Book Review: The Mistakes that Make Us
A Guide to Transforming Your Thinking About Mistakes
By what method could new leaders bring about improvement in living? Do they possess knowledge requisite for improvement? What characteristics ought a leader to possess? Will best efforts bring improvement? Unfortunately, no. Best efforts and hard work, not guided by new knowledge, they only dig deeper the pit we are in…
Knowledge necessary for improvement comes from outside.
Deming, Dr. W.E., The New Economics, 3rd ed. (p. 1)
THE AIM for this post is to share a brief review of a brand new book released by a very old friend and colleague, Mark Graban, entitled The Mistakes that Make Us: Cultivating a Culture of Learning and Innovation. I’ve spoken about Mark in prior posts, drawing reference to his last book Measures of Success: React Less, Lead More, an excellent guide for learning how to use Process Behaviour Charts for diagnosing and improving organizational performance. In addition, he has written extensively on lean healthcare including Lean Hospitals: Improving Quality, Patient Safety and Engagement, Healthcare Kaizen: Engaging Frontline Staff in Sustainable Continuous Improvements, and The Executive Guide to Healthcare Kaizen: Leadership for a Continuously Learning and Improving Organization. He’s also the author of the long-running LeanBlog site and a seventeen year veteran of podcasting. Mark is also, unsurprisingly, a huge devotee of Dr. Deming’s and I credit him with directing my attention toward his teachings and philosophy of management many years ago. So, when Mark approached me with a review manuscript of his book, I couldn’t turn down the opportunity and dived right in.
tl;dr
At its heart this is a book about transforming your thinking about common mistakes and errors for the better. Bolstered by real-life stories drawn from guests on his podcast and his own personal experiences, My Favourite Mistake, Mark leads you through how to reframe potentially bad situations into learning opportunities for improvement, along with some interesting techniques that you can begin to implement right away.
Dr. Deming’s influence is felt throughout the book, from Mark’s deliberate insistence to blame systems before people, improve systems to correct and prevent mistakes, and guide interventions with PDSA (Plan-Do-Study-Adjust/Act) experiments. It is an example of the “outside knowledge” Deming would advise leaders to heed and learn.
A caveat, however: This isn’t a how-to manual with prescribed solutions to give you all the answers and the false safety of following “best practices”, but inspirational material for correcting flaws in yourself first before setting out to correct your organization. It is a book about learning to lead by leading by example.
Despite the apparent weight of the topic, Mistakes that Make Us is a very approachable, light book that should be on the summer/fall reading list for any managers and leaders who are undertaking transformations.
Inspiration
The roots for The Mistakes that Make Us extend all the way back to May 2020 when Mark was approached by a PR rep to interview Kevin Harrington, one of the original “sharks” on the hit entrepreneurial pitch show, Shark Tank. One thing led to another and the podcast My Favourite Mistake was born as a way to frame discussions around a mistake that ended up being fortune in disguise.
Mark gives the following operational definition for a “favourite mistake” for the podcast as:
A mistake important enough to stick with you
A mistake that’s created a fortuitous opportunity or new direction
A mistake we hope others can avoid
A mistake that led to learning, including the actions required to prevent making the mistake
While not intentional, the meat of the book emerged after he conducted over a hundred interviews. Mark observes that what he learned went beyond the folk-wisdom of fail-fast, fail-early; how leaders handled mistakes is a marker for their success irrespective of their size: “The ability to learn from mistakes isn’t a technology only the largest companies can afford. It’s something anybody can cultivate.”
What Is a “Mistake”?
In the first chapter Mark provides the reader with his operational definition of a mistake as an “action or judgment that later turns out to be misguided or wrong” which present us with a decision: Do we turn it into something positive or make things worse?
AIM: Transforming Our Thinking About Mistakes
An old Turkish proverb tells us that no matter how far down the wrong road you may go, you can always turn back. It is ancient wisdom that teaches us while we all make mistakes, they can always be corrected and learned from if we have the courage to face them.
We all err and we all have stories in our past about the one that caused us to catch hell from our boss, colleagues, spouse, family, or friends. In some cases, we make mistakes when we’re the ones in charge, which makes the fallout even more grievous to us and one we’d rather not revisit. In all cases we tend to beat ourselves up for it and try to wall-off the whole affair, colouring our judgment and interactions thereafter.
Mark’s aim with his book is to challenge this behaviour and reframe making mistakes as a positive step toward self improvement and leadership by example drawing from the experiences of others who looked at their own foibles differently and made changes for the better instead of just projecting blame on themselves or others.
Frames of Reference
Mistakes that Make Us is a light read of 180 pages spread across eight chapters that can be thought of as frames of reference for transforming your thinking about mistakes:
Think Positively
Admit Mistakes
Be Kind
Prevent Mistakes
Help Everyone to Speak Up
Choose Improvement, Not Punishment
Iterate Your Way to Success
Cultivate Forever
Each chapter is further broken down into guidance supported by anecdotal stories drawn from Mark’s podcast or his own personal experiences. For example, in Chapter 2: Admit Mistakes, we get lessons on fighting our instincts to hide mistakes out of pride or fear and admitting when things go wrong to demonstrate leadership and create a culture of cooperative learning, while in Chapter 4 we learn about how Toyota implements poka-yoke to prevent errors where they occur and the power of checklists to control mistakes in execution. Psychological safety, a mainstay in transformations, appears throughout, especially in Chapter 5.
Types of Mistakes
Early in the book, Mark introduces readers to the multiple types of mistakes people make every day, each with their own unique countermeasures that he expands on in each chapter.
Actions or judgments that turn out to be wrong
A Decision Point: Turn it into something positive or make things worse?
Inaction Mistakes: Maintaining the status quo when we should have changed.
Planning Mistakes: Decisions and actions that were intentional but turned out to be wrong.
Execution Mistakes: When our intended actions would have been correct but we failed to follow our plan for some reason. AKA “human error”.
Errors in action, calculation, opinion or judgment caused by poor reasoning, carelessness, insufficient knowledge, assumptions, etc.
Filling gaps in knowledge with assumptions or stubbornly holding on to assumptions even in the face of contradicting evidence.
He also explains the phenomena of verschlimmbesserung, a German expression for making things worse by attempting to improve it, which is, I think, a perfect summation of modern management theory and practices. Mark advises, in simpatico with the old Turkish proverb above, that once we admit we’ve made things worse, we’re half way to making things better.
Shifting Your Thinking About Mistakes and Improvement
As Deming advised years ago, transformation begins with the individual learning new theory to replace the one that is holding them back, and to do so without feelings of guilt or shame. Mark encourages this philosophy by providing an “outside” view of mistakes and how to think about them differently:
Replacing punishment for mistakes with improvements, first to yourself, then to causes;
Make it safe for anyone to speak up and call out mistakes by going first and admitting your own foibles;
Looking for gaps between expectations and results when a mistake happens;
Building an explicit expectation for making mistakes when learning or trying something new so as to not discourage people, but support them;
Developing an experimentation mindset with the aim to reform interventions or actions into tests of hypotheses to gain knowledge;
Learning to be open to the possibility you can be wrong and to hear the ideas of others;
Stop trying to be the smartest person in the room with all the answers;
Finding the courage to say “I don’t know” and “I made a mistake”;
Shifting thinking from “fail early, fail often” to “make small mistakes early, learn, adjust, and succeed” or “small mistakes lead to success”.
Practical Suggestions to Improve Handling or Preventing Mistakes
Lest you think this is just a book of anecdotes and gathered wisdom, Mark also provides some examples of techniques and methods you can use to improve how you handle mistakes, including:
The Just Culture Framework, an algorithm for determining if a bad outcome is attributable to the system (common causes) or an individual act (special causes). NB: Mark opens the door here, but doesn’t go into detail.
The six questions Value Capture uses to prime a retrospection after a mistake occurs to shift thinking from blaming people to critically looking at the system.
How to design a checklist that actually gets used instead of ignored, and yes, he references Atul Gawande’s book, The Checklist Manifesto.
How to use the US Military’s FMEA Protocols (Failure Mode and Effects Analysis) for anticipating potential mistakes.
How to create a culture of psychological safety (based on the famous Google Project Aristotle experiment) by leading first.
Anecdotal Stories
Since time immemorial humans have used the power of story telling to communicate lessons learned and cautionary tales for the unwary. Mistakes that Make Us is chock-full of stories from a wide range of people who have erred in their personal and professional lives. Some of the stories I enjoyed included:
The story of a doctor whose entire career trajectory changed after witnessing an attending surgeon covering for a mistake their student made by starting a hernia operation on the wrong side of the patient.
Iaso Yoshino’s classic story of his first experiences working at Toyota in the paint department and confusing cans of solvent for paint. I first read this in Katie Anderson’s excellent book, Learning to Lead, Leading to Learn which I reference below.
The legendary story of Toyota’s mid-1980s NUMMI experiment partnering with GM at their notorious Fremont, CA plant. You may know this better as the site of the current Tesla Gigafactory…
Mark and I share an abiding interest in bourbon, so I really enjoyed his stories about Garrison Bros. Distillery and how they handled messing up a special-order barrel of bourbon for him and how they accidentally created their best bourbon ever after ordering the wrong type of corn.
How staff at the Mary Greeley Medical Center avoided a $4,400 patient improvement mistake by conducting a smaller, cheaper experiment to gain knowledge - a brilliant example of PDSA thinking.
Deming Highlights
While you can find Dr. Deming’s influence in just about every chapter of Mistakes that Make Us, Mark references him directly in three ways that you’d most expect:
First and foremost, look to the system or process for the majority of contributing causes to a mistake, and of course follow Gipsie Ranney’s corollary of never confusing coincidence with cause-and-effect;
Second, and building on the first, improve the system to alleviate the causes of mistakes;
Third, regulate your corrections and interventions using PDSA (Plan-Do-Study-AdjustA/Act) loops so as to build knowledge through tests of hypotheses (or hunches) rather than reacting to every problem and losing the opportunity.
With respect to PDSA, my only criticism would be in not providing some example of how to get started with the method or even a pointer to a resource to get started. I’ve included one below for those who may be curious.
MIA: Mistake 1 / Mistake 2
While on the topic of Deming, I found it odd that Mark didn’t explicitly mention his two classic management errors that come from not understanding variation: Over-reacting to random noise in a process (Mistake 1) and under-reacting to legitimate signals (Mistake 2). I get it that something has to fall on the cutting room floor to maintain flow (this isn’t a book expressly about Deming, after all), but this seemed an obvious gimme.
My Favourite Chapter: 7 - Iterate Your Way to Success
Given my background in agile software development, and current work in advising on how to improve organizational function by applying Deming’s philosophy, I found Chapter 7 to resonate with me most with supporting stories ranging across healthcare, management, and software/product development. I especially liked the notion of getting started with an “80% solution” to iterate forward rather than delaying and waiting for perfection, and Melissa Perri’s example of moving from phased delivery (waterfall) to iterative (agile) and then experimental (Lean Startup).
Conclusion:
According to Dr. Deming, the first step toward transforming the prevailing style of management is transformation of the individual by learning about each of the four domains of the System of Profound Knowledge (SoPK). “The individual, transformed, will perceive new meaning to his life, to events, to numbers, to interactions between people.” The Mistakes that Make Us is a perfect companion for anyone studying and applying Deming’s philosophy of transformation, which in a meta-sense, is all about correcting the mistakes of the prevailing style of management.
Get your copy on Amazon.
Further Reading for the Curious
While reading The Mistakes that Make Us I was reminded of some other related books that pick up on some of the core themes and topics you might find interesting:
Black Box Thinking, by Matthew Syed. This book takes a deep-dive into the psychology of errors and how we have designed our institutions to encourage faulty “black box” thinking that creates opportunities for mistakes. He opens with a story of a simple medical procedure gone wrong that corresponds with the culture of punishing mistakes in hospitals that Mark shares from fellow Deming disciple, Dr. Donald Berwick MD in Chapter 1.
The High Velocity Edge, by Steven J. Spear. This book outlines the practices highly adroit organizations practice that separate them from their peers. It’s a touchstone that has inspired many in the lean and organizational systems thinking field, and contains a retelling of Gary Convis’ story that Mark relates in Chapter 5.
The Improvement Guide, by Cliff Norman, Ron Moen, et. al. This book expands on how to design process improvement experiments using Deming’s Plan-Do-Study-Act/Adjust cycle that Mark introduces in Chapter 7. This is a classic text that helps to demystify the theory and how to successfully apply it for encouraging a culture of continual learning and improvement.
Learning to Lead, Leading to Learn, by Katie Anderson. This book is a chronicle of leadership lessons imparted to the author by legendary Toyota leader, Isao Yoshino, over the course of their working relationship in Japan and afterward. Mark references both Katie and Isayo in Chapters 3 and 5 respectively.
The Checklist Manifesto, by Atul Gawande. Mark directly references Gawande in Chapter 4: Preventing Mistakes, or as Mark calls them “execution mistakes”. In this 2009 classic, Gawande, who is a surgeon, walks you through some harrowing stories of near-misses and tragedies that occurred due to people failing for a range of reasons, and how they could be prevented or mitigated by implementing checklists to cross-check assumptions and actions. A must-have on any Deming practitioner’s bookshelf!