I’m moving on from the Hitchhikers Guide to the Galaxy to the Pink Panther movies this week. My grandchildren and I have watched all of them at least six times over the last couple of months. We love the way that Clouseau manages to turn utter stupidity into a winning art form. For example, who else would survive a bomb attack dressed as the hunchback of Notre Dame, inflating a hump on their back and floating out of their bedroom whilst chatting on the phone. Not realising what was was going on until the bomb went off and he floated over the cathedral- under the disproving eye of a group of nuns.
What strikes me about the Pink Panther movies is how incompetence wins over competence every time and how everything has a habit of turning out alright in the end.
Now I’m not saying that in social care and health we are mired with masses of incompetence. I am saying we don’t spend enough time celebrating our mistakes and learning from our failures.
I see so many case studies and examples that relay to me how well things went without telling me the full story of how hard it was to get there. Or what was messed up and what damage that mess up did on the way. I have had many conversations with people who have written a case study, who in an embarrassed tone tell me, ‘it wasn’t quite like that but we couldn’t really be totally honest in what we wrote. Please don’t tell anyone the truth.’
I don’t know about you, but over the years I have learned more from my mistakes and failures than I have from for my successes.
Sometimes it’s about taking my mistakes and failures and taking time to turn them into successes
Sometimes it’s about recognising that something wasn’t ever going to work, and as long as it didn’t do long-term damage to anybody, we can learn from this and we can do things differently next time.
A few years ago I read some research into a large health organisation in the United States, where senior leaders were getting very concerned about how much money they were having to spend on fighting court cases about things that had gone wrong within their organisation.
They did two things. First they went back to the families and patients who were suing them and asked them what it was that motivated them to sue the organisation. the answers they got back surprised them. More often than not the family and patients said, ‘it’s not about the money it’s about learning the truth about what happened to us or our loved ones.’
The second thing they did was to go back to the staff in their organisation and ask the staff what they thought. The senior team quickly realised that there was a culture across the organisation of celebrating success and hiding, and not talking about, failure. Hiding or not talking about failure made it much harder for people across the organisation to learn from their mistakes. It also made it very hard for people across the organisation to know what was and what wasn’t working. If you are constantly being told everything is wonderful because that’s what people think you want to hear, you very quickly get a warped view of what is happening in your organisation.
The senior leadership team decided they needed to take action. So they introduced an extensive no blame culture training program across the organisation. Making it absolutely clear to everybody that whatever the mistake, big or small, it was okay to talk about it and to learn from it and people wouldn’t get disciplined or sacked for sharing their mistakes and the mistakes of others. They also introduced a strategy and policy of complete open straightforward honesty with patients and with their loved ones about what had gone well and what had not gone so well in relation to any care and treatment. Often finding that patients and loved ones had no idea that anything had gone wrong in the first place.
Over a number of years this policy of openness about failure had a massive impact not only on the culture across the organisation, it also a delivered a big reduction in the number of lawsuits that the organisation faced. Saving a lot of money that could be reinvested in their workforce. You see families and patients more often than not weren’t suing to get money, they just wanted to know the truth and what could be learnt to make things work out better next time.
And I think for me that’s why I believe that the introduction of league tables for any health organisation is completely the wrong thing to do. If I was sitting in the senior leadership role in a health care organisation right now, I’d be wanting to think about how I could get my organisation as high up that league table as I possibly could. One of the things I wouldn’t want to do would be to air my dirty laundry in public. A league table system doesn’t encourage effective learning about what an organisation has done well and more importantly what it has done not so well. It encourages people to hide their mistakes and to not tell the truth and to embellish where they are doing well at any point in time. We need a culture that enables us to be honest with each other, patients and families – that’s what will improve productivity, raise morale and save money. Let’s all be more Clouseau (well may not quite so Clouseau but…..)
Jim Thomas
December 2024
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