The following is excerpted and adapted from my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.
In healthcare, there are so many high-stakes mistakes that can be made. I appreciate that Value Capture has long focused on helping leaders cultivate a culture that works diligently toward “zero harm” through a culture that focuses on systemic prevention and improvement instead of naming, blaming, and shaming individuals.
We’re all human. Therefore, we’re not just prone to human error; we’re guaranteed to make them. The way leaders react to mistakes makes all the difference, as the story shared by Value Capture CEO Ken Segel (from early in his career) illustrates.
Here is the episode of "My Favorite Mistake" where Ken told this story:
What Are Mistakes?
Mistakes are actions or judgments that turn out to be misguided or wrong. We believe we are making the right decision at the time, but eventually discover it was wrong, whether seconds or years later. The word “mistake” is a noun. Mistakes exist, whether we recognize and admit them or not. After discovering a mistake, our choices determine if we turn it into something positive (learning and improving) or make things worse (dooming ourselves to repeating them).
The Congressman Who Chose Learning over Punishment
Ken Segel is a co-founder and CEO of Value Capture. Decades ago, Ken started his career in politics, most notably running the overnight “war room” operations during the 1992 Clinton-Gore campaign.
Ken’s first job after college, in 1988, was as a congressional aide for U.S. Representative Howard Berman, from California. As an advisor on immigration policy, Ken received the call when a USA Today reporter called. Ken asked to speak with the reporter “on background,” a commonly used ground rule that would allow Ken to speak more frankly without fear of being quoted with attribution—or so he thought.[i]
Two days later, Ken found the article in his mailbox with the phrase “See me” written by his boss. Ken read the piece for the first time and was dismayed to read a quote directly attributed to him saying that legislation introduced by Sen. Alan Simpson still treated people from whole sections of the world, including Africa, as if they were “the plague, not human beings seeking a better life for their kids.” Ken remembers his life passing before his eyes when he read the quote and the note.
Having worked for the Congressman for just a month or two, Ken assumed Rep. Berman would be quite angry and thought he might be fired. “I’d embarrassed my boss and made it harder to work with a key stakeholder,” Ken recalls.
Ken scheduled time to see him at the end of the day. Rep. Berman started by asking Ken questions about other issues related to their work. Ken was a little dumbfounded that the USA Today story wasn’t the first topic of conversation—and didn’t seem to be on the agenda at all.
Ken finally held up the clip and asked, “Don’t you want to talk about this?”
Rep. Berman reacted in a way that suggested it wasn’t top of mind. “Oh yeah.” He asked, “Do you understand why this is problematic?” Of course, Ken did. He explained how he asked the reporter to treat his comments as background. But, perhaps the quote was just “too juicy not to use,” Ken now wonders.
The Congressman replied,
“All right, forget it. Just learn, and we’ll move on. Forget it.”
Rep. Berman took the clip, crumpled it up, and threw it in the trash.
Why did Rep. Berman respond that way? Ken doesn’t know for sure but thinks the Congressman saw himself as a leader who developed people, adding, “Many other members of Congress have a very different leadership style, which is based on a lot of aggression and taking advantage of their authority over others. But [Rep. Berman] quite deliberately chose a different way.”
Ken never learned why the reporter quoted him. Either the reporter intentionally violated his request to be used as background, or it was a mistake. Ken acknowledges one other possibility, saying, “I didn’t do a binary check to confirm we were on background,” something he learned to do later in his career (through the “Rules in Use” approach that Value Capture teaches clients).
Instead of blaming the reporter, he took ownership of his words. Ken realized that what he said was “endlessly defensible, but not constructive.” Ken didn’t avoid talking with reporters after that incident but learned to be more cautious in what he said.
Ken left politics and began focusing on various aspects of healthcare improvement. As a core aspect of that work, he and the team at Value Capture help health-system leaders improve their organizations’ systems of working, managing, and improving, aiming for a goal of zero harm. For Value Capture to fully help their clients “see, solve, and share problems,” as Ken describes, the people working in those organizations need to feel safe bringing problems into the open.
Ken points to two deeper lessons for leaders from his experience with Congressman Berman. First, leaders make the biggest difference for their people when they avoid reacting with blame in the moments when it’s hardest not to—when something has gone wrong that puts the leader and the organization under pressure.
Second, when leaders extend forgiveness or safety in the way Congressman Berman did—even in extreme moments—the impact is more than an increased willingness to work on solving problems. When that leader behavior is a habit, we see a tremendous surge of energy, alignment, and loyalty—positive forces that can change the performance trajectory of organizations and last a lifetime.
Ken describes this as his favorite mistake because of how the Congressman handled the situation and the way that made him feel included and safe to learn. Ken was “forever with Howard” because of his constructive response.
How to Reflect on a Mistake
When reflecting on a mistake, including Ken’s, we can ask additional questions that I learned from the team at Value Capture:
- What decision did I make?
- What did I expect to happen?
- What actually happened?
- What do I learn from the gap?
- What would I do differently?
- What would I expect to happen?
Answering those questions helps us focus on learning from mistakes instead of shaming ourselves or others for them.
Please join the discussion by posting a comment. How surprised were you to read Rep. Berman’s reaction to Ken’s mistake? What reaction do you expect when mistakes occur in your organization? Has your organization managed to shift (or start shifting) from punitive responses to approaches that are kind and constructive?
Written by Mark Graban
Mark Graban has served healthcare clients since 2005. Mark is internationally recognized as a leading author and speaker on Lean healthcare. His upcoming book is "The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation."