Topics

Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal. #COVID-19


 

Dear Colleagues

 

I offer my latest article for a read and comment if you chose to do so: Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

 

I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?

 

Would be interested in your perspectives.

 

Best

 

Bill

 

 

  

 

Learn more about the solutions and value we provide at www.workingknowledge-csp.com

 

 


Murray Jennex
 

nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex


-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Dear Colleagues
 
 
I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?
 
Would be interested in your perspectives.
 
Best
 
Bill
 
 
  
 
Learn more about the solutions and value we provide at www.workingknowledge-csp.com
 
 


 

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.

 

From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

 

nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Dear Colleagues

 

 

I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?

 

Would be interested in your perspectives.

 

Best

 

Bill

 

 

  

 

Learn more about the solutions and value we provide at www.workingknowledge-csp.com

 

 


Anna Gene Jonassen
 

This really resonated with me, and struck me as a better formed, more eloquent version of some of my swear-filled rants (after I encounter mass media articles ) that my fiance has had to endure as we've been sheltering in place together! Hah! These articles (I've generalized as I feel they are ubiquitous) feel shockingly tone deaf to the real issues I feel I see so clearly - instead of focusing on education and problem-solving, they focus on sensationalist, unnecessarily politicized headlines that detract from any forward momentum and erode our fleeting sense of global camaraderie (when have I ever felt so connected in experience to people in Wuhan or rural villages in southern Italy?) . Now is not the time for finger-pointing. Now is not the time to be bureaucratic. Now is not even the time to get frustrated or defeated about the things we cannot change (i.e. systemic issues - I think about articles from NY times about race-specific communities are disproportionally at risk for COVID-19 - nowhere is there mention of WHY they might be at greatest risk as an opportunity educate and reinforce shelter in place orders - I could go on...) It is appalling to me the a politician(s) would withhold critical funding from some of the only organizations that possess the knowledge to help us as a collective move forward.

So truly, now is the time for action. 

I work at a healthcare technology strategy & consulting firm as a knowledge manager - at a company that is laser-focused on trying to deliver intel / lessons learned on digital solutions that can be rapidly stood up to deal with the immediate crisis of the surge of patients, and the analysis required to move forward, and potentially repurpose lessons learned for the long haul (this part, naturally, is trickier, and we lack the luxury of retrospect and are relegated to speculation in a lot of cases but health systems can't afford to do anything less)...

Because our clients are health systems that are on the front lines, they are not embroiled, nor do they care, about the politicization of the pandemic (aside from how it is impacting funding relief and it has proven to have more strings attached than it should which is ugly business) - as they are dealing with being hit/put at risk and/or gutted financially from every angle - they still have to care for communities. I have seen beautiful examples where clients have swept past bureaucracy, perhaps in an act of desperation, to rapidly share learnings, bridge partnerships (ie. competitors), enlist unusual applications of technologies, and whether they like it or not, have to dedicate time and resources to planning ahead and anticipating the worst case scenarios. These strategies may be executed in a more hodgepodge fashion than they'd ever hope for (ie. financial modeling for residual surges of the virus during a slow recovery, planning for operations where they are down all non-clinical staff, figuring out ways to recoup revenue as millions of Americans lose insurance) - but it is amazing to see how quickly some of them have been able to innovate, all while being in crisis mode.

Forgive my long-winded and scattered reply..long story short, great piece you wrote!


Murray Jennex
 

Good point Bill, I was part of Admiral Richover's nuclear navy and that was a foundation point there also, learn first, prevent recurrence, then worry about corrective actions.  We were still held accountable for "stupid" mistakes but it was considered more important to determine why a bad decision was made and how to prevent it again than it was to punish someone for making the bad decision.  Same in nuclear industry.  I also believe people are more willing to be accountable and are more professional when they know the organization realizes that bad decisions by well trained people are not always because they weren't competent.  Most of the time it was a deficiency in training or procedure.  Sometimes it was because one of those unknown unknowns that hadn't been considered happened.  Most of our human errors were due to fatigue, other stressors, process error, and poor human factor design but not because people didn't know better or wanted to make an error.....murray jennex


-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:25 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.
 
From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
 
nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
Dear Colleagues
 
 
I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?
 
Would be interested in your perspectives.
 
Best
 
Bill
 
 
  
 
Learn more about the solutions and value we provide at www.workingknowledge-csp.com
 
 


T J Elliott
 

Amy Edmondson has much to say about the subject of how we deal with failure and especially how we assign blame — often incorrectly as it turns out


But, I think, that the University of Chicago philosopher Agnes Callard points out how difficult it is for people to forgo their anger even in those circumstances where there does appear to be a failure of accountability:
. "If the argument works, it follows that a person gives up his or her anger not (emphasis added) because the issue has been resolved or even addressed in any way but merely because, for example, he or she sees that he or she will be better off in a nonangry condition. Pragmatic reasons for ceasing to be angry have positive counterparts: pragmatic reasons to get angry." It may strain the definitions of what we would accept this pragmatism, but there may be a fear that if we don't get angry that we are going to get stepped on again, that we will have to accept bad behavior forever and ever. I note this because as worthy as the desire to forgo blame is and as practical as such an action might be especially from the perspective of learning and knowledge generation as a prelude to better decision-making and action, persuading humans to do that is very difficult. As Callard notes, in order to get rid of the kind of anger that blame engenders, there needs to be a "bilaterality", a recognition on both sides that something has happened here that violates what at least one side thought of as the norms of the relationship. Callard continues, "Anger is not a desire to fix something but a way of grasping the fact that it is broken..." If there is a resolute unwillingness to admit that something was broken, then people are going to find it difficult to move on, to forgo blame, to learn rather than burn. Nancy Dixon on this list has as much experience with after action reviews as anybody in the world I will bet and I wonder what she thinks about how we suspend our tendency to blame at these moments.
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles


 



On Wed, Apr 15, 2020 at 2:18 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Good point Bill, I was part of Admiral Richover's nuclear navy and that was a foundation point there also, learn first, prevent recurrence, then worry about corrective actions.  We were still held accountable for "stupid" mistakes but it was considered more important to determine why a bad decision was made and how to prevent it again than it was to punish someone for making the bad decision.  Same in nuclear industry.  I also believe people are more willing to be accountable and are more professional when they know the organization realizes that bad decisions by well trained people are not always because they weren't competent.  Most of the time it was a deficiency in training or procedure.  Sometimes it was because one of those unknown unknowns that hadn't been considered happened.  Most of our human errors were due to fatigue, other stressors, process error, and poor human factor design but not because people didn't know better or wanted to make an error.....murray jennex


-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:25 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.
 
From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
 
nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
Dear Colleagues
 
 
I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?
 
Would be interested in your perspectives.
 
Best
 
Bill
 
 
  
 
Learn more about the solutions and value we provide at www.workingknowledge-csp.com
 
 


Murray Jennex
 

Anna, I truly appreciate your post as it reflects much of what I feel about this pandemic and about the overall approach we (humans) seem to be taking to argue among ourselves.  You are right, viruses are not racist or sexist, if the data shows that certain groups are suffering more than instead of arguing social factors we need to identify risk factors so the right questions are always why is one group reacting differently rather than blaming society for that groups problems.  

I also worry about people over relying on science and data. Since I'm working at home I've caught up on some reading and an interesting article I read condemned the idea that having more data will always make our decision making better.  The model argument is given enough data we can be absolutely sure on the prediction but intuition math says we will cannot know it all.  I've had to referee debates among friends and acquaintances about the Washington model being used to guide policy.  Models are best approximations of what we know now that we use to help us predict the future.  The more we learn the better the model.  The one fallacy of this is that life is not linear and predetermined.  Life evolves and it will change in ways we cannot predict and models will never be perfect.  What I'm getting to is that political arguments about following science are wrong when the science is based on imperfect models.  Scientists know this, politicians do not.  Scientists know that models help them understand what they know, and what they don't, and good scientists look at models as a recommender system, good advice but not always right.  This is where KM steps in, we take past knowledge and apply it, hopefully appropriately, to current situations.  This is also a valid path and suggests that what we should be doing is using data and experience to guide decision making but not as the decision maker.  This means there will always be some ambiguity and this is particularly true with crisis response.  Crisis response will never be perfect but it guides us to be the best we can.  This is why we need to not worry about blaming and instead focus on learning....murray jennex

-----Original Message-----
From: Anna Gene Jonassen <ajonassen@...>
To: SIKM <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:34 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

This really resonated with me, and struck me as a better formed, more eloquent version of some of my swear-filled rants (after I encounter mass media articles ) that my fiance has had to endure as we've been sheltering in place together! Hah! These articles (I've generalized as I feel they are ubiquitous) feel shockingly tone deaf to the real issues I feel I see so clearly - instead of focusing on education and problem-solving, they focus on sensationalist, unnecessarily politicized headlines that detract from any forward momentum and erode our fleeting sense of global camaraderie (when have I ever felt so connected in experience to people in Wuhan or rural villages in southern Italy?) . Now is not the time for finger-pointing. Now is not the time to be bureaucratic. Now is not even the time to get frustrated or defeated about the things we cannot change (i.e. systemic issues - I think about articles from NY times about race-specific communities are disproportionally at risk for COVID-19 - nowhere is there mention of WHY they might be at greatest risk as an opportunity educate and reinforce shelter in place orders - I could go on...) It is appalling to me the a politician(s) would withhold critical funding from some of the only organizations that possess the knowledge to help us as a collective move forward.

So truly, now is the time for action. 

I work at a healthcare technology strategy & consulting firm as a knowledge manager - at a company that is laser-focused on trying to deliver intel / lessons learned on digital solutions that can be rapidly stood up to deal with the immediate crisis of the surge of patients, and the analysis required to move forward, and potentially repurpose lessons learned for the long haul (this part, naturally, is trickier, and we lack the luxury of retrospect and are relegated to speculation in a lot of cases but health systems can't afford to do anything less)...

Because our clients are health systems that are on the front lines, they are not embroiled, nor do they care, about the politicization of the pandemic (aside from how it is impacting funding relief and it has proven to have more strings attached than it should which is ugly business) - as they are dealing with being hit/put at risk and/or gutted financially from every angle - they still have to care for communities. I have seen beautiful examples where clients have swept past bureaucracy, perhaps in an act of desperation, to rapidly share learnings, bridge partnerships (ie. competitors), enlist unusual applications of technologies, and whether they like it or not, have to dedicate time and resources to planning ahead and anticipating the worst case scenarios. These strategies may be executed in a more hodgepodge fashion than they'd ever hope for (ie. financial modeling for residual surges of the virus during a slow recovery, planning for operations where they are down all non-clinical staff, figuring out ways to recoup revenue as millions of Americans lose insurance) - but it is amazing to see how quickly some of them have been able to innovate, all while being in crisis mode.

Forgive my long-winded and scattered reply..long story short, great piece you wrote!


Murray Jennex
 

Another good post TJ!  What I'm taking from it is that organizational culture dictates if we blame or learn and so leadership plays a big role.  Unfortunately I don't see the US as having a learning culture (and I'm not blaming the President or the Democrats) as our system is adversarial by design meaning that we want each side to blame the other.  One funny thing I noticed is that Richover could force an organizational culture on the nuclear navy that was different than the regular navy, this carried through to the commercial nuclear industry, in my own company we had the nuclear way and the company way so playing the blame game could not be overcome at the organizational level, only at the sub-organizational level.  So learning versus blame is going to be an issue for all organizations....murray jennex


-----Original Message-----
From: T J Elliott <tjell2010@...>
To: SIKM <SIKM@groups.io>; nancydixon <nancydixon@...>
Sent: Wed, Apr 15, 2020 11:51 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Amy Edmondson has much to say about the subject of how we deal with failure and especially how we assign blame — often incorrectly as it turns out


But, I think, that the University of Chicago philosopher Agnes Callard points out how difficult it is for people to forgo their anger even in those circumstances where there does appear to be a failure of accountability:
. "If the argument works, it follows that a person gives up his or her anger not (emphasis added) because the issue has been resolved or even addressed in any way but merely because, for example, he or she sees that he or she will be better off in a nonangry condition. Pragmatic reasons for ceasing to be angry have positive counterparts: pragmatic reasons to get angry." It may strain the definitions of what we would accept this pragmatism, but there may be a fear that if we don't get angry that we are going to get stepped on again, that we will have to accept bad behavior forever and ever. I note this because as worthy as the desire to forgo blame is and as practical as such an action might be especially from the perspective of learning and knowledge generation as a prelude to better decision-making and action, persuading humans to do that is very difficult. As Callard notes, in order to get rid of the kind of anger that blame engenders, there needs to be a "bilaterality", a recognition on both sides that something has happened here that violates what at least one side thought of as the norms of the relationship. Callard continues, "Anger is not a desire to fix something but a way of grasping the fact that it is broken..." If there is a resolute unwillingness to admit that something was broken, then people are going to find it difficult to move on, to forgo blame, to learn rather than burn. Nancy Dixon on this list has as much experience with after action reviews as anybody in the world I will bet and I wonder what she thinks about how we suspend our tendency to blame at these moments.
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles

 


On Wed, Apr 15, 2020 at 2:18 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Good point Bill, I was part of Admiral Richover's nuclear navy and that was a foundation point there also, learn first, prevent recurrence, then worry about corrective actions.  We were still held accountable for "stupid" mistakes but it was considered more important to determine why a bad decision was made and how to prevent it again than it was to punish someone for making the bad decision.  Same in nuclear industry.  I also believe people are more willing to be accountable and are more professional when they know the organization realizes that bad decisions by well trained people are not always because they weren't competent.  Most of the time it was a deficiency in training or procedure.  Sometimes it was because one of those unknown unknowns that hadn't been considered happened.  Most of our human errors were due to fatigue, other stressors, process error, and poor human factor design but not because people didn't know better or wanted to make an error.....murray jennex


-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:25 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.
 
From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
 
nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
Dear Colleagues
 
 
I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?
 
Would be interested in your perspectives.
 
Best
 
Bill
 
 
  
 
Learn more about the solutions and value we provide at www.workingknowledge-csp.com
 
 


T J Elliott
 

Murray, I agree with you completely. So glad to see you invoke Admiral Rickover; my dad was an electrical engineer and Rickover was one of his heroes. What has stuck with me from Amy Edmondson's work is the research that she did in which she presented high level executives at organizations with the spectrum of causes of failure. (You can see it in this article here very easily.) When Amy asked the execs to identify where they thought the causes were with some recent failure within their organization, they did so and then she asked them to articulate where blame was laid actually at the moment of the failure. It was amazing that executives admitted that they had blamed people for their lack of ability when they knew that the problems lay elsewhere; e.g. process inadequacy, process complexity, uncertainty, etc. It reminds me of stuff that I learned from Tom Gilbert, Harold Stolovitch, and others around human performance technology in which the research indicated that somewhere between 20 and 40% of performance was within the control of the individual and the rest of the effect had to do with factors such as whether the right person had been chosen for the job in the first place, the quality of management, the specificity of objectives, whether requisite tools and knowledge were available, etc.

Where your example of Rickover is particularly valid for me is in its invocation of a leadership exerting not just a first-order control that requires people to adopt a mindset and set of behaviors, but also because Rickover stipulated certain systemic changes so that the lower less visible methods of control (e.g., forms, meeting agendas, procedures, etc.) also enforced this notion of learning. Thanks for the example and thanks for the reply, Murray
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles


 



On Wed, Apr 15, 2020 at 3:21 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Another good post TJ!  What I'm taking from it is that organizational culture dictates if we blame or learn and so leadership plays a big role.  Unfortunately I don't see the US as having a learning culture (and I'm not blaming the President or the Democrats) as our system is adversarial by design meaning that we want each side to blame the other.  One funny thing I noticed is that Richover could force an organizational culture on the nuclear navy that was different than the regular navy, this carried through to the commercial nuclear industry, in my own company we had the nuclear way and the company way so playing the blame game could not be overcome at the organizational level, only at the sub-organizational level.  So learning versus blame is going to be an issue for all organizations....murray jennex


-----Original Message-----
From: T J Elliott <tjell2010@...>
To: SIKM <SIKM@groups.io>; nancydixon <nancydixon@...>
Sent: Wed, Apr 15, 2020 11:51 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Amy Edmondson has much to say about the subject of how we deal with failure and especially how we assign blame — often incorrectly as it turns out


But, I think, that the University of Chicago philosopher Agnes Callard points out how difficult it is for people to forgo their anger even in those circumstances where there does appear to be a failure of accountability:
. "If the argument works, it follows that a person gives up his or her anger not (emphasis added) because the issue has been resolved or even addressed in any way but merely because, for example, he or she sees that he or she will be better off in a nonangry condition. Pragmatic reasons for ceasing to be angry have positive counterparts: pragmatic reasons to get angry." It may strain the definitions of what we would accept this pragmatism, but there may be a fear that if we don't get angry that we are going to get stepped on again, that we will have to accept bad behavior forever and ever. I note this because as worthy as the desire to forgo blame is and as practical as such an action might be especially from the perspective of learning and knowledge generation as a prelude to better decision-making and action, persuading humans to do that is very difficult. As Callard notes, in order to get rid of the kind of anger that blame engenders, there needs to be a "bilaterality", a recognition on both sides that something has happened here that violates what at least one side thought of as the norms of the relationship. Callard continues, "Anger is not a desire to fix something but a way of grasping the fact that it is broken..." If there is a resolute unwillingness to admit that something was broken, then people are going to find it difficult to move on, to forgo blame, to learn rather than burn. Nancy Dixon on this list has as much experience with after action reviews as anybody in the world I will bet and I wonder what she thinks about how we suspend our tendency to blame at these moments.
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles

 


On Wed, Apr 15, 2020 at 2:18 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Good point Bill, I was part of Admiral Richover's nuclear navy and that was a foundation point there also, learn first, prevent recurrence, then worry about corrective actions.  We were still held accountable for "stupid" mistakes but it was considered more important to determine why a bad decision was made and how to prevent it again than it was to punish someone for making the bad decision.  Same in nuclear industry.  I also believe people are more willing to be accountable and are more professional when they know the organization realizes that bad decisions by well trained people are not always because they weren't competent.  Most of the time it was a deficiency in training or procedure.  Sometimes it was because one of those unknown unknowns that hadn't been considered happened.  Most of our human errors were due to fatigue, other stressors, process error, and poor human factor design but not because people didn't know better or wanted to make an error.....murray jennex


-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:25 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.
 
From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
 
nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
Dear Colleagues
 
 
I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?
 
Would be interested in your perspectives.
 
Best
 
Bill
 
 
  
 
Learn more about the solutions and value we provide at www.workingknowledge-csp.com
 
 


John Lewis
 

Thanks Bill (Kaplan) for this thread! This topic is directly on target and more fundamental than most grasp towards learning, decisions, collaboration, and leadership. It is core to the topic of epistemology for what we know and how we know. In moving organizations towards a learning culture, it helps to measure the ratio of emphatic statements (count exclamation points) versus questions (count question marks). Then measure the ratio of questions from curiosity (inquiry) versus questions from conviction (inquisition). Then measure the ratio of questions from curiosity that seek a single “root cause” versus the questions from curiosity that seek the “root factors” which in combination can create a “perfect storm.” I call it moving from a “5-WHYs” questioning technique to a “5-WHATs” questioning technique. We will find the answers to the questions we ask. And T.J. Elliott makes a great point that the answers for causality will normally be found at the organization level, not the individual level, as noted by ISPI, Tom Gilbert, and Harold Stolovitch.

All the best,
John Lewis, Ed.D.
John@...
Author - Story Thinking: Transforming Organizations for the Fourth Industrial Revolution


On Wed, Apr 15, 2020 at 3:33 PM T J Elliott <tjell2010@...> wrote:
Murray, I agree with you completely. So glad to see you invoke Admiral Rickover; my dad was an electrical engineer and Rickover was one of his heroes. What has stuck with me from Amy Edmondson's work is the research that she did in which she presented high level executives at organizations with the spectrum of causes of failure. (You can see it in this article here very easily.) When Amy asked the execs to identify where they thought the causes were with some recent failure within their organization, they did so and then she asked them to articulate where blame was laid actually at the moment of the failure. It was amazing that executives admitted that they had blamed people for their lack of ability when they knew that the problems lay elsewhere; e.g. process inadequacy, process complexity, uncertainty, etc. It reminds me of stuff that I learned from Tom Gilbert, Harold Stolovitch, and others around human performance technology in which the research indicated that somewhere between 20 and 40% of performance was within the control of the individual and the rest of the effect had to do with factors such as whether the right person had been chosen for the job in the first place, the quality of management, the specificity of objectives, whether requisite tools and knowledge were available, etc.

Where your example of Rickover is particularly valid for me is in its invocation of a leadership exerting not just a first-order control that requires people to adopt a mindset and set of behaviors, but also because Rickover stipulated certain systemic changes so that the lower less visible methods of control (e.g., forms, meeting agendas, procedures, etc.) also enforced this notion of learning. Thanks for the example and thanks for the reply, Murray
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles


 



On Wed, Apr 15, 2020 at 3:21 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Another good post TJ!  What I'm taking from it is that organizational culture dictates if we blame or learn and so leadership plays a big role.  Unfortunately I don't see the US as having a learning culture (and I'm not blaming the President or the Democrats) as our system is adversarial by design meaning that we want each side to blame the other.  One funny thing I noticed is that Richover could force an organizational culture on the nuclear navy that was different than the regular navy, this carried through to the commercial nuclear industry, in my own company we had the nuclear way and the company way so playing the blame game could not be overcome at the organizational level, only at the sub-organizational level.  So learning versus blame is going to be an issue for all organizations....murray jennex


-----Original Message-----
From: T J Elliott <tjell2010@...>
To: SIKM <SIKM@groups.io>; nancydixon <nancydixon@...>
Sent: Wed, Apr 15, 2020 11:51 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Amy Edmondson has much to say about the subject of how we deal with failure and especially how we assign blame — often incorrectly as it turns out


But, I think, that the University of Chicago philosopher Agnes Callard points out how difficult it is for people to forgo their anger even in those circumstances where there does appear to be a failure of accountability:
. "If the argument works, it follows that a person gives up his or her anger not (emphasis added) because the issue has been resolved or even addressed in any way but merely because, for example, he or she sees that he or she will be better off in a nonangry condition. Pragmatic reasons for ceasing to be angry have positive counterparts: pragmatic reasons to get angry." It may strain the definitions of what we would accept this pragmatism, but there may be a fear that if we don't get angry that we are going to get stepped on again, that we will have to accept bad behavior forever and ever. I note this because as worthy as the desire to forgo blame is and as practical as such an action might be especially from the perspective of learning and knowledge generation as a prelude to better decision-making and action, persuading humans to do that is very difficult. As Callard notes, in order to get rid of the kind of anger that blame engenders, there needs to be a "bilaterality", a recognition on both sides that something has happened here that violates what at least one side thought of as the norms of the relationship. Callard continues, "Anger is not a desire to fix something but a way of grasping the fact that it is broken..." If there is a resolute unwillingness to admit that something was broken, then people are going to find it difficult to move on, to forgo blame, to learn rather than burn. Nancy Dixon on this list has as much experience with after action reviews as anybody in the world I will bet and I wonder what she thinks about how we suspend our tendency to blame at these moments.
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles

 


On Wed, Apr 15, 2020 at 2:18 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Good point Bill, I was part of Admiral Richover's nuclear navy and that was a foundation point there also, learn first, prevent recurrence, then worry about corrective actions.  We were still held accountable for "stupid" mistakes but it was considered more important to determine why a bad decision was made and how to prevent it again than it was to punish someone for making the bad decision.  Same in nuclear industry.  I also believe people are more willing to be accountable and are more professional when they know the organization realizes that bad decisions by well trained people are not always because they weren't competent.  Most of the time it was a deficiency in training or procedure.  Sometimes it was because one of those unknown unknowns that hadn't been considered happened.  Most of our human errors were due to fatigue, other stressors, process error, and poor human factor design but not because people didn't know better or wanted to make an error.....murray jennex


-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:25 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.
 
From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
 
nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
Dear Colleagues
 
 
I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?
 
Would be interested in your perspectives.
 
Best
 
Bill
 
 
  
 
Learn more about the solutions and value we provide at www.workingknowledge-csp.com
 
 


 

Thank you Dr Lewis and all my other colleagues for your comments.  Wonder how far up those in the political and governmental hierarchy will be thinking about this?

 

Bill

 

  

 

Learn more about the solutions and value we provide at www.workingknowledge-csp.com

 

 

 

From: SIKM@groups.io <SIKM@groups.io> On Behalf Of John Lewis via groups.io
Sent: Wednesday, April 15, 2020 13:53
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

 

Thanks Bill (Kaplan) for this thread! This topic is directly on target and more fundamental than most grasp towards learning, decisions, collaboration, and leadership. It is core to the topic of epistemology for what we know and how we know. In moving organizations towards a learning culture, it helps to measure the ratio of emphatic statements (count exclamation points) versus questions (count question marks). Then measure the ratio of questions from curiosity (inquiry) versus questions from conviction (inquisition). Then measure the ratio of questions from curiosity that seek a single “root cause” versus the questions from curiosity that seek the “root factors” which in combination can create a “perfect storm.” I call it moving from a “5-WHYs” questioning technique to a “5-WHATs” questioning technique. We will find the answers to the questions we ask. And T.J. Elliott makes a great point that the answers for causality will normally be found at the organization level, not the individual level, as noted by ISPI, Tom Gilbert, and Harold Stolovitch.

All the best,
John Lewis, Ed.D.
John@...
Author - Story Thinking: Transforming Organizations for the Fourth Industrial Revolution

 

 

On Wed, Apr 15, 2020 at 3:33 PM T J Elliott <tjell2010@...> wrote:

Murray, I agree with you completely. So glad to see you invoke Admiral Rickover; my dad was an electrical engineer and Rickover was one of his heroes. What has stuck with me from Amy Edmondson's work is the research that she did in which she presented high level executives at organizations with the spectrum of causes of failure. (You can see it in this article here very easily.) When Amy asked the execs to identify where they thought the causes were with some recent failure within their organization, they did so and then she asked them to articulate where blame was laid actually at the moment of the failure. It was amazing that executives admitted that they had blamed people for their lack of ability when they knew that the problems lay elsewhere; e.g. process inadequacy, process complexity, uncertainty, etc. It reminds me of stuff that I learned from Tom Gilbert, Harold Stolovitch, and others around human performance technology in which the research indicated that somewhere between 20 and 40% of performance was within the control of the individual and the rest of the effect had to do with factors such as whether the right person had been chosen for the job in the first place, the quality of management, the specificity of objectives, whether requisite tools and knowledge were available, etc.

Where your example of Rickover is particularly valid for me is in its invocation of a leadership exerting not just a first-order control that requires people to adopt a mindset and set of behaviors, but also because Rickover stipulated certain systemic changes so that the lower less visible methods of control (e.g., forms, meeting agendas, procedures, etc.) also enforced this notion of learning. Thanks for the example and thanks for the reply, Murray

Peace,

T.J. Elliott

609 306-4129

 

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles

 

 

 

 

On Wed, Apr 15, 2020 at 3:21 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:

Another good post TJ!  What I'm taking from it is that organizational culture dictates if we blame or learn and so leadership plays a big role.  Unfortunately I don't see the US as having a learning culture (and I'm not blaming the President or the Democrats) as our system is adversarial by design meaning that we want each side to blame the other.  One funny thing I noticed is that Richover could force an organizational culture on the nuclear navy that was different than the regular navy, this carried through to the commercial nuclear industry, in my own company we had the nuclear way and the company way so playing the blame game could not be overcome at the organizational level, only at the sub-organizational level.  So learning versus blame is going to be an issue for all organizations....murray jennex

-----Original Message-----
From: T J Elliott <tjell2010@...>
To: SIKM <SIKM@groups.io>; nancydixon <nancydixon@...>
Sent: Wed, Apr 15, 2020 11:51 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Amy Edmondson has much to say about the subject of how we deal with failure and especially how we assign blame — often incorrectly as it turns out

 

 

But, I think, that the University of Chicago philosopher Agnes Callard points out how difficult it is for people to forgo their anger even in those circumstances where there does appear to be a failure of accountability:

. "If the argument works, it follows that a person gives up his or her anger not (emphasis added) because the issue has been resolved or even addressed in any way but merely because, for example, he or she sees that he or she will be better off in a nonangry condition. Pragmatic reasons for ceasing to be angry have positive counterparts: pragmatic reasons to get angry." It may strain the definitions of what we would accept this pragmatism, but there may be a fear that if we don't get angry that we are going to get stepped on again, that we will have to accept bad behavior forever and ever. I note this because as worthy as the desire to forgo blame is and as practical as such an action might be especially from the perspective of learning and knowledge generation as a prelude to better decision-making and action, persuading humans to do that is very difficult. As Callard notes, in order to get rid of the kind of anger that blame engenders, there needs to be a "bilaterality", a recognition on both sides that something has happened here that violates what at least one side thought of as the norms of the relationship. Callard continues, "Anger is not a desire to fix something but a way of grasping the fact that it is broken..." If there is a resolute unwillingness to admit that something was broken, then people are going to find it difficult to move on, to forgo blame, to learn rather than burn. Nancy Dixon on this list has as much experience with after action reviews as anybody in the world I will bet and I wonder what she thinks about how we suspend our tendency to blame at these moments.

Peace,

T.J. Elliott

609 306-4129

 

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles

 

 

 

 

On Wed, Apr 15, 2020 at 2:18 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:

Good point Bill, I was part of Admiral Richover's nuclear navy and that was a foundation point there also, learn first, prevent recurrence, then worry about corrective actions.  We were still held accountable for "stupid" mistakes but it was considered more important to determine why a bad decision was made and how to prevent it again than it was to punish someone for making the bad decision.  Same in nuclear industry.  I also believe people are more willing to be accountable and are more professional when they know the organization realizes that bad decisions by well trained people are not always because they weren't competent.  Most of the time it was a deficiency in training or procedure.  Sometimes it was because one of those unknown unknowns that hadn't been considered happened.  Most of our human errors were due to fatigue, other stressors, process error, and poor human factor design but not because people didn't know better or wanted to make an error.....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:25 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.

 

From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

 

nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Dear Colleagues

 

 

I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?

 

Would be interested in your perspectives.

 

Best

 

Bill

 

 

  

 

Learn more about the solutions and value we provide at www.workingknowledge-csp.com

 

 


Murray Jennex
 

John, you mention the lead tool we in the nuclear world use to learn, root cause analysis.  No determination of fault was made till root causes were identified and in almost all cases I participated in one of the root causes was organizational issues, such as failed chain of command, inadequate change reviews, poorly communicated expectations, poor training, etc.  I only recall one event that was attributed to someone intentionally doing something wrong.  On a global level you have Chernobyl as the main example where people did something wrong on purpose, then you have Fukushima where individuals did outstanding efforts and sacrifice to mitigate what was essentially an organizational fault.  For those wondering, TMI-2 was mostly a human performance issue in that systems were poorly designed from a human factors perspective and then procedures didn't counter the fog of crisis issue.  We had a saying that it was okay for a mistake to happen once, unforgivable for it to happen again.  This is the essence of learning from crisis and failures.....murray jennex


-----Original Message-----
From: John Lewis <johnlewisedd@...>
To: SIKM <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 1:53 pm
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Bill (Kaplan) for this thread! This topic is directly on target and more fundamental than most grasp towards learning, decisions, collaboration, and leadership. It is core to the topic of epistemology for what we know and how we know. In moving organizations towards a learning culture, it helps to measure the ratio of emphatic statements (count exclamation points) versus questions (count question marks). Then measure the ratio of questions from curiosity (inquiry) versus questions from conviction (inquisition). Then measure the ratio of questions from curiosity that seek a single “root cause” versus the questions from curiosity that seek the “root factors” which in combination can create a “perfect storm.” I call it moving from a “5-WHYs” questioning technique to a “5-WHATs” questioning technique. We will find the answers to the questions we ask. And T.J. Elliott makes a great point that the answers for causality will normally be found at the organization level, not the individual level, as noted by ISPI, Tom Gilbert, and Harold Stolovitch.

All the best,
John Lewis, Ed.D.
John@...
Author - Story Thinking: Transforming Organizations for the Fourth Industrial Revolution


On Wed, Apr 15, 2020 at 3:33 PM T J Elliott <tjell2010@...> wrote:
Murray, I agree with you completely. So glad to see you invoke Admiral Rickover; my dad was an electrical engineer and Rickover was one of his heroes. What has stuck with me from Amy Edmondson's work is the research that she did in which she presented high level executives at organizations with the spectrum of causes of failure. (You can see it in this article here very easily.) When Amy asked the execs to identify where they thought the causes were with some recent failure within their organization, they did so and then she asked them to articulate where blame was laid actually at the moment of the failure. It was amazing that executives admitted that they had blamed people for their lack of ability when they knew that the problems lay elsewhere; e.g. process inadequacy, process complexity, uncertainty, etc. It reminds me of stuff that I learned from Tom Gilbert, Harold Stolovitch, and others around human performance technology in which the research indicated that somewhere between 20 and 40% of performance was within the control of the individual and the rest of the effect had to do with factors such as whether the right person had been chosen for the job in the first place, the quality of management, the specificity of objectives, whether requisite tools and knowledge were available, etc.

Where your example of Rickover is particularly valid for me is in its invocation of a leadership exerting not just a first-order control that requires people to adopt a mindset and set of behaviors, but also because Rickover stipulated certain systemic changes so that the lower less visible methods of control (e.g., forms, meeting agendas, procedures, etc.) also enforced this notion of learning. Thanks for the example and thanks for the reply, Murray
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles

 


On Wed, Apr 15, 2020 at 3:21 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Another good post TJ!  What I'm taking from it is that organizational culture dictates if we blame or learn and so leadership plays a big role.  Unfortunately I don't see the US as having a learning culture (and I'm not blaming the President or the Democrats) as our system is adversarial by design meaning that we want each side to blame the other.  One funny thing I noticed is that Richover could force an organizational culture on the nuclear navy that was different than the regular navy, this carried through to the commercial nuclear industry, in my own company we had the nuclear way and the company way so playing the blame game could not be overcome at the organizational level, only at the sub-organizational level.  So learning versus blame is going to be an issue for all organizations....murray jennex


-----Original Message-----
From: T J Elliott <tjell2010@...>
To: SIKM <SIKM@groups.io>; nancydixon <nancydixon@...>
Sent: Wed, Apr 15, 2020 11:51 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Amy Edmondson has much to say about the subject of how we deal with failure and especially how we assign blame — often incorrectly as it turns out


But, I think, that the University of Chicago philosopher Agnes Callard points out how difficult it is for people to forgo their anger even in those circumstances where there does appear to be a failure of accountability:
. "If the argument works, it follows that a person gives up his or her anger not (emphasis added) because the issue has been resolved or even addressed in any way but merely because, for example, he or she sees that he or she will be better off in a nonangry condition. Pragmatic reasons for ceasing to be angry have positive counterparts: pragmatic reasons to get angry." It may strain the definitions of what we would accept this pragmatism, but there may be a fear that if we don't get angry that we are going to get stepped on again, that we will have to accept bad behavior forever and ever. I note this because as worthy as the desire to forgo blame is and as practical as such an action might be especially from the perspective of learning and knowledge generation as a prelude to better decision-making and action, persuading humans to do that is very difficult. As Callard notes, in order to get rid of the kind of anger that blame engenders, there needs to be a "bilaterality", a recognition on both sides that something has happened here that violates what at least one side thought of as the norms of the relationship. Callard continues, "Anger is not a desire to fix something but a way of grasping the fact that it is broken..." If there is a resolute unwillingness to admit that something was broken, then people are going to find it difficult to move on, to forgo blame, to learn rather than burn. Nancy Dixon on this list has as much experience with after action reviews as anybody in the world I will bet and I wonder what she thinks about how we suspend our tendency to blame at these moments.
Peace,
T.J. Elliott
609 306-4129

"Whoever wishes to have honor or strength instead of good friends, reckons badly."
Euripides, Herakles

 


On Wed, Apr 15, 2020 at 2:18 PM Murray Jennex via groups.io <murphjen=aol.com@groups.io> wrote:
Good point Bill, I was part of Admiral Richover's nuclear navy and that was a foundation point there also, learn first, prevent recurrence, then worry about corrective actions.  We were still held accountable for "stupid" mistakes but it was considered more important to determine why a bad decision was made and how to prevent it again than it was to punish someone for making the bad decision.  Same in nuclear industry.  I also believe people are more willing to be accountable and are more professional when they know the organization realizes that bad decisions by well trained people are not always because they weren't competent.  Most of the time it was a deficiency in training or procedure.  Sometimes it was because one of those unknown unknowns that hadn't been considered happened.  Most of our human errors were due to fatigue, other stressors, process error, and poor human factor design but not because people didn't know better or wanted to make an error.....murray jennex


-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:25 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Thanks Murray. I have found over the past 20 years and before that in the Air Force working with the IG that the context of the research or investigation or assessment directly impacts the quality of the outcome and how that outcome then impacts the needed changes.
 
From: SIKM@groups.io <SIKM@groups.io> On Behalf Of Murray Jennex via groups.io
Sent: Tuesday, April 14, 2020 18:27
To: SIKM@groups.io
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
 
nice article and I totally agree with you Bill!  I worked in the nuclear industry for many years and the foundation of event analysis and investigation was to learn first and not worry about blame.  We found people were a lot more forthcoming and honest when investigations weren't about blame and were focused on learning from the event and preventing its recurrence.  Politicians could learn much from this!....murray jennex

-----Original Message-----
From: Bill Kaplan <bill@...>
To: SIKM@groups.io <SIKM@groups.io>
Sent: Tue, Apr 14, 2020 9:08 am
Subject: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.
Dear Colleagues
 
 
I share a perspective on the value of focusing on learning rather than blaming now that we can see ourselves turning the ?corner in the pandemic fight.  Where should we be spending our valuable and limited time and resources?  What is the opportunity in front to of us to learn from all of this?
 
Would be interested in your perspectives.
 
Best
 
Bill
 
 
  
 
Learn more about the solutions and value we provide at www.workingknowledge-csp.com
 
 


Stephen Bounds
 

Nicely said Murray.

The deeper problem is that sometimes there literally isn't a "right" answer to be solved by more data.

I recently came across Benedetti's Puzzle, which I think is a nice illustration/metaphor. Despite the well-known "knowledge" that music intervals are defined as a set of perfect ratios (eg the C-G interval of a fifth is a 3:2 frequency ratio), applying this strictly to a melody will lead to a gradual move "off key". (This isn't just theoretical -- a capella choirs experience this.)

So cultures are faced with a subjective choice: to compromise and adopt an even-tempered scale, or to factor this melodic drift into musical performance? Different culture have chosen different solutions, and neither can be argued as "right" or "wrong" in their approach.

(I recommend the whole video if you want a fascinating 10 minute diversion to your day BTW.)

Cheers,
Stephen.

====================================
Stephen Bounds
Executive, Information Management
Cordelta
E: stephen.bounds@...
M: 0401 829 096
====================================
On 16/04/2020 5:10 am, Murray Jennex via groups.io wrote:

Anna, I truly appreciate your post as it reflects much of what I feel about this pandemic and about the overall approach we (humans) seem to be taking to argue among ourselves.  You are right, viruses are not racist or sexist, if the data shows that certain groups are suffering more than instead of arguing social factors we need to identify risk factors so the right questions are always why is one group reacting differently rather than blaming society for that groups problems.  

I also worry about people over relying on science and data. Since I'm working at home I've caught up on some reading and an interesting article I read condemned the idea that having more data will always make our decision making better.  The model argument is given enough data we can be absolutely sure on the prediction but intuition math says we will cannot know it all.  I've had to referee debates among friends and acquaintances about the Washington model being used to guide policy.  Models are best approximations of what we know now that we use to help us predict the future.  The more we learn the better the model.  The one fallacy of this is that life is not linear and predetermined.  Life evolves and it will change in ways we cannot predict and models will never be perfect.  What I'm getting to is that political arguments about following science are wrong when the science is based on imperfect models.  Scientists know this, politicians do not.  Scientists know that models help them understand what they know, and what they don't, and good scientists look at models as a recommender system, good advice but not always right.  This is where KM steps in, we take past knowledge and apply it, hopefully appropriately, to current situations.  This is also a valid path and suggests that what we should be doing is using data and experience to guide decision making but not as the decision maker.  This means there will always be some ambiguity and this is particularly true with crisis response.  Crisis response will never be perfect but it guides us to be the best we can.  This is why we need to not worry about blaming and instead focus on learning....murray jennex

-----Original Message-----
From: Anna Gene Jonassen <ajonassen@...>
To: SIKM <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:34 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

This really resonated with me, and struck me as a better formed, more eloquent version of some of my swear-filled rants (after I encounter mass media articles ) that my fiance has had to endure as we've been sheltering in place together! Hah! These articles (I've generalized as I feel they are ubiquitous) feel shockingly tone deaf to the real issues I feel I see so clearly - instead of focusing on education and problem-solving, they focus on sensationalist, unnecessarily politicized headlines that detract from any forward momentum and erode our fleeting sense of global camaraderie (when have I ever felt so connected in experience to people in Wuhan or rural villages in southern Italy?) . Now is not the time for finger-pointing. Now is not the time to be bureaucratic. Now is not even the time to get frustrated or defeated about the things we cannot change (i.e. systemic issues - I think about articles from NY times about race-specific communities are disproportionally at risk for COVID-19 - nowhere is there mention of WHY they might be at greatest risk as an opportunity educate and reinforce shelter in place orders - I could go on...) It is appalling to me the a politician(s) would withhold critical funding from some of the only organizations that possess the knowledge to help us as a collective move forward.

So truly, now is the time for action. 

I work at a healthcare technology strategy & consulting firm as a knowledge manager - at a company that is laser-focused on trying to deliver intel / lessons learned on digital solutions that can be rapidly stood up to deal with the immediate crisis of the surge of patients, and the analysis required to move forward, and potentially repurpose lessons learned for the long haul (this part, naturally, is trickier, and we lack the luxury of retrospect and are relegated to speculation in a lot of cases but health systems can't afford to do anything less)...

Because our clients are health systems that are on the front lines, they are not embroiled, nor do they care, about the politicization of the pandemic (aside from how it is impacting funding relief and it has proven to have more strings attached than it should which is ugly business) - as they are dealing with being hit/put at risk and/or gutted financially from every angle - they still have to care for communities. I have seen beautiful examples where clients have swept past bureaucracy, perhaps in an act of desperation, to rapidly share learnings, bridge partnerships (ie. competitors), enlist unusual applications of technologies, and whether they like it or not, have to dedicate time and resources to planning ahead and anticipating the worst case scenarios. These strategies may be executed in a more hodgepodge fashion than they'd ever hope for (ie. financial modeling for residual surges of the virus during a slow recovery, planning for operations where they are down all non-clinical staff, figuring out ways to recoup revenue as millions of Americans lose insurance) - but it is amazing to see how quickly some of them have been able to innovate, all while being in crisis mode.

Forgive my long-winded and scattered reply..long story short, great piece you wrote!


Murray Jennex
 

Good points Stephen and I agree, there may not be a right answer regardless of how much data you have and I'll add that there may also be many right answers!  The hardest thing I've had to learn as a engineer, manager, and then teacher is that there is almost always more than one right answer and just because I think one way is right doesn't make it so.  The teaching culture is one where I've had to learn that there are many approaches (especially once you get to the graduate level) and it is rare that any one approach is purely right or purely wrong, I have to evaluate them all to see the merit in each....murray jennex


-----Original Message-----
From: Stephen Bounds <km@...>
To: SIKM <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 6:51 pm
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

Nicely said Murray.
The deeper problem is that sometimes there literally isn't a "right" answer to be solved by more data.
I recently came across Benedetti's Puzzle, which I think is a nice illustration/metaphor. Despite the well-known "knowledge" that music intervals are defined as a set of perfect ratios (eg the C-G interval of a fifth is a 3:2 frequency ratio), applying this strictly to a melody will lead to a gradual move "off key". (This isn't just theoretical -- a capella choirs experience this.)
So cultures are faced with a subjective choice: to compromise and adopt an even-tempered scale, or to factor this melodic drift into musical performance? Different culture have chosen different solutions, and neither can be argued as "right" or "wrong" in their approach.
(I recommend the whole video if you want a fascinating 10 minute diversion to your day BTW.)
Cheers,
Stephen.
====================================
Stephen Bounds
Executive, Information Management
Cordelta
E: stephen.bounds@...
M: 0401 829 096
====================================
On 16/04/2020 5:10 am, Murray Jennex via groups.io wrote:
Anna, I truly appreciate your post as it reflects much of what I feel about this pandemic and about the overall approach we (humans) seem to be taking to argue among ourselves.  You are right, viruses are not racist or sexist, if the data shows that certain groups are suffering more than instead of arguing social factors we need to identify risk factors so the right questions are always why is one group reacting differently rather than blaming society for that groups problems.  

I also worry about people over relying on science and data. Since I'm working at home I've caught up on some reading and an interesting article I read condemned the idea that having more data will always make our decision making better.  The model argument is given enough data we can be absolutely sure on the prediction but intuition math says we will cannot know it all.  I've had to referee debates among friends and acquaintances about the Washington model being used to guide policy.  Models are best approximations of what we know now that we use to help us predict the future.  The more we learn the better the model.  The one fallacy of this is that life is not linear and predetermined.  Life evolves and it will change in ways we cannot predict and models will never be perfect.  What I'm getting to is that political arguments about following science are wrong when the science is based on imperfect models.  Scientists know this, politicians do not.  Scientists know that models help them understand what they know, and what they don't, and good scientists look at models as a recommender system, good advice but not always right.  This is where KM steps in, we take past knowledge and apply it, hopefully appropriately, to current situations.  This is also a valid path and suggests that what we should be doing is using data and experience to guide decision making but not as the decision maker.  This means there will always be some ambiguity and this is particularly true with crisis response.  Crisis response will never be perfect but it guides us to be the best we can.  This is why we need to not worry about blaming and instead focus on learning....murray jennex

-----Original Message-----
From: Anna Gene Jonassen <ajonassen@...>
To: SIKM <SIKM@groups.io>
Sent: Wed, Apr 15, 2020 9:34 am
Subject: Re: [SIKM] Learning Not Blame -- “Inquiry” Not “Inquisition.” We Can Work With This in Getting Back to Some Form of Normal.

This really resonated with me, and struck me as a better formed, more eloquent version of some of my swear-filled rants (after I encounter mass media articles ) that my fiance has had to endure as we've been sheltering in place together! Hah! These articles (I've generalized as I feel they are ubiquitous) feel shockingly tone deaf to the real issues I feel I see so clearly - instead of focusing on education and problem-solving, they focus on sensationalist, unnecessarily politicized headlines that detract from any forward momentum and erode our fleeting sense of global camaraderie (when have I ever felt so connected in experience to people in Wuhan or rural villages in southern Italy?) . Now is not the time for finger-pointing. Now is not the time to be bureaucratic. Now is not even the time to get frustrated or defeated about the things we cannot change (i.e. systemic issues - I think about articles from NY times about race-specific communities are disproportionally at risk for COVID-19 - nowhere is there mention of WHY they might be at greatest risk as an opportunity educate and reinforce shelter in place orders - I could go on...) It is appalling to me the a politician(s) would withhold critical funding from some of the only organizations that possess the knowledge to help us as a collective move forward.

So truly, now is the time for action. 

I work at a healthcare technology strategy & consulting firm as a knowledge manager - at a company that is laser-focused on trying to deliver intel / lessons learned on digital solutions that can be rapidly stood up to deal with the immediate crisis of the surge of patients, and the analysis required to move forward, and potentially repurpose lessons learned for the long haul (this part, naturally, is trickier, and we lack the luxury of retrospect and are relegated to speculation in a lot of cases but health systems can't afford to do anything less)...

Because our clients are health systems that are on the front lines, they are not embroiled, nor do they care, about the politicization of the pandemic (aside from how it is impacting funding relief and it has proven to have more strings attached than it should which is ugly business) - as they are dealing with being hit/put at risk and/or gutted financially from every angle - they still have to care for communities. I have seen beautiful examples where clients have swept past bureaucracy, perhaps in an act of desperation, to rapidly share learnings, bridge partnerships (ie. competitors), enlist unusual applications of technologies, and whether they like it or not, have to dedicate time and resources to planning ahead and anticipating the worst case scenarios. These strategies may be executed in a more hodgepodge fashion than they'd ever hope for (ie. financial modeling for residual surges of the virus during a slow recovery, planning for operations where they are down all non-clinical staff, figuring out ways to recoup revenue as millions of Americans lose insurance) - but it is amazing to see how quickly some of them have been able to innovate, all while being in crisis mode.

Forgive my long-winded and scattered reply..long story short, great piece you wrote!