up for.
Amy Edmondson: They did not realize what they were signing up for. So here she is, kind of contemplating what they've gotten done so far over about six months, and what lies ahead.
Brian Kenny: When we were talking about your book recently, you said this case is a great illustration of the ideas in the book. What led you to writing this particular case?
Amy Edmondson: This was a case where I recognized the opportunity to achieve that sought-after synergy, where I could be teaching what I know about, and teaching it in an engaging way, and then bringing that research alive in the classroom. So I saw, I learned about the hospital from published reports in US News and World Reports. Actually, my wonderful colleague and coauthor Mike Roberto, first noticed the article and brought it to my attention. He said, "You ought to write that case," because my research was on psychological safety and he could see that that was going to play a central role in the case. And I said, "Well, write it with me."
Brian Kenny: For listeners who don't know, tell us about Children's Hospital and Clinics.
Amy Edmondson: Children's Hospital and Clinics is a tertiary care hospital in Minneapolis-Saint Paul. It is a large and complex organization. It takes care of some of the very sickest kids in the region. It's a place where patients, children come, and they're very, very sick, and they have complex things wrong with them. People really have to work together to take care of these kids, and get the best possible outcome.
Brian Kenny: This case opens up pretty dramatically. I mean, it sort of had me like almost like a novel in the opening couple of pages. I think it would be really helpful for people to understand the situation that opens the case up because it's really instructive for the rest of the case. Could you just explain that?
Amy Edmondson: Absolutely. So the case opens with the gripping story of a child, a young boy, who has just received a massive overdose of a medication. And the case describes the exact steps, and issues, and situation that led up to this adverse drug event. The boy does not, he does fine, right. They quickly administered the antidote and he does okay, but what you're able to see in the first page of the case is, if you read it carefully, you're able to see eight different process failures. Eight different little things that went wrong, that lined up in just the wrong way to produce this bad outcome. This is a quintessential medical error, in that it's not one person doing some boneheaded thing, it's so much more likely in this setting and many others, for just a number of small, little problems to line up, and essentially create a tunnel that the error flows right through, and gets to harm the patient. And so it shows the reader, the thoughtful reader, that right away that the nature of the beast, right, the nature of the beast is more often than not, you are doing something that has never been done before in this exact way. I mean, clearly, we care for patients every single day, all day. But there's never been a boy with this exact condition, in this exact bed, with this exact set of caregivers. And things went wrong, and so this opens the story of a hospital that understands that this is how things go wrong, and they call them system failures. And because much more often than not, when things go wrong, it's a system failure, not an individual screwing up, they want to set out to figure out, "How do we vastly improve the organization so that system failures are far less likely?" And central to doing that, is ensuring that people feel safe to speak up about what they see.
Brian Kenny: So maybe you can help us by talking a little bit about this sort of existing climate in the hospital when Julie gets there, and some of the things that she sees as areas that need to be taken on, to improve in that area.
“One of the things she recognizes right away, is that the culture of the organization is not conducive to learning."
Amy Edmondson: One of the things she recognizes right away, is that the culture of the organization is not conducive to learning, that people are far more likely to hide the mistakes and failures they're aware of, to when things do go wrong, to point the fingers and assign blame to someone, rather than to sort of roll up their sleeves and figure out, "How can we improve and be better?”
This isn't to say they were bad people, or not well-intentioned. It's to say that this was just the normal culture. In fact, she calls it the ABCs of Medicine: Accuse, Blame Criticize.
Brian Kenny: I'm sure a lot of us are thinking, "Yes, that sounds like this place.”
Amy Edmondson: You bet. And so she sets out to really change the culture, and one of the ways she does that is by instituting a new policy called “Blameless Reporting,” which is exactly what it sounds like. You can and must report anything you see that goes wrong or seems substandard, without fear of reprisal for the act of reporting. Like you report in a safe way.
Brian Kenny: So blameless reporting. Is that anonymous? What's the mechanism by which you do that?
Amy Edmondson: You actually have both options. You can do it anonymously, or you can do it openly, and people did do both.
Brian Kenny: Okay. When you are blameless, is that the same as not holding people accountable?
Amy Edmondson: That's a great question. And in fact, that's one of the central debates that we have in the classroom. And the answer is, "No." It's not at all the same. In fact, I think of these as two different dimensions that create a kind of two-by-two, right. Where one dimension is, make sure the environment is psychologically safe for speaking up. It just has to be. If you're in a complex error-prone system, you better be creating conditions whereby people can speak up. The other dimension is holding people accountable for high standards. And that's about coaching, and giving feedback, and ensuring that people are really willing and able to show up every day to do the best possible job. And you can readily recognize that if you have an environment of low accountability and low psychological safety, you're sort of in trouble. That's just apathy, that's terrible. But if you have high psychological safety and high accountability, then you're in what I call the Learning Zone or the High Performance Zone. Where people are able and willing to offer what they know, they're motivated and engaged, they know that what they do matters, and they're determined to do it well. And that's, of course, where any hospital today needs to be, right. They need to be both safe for voice and people who are working hard and feeling accountable for their actions.
Brian Kenny: One of the things that comes through pretty clearly in the case is this sort of cultural divide in the hospital setting between the doctors, and the nurses, and the support staff. And the doctors, obviously, in that scenario, I would think, are the sort of supreme beings, right?
Amy Edmondson: Yes.
Brian Kenny: Does that make it really difficult to do the kind of thing that Julie was trying to do?
Amy Edmondson: It really does, because part of the culture, pre-existing culture of the industry and the hospital, were those status differences, and people who are in lower status roles in organizations, often have a particularly hard time speaking up. So part of what Morath was trying to do was reframe that, and reframe everybody's job, as one where they are the eyes and ears of the organization. They are the fail-safe mechanisms for the patients. So she would often say things like, "Healthcare, by its nature, is a complex error-prone system." In other words, when things go wrong, it's not necessarily you, it's the system, which means that, speaking up saves lives. Now who doesn't want to save lives?
Brian Kenny: Right.
Amy Edmondson: So it's a reframe from, "When things go wrong, there's a culprit," to, "When things go wrong, our very complex error-prone system just broke down, and it's up to us to get it back on its feet."
Brian Kenny: Sure. The case refers to zero defects, and I mentioned it in the introduction. Is that too lofty a goal? Is it really possible to have like zero defects?
Amy Edmondson: Another great question. It is not possible to be error-free. As human beings, we will never be error-free. However, it is possible to have zero defects [at the] end of the pipe, right? Meaning, that we'll make mistakes, but as long ... I'll make a mistake, but you're alert and vigilant, and you see it, and you catch it. And we correct it before it harms patients. So you'll never make error go away, but you can make patient-relevant defects go away.
“You'll never make error go away, but you can make patient-relevant defects go away."
Brian Kenny: Okay.
Amy Edmondson: When you're really good.
Brian Kenny: You talk about blameless reporting, and some of the cultural challenges here. What were some of the other things that she identified as sort of levers that she needed to activate?
Amy Edmondson: Well, she really put in place a number of disparate mechanisms for people to start to speak up about what they knew, problem solve together on ways to make it better. So in a sense, she distributed a learning process. She recognized that the learning that needed to happen needed to be team-based and needed to be work relevant, sort of situated in the work. So I can't tell you how to do your job in oncology, or your job in billing, right. You know that job better than I ever will, but I can put in place or encourage you to put in place processes by which you can learn to do that job better. So it was really a kind of distributed mindset and set of processes for continuous learning that she put in place.
Brian Kenny: Yeah, and it seemed in the case, as if people started to glom onto the idea, and formed their own ways of addressing some of the issues. Can you talk a little bit about that?
Amy Edmondson: Sure. In fact, that's one of my favorite things about the case. Because I have, in my own case set, and of course in our collection, many cases that we would call change cases, where a leader comes in and leads change. And some of them are the kind of change for which there's a blueprint, right. There's a playbook, people have done this before, and the job is to engage and motivate people to do it here. This is not one of those cases, right. This is a case where there's a desired outcome, right. There's a goal, zero defects. And there is, truly, no playbook, right. She was a pioneer, really. She was really out ahead of the industry, in terms of the patient safety movement. And there was no one you could turn to and say, "Okay. Well, how do you do it? And what do you do next? And what do you do after that?" So what she tried to do, was inspire and lead a learning process. Like she wanted to create a learning organization.
Brian Kenny: The case also goes into the importance of language. And I was really intrigued by that section because I think, so often, we all use terminology, and I think we hear different things when we use it. And I would imagine in a healthcare setting, this becomes a really critical element.
Amy Edmondson: Yes. I mean, if you're going to change the culture, you're often going to have to change the language you use. And there is an exhibit in the case called, “Words To Work By”, which came right from Morath.
Brian Kenny: Long list.
Amy Edmondson: A long list. And she wanted to change words like instead of investigate or have an investigation, we study.
Brian Kenny: That's like a really important one, I think, right there because investigation immediately puts somebody on the defensive.
Amy Edmondson: You immediately think police.
Brian Kenny: Exactly right.
Amy Edmondson: Study, well, you think scholar. Researcher.
Brian Kenny: Exactly, and some of this I thought played out pretty clearly illustrated in the meeting that they had right after this incident happened. Can you talk about what that meeting was like?
So as soon as something happens, whether it's an all-out harm, as in an overdose of a medication, or a near miss, we immediately convene a group of people, who touched the event from different perspectives, or maybe at different times. Immediately, we get together around a table and everybody shares, one at a time, what happened. We're trying to paint a realistic picture of what happened. Again, not who did it, what happened? And people get quite surprised by how different the same event looks from a different vantage point. And we realize, that in order to paint a full picture of something that happened, we have to have those different perspectives represented, and then you start the process of thinking about, "What might we need to change to make sure that never happens again?"
“You don't do the family or the hospital any good by stonewalling."
Brian Kenny: You have a lot of comments, direct quotes in the case. And one of them was about, "Everybody's touching a different part of the elephant."
Amy Edmondson: Yes, exactly.
Brian Kenny: I think, in this setting, the importance of understanding why something happened takes on really increased importance in a situation where you've got a family who wants to know what happened to their loved one. Like, "Why did my child almost suffer a fatal consequence for your mistake?"
Amy Edmondson: It's true. And one of the things we've learned over the years since that case, and I think they had an intuitive understanding there, was you don't do the family or the hospital any good by stonewalling. Your instinct, and maybe the lawyers will reinforce it, is to hold back. Say, "Well, we can't tell you. We're looking into it." But, in fact, transparency is your best strategy. It turns out that most of the time that people really resort to legal action, they're motivated by one of two things. One being, "We just needed to find out what happened," and that's the discovery process allows that to do that. And another being a sense of anger and frustration that they're not being talked to.
Brian Kenny: What were some of the challenges that Julie ran into as she tried to make this happen? It couldn't have been easy?
Amy Edmondson: Initially, she ran into the challenge of resistance. Now that's an old story, right. People resist change leaders.
Brian Kenny: Change is hard.
Amy Edmondson: They resist change. Change is hard. And they resisted her change, primarily because they really didn't believe. I think they sincerely didn't believe they had a problem, right. After all, they were certainly the best children's hospital in the region. They were considered a very good place, they had lots of good doctors, they were. Lots of good nurses, right. They were a great organization. And Morath's belief was, "Yes, it's a great organization, and it's still a complex, error-prone system, and it's up to us to make it even better so that children don't get harmed by things that happen to them under our watch." Right, so there was this kind of, "She seems like a nice person, but we don't have a problem." And she responded to that in an extraordinary way. I mean, I don't know about you, but my temptation, had I been her, would be to sort of explain again, why, in fact, even though you think you're pretty good and you probably are, we're never standing in the same river twice. All sorts of things can go wrong, it's a complex error-prone system. So look around again. Don't you think there might be some problems we could fix? That's not what she did, right. Tempting, though it might have been, what she did instead was say essentially, "Maybe you're right. I just got here. Let me ask you to reflect on your experiences with your patients last week." Very concrete. And if you think about it, that very request honors their experience. Like, "You're the ones who know best. You're there by the bedside." So she says, "Let me ask you to reflect on your patients last week." And then she says, "Was everything as safe as you would like it to be?" Right, this wonderful, aspirational question. And suddenly, she says, "My office became a confessional," right. So they flipped from, "We don't think we have a problem," to, "What can I do to help?" And I think that was really because she opened their eyes to something they already knew, which was, "Yeah, we do pretty well most of the time, but around every corner, there's a potential hazard, and we just swim upstream every day. And maybe we can do better."
Brian Kenny: I would imagine that's a really common belief in most organizations. It's like, "There's no fire here. Everything's going fine. Why do we want to upset this?" Right?
Amy Edmondson: Exactly, exactly. There's no fire. It's not a burning platform. That's okay, but it may not be good enough and it's certainly not going to be good enough for five years from now. And so this is exactly why I love this case, because so far, we've been talking in a pretty specific way about healthcare, and it is. It's a great healthcare delivery case, and it's so much more than that. I teach it all the time to executives and MBA students that have no connection to healthcare whatsoever, because it is such a good leadership case. It's a good case on how you come in from the outside into a new system and inspire people to be even better than they already are. How do you then empower and authorize a kind of set of learning processes through which they can do that? And health care is simply an extreme case of the challenges-
Brian Kenny: Because the stakes are so high.
Amy Edmondson: Because the stakes are so high, exactly. And the patients are so unique, right. So that you have a lot of repeating processes, but you also have a lot of customization that you need to do all the time. So it sort of a, it's a highly-customized, complex service operation. But many organizations can identify with being a complex service operation.
Brian Kenny: I should point out, too, that the incident that opens up the case happens after she's already made a lot of these changes.
Amy Edmondson: Right.
Brian Kenny: So my question is, is it better to come in and try to create a sense of urgency, through sort of fear. Like, "This really bad thing's going to happen if we don't make these changes." Or, kind of use the approach that she took, which is, "Are we as good as we could be or we want to be?"
“How do you come in from the outside into a new system and inspire people to be even better than they already are?”
Amy Edmondson: Right, right. Right, because notice, even with that question that she asked, she doesn't say, "Think about your patients last week, did you see lots of hazards?" Right, she says, "Was everything as safe as you would like it to be?" And I think, personally, fear is not the right strategy. I mean, there's always going to be some fear out there. Like competition, future issues that are coming our way that we don't see coming, but fear inhibits creativity. And she needed their creativity, right. And fear inhibits great collaboration, and she needed great collaboration. So hope is better.
Brian Kenny: Hope is better. Are these some of the big ideas that you talk about in the Fearless Organization?
Amy Edmondson: Yeah, so the Fearless Organization is all about psychological safety, that climate of being able to speak up, bring your full-self to work, ask your questions, offer your ideas, point out mistakes. That's mission critical in the knowledge economy. So the book is about why psychological safety matters, what it is, what it isn't. It's not about being nice, for instance. And how do you get it?
Brian Kenny: Well, these are all great ideas. I'm sure our listeners are connecting all the dots right now back to their organizations. Thank you so much for joining us today.
Amy Edmondson: Thank you so much for having me.
Brian Kenny: If you enjoy Cold Call, you should check out our podcasts from Harvard Business School, including After Hours, Sky Deck, and Managing the Future of Work. Find them on Apple Podcasts, or wherever you listen. Thanks again for joining us. I'm your host, Brian Kenny, and you've been listening to Cold Call, an official podcast of Harvard Business School, brought to you by the HBR Presents Network.
With the conflict looming in Vietnam, the Army demanded the missile be delivered ahead of schedule, and Phil's bosses challenged him to drive down defects. Phil marshaled his resources, and in spring of 1962, Martin Company delivered the missile program a month ahead of schedule, with no discrepancies in hardware or documentation. In effect, perfect. And from this arose the concept of Zero Defects, a management approach aimed at preventing mistakes through motivational techniques and tools. It's been the subject of articles and books ever since. Mistakes happen, and fortunately for most of us, a mistake at work isn't the difference between life and death. But in some jobs, the consequences can be tragic.
So, can a concept that originated in the defense industry be applied to saving the lives of children? Today we'll hear from Professor Amy Edmondson about her case entitled, Children's Hospital and Clinics. I'm your host, Brian Kenny, and you're listening to Cold Call, recorded live in Klarmen Hall Studio at Harvard Business School.
Amy Edmondson's areas of expertise include leadership, teams, innovation, and organizational learning. She's the author of a recent book called, The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. And we're going to talk about all of that today.
Amy, thanks for joining me.
Amy Edmondson: Delighted to be here.
Brian Kenny: It's a fabulous case, and I think one that many people will be able to relate to, many people have probably experienced some sort of a scare in a healthcare setting, and we know that as much as it is a science, it's also a management practice. And the ideas that the case brings to the surface, I think, will be eye-opening for a lot of people. How does the case begin? Who's the protagonist and what's on her mind?
Amy Edmondson: The protagonist is Julie Morath, and she is the chief operating officer of Children's Hospital and Clinics. And in fact, she's just joined the organization. She was hired from the outside when they needed a new COO, and she had a pretty good reputation in the Minneapolis area. She was a former nurse, she had been working in Allina Healthcare System, and they asked her to come in. She, in fact, negotiated on her way in, that she was interested in the job, but only if they would allow her to lead something called the Patient Safety Initiative. I think they didn't really think about it one way or another, they wanted Julie, and they hired her.
Brian Kenny: They didn't realize what they were signing up for.
Amy Edmondson: They did not realize what they were signing up for. So here she is, kind of contemplating what they've gotten done so far over about six months, and what lies ahead.
Brian Kenny: When we were talking about your book recently, you said this case is a great illustration of the ideas in the book. What led you to writing this particular case?
Amy Edmondson: This was a case where I recognized the opportunity to achieve that sought after synergy, where I could be teaching what I know about, and teaching it in an engaging way, and then bringing that research alive in the classroom. So I saw, I learned about the hospital from published reports in US News and World Reports. Actually, my wonderful colleague and coauthor Mike Roberto, first noticed the article and brought it to my attention. He said, "You ought to write that case," because my research was on psychological safety and he could see that that was going to play a central role in the case. And I said, "Well, write it with me."
Brian Kenny: For listeners who don't know, tell us about Children's Hospital and Clinics.
Amy Edmondson: Children's Hospital and Clinics is a tertiary care hospital in Minneapolis-Saint Paul. It is a large and complex organization. It takes care of some of the very sickest kids in the region. It's a place where patients, children come, and they're very, very sick, and they have complex things wrong with them. People really have to work together to take care of these kids, and get the best possible outcome.
Brian Kenny: This case opens up pretty dramatically. I mean, it sort of had me like almost like a novel in the opening couple of pages. I think it would be really helpful for people to understand the situation that opens the case up because it's really instructive for the rest of the case. Could you just explain that?
Amy Edmondson: Absolutely. So the case opens with the gripping story of a child, a young boy, who has just received a massive overdose of a medication. And the case describes the exact steps, and issues, and situation that led up to this adverse drug event. The boy does not, he does fine, right. They quickly administered the antidote and he does okay, but what you're able to see in the first page of the case is, if you read it carefully, you're able to see eight different process failures. Eight different little things that went wrong, that lined up in just the wrong way to produce this bad outcome. This is a quintessential medical error, in that it's not one person doing some boneheaded thing, it's so much more likely in this setting and many others, for just a number of small, little problems to line up, and essentially create a tunnel that the error flows right through, and gets to harm the patient. And so it shows the reader, the thoughtful reader, that right away that the nature of the beast, right, the nature of the beast is more often than not, you are doing something that has never been done before in this exact way. I mean, clearly we care for patients every single day, all day. But there's never been a boy with this exact condition, in this exact bed, with this exact set of caregivers. And things went wrong, and so this opens the story of a hospital that understands that this is how things go wrong, and they call them system failures. And because much more often than not, when things go wrong, it's a system failure, not an individual screwing up, they want to set out to figure out, "How do we vastly improve the organization so that system failures are far less likely?" And central to doing that, is ensuring that people feel safe to speak up about what they see.
Brian Kenny: So maybe you can help us by talking a little bit about this sort of existing climate in the hospital when Julie gets there, and some of the things that she sees as areas that need to be taken on, to improve in that area.
Amy Edmondson: One of the things she recognizes right away, is that the culture of the organization is not conducive to learning, that people are far more likely to hide the mistakes and failures they're aware of, to when things do go wrong, to point the fingers and assign blame to someone, rather than to sort of roll up their sleeves and figure out, "How can we improve and be better?”
This isn't to say they were bad people, or not well-intentioned. It's to say that this was just the normal culture. In fact, she calls it the ABCs of Medicine: Accuse, Blame Criticize.
Brian Kenny: I'm sure a lot of us are thinking, "Yes, that sounds like this place.”
Amy Edmondson: You bet. And so she sets out to really change the culture, and one of the ways she does that is by instituting a new policy called “Blameless Reporting,” which is exactly what it sounds like. You can and must report anything you see that goes wrong or seems substandard, without fear of reprisal for the act of reporting. Like you report in a safe way.
Brian Kenny: So blameless reporting. Is that anonymous? What's the mechanism by which you do that?
Amy Edmondson: You actually have both options. You can do it anonymously, or you can do it openly, and people did do both.
Brian Kenny: Okay. When you are blameless, is that the same as not holding people accountable?
Amy Edmondson: That's a great question. And in fact, that's one of the central debates that we have in the classroom. And the answer is, "No." It's not at all the same. In fact, I think of these as two different dimensions that create a kind of two-by-two, right. Where one dimension is, make sure the environment is psychologically safe for speaking up. It just has to be. If you're in a complex error-prone system, you better be creating conditions whereby people can speak up. The other dimension is holding people accountable for high standards. And that's about coaching, and giving feedback, and ensuring that people are really willing and able to show up every day to do the best possible job. And you can readily recognize that if you have an environment of low accountability and low psychological safety, you're sort of in trouble. That's just apathy, that's terrible. But if you have high psychological safety and high accountability, then you're in what I call the Learning Zone or the High Performance Zone. Where people are able and willing to offer what they know, they're motivated and engaged, they know that what they do matters, and they're determined to do it well. And that's, of course, where any hospital today needs to be, right. They need to be both safe for voice and people who are working hard and feeling accountable for their actions.
Brian Kenny: One of the things that comes through pretty clearly in the case is this sort of cultural divide in the hospital setting between the doctors, and the nurses, and the support staff. And the doctors, obviously, in that scenario, I would think, are the sort of supreme beings, right?
Amy Edmondson: Yes.
Brian Kenny: Does that make it really difficult to do the kind of thing that Julie was trying to do?
Amy Edmondson: It really does, because part of the culture, pre-existing culture of the industry and the hospital, were those status differences, and people who are in lower status roles in organizations, often have a particularly hard time speaking up. So part of what Morath was trying to do was reframe that, and reframe everybody's job, as one where they are the eyes and ears of the organization. They are the fail-safe mechanisms for the patients. So she would often say things like, "Healthcare, by its nature, is a complex error-prone system." In other words, when things go wrong, it's not necessarily you, it's the system, which means that, speaking up saves lives. Now who doesn't want to save lives?
Brian Kenny: Right.
Amy Edmondson: So it's a reframe from, "When things go wrong, there's a culprit," to, "When things go wrong, our very complex error-prone system just broke down, and it's up to us to get it back on its feet."
Brian Kenny: Sure. The case refers to zero defects, and I mentioned it in the introduction. Is that too lofty a goal? Is it really possible to have like zero defects?
Amy Edmondson: Another great question. It is not possible to be error-free. As human beings, we will never be error-free. However, it is possible to have zero defects end of pipe, right. Meaning, that we'll make mistakes, but as long ... I'll make a mistake, but you're alert and vigilant, and you see it, and you catch it. And we correct it before it harms patients. So you'll never make error go away, but you can make patient relevant defects go away.
Brian Kenny: Okay.
Amy Edmondson: When you're really good.
Brian Kenny: You talk about blameless reporting, and some of the cultural challenges here. What were some of the other things that she identified as sort of levers that she needed to activate?
Amy Edmondson: Well, she really put in place a number of disparate mechanisms for people to start to speak up about what they knew, problem solve together on ways to make it better. So in a sense, she distributed a learning process. She recognized that the learning that needed to happen needed to be team-based and needed to be work relevant, sort of situated in the work. So I can't tell you how to do your job in oncology, or your job in billing, right. You know that job better than I ever will, but I can put in place or encourage you to put in place processes by which you can learn to do that job better. So it was really a kind of distributed mindset and set of processes for continuous learning that she put in place.
Brian Kenny: Yeah, and it seemed in the case, as if people started to glom onto the idea, and formed their own ways of addressing some of the issues. Can you talk a little bit about that?
Amy Edmondson: Sure. In fact, that's one of my favorite things about the case. Because I have, in my own case set, and of course in our collection, many cases that we would call change cases, where a leader comes in and leads change. And some of them are the kind of change for which there's a blueprint, right. There's a playbook, people have done this before, and the job is to engage and motivate people to do it here. This is not one of those cases, right. This is a case where there's a desired outcome, right. There's a goal, zero defects. And there is, truly, no playbook, right. She was a pioneer, really. She was really out ahead of the industry, in terms of the patient safety movement. And there was no one you could turn to and say, "Okay. Well, how do you do it? And what do you do next? And what do you do after that?" So what she tried to do, was inspire and lead a learning process. Like she wanted to create a learning organization.
Brian Kenny: The case also goes into the importance of language. And I was really intrigued by that section because I think, so often, we all use terminology, and I think we hear different things when we use it. And I would imagine in a healthcare setting, this becomes a really critical element.
Amy Edmondson: Yes. I mean, if you're going to change the culture, you're often going to have to change the language you use. And there is an exhibit in the case called, “Words To Work By”, which came right from Morath.
Brian Kenny: Long list.
Amy Edmondson: A long list. And she wanted to change words like instead of investigate or have an investigation, we study.
Brian Kenny: That's like a really important one, I think, right there because investigation immediately puts somebody on the defensive.
Amy Edmondson: You immediately think police.
Brian Kenny: Exactly right.
Amy Edmondson: Study, well, you think scholar. Researcher.
Brian Kenny: Exactly, and some of this I thought played out pretty clearly illustrated in the meeting that they had right after this incident happened. Can you talk about what that meeting was like?
So as soon as something happens, whether it's an all-out harm, as in an overdose of a medication, or a near miss, we immediately convene a group of people, who touched the event from different perspectives, or maybe at different times. Immediately, we get together around a table and everybody shares, one at a time, what happened. We're trying to paint a realistic picture of what happened. Again, not who did it, what happened? And people get quite surprised by how different the same event looks from a different vantage point. And we realize, that in order to paint a full picture of something that happened, we have to have those different perspectives represented, and then you start the process of thinking about, "What might we need to change to make sure that never happens again?"
Brian Kenny: You have a lot of comments, direct quotes in the case. And one of them was about, "Everybody's touching a different part of the elephant."
Amy Edmondson: Yes, exactly.
Brian Kenny: I think, in this setting, the importance of understanding why something happened takes on really increased importance in a situation where you've got a family who wants to know what happened to their loved one. Like, "Why did my child almost suffer a fatal consequence for your mistake?"
Amy Edmondson: It's true. And one of the things we've learned over the years since that case, and I think they had an intuitive understanding there, was you don't do the family or the hospital any good by stonewalling. Your instinct, and maybe the lawyers will reinforce it, is to hold back. Say, "Well, we can't tell you. We're looking into it." But, in fact, transparency is your best strategy. It turns out that most of the time that people really resort to legal action, they're motivated by one of two things. One being, "We just needed to find out what happened," and that's the discovery process allows that to do that. And another being a sense of anger and frustration that they're not being talked to.
Brian Kenny: What were some of the challenges that Julie ran into as she tried to make this happen? It couldn't have been easy?
Amy Edmondson: Initially, she ran into the challenge of resistance. Now that's an old story, right. People resist change leaders.
Brian Kenny: Change is hard.
Amy Edmondson: They resist change. Change is hard. And they resisted her change, primarily because they really didn't believe. I think they sincerely didn't believe they had a problem, right. After all, they were certainly the best children's hospital in the region. They were considered a very good place, they had lots of good doctors, they were. Lots of good nurses, right. They were a great organization. And Morath's belief was, "Yes, it's a great organization, and it's still a complex, error-prone system, and it's up to us to make it even better so that children don't get harmed by things that happen to them under our watch." Right, so there was this kind of, "She seems like a nice person, but we don't have a problem." And she responded to that in an extraordinary way. I mean, I don't know about you, but my temptation, had I been her, would be to sort of explain again, why, in fact, even though you think you're pretty good and you probably are, we're never standing in the same river twice. All sorts of things can go wrong, it's a complex error-prone system. So look around again. Don't you think there might be some problems we could fix? That's not what she did, right. Tempting, though it might have been, what she did instead was say essentially, "Maybe you're right. I just got here. Let me ask you to reflect on your experiences with your patients last week." Very concrete. And if you think about it, that very request honors their experience. Like, "You're the ones who know best. You're there by the bedside." So she says, "Let me ask you to reflect on your patients last week." And then she says, "Was everything as safe as you would like it to be?" Right, this wonderful, aspirational question. And suddenly, she says, "My office became a confessional," right. So they flipped from, "We don't think we have a problem," to, "What can I do to help?" And I think that was really because she opened their eyes to something they already knew, which was, "Yeah, we do pretty well most of the time, but around every corner, there's a potential hazard, and we just swim upstream every day. And maybe we can do better."
Brian Kenny: I would imagine that's a really common belief in most organizations. It's like, "There's no fire here. Everything's going fine. Why do we want to upset this?" Right?
Amy Edmondson: Exactly, exactly. There's no fire. It's not a burning platform. That's okay, but it may not be good enough and it's certainly not going to be good enough for five years from now. And so this is exactly why I love this case, because so far, we've been talking in a pretty specific way about healthcare, and it is. It's a great healthcare delivery case, and it's so much more than that. I teach it all the time to executives and MBA students that have no connection to healthcare whatsoever, because it is such a good leadership case. It's a good case on, "How do you come in from the outside into a new system? How do you inspire people to be even better than they already are? How do you then empower and authorize a kind of set of learning processes through which they can do that? And healthcare is simply an extreme case of the challenges-
Brian Kenny: Because the stakes are so high.
Amy Edmondson: Because the stakes are so high, exactly. And the patients are so unique, right. So that you have a lot of repeating processes, but you also have a lot of customization that you need to do all the time. So it sort of a, it's a highly-customized, complex service operation. But many organizations can identify with being a complex service operation.
Brian Kenny: I should point out, too, that the incident that opens up the case happens after she's already made a lot of these changes.
Amy Edmondson: Right.
Brian Kenny: So my question is, is it better to come in and try to create a sense of urgency, through sort of fear. Like, "This really bad thing's going to happen if we don't make these changes." Or, kind of use the approach that she took, which is, "Are we as good as we could be or we want to be?"
Amy Edmondson: Right, right. Right, because notice, even with that question that she asked, she doesn't say, "Think about your patients last week, did you see lots of hazards?" Right, she says, "Was everything as safe as you would like it to be?" And I think, personally, fear is not the right strategy. I mean, there's always going to be some fear out there. Like competition, future issues that are coming our way that we don't see coming, but fear inhibits creativity. And she needed their creativity, right. And fear inhibits great collaboration, and she needed great collaboration. So hope is better.
Brian Kenny: Hope is better. Are these some of the big ideas that you talk about in the Fearless Organization?
Amy Edmondson: Yeah, so the Fearless Organization is all about psychological safety, that climate of being able to speak up, bring your full-self to work, ask your questions, offer your ideas, point out mistakes. That's mission critical in the knowledge economy. So the book is about why psychological safety matters, what it is, what it isn't. It's not about being nice, for instance. And how do you get it?
Brian Kenny: Well, these are all great ideas. I'm sure our listeners are connecting all the dots right now back to their organizations. Thank you so much for joining us today.
Amy Edmondson: Thank you so much for having me.
Brian Kenny: If you enjoy Cold Call, you should check out our podcasts from Harvard Business School, including After Hours, Sky Deck, and Managing the Future of Work. Find them on Apple Podcasts, or wherever you listen. Thanks again for joining us. I'm your host, Brian Kenny, and you've been listening to Cold Call, an official podcast of Harvard Business School, brought to you by the HBR Presents Network.