work in progress
The mindset 2 min System Scope: authority over the conditions involved

⇄ If being wrong costs status, nobody will be wrong out loud

What you are asking for

“Flag mistakes early enough for us to react.”

The team has to be able to raise a problem, including when the person who sees it took part in the decision.

What the system hears

“What will happen when I say what happened?”

What that produces

How one report is received shapes the next ones. Thanking the person helps, but they will also watch whether they can explain the facts without being exposed or sidelined before the situation is understood.

A team can learn more about its mistakes when reporting them gets easier. So the number of reports is not on its own a measure of the quality of the work. Look also at their severity, at how long it took before the alert, and at what the fixes changed.

Learning and accountability each have their place. A mistake can reveal an ambiguous instruction, a check nobody could reach, an excessive workload, or a rule that was ignored. Examining those causes is what lets you decide on a proportionate response. Having raised the alert has to stay separate from the action that caused the problem.

The frame has to work for a person who has just arrived as well as for a long-standing colleague. Offer a private channel when the subject touches people or sensitive information. The group can learn from a mechanism without knowing every name.

The decision

On the next report, look first for what has to be protected and who can step in. Then confirm how the facts will be examined and with whom.

Keep that review separate from individual assessment. If you share one of your own mistakes, show the reasoning and the fix, without asking everyone to expose theirs in return.

After the review, check that the action decided was carried out, and ask privately whether the report could be made under decent conditions. Those answers will help you correct the frame.

From where you sit

To discuss

On a recent incident, what made the alert easier or slower, and which condition can we improve?

Discuss this