Tag Archives: error

“Forgive and remember”

Forgive and remember

File this under “lessons about failure that the nonprofit sector can learn from medical sociology.”

Forgive and Remember: Managing Medical Failure, by Charles Bosk, is a classic of medical sociology, an analysis of how coping with failure is built into the training that surgeons receive in hospital rounds, mobidity and mortality conferences, and other settings.

Please note that I am not claiming that surgeons themselves have a lot to teach us about dealing with failure, because my experience is that while their sub-culture does have rituals and protocols that they enact privately, they still have a way to go in transparency and accountability to others.

This has been my experience in three instances of major surgery:

  1. Surgeon did not follow instructions given by the specialist physician managing my condition.  Acknowledgement: Partial.  Apology: No.
  2. Surgeon did not inform me that the tumor to be removed might be malignant and require addition surgery until I was under anesthesia. Acknowledgement: Yes, after I complained. Apology: Yes, after I complained.
  3. Surgeon did not respect my request regarding administration of anesthesia:  Acknowledgement: Yes, after I complained. Apology: No.

Not that I am bitter.

But let’s face it:  most of us are highly invested in showing the world that we are skillful, trustworthy, and deserving of whatever prestige is ascribed to us.  As a patient, I naturally blamed the surgeons, not only for their errors in judgement, but for the instances in which they failed to acknowledge or apologize for their mistakes.  As a fellow human being, I completely empathize with their reluctance.  I imagine that that reluctance is more acute among professionals who have to cut people open.  Their work is obscenely invasive but often lifesaving,  and therefore must maintain an impeccably trustworthy reputation.

That’s why Brent James is one of my heroes, along with surgeons and physicians like him who are putting it on the line for evidence-based practice.  There will be no accountability, transparency, or improvement in health care unless successes and failures are accurately documented.  Those results must then be carefully analyzed, made available to the public in appropriate ways, and used to improve their efforts.

As with medicine, so with other mission-based organizations.  We need to track outcomes, acknowledge failures, and then do better.  If it takes a pink feather boa and an amusing ritual for nonprofits to get there, I’m all for it, though I’m not expecting surgeons to adopt the feather boa.

As for the slogan, “forgive and remember,” I think of it as both a spiritual and a practical precept.  We not only need to forgive ourselves and others when we have failed – we also need to bear the lessons of failure in mind.  Both individuals and organizations not only need to keep learning, but to take appropriate action to protect those who are at risk.

I used to work in violence prevention, and for me, one of the most heart-rending aspects of it was the well-documented difficulty in stopping offenders from repeatedly battering their loved ones.  In some cases, they simply didn’t see their behavior as abusive, or their loved ones didn’t see any alternative to accepting abuse.

As I reflect on that today, it drives home very painfully the lesson that we cannot always change others, or even control a specific behavior of theirs.  The old cliche that they “have to really want to change” is true, and it’s also true that not everyone who wants to change can do so. This is the really difficult side of facing failure for nonprofit organizations – in some cases, there may be no alternative to severing ties with individuals or organizations, if the organization is going to face its failure and move on.  It’s going to take more than a pink feather boa, a “joyful funeral,” or a FailFaire to get past that.  When the well-being of vulnerable people is on the line, there are cases where forgiving and remembering is crucial, but it isn’t enough.


Bonus item:

Q:  How many psychotherapists does it take to change a lightbulb?

A:  Only one, but the light bulb really has to want to change.

Let’s revisit the concept of failure-friendliness

Eight years ago, I wrote a blog article about failure-friendliness in nonprofit technology. It was very much inspired by my friend and colleague, Dan Scharfman. Since Dan died this week, and this is also a week when I have been thinking hard about the obstacles that nonprofit organizations face in tracking their outcomes, it seems appropriate to reprise the article here and now. Having coped with the need for failure-friendliness in nonprofit technology for years, I see that my understanding is still superficial when it comes to the difficulties that nonprofits have in acknowledging programmatic failure. I invite your thoughts on how we can be more transparent about and more open to learning from failure. Meanwhile, special thanks go out to Beth Kanter, for her outstanding blog articles on this topic.

FAIL stamp

Wed 26 Jan 2005 05:41 PM EST

The term “failure-friendly organization” was first introduced to me by a colleague I revere – Dan Scharfman of Baird Associates.

My first impression was that he was an unlikely champion of failure, since Massachusetts is well-supplied with nonprofit organizations that consider the technology services that he has provided to them very successful indeed.

However, many of us in the nonprofit sector have seen the following things happen with major implementations or upgrades:

  • The technology doesn’t work, or doesn’t work nearly as well as it should;
  • The intended users won’t have anything to do with the technology;
  • Major changes in technology in the outside world quickly render the organization’s choices obsolete;
  • Programmatic priorities change, and the technology is all but irrelevant;
  • The organization has not factored in the shocking cost of customizing, tweaking, maintaining, and upgrading the technology.

Although techies vary greatly in their attitudes about projects that don’t work out, we also tend to make tacit assumptions that everyone concerned understands that we are not engaged in an exact science but in an evolving process.

Techies also tend to regard failure as pretty interesting – as a good source of information about what ought to be fixed when Version 97.53.01 of the software is released.  We also enjoy working on cool tools, even if such tools don’t actually deliver the outcomes desired by those who are underwriting the project.  This form of process orientation can be less than endearing to decision-makers in nonprofit organizations.

Oddly enough, nonprofit workers tend to be very good at process orientation when they are on familiar ground.

Sometimes this process orientation is a grim necessity, with governmental agencies strictly mandating, auditing, and enforcing protocols that nonprofits must follow in order to maintain their tax-exempt status, accreditation, or contracts for services.  These are headaches that would impel just about any organization or individual to worry a great deal about operating according to plan and documenting the process, rather than ensuring a specific outcome. This of course is a very “functional” (or “instrumental“) form of process orientation.

A more “expressive” form of process orientation is also frequently seen in nonprofit organizations – manifesting as a desire to be flexible and responsive to changing situations, or as a desire to arrive at decisions through consensus.  However, it can be difficult to extend that attitude to technology, which tends to be difficult for non-specialists to comprehend, time-consuming, and expensive.

Another challenge is that organizations and individuals (including yours truly) can be reluctant to cut their losses, and say, “This isn’t working.  Let’s stop, figure out why, and decide on some next steps.”  Of course, in some settings, the decoded version of this message is “Let’s find someone to blame and punish…maybe YOU.”

Yikes!

Is there any solution in sight?  I only wish I had something certain and simple to offer.  Here are a few ideas, although none of them come with guarantees of success:

  • Techies need to understand the nonprofit organizational cultures in which they are operating.  Progress toward this goal is possible if the techies listen, ask questions, and listen some more.  These conversations should start early in the planning phase.
  • Nonprofit workers need to understand how technology innovations and implementations happen in real life, and have a reasonable idea of what factors can lead to unexpected outcomes in technology projects.  Progress is possible if – yes, you guessed it – the nonprofit workers listen, ask questions, and listen some more.
  • Everyone needs to cooperate in creating incentives for spotting, discussing, and correcting errors rather than evading their detection.  I freely admit that I always find it easier to do these things when the mistake was made by someone else, but am always striving to do better.

I wish I could remember who it was that first said to me, “This is not about one person against another. This is about our team against the problem.”  Anyone who can say that is a saint, a boddhisatva, a tzadik, or an unusually effective manager.

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