Learning from Failure

OVERVIEW

Failure is an outcome that deviates from that which was expected or desired

  • Learning from failure are the processes and behaviours that individuals, groups or organisations use to gain insights and modify future behaviours, processes and systems
  • Learning from failure is rarely consistently practised, despite research findings that organisations learn more from failures than from success (Madsen and Desai, 2010)

In Blackbox Thinking, Matthew Syed argues that a “stigmatising attitude towards error” pervades everyday life. This attitude is a major barrier to learning from failure as individuals and organisations.

**This page is largely derived from the work of Amy Edmondson (see multiple references).

REASONS FOR FAILURE

A spectrum of reasons for failure is described by Edmondson (2011):

  • deviance – individual chooses to violate a prescribed process or practice
  • inattention —individual inadvertently deviates from specifications
  • lack of ability — individual lacks the knowledge, attitude, skills or perceptions required to execute a task
  • process inadequacy — competent individual adheres to a faulty prescribed process
  • task challenge —task is too difficult for an individual to reliably perform every time
  • process complexity —process comprised of many elements breaks down when it encounters novel interactions
  • uncertainty — lack of clarity about uncertain events means people take seemingly reasonable actions that produce undesired results
  • hypothesis testing – an experiment conducted to prove that an idea or design will succeed fails
  • exploratory testing – an experiment conducted to expand knowledge and investigate a possibility leads to an undesirable result

“Blameworthiness” varies across the spectrum

  • in general, degree of blameworthiness increases down the above list
  • many of the activities in the lower part of the list are actually praiseworthy
  • in business, about 90% of failures are attributed blame, but only 2-5% are actually blame-worthy (Edmondson, 2011)

TYPES OF FAILURE

Edmondson (2011) classifies failure into 3 types:

  1. preventable failures
  2. unavoidable, complexity-related failures
  3. intelligent failures

Preventable failure

  • usually involves deviance, inattention, lack of ability or task challenge
  • can be prevented by techniques such as:
    • effective training
    • ensuring adequate rest
    • checklists
    • creating a flat hierarchy where all individuals are encouraged to ‘speak up’ (e.g. Toyota assembly line)

Unavoidable, preventable failure

  • inevitable in complex systems (e.g. nuclear, aviation, healthcare)
  • occur due to the inherent uncertainty of work (e.g. emergency room, battlefield, ‘start ups’) or systems failure (e.g. process inadequacy or complexity)
  • (most) serious process failures can be prevented by early identification and correction of small process failures (e.g. ‘prevent the holes in the Swiss cheese from lining up’)

Intelligent failure

  • involves hypothesis testing or exploratory testing when to obtain new knowledge
  • useful when answers are not otherwise knowable in advance (e.g. scientific discovery, innovation, invention, market research)
  • the goal is to achieve ‘good’ failures quickly

HOW INDIVIDUALS CAN LEARN FROM FAILURE

Avoid preventable/ harmful failure

  • Conduct a ‘premortem’
    • “let’s say that in 2 years time this decision turned out to be a disaster… what went wrong?”
    • can also ask ‘ things went great… what went well?’
  • Guard against hubris
    • we are more likely to over-estimate our ability to predict the future if we have recently be lauded for our expertise and achievements or have a high degree of self-importance
  • Develop individual and collective competence (education and training)
  • Perform experiments/ pilots that ‘fail fast and intelligently’ to gain knowledge
  • Obtain feedback before projects are complete (so that failure is not final, able to get calibration and correct if needed)

Prepare for inevitable/ useful failure

  • Develop a learning-orientated ‘growth mindset’
  • View failure as a chance to learn (FAIL = “first attempt in learning”) and as a necessary step on the way to success
  • Reward the struggle, not success
  • Guard against irrational loss aversion (the tendency for losses to be perceived as being greater in magnitude than quantitatively similar success)

Learn from failure

  • Monitor performance for feedback
  • Reflection, involving consideration of:
    • Planning?
    • Preparation?
    • Execution? (consider to knowledge, skills, attitudes or behaviours)
    • Which variables were within your control?
  • Create action items with SMART goals following reflection

HOW ORGANIZATIONS CAN LEARN FROM FAILURE

Establish a learning culture

  • Strong leadership that establishes tolerance of failure and commitment to:
    • An ethos that a certain amount of failure is expected
    • Reporting and early identification of failures
    • Discovering ‘what happened’ rather than ‘who did it’
  • Create a psychologically safe, “no blame” environment
    • Frame the work accurately – create a shared understanding of the types of failures expected and why openness is necessary (e.g. presentations, discussion groups, teams of champions)
    • Embrace messengers – reward those who come forward and allow anonymous reporting; ensure people feel able to ‘speak up’ People feel able to “speak up”
    • Acknowledge limits – leaders should be open about what they don’t know and what mistakes they have made, and that they will need help
    • Invite participation – encourage observations, ideas and create opportunities for people to analyse failures and promote intelligent experiments (e.g. cross-disciplinary teams)
    • Set boundaries and hold people accountable – e.g. explain that reporting will not be punished, but certain behaviours will be (e.g. reckless conduct) and explain to those directly and indirectly affected.

Detection of failure

  • Goal is to spot hidden failures before they accumulate and lead to obvious harm
  • Techniques
    • Employee reporting (e.g. RISKMAN)
    • Total Quality Management
    • Soliciting feedback from customers/ patients
    • High-reliability Organisation practices, e.g. tracking and investigating any process anomalies
  • Reporting depends on behaviour of midlevel managers
    • need to encourage open discussion of failures, show humility and curiosity and welcome questions
  • Need to reduce stigma of failure
    • prevent failing projects from continuing unduly, e.g. “failure parties” to celebrate intelligent failures

Analysis of failure

  • Requires:
    • openness
    • patience
    • time
    • tolerance of causal ambiguity to identify true root causes
  • Must not succumb to:
    • confirmation bias (settling for superficial, obvious reasons that we already believe)
    • fundamental attribution error (assume due to a ‘bad’ person, rather than the circumstances of the event)
  • Requires:
    • interdisciplinary teams with diverse skills and perspectives
    • detailed, team-based discussion and analysis
  • e.g. Challenger disaster
    • First order cause: piece of foam hit shuttle’s leading edge during launch
    • Second order cause: rigid hierarchy and schedule-driven culture made it hard for engineers to speak up

Experimentation

  • Systematic experimentation to create the right failures at the right time is crucial for learning – the best learning organisations go beyond the detection of failure
  • Pilot trials/ projects need to be performed in realistic, rather than optimal, conditions with the goal of producing intelligent failures as quickly as possible (rather than being designed to succeed)
    • Is the pilot being tested under typical circumstances?
    • Do the employees, customers/ patients, and environment fit the real operating environment?
    • Is the goal to learn as much as possible?
    • Is the goal understood by all employees and managers?
    • Is it clear that performance reviews will not be affected by the success of the pilot?
    • Will explicit changes be made as a result of the pilot test?
  • e.g. multiple iterations of simulated ECMO-CPR events in different environments to refine the Alfred ICU protocol

Organisations should provide training and support staff with expertise in facilitating each of the components of learning from failure

BARRIERS TO LEARNING FROM FAILURE

Perceptions of failure are often negative and often incorrect — failure:

  • is associated with fault from a young age, and leads to a stigmatising attitude and a ‘blame culture’
  • is sometimes viewed as preventable when it was actually inevitable, and vice versa
  • is often assumed to have a single root cause, even though causation may be complex
  • may be considered a ‘one off’, even though latent safety threats remain
  • may be ignored or diminished by individuals to decrease cognitive dissonance (‘ego defence’)
  • may be explained by superficial (e.g. procedures were not followed) or self-serving (e.g. “the world wasn’t ready for us”) explanations
  • may be punished out of fear that failure to do so will lead to an ‘anything goes’ culture and worse performance

Social barriers

  • Lack of a learning culture and psychological safety
  • Fear of reprisals or consequences of reporting failure
  • Lack of an open dialogue involving different groups (e.g. competition, work politics
  • Use of workarounds and ‘quick fixes’ to avoid detailed analysis and definitive solutions (e.g. time pressure)
  • Counter-productive organisational rewards systems that inhibits innovation and experimentation
  • Tendency to focus on learning from ‘big’ failures rather than more common ‘small’ failures

Technical barriers

  • Lack of metrics, data feedback or information systems to allow detection of failure
  • Lack of technical knowledge about how to rigorously examine a failure, understand root causes and draw relevant implications
  • Lack of training in experimental design

FAMOUS QUOTATIONS ABOUT LEARNING FROM FAILURE

“There are no secrets to success. It is the result of preparation, hard work, and learning from failure.”— Colin Powell

“Success is failure in progress.” — Albert Einstein

“Failure is instructive. The person who really thinks learns quite as much from his failures as from his successes.”— John Dewey

“Far better is it to dare mighty things, to win glorious triumphs, even though checkered by failure… than to rank with those poor spirits who neither enjoy nor suffer much, because they live in a gray twilight that knows not victory nor defeat.”— Theodore Roosevelt

“Success is going from failure to failure without loss of enthusiasm.”— attributed to Winston Churchill

“I have not failed. I’ve just found 10,000 ways that won’t work.”—Thomas Edison

“I’ve missed more than 9000 shots in my career. I’ve lost almost 300 games. 26 times, I’ve been trusted to take the game winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.”— Michael Jordan

References and Links

Journal articles

  • Baumard P, Starbuck WH. Learning from failures: Why it May Not Happen. Long Range Planning. 38(3):281-298. 2005.
  • Bohmer RM. Fixing health care on the front lines. Harvard business review. 88(4):62-9. 2010. [PMID 20402057]
  • Cannon MD, Edmondson AC. Confronting failure: antecedents and consequences of shared beliefs about failure in organizational work groups. J. Organiz. Behav.. 22(2):161-177. 2001. [article]
  • Cannon MD, Edmondson AC. Failing to Learn and Learning to Fail (Intelligently). Long Range Planning. 38(3):299-319. 2005. [article]
  • Edmondson AC. Learning from Mistakes is Easier Said than Done: Group and Organizational Influences on the Detection and Correction of Human Error. j appl behav sci. 40(1):66-90. 2004. [article]
  • Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44, 350–383.
  • Raspin P. Failing to learn? How organizations can learn from failure. Strategic Direction. 27(1):4-6. 2011. [article]
  • Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change. California Management Review. 45(2):55-72. 2003. [article]
  • Madsen PM, Desai V. Failing to Learn? The Effects of Failure and Success on Organizational Learning in the Global Orbital Launch Vehicle Industry. Academy of Management Journal. 53(3):451-476. 2010. [article]

Books

FOAM and web resources

MIME 700 2

SMILE

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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