Book: Black Box Thinking by Matthew Syed
Originally published on business blog
I loved Bounce so have been anticipating this with some excitement. Matthew Syed undertakes all the research so we can just sit back and learn it all by reading his books.Bounce took the idea that just about anyone can be good at pretty much anything, it just takes practice. My take on Black Box Thinking puts out the idea that if more of us learnt from mistakes, the world would be a safer, better place.Having been to the authors promotional event at the local Waterstones, I was warned about the heart-breaking opening story about Elaine Bromiley, a healthy lady dying on the operating table during a routine operation.The author asks who in the audience was interested in sports, education or teaching? Whilst I have an interest in all three, my category – business – wasn’t mentioned. Being a fan-girl, I just turned up and bought the book on the day. There are always a few avid readers who go to these things armed with questions. I’m not one of those.This is how I learnt what this book was about and it is indeed entirely relevant to my world.A good summary of Black Box Thinking is that whereas in the aviation industry, they immediately look for evidence as to why the accident happened and how they can do better next time, saving untold lives, the medical profession, in the main fails to learn from it's mistakes.In an American study, a million people are said to be injured by hospital errors. 120,000 each year. A later 2013 study puts figure at 400,000. This is the equivalent of a 9/11 catastrophe happening every 2 months.
We wouldn’t tolerate this in any other area of preventable harm.
In the UK, 34,000 are killed due to human error.In aviation, independent investigators immediately find out what went wrong, how to fix it and then share that openly with the world. Every pilot has access to the data. Syed says soon we won't need black box as all the info will have been already transmitted to a central database while the accident is happening.
Learn from the mistakes of others. You can't live long enough to make them all yourself.
Sullenberger, who landed the plane in the Hudson River (while I was living in just up the road in New York, incidentally) credited all the lessons learnt from aviation deaths to his safe landing.The Toyota Production System (TPS) was put in place so if anyone on the car production line had a problem, they pull a cord which halts production. The error is assessed, lessons learnt and the system adapted. Try putting that into health service where mistakes are frowned upon & people are too scared to report their seniors, which is why the preventable death in the opening paragraph occurred.30-60000 deaths in USA are due to central line infections (catheter placement)A healthcare organisation in America, Virginia Mason tried to put into place Patient Safety Alerts in 2002 but no one would report the errors. After the next death, their boss issued a public, heartfelt apology. Complaints started coming in and it’s now one of the safest hospitals in the world and they saved 75% in insurance premiums too.Pronovost (who wrote Safe Patients, Smart Hospitals) instituted 5 point check list and saved 1500 lives. Plus c $100m over 18 months in Michigan.To really bring it home, I learn it took 264 years to put a preventative measure for scurvy in place.
So that others may learn, and even more may live - Martin Bromiley, husband of Elaine and campaigner.
Cognitive Dissonance
It is better that ten guilty persons escape than one innocent suffer - William Blackstone, juristWe assume smart people are most likely to reach sound judgments (Blair/Bush/Iraq/Iraq) but (these) people won't admit to mistakes or indeed close a business/project that's no longer working. Coincidently, this is something I have just done after 3 years of working for free on community project. It worked well, but there are so many people doing something similar now, I am no longer needed. It was hard, and I should have done it a year ago.Talking of smart people, economists don't change their school (of thought) ever. But if they're not learning, how are they still experts? There’s the story of a surgeon who refuses to change gloves even when the patient had a latex allergy.MemoryWhat you remember seeing and what you actually see are two different things. i.e. you can believe it but that doesn't mean it's true. I’d recently come across America’s Innocence project which helps exonerate innocent people locked up and the work they’ve done features a few times in Black Box Thinking.As well as exonerating those that are wrongly imprisoned, they are campaigning for line-ups to be administered by an officer who doesn't know the suspect and for sequential line ups rather than all together. Also to film all the interrogations.I would have thought all of this was obvious in a fair society.PerfectionHow many people miss out because they want to make their product perfect before taking it to market? I’m off the mind-set that it’s better to (quietly) put your service out there and gain some feedback, then keep improving it. The author refers to this as MVP = minimum viable product.Moving back the prison service for a minute, Scared Straight is a programme in America designed to scare young people into going straight by spending a day in prison with convicts doing time for extremely violent crimes. A documentary aired in America ignored the data – which provided no proof it worked - but believed the stories i.e. parents saying their child was different when they returned from the trip. Well of course they would be, but how?If you ask a simple question in such a way, you’ll get the answer you want.
Many people are convinced that that government figures are fudged to look good. I’m also of the belief that some not-for-profits* are often disguised as social enterprises do the same thing, by asking the simple question.
How many people have you helped with your social business? Answer 50.That doesn’t necessarily mean 50 people have changed (not re-offended, settled into a job, stayed sober, been clean). That just means they say they have.People want to believe they hype that ALL not-for-profits/charities/social businesses are saints and believe the hype. I know many regular businesses that do much uncredited work for the community and causes.There were more Scared Straight documentaries that continued with the positive outcome theory. One person featured on that first programme offended soon after & got caught decades later when he was convicted of theft and DNA was collected.* What a term! An organisation needs to make profit in order to do good.
American Airlines took 1 olive out of their salads & saved $500,000
(and added a row of seats, as I recall).
Failure Drives Innovation3 groups are asked to come with ideas:
- One asked to brainstorm
- Second had no guidelines given
- Third asked to question & pull apart others ideas
Last one came up with 25% more ideas.Dyson, Dropbox, windup radio, ATM, collapsible buggy all dreamt up due to one person having a frustrating problem.Some people change the world, others are footnotes on the patent catalogue.James Dyson says when he goes to patent, someone else has always done it first, his has to be a little different.
Cultures without the blame culture report more errors but make less of them.
The tragic death of baby Peter Connelly who died in the hands of his mother, her partner and his brother resulted in a media witch hunt for Social Services, rather than the culprits. This bought about death threats to the head and her family. Worse, social workers were so scared of getting the blame again, those that stayed in the profession, removed more children from families, and there weren’t enough foster parents available to look after them. A huge knock-on effect of the media's reporting caused chaos where more care was needed.The first pilot in history to be put on trial committed suicide years after being found guilty despite doing everything he could in exceptional circumstances & saving the day by landing the BA flight in safety back in 1989. It could have gone terribly wrong, but it didn’t. He was only fined £2000 which leads us to think the judge didn’t think it should have gone to trial.Both of these two stories clearly ended with intelligent people bought into depression by the blame culture. Imagine what may have been?
- enthusiasm
- disillusionment
- panic
- search for the guilty
- punishment of the innocence
- rewards for the uninvolved
= the 6 phases of a project