How to Use Pre-mortems to Prevent Problems, Blunders, and Disasters
In my previous article, I introduced the Preventable Problem Paradox and described why it’s so prevalent and pernicious. Now, it’s time to talk about combating it and creating a culture of problem prevention within your organization, by using pre-mortems.
In this article, we’ll look at the “what” and “how” of pre-mortems, along with a novel technique of using Tigers, Paper Tigers, and Elephants to run effective pre-mortems. My aim here is to be as concrete as possible so that you can take the steps described here and literally run your very first pre-mortem on Monday.
Post-mortems, After Action Reviews (AARs), etc. are becoming a part of the standard process at many organizations, usually implemented after an outage, a failure, or even a fairly successful execution of a project.
So, what’s a pre-mortem and what role does it play?
The best way to describe a pre-mortem is that if you do it right, you won’t need a tough post-mortem. Unlike a post-mortem — where you discuss what went wrong (and what you can learn from it) — in a pre-mortem, you get together earlier in a project’s lifecycle and ask the team to assume that the project has failed. And you prompt the team to come up with the reasons why.
This short and excellent HBR article by Gary Klein is required reading on this topic.
Here are the highlights of the standard pre-mortem process, from that article:
I’ll now share a modified pre-mortem script that has worked well on the teams I’ve worked with.
As background, at Stripe, the teams I’ve led have regularly run pre-mortems for our products, particularly major product launches. And while we haven’t been 100% mistake-free, pre-mortems have enabled “calm product launches” and enhanced team productivity & morale.
Why change the standard pre-mortem script? In my experience, the standard pre-mortem meeting was very engaging *while* the team was in the room.
But how many times have you had an engaging meeting and then people leave the room and everybody forgets about it and reverts to old patterns?
That’s what I saw repeatedly when we employed the standard script. So, I began looking for ways to change that.
I wanted the team to
A. be spotting major problems, and
B. surface those problems up to other team members *throughout the lifecycle of the project*, not just at that one pre-mortem meeting.
What was missing, I realized, was an evocative, convenient lexicon that allowed people to talk about these things in a psychologically safe manner.
Enter the metaphors: Tigers, Paper Tigers, Elephants
The way I like to run pre-mortems now is to ask the team to list out their concerns about the project in 3 different categories:
Why are you not worried about a Paper Tiger (even though others might be)? Usually because you’re responsible for the said area and have strong conviction that the ostensible Tiger is fully under control. You’ve got it!
An Elephant might not be a threat per se, but it’s the thing you’re worried no one is talking about. It’s the “elephant in the room”.
So, with this lexicon, here’s how I recommend running a pre-mortem meeting. It’s 1 hour long and the flow looks like this:
During the context setting part, I introduce the pre-mortem concept (it’s always *someone’s* first pre-mortem) and ask everyone on the team to come up with 2 Tigers (at least), and any Paper Tigers and Elephants they can think of.
There is absolutely no talking during this time—it’s Quiet Time. It’s amazing how long & productive a 10 minute stretch of silence can be in a meeting, when no one is talking.
After that, there’s another 10 minutes of Quiet time. During this time, people read everyone else’s Tigers, Paper Tigers, and Elephants. And they get to +1 others’ Tigers, Paper Tigers, and Elephants. Each person can give up to five +1s. So you need to be quite selective.
And then, Quiet Time is over. You go around the room, and people share their observations (e.g. what Tiger resonated the most, what they found surprising, etc.)
And, as the facilitator, you wrap the meeting up by summarizing the top themes that have emerged from the pre-mortem and sharing what people can expect next.
So, what’s next? It’s the most important part of the entire process. The pre-mortem action plan. As the facilitator, you prioritize the top N Tigers / Elephants that emerged from the pre-mortem exercise.
You create a document that summarizes the action plan and share it with the team for commentary. Here’s a hypothetical example:
Note that your goal isn’t to list *every possible problem* in the action plan. You must focus on the major problems (i.e. the deadliest Tigers), and be fine with living with the minor ones. You cannot (and should not) fix all problems because you don’t want progress to grind to a halt. But more importantly, I’ll observe that solving one problem often creates a different problem. So you’ve got to have clarity on which problems you’re willing to live with and which ones you can’t live with. (this is perhaps also applicable outside of the work context)
Also note that it’s important to list the verbatim Tigers and Elephants (as in column 2), since it reassures team members that their *direct input* was useful. Every item must have a single Directly Responsible Individual (the DRI can of course delegate, as appropriate). And the last column lists the proposed mitigating actions, in priority order, that will *reduce the chances* of the problem occurring, OR will *limit its negative impact* if it does occur.
Once you’ve reviewed the action plan with the team, make sure that you track progress against the action plan during the rest of the life of the project. You can do it by merging the action plan with the overall project plan, so it becomes an integral part of “how we do things around here” vs. a one-off effort. So that’s pretty much it.
How do these pre-mortems help the team? Besides the obvious benefit of reducing the chances of major mistakes, I love it when team members wholly adopt the “Tiger”, “Paper Tiger”, “Elephant” metaphors.
It’s quite typical that, N days after the pre-mortem meeting, team members will say in a meeting/on Slack/email: “I recently thought of a Tiger that’s been worrying me since” “Remember, that’s the Elephant that Bob pointed out earlier. We still need to do work there.”, etc.
Saying in a meeting “I’d like to talk about a Tiger” is lower pressure on the individual than dealing with the fear (rational or not) of coming across as “pessimistic” or a “naysayer” when expressing their concerns in normal English. These metaphors can be quite powerful!
And by calling out the importance of spotting deadly Tigers and talking about the big Elephants, you create more psychological safety for team members to bring up their concerns. After a well-run pre-mortem meeting, observe your team members as they exit the meeting. Odds are high that their faces will look more relieved, their gait more optimistic.
Why? Because the problem that had been worrying thus far them is no longer just THEIR problem to carry. This catharsis can by itself be priceless.
A couple of months ago, I ran a (highly unscientific) Twitter poll to assess how common the practice of pre-mortems is. Only ~10% regularly run pre-mortems:
I believe that a consistent practice of running pre-mortems will have a profound positive impact on our society. Just in the tech industry, I hope more pre-mortems will mean:
- fewer privacy gaffes
- fewer security issues
- reduced system downtime
- fewer “should-have-succeeded-but-actually-failed” products
- clearer policy change communications
- and ultimately, happier customers
To conclude then, my request to you is simple: consider adding pre-mortems to your leadership toolkit and encourage others to do the same.
I wish you all the best in your problem prevention journey!
Footnote:
Want to explore this topic further? Check out this video of my December 2019 SVPMA talk below. Start at 5:04 mark for the problem solving vs. problem prevention piece. The Q&A section, which starts at the 57:39 mark, has additional commentary on pre-mortems.