Asking Engineers the Right Questions

In our extensive study of the Columbia space shuttle accident, Amy Edmondson, Richard Bohmer, and I examined the culture and leadership at NASA. Specifically, we analyzed the forces that made it difficult for engineers such as Rodney Rocha to speak up regarding their safety concerns, and we looked at how leaders did not ask probing questions to elicit dissenting views. 

When I teach the case to engineers and other technical experts, I often hear them say that management needs to understand how to ask engineers the right questions, and how to interpret their results. They argue that engineers were not going to scream, "There is a safety-of-flight risk!" unless they had conclusive evidence. The engineers' lack of complete certainty might lead to them to give answers that that are interpreted incorrectly by management. Organizational leaders might be looking for a definitive statement expressing alarm and grave concern, but they won't get it if there is scientific uncertainty. 

Today, I ran across a good quote (in Fast Company) from Google's long-time Chairman and CEO, Eric Schmidt, regarding this issue. Scmidt explains how you have to ask multiple questions, in different ways, to make sure you are getting the whole picture when working with technical experts: 

They are taught to think logically. If you ask engineers a precise question, they will give you a precisely truthful answer. That also tends to mean that they’ll only answer the question that you asked them. If you don’t ask them exactly the right question, sometimes they’ll evade you — not because they’re lying but because they’re being so scrupulously truthful.”

Going Public With Your Mistakes: The Brigham & Women's Hospital in Boston

Imagine a hospital that discusses its mistakes publicly.   Does that sound like a good idea?  Could it help advance the cause of patient safety.  Yesterday we learned that scholars at Johns Hopkins have conducted research demonstrating that medical errors are the third leading cause of death in the United States.   That's alarming in its own right, but especially so since many hospitals have been  trying to reduce medical accidents over the past decade.   

The Brigham & Women's Hospital in Boston has been trying to reduce errors, and now they have taken their efforts one step further.   They have decided to go public with a safety blog that they have been publishing internally for several years. I applaud their courageous decision. Karen Fiumara, senior director of patient safety at Brigham and Women’s Hospital, explains the decision to go public about the hospital's mistakes.  

Hospitals celebrate their safety records, but rarely discuss their mistakes. Yet it’s difficult, if not impossible, to improve safety without identifying and learning from errors. That’s why Brigham and Women’s Hospital has launched Safety Matters. This blog aims to describe mistakes made at the hospital along with steps the hospital is taking to prevent them in the future.  We began Safety Matters in 2011. At the time, it was an internal communication available only to Brigham and Women’s employees via the hospital’s intranet. One goal is to make sure that everyone on the staff knows that the hospital is committed to being open and transparent about mistakes and learning from them. Another goal is to convey that reporting mistakes is not only encouraged, but is also the right thing to do.  Another element of some blog entries is the “Just Culture Corner.” It helps promote a culture in which hospital staff and patients feel safe and supported when speaking up about mistakes and risks.

Safety Matters went public in January 2016. We did this for several reasons:

• It’s now more accessible to the entire staff, and can be read from home or a mobile device.
• It demonstrates to patients, prospective patients, and other stakeholders that the hospital is committed to transparency and continuous improvement.
• It can be a resource for other hospitals in the United States and around the world to provide safer patient care.

Chipotle Responds to a Food Safety Crisis

Chipotle finds itself facing a major crisis these days.   The company has experienced a major E. coli outbreak.  It began in the northwestern United States, and the firm closed a number of restaurants temporarily to address the situation.  However,  reports now indicate that some Boston College students may have gotten ill after eating at a Chipotle in Boston.   According to Boston.com, "City inspectors closed the Chipotle, located in Brighton near BC’s campus, “until further notice” after reporting three critical health violations following a visit Monday... Chipotle believes norovirus is to blame for the rash of illnesses that seemingly stem from the Cleveland Circle restaurant, but the Boston Public Health Commission says it’s too early to tell."

The Wall Street Journal asked several crisis management experts to assess Chipotle's response to the crisis.  Richard Levick commented,

"Long term, Chipotle will need to carefully examine its supply chain. Its 5% stock drop is likely due to the fact that this is the third instance of foodborne illness connected to Chipotle since August. That leaves the company more vulnerable to lawsuits and potential regulatory action. It also directly contradicts a brand built, at least in part, on the sourcing of fresh, organic, farm-sourced fare. Thus far, the supply chain has not been a major focus of the company’s communications. In the coming weeks, that may need to change."

Levick raises a crucial point. Product quality and safety crises become especially threatening to a company when they go to the heart of what a brand has chosen to stand for over many years. In fact, companies can be punished even more extremely by customers (and investors) when a crisis undermines the core of their competitive positioning. Chipotle has staked its reputation on the quality and freshness of its ingredients. Thus, the supply chain has been at the heart of their competitive positioning. Any substantial defect in that supply chain will have long-lasting repercussions. The company not only has to address the situation at the restaurants, but they will have to reassure customers that the supply chain indeed lives up to the reputation that has been cultivated over time. As a big fan of Chipotle, I hope they get it right! 

Mary Barra at GM

The Wall Street Journal reports this morning on new developments in the GM ignition switch scandal. According to the newspaper, 

For the first time within General Motors executives will be told of vehicle safety problems when they are first reported and are now expected to expand any potential recalls if they deem it necessary, Chief Executive Mary Barra said in an interview.  "The executive team can only expand, they can never make it smaller," Ms. Barra told The Wall Street Journal. "I am trying really hard to communicate that we have made great strides to reduce the bureaucracy within GM."

Barra's comments are certainly welcome, but a key point needs to be made here.  You can't simply order lower-level employees to report all safety issues to senior executives.    You have to create an environment and a culture where people feel comfortable bringing bad news to the boss.  Moreover, senior leaders need to recognize that some people will feel hesitant to share bad news.  Therefore, senior executives at GM need to become "problem finders" who actively seek the bad news.  They have to do more than just say that they have an open door.  They have to get out of their offices and dig for problems.  They have to become seekers, rather than just receivers of safety information. 

Chevron Cuts Executive Compensation

The Wall Street Journal reports today that Chevron's Board of Directors has cut compensation for senior executives at the firm, despite stellar financial results.  What's the reason?   Apparently, Chevron has had a spotty safety record over the past year or so.  Therefore, despite strong financial performance, the bonuses for top executives have been scaled back.

Now, the total compensation numbers are still very high.  So, I don't think anyone is crying about the compensation changes.  However, the move does send an important message.  Unlike many other firms, Chevron's board is saying that financial performance at all costs will not be rewarded.   A strong safety culture has many facets, so incentives alone will not improve safety.  However, incentives are a key component.  You have to reward the right kinds of behaviors if you want a strong safety culture.  You also have to send the right symbolic messages.  Chevron seems to have taken a step in the right direction. 

VIP Tours: The BP Spill and The USS Greenville Accident

As I'm finishing up my new case study on the BP Oil Spill in the Gulf of Mexico, I am struck by an interesting similarity to another major accident.  In February 2001 the USS Greenville, a U.S. Navy nuclear submarine (SSN 772 Los Angeles class), collided with a Japanese fishing boat - the Ehime Maru.  On the day of the collision, Commander Scott Waddle hosted sixteen VIPs on board his submarine.   On April 20, 2010 when the Deepwater Horizon blowout occurred in the Gulf of Mexico, four VIPs were visiting the rig.   Could the VIP visits have had any effect on safety-related behavior?

Perhaps the presence of the VIPs may have affected behavior in several ways.  First, it may have distracted senior leaders on both the submarine and the oil drilling rig.  After all, the leaders had to spend time escorting the VIPs.  They may have otherwise spent that time directly supervising the work of their crews.  Second, lower level workers may have been more reticent to raise concerns, express dissent, and ask questions about safety procedures given the presence of the VIPs.  After all, they may not have wanted to make their bosses look bad in front of the VIPs, or they may not have wanted to bother the senior leaders.  Third, the presence of the VIPs may have created additional stress and anxiety.  Perhaps that stress may have affected decision-making.  

What's the lesson for business leaders in all fields?   Executives have to get out of their offices and make visits in the field.  They must connect with front-line employees to see what is actually going on in the organization.  However, they must be very careful about diverting attention away from critical tasks or distorting the behavior of their employees.  In most cases, the distractions won't be matters of life or death, but they may adversely affect key processes and outcomes.