Evidence-based management works best in wise organizations. Harvard Business School researcher Amy Edmondson found out that within such organizations, employees are seldom quiet or well behaved – at least by traditional “the boss is always right” standards.
In the mid-1990s, Edmondson was doing what she thought was a straightforward study of how leader and co-worker relationships might increase or decrease nurses’ errors. She was flabbergasted when nurse questionnaires showed that the units with the best leadership and best coworker relationships reported making 10 times more errors than the worst!
Edmondson later realized that better units reported more errors because people felt “psychologically safe” to do so. In these units, nurses said, “mistakes are natural and normal to document” and “mistakes are serious because of the toxicity of the drugs, so you are never afraid to tell the nurse manager.” In the units where errors were rarely reported, nurses said things like “The environment is unforgiving. Heads will roll.”
The physicians who helped sponsor her research no longer view error reports as purely objective evidence. Instead, they understand that they are partly a reflection of whether people are learning from and admitting mistakes, or covering things up to avoid blame.
In another study of nurses, Edmondson and colleague Anita Tucker concluded that those nurses whom doctors and administrators saw as most talented unwittingly caused the same mistakes to happen over and over. These “ideal” nurses quietly adjusted to inadequate materials without complaint, silently corrected others’ mistakes without confronting the error makers, created the impression that they never fail, and found ways to do their job quietly, without questioning flawed practices. While these nurses were getting sterling evaluations, their silence and ability to work around problems were undermining organizational learning.
Rather than hiring smart, silent types, Edmondson and Tucker concluded, hospitals would better serve their patients if instead they hired wise and noisy types, like the following:
Noisy Complainers repair problems right away and then let every relevant person know that the system failed.
Noisy Troublemakers always note others’ mistakes, but do so to help them and the system learn, not to point fingers.
Mindful Error Makers tell managers and peers about their own mistakes, so that others can avoid making them.
Disruptive Questioners won’t leave well enough alone; constantly ask why things are done that way, and whether there is a better way of doing the job.
Sources: Edmondson, A. “Learning From Mistakes Is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error.” Journal of Applied Behavioral Science 32: (1996): 5-28; Tucker, A. & Edmondson, A. “Why Hospitals Don’t Learn From Failures: Organizational and Psychological Dynamics That Inhibit System Change,” California Management Review 45 (2003): 55-72.