We don’t waste any misses or mistakes

What are M&Ms?

In medicine, there are traditional, recurring conferences held by medical services at academic centers called Morbidity and Mortality (M&M) Conferences. Morbidity refers to disease or sickness and mortality means death. At these peer review meetings, doctors take turns on a recurring basis presenting to their peers (other doctors) mistakes that either they directly committed or occurred on their watch while they were taking care of patients.

The goals of a well-run M&M conference is to learn from complications and mistakes, modify behavior and judgment that led to the mistakes, and to prevent the errors from happening again. The mistakes talked about often include deadly consequences for the patients involved. Yet, the conferences are non-punitive and the focus is to improve patient care. Everything discussed during an M&M conference is usually kept confidential by law.

M&M conferences aren’t only focused on the physician’s mistakes and how those could be corrected. It also looks at the systems issues — e.g. outdated policies, systems that don’t support effective patient care, etc. When necessary, systems may even be set in place to help catch human errors when they happen so that the patient doesn’t suffer from these errors.

When I was in medical school at a large tertiary hospital with many specialties, M&M conferences occurred on a regular basis, usually weekly. At smaller hospitals, they may occur less frequently, like bi-weekly or monthly.

I believe that the benefits of the phenomenon of M&Ms in the medical tradition today can be extended to any other organizational setting. That’s why I came up with “Misses and Mistakes (M&Ms). As the name implies, Misses and Mistakes are basically like omissions & commissions that we make that either lead to poor outcomes or inspire poor outcomes in the future.

While I believe that there will be tremendous benefits to any organization that implements this approach, I also know that there will be serious challenges to any leader who dares to introduce this kind of system in his company. M&M conferences didn’t start in medicine without a fight. Dr. Ernest Codman, a surgeon, who first introduced M&Ms at Massachusets General Hospital in the early 1900s was fired for that! Yet, with time, the American College of Surgeons saw the benefits of Codman’s ideas and supported it. Almost a hundred years later, M&M conferences are held in medical centers all over the world and countless lives have been saved by the innovation he introduced into medicine.

Benefits of Implementing M&Ms Conferences in an Organizational Culture

-Harness the power of vulnerability and the benefits that come from being vulnerable.
-Personally: Make the most of every miss or mistake. You will learn more from your M&Ms as you teach others about them.
-Group: Allow the team to learn from your mistake. Together, we will learn from “complications and errors, modify behavior and judgment based on previous experiences, and prevent the repetition of errors that lead to complications.”
-Eliminate the need to call people out in public so that others can learn from it or not be mislead by a miss or mistake. If someone notices another committing a significant M&M, he/she will tell that person in private and the person who committed the M&M will call for an M&M conference and teach the group about it. That person gets the credit for bringing it forward.
-Model Self-correction
-Feel more respected since others won’t have to call you out in public.
-Raise team morale
-Take responsibility for educating others with your own life.
-Create a culture where people are not ashamed to talk about their weaknesses.
-Create a culture where people can feel free to experiment
-Encourages innovation and creativity.
-Enhances patient care or achieving the team’s shared vision.
-Allows people to be more vulnerable and authentic.

M&M conferences are something I’m introducing in my organizations. I’m teaching staff at Shaping Destiny. My goal is that as M&M conferences become entrenched in our organizational culture, leaders, as well as team members, will never feel the need to correct a team member in public because they want to make sure others either learn from their errors or are not led astray by the actions of a team member who is committing an M&M.  A person who notices an M&M will simply bring it up to the attention of the person who committed it and they will take the joy of presenting the M&M as well as researching solutions to present to the group for review and implementation to correct the mistake and prevent it from ever happening again.

Renown leader, Dr. Rick Warren, encourages his team members to make mistakes. He tells them, if you don’t make at least one NEW mistake a week, you aren’t trying hard enough. In fact, he encourages them to make at least one new mistake a week — as long as it isn’t the same old one! He says mistakes are how we learn and get better. He’s absolutely right.

Without encouraging mistakes, we kill innovation and creativity. We encourage people to only do what is safe. Yet, we cannot simply encourage people to make mistakes without also creating a system to allow mistakes to be exploited to benefit the team and to close loopholes in the system that allowed the mistakes to happen. When done properly, we can learn from the mistake and make it harder to happen again.

A good M&M conference in a workplace, in addition to the benefits listed, above will give someone the opportunity to tell their colleagues, “Watch out, I fell in this hole. I’m showing you because I don’t want you to fall into it as well. I want you to learn from my mistakes. Also, I don’t want my mistaken actions to have been seen by you as correct and so be misguided by me. So, I am showing you my mistake so that you can correct your views if you were misled by my actions.”

As stated above, one advantage that this gives to us who are working with SD is that we don’t have to correct each other in front of others because we are trying to make sure others aren’t misled. Instead, we will simply tell the person in private and he/she will be responsible for communicating his mistake or miss clearly to others and articulating a better solution. They will take responsibility for both their miss and the correction. This will avoid correcting people in front of their peers, them feeling ashamed, etc.

Also, when people talk about their miss or mistake, they understand them more. When that happens, they will be better able to avoid it next time.

Experimenting vs. Recklessness

We want a culture where people are learning vigorously and free to experiment where the currently available knowledge has ended. In science, you don’t experiment on something that has already been discovered and is well known. You learn everything that has been discovered about the subject and then you run experiments to discover new things that haven’t been discovered yet so that you can become a pioneer that extends the field further and discover new things for others to learn in the future. That’s they way prudent and wise people experiment.

Some people confuse experimenting with carelessness. They think that simply guessing, or trying something they don’t know, without first researching and consulting those who have gone before us is experimenting. That’s recklessness, not experimenting. A good experimenter doesn’t reinvent the wheel. He learns the current cutting edge ideas and advancements and when he is not satisfied with what they have to offer, he researches further and builds on the knowledge already attained by the human race. He doesn’t ignore knowledge and isn’t lazy to go out and find it. He finds out what others have done, learns from it, and then makes his decisions about how to move forward from there. It doesn’t mean he will agree with everything he learns.

No retaliation, only learning from making mistakes

I want people to feel free to learn, to make mistakes, but to always take steps to prevent future mistakes without being discouraged to learn and experiment where the knowledge is ended. Blind experimentation is recklessness. Informed experimentation pushes the limits of learning further.

The only requirement is that people learn from their mistakes, take steps to avoid them, and teach the group about their mistake and how to avoid it. We will not punish, make fun of, look down, or ridicule anyone for sharing their miss or mistake with the group.

Vulnerability

A culture of M&M allows team members not only to learn from their mistakes but also to be vulnerable. Brene Brown did a great TED talk on Vulnerability that you may want to listen to. Great speakers, like Joyce Meyer, connect well with their audience because they are vulnerable. They talk about their mistakes, how she hurt herself and others, how she learned to stop making them, and how others can stop making the same mistakes.

How to talk about your miss or mistake

A good M&M presentation at an M&M conference should have the following ingredients:

  1. What was the miss or mistake? What is the hole you want others to avoid?
  2. How did you fall into it?
  3. What did you learn about it?
  4. How did committing that mistake hurt the organization or slow our work?
  5. What is the impact on others?
  6. Teach others how to avoid that hole
  7. What steps have you taken to avoid that hole in the future?
  8. How will our organization and culture be better when we all avoid that mistake?

At the end of an M&M presentation, the presenter should ask her peers for feedback and ideas they may have that will help her avoid the M&M in the future as well as helping all other team members do the same.

We encourage every organization that implements an M&M conference to also find time to reflect on successes and affirm team members for what they are doing right. It’s important to learn from misses and mistakes. And it’s also very important to learn from what is going right.

References

http://www.emsworld.com/article/11172553/quality-corner-morbidity-and-mortality-mm-conferences-a-tool-for-teaching-responsibility-for-ems-providers-following-negative-patient-outcomes

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