Opportunities to learn from failure are well established in hospital learning environment in the from of a a morbid and mortality conference. From Wikipedia:

Morbidity and mortality (M&M) conferences are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. They are usually peer reviews of mistakes occurring during the care of patients.

The article goes on to summarise the objective of the conference:

The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.

You would think that there is little incentive to share information regarding failures in care given the current litigious climate. On the contrary:

Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law. M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.

Teams can apply these M&M conference ideas to drive improved delivery and ways for working.

Hold a retrospective focused on 3 key points from the scrum guide:

  • Inspect how the last Sprint went with regards to people, relationships, process, and tools;
  • Identify and order the major items that went well and potential improvements; and,
  • Create a plan for implementing improvements to the way the Scrum Team does its work.

Make it confidential. Team members will be more willing to open up if they know their pointy haired boss wonts be analysing the proceedings. Teams that are forced to share their proceedings tend to operate in bureaucratic blame cultures.

Be self critical. Reflect deeply about the challenges and errors made by you and the team so that the root casues may be adressed.

Hold it frequently. Scrum teams will hold it at the end of every sprint. Non scrum teams should still hold one every 1 – 4 weeks.

Drive improvement as a consequence. there isn’t much point just discussing something. Make lasting improvements as an output. consider implementing checklists, ways of working statements, process changes, automation, etc


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