Learning from failure in complex environments

It’s been a while since the Learning from Failure workshop, and my subsequent admission that I haven’t been very good at learning from my own failure. The event took place at the Wales Audit Office, so it was perhaps inevitable that we discussed the role of audit in learning from failure.

Systematic failure

James Reason Swiss Cheese Model. Source: BMJ, 2000 Mar 18:320(7237): 768–770

Chris Bolton’s presentation was on the James Reason Swiss Cheese Failure Model, which compares human systems to layers of Swiss Cheese. Reason chose Swiss Cheese for a reason (see what I did there), as each layer is a defence against mistakes and errors, and things go badly wrong when the holes line-up. There’s an interesting critique of the model in the comments by Matt Wyatt of Complex Wales.

After a good Twitter conversation on the merits of different types of cheese as defence (I went patriotic and chose Caerphilly — ‘I crumble in the face of failure’), I looked at a model that Matt has developed, called the ‘Timeline of Inevitable Failure.’

Whereas the Swiss Cheese Model is a reflective model (you look back and check out the failure after it’s occurred), Matt’s model is interesting as it offers opportunities to reflect on failure and its consequences at different stages, which fits in with a systematic approach to failure and chimes with some of the thinking in my last post on examining failure rigorously.

To be able to rectify failures at the early stage of the timeline, we have to be open and frank about failure, or issues will escalate and become bigger problems. By being comfortable with minor instances of failure, we’ll also be better prepared for when things go drastically wrong. As Matt says in another comment, ‘complex living systems will always fail, so instead of trying to make them failsafe, it’s much more useful to make them safe to fail.’ It’s well worth reading Chris’ post on Trojan Mice, which are safe to fail pilots, before delving in to the below video of Dave Snowden discussing them as part of the Cynefin Framework.

You can see this approach in action through the work of the Bromford Lab and Dublin City Council’s Beta Projects. In terms of the latter, it’s worth checking out how their painting of traffic signal boxes led to less tagging and graffiti.

What does this mean for audit and audited bodies?

Aside for the recommendation in the workshop to take your auditor out for lunch to better understand their approach to failure (which I’m completely on board with by the way!), this all relates to the complex environment in which public services are delivered and audited.

In Wales, this environment is about to change fundamentally with the Wellbeing of Future Generations Act. It’ll need a shift in thinking for organisations, as they’ll have to improve people’s wellbeing without compromising the ability of future generations to meet their needs. It’ll also be a challenge for us at the Wales Audit Office — it’s difficult to measure success when you don’t know what the future will look like. There’s a great post on the Wales Audit Office blog that outlines these challenges by Ann Webster, Assistant Auditor-General of New Zealand.

We’ve already shared steps that organisations can take to report effectively, including integrated reporting, at a seminar we held with the Sustainable Futures Commissioner. But in terms of this event, I was struck by some simple steps that organisations can take to evidence improvement. Jonathan Flowers gave a great example of how a Neighbourhood Network Scheme Manager asked for two instances a month of how the service had improved people’s lives. These narratives show that the service is moving in the right direction and can be used at the project evaluation stage.

Where now?

When it comes to evaluating our project, we’ve been gathering examples of how our work has led to organisations adopting good practice. These aren’t often measures in themselves, but complex case studies of how services have changed.

And in terms of our work, it’s important that we continue to have these conversations about failure, so that it’s normalised and people can be honest about it. And if we can do that, we’re in a better place to help organisations take further steps to improve their services.

This post orginally appeared on the blog of the Good Practice Exchange at the Wales Audit Office.