Safety can’t be built right at the start

I constantly see people rise in life who are not the smartest, sometimes not even the most diligent, but they are learning machines. They go to bed every night a little wiser than they were when they got up and boy does that help, particularly when you have a long run ahead of you.’ - Charlie Munger

Health services, child protection, taking care of disabled people — all of these are important social services that determine the difference in the quality of living in a country. The way we take care of the most in need determines out ability to create a better society. Considering the importance of this; the challenge that most leaders currently face is to manage the complexity of building organisations that can do this. Organisations that can deliver high quality care to a child who is removed from their parents by the government. Taking care of dementia patients and helping them live a good life. Designing systems that can provide opportunity and care to people with disabilities. Implementing new policies that don’t kill people. Lets look at some examples from Australia.

Families SA - the child protection agency in South Australia has been in a lot of fire lately. From Foster Carers:

We see the decisions that are made at the top and we see the repercussions that families and children have to endure - it is too big a gap, they are too far removed [from those decisions]. [It] is easy to sit up here in Flinders Street [government offices] or wherever you are with your head in a flaming ivory tower making some flaming decision, but if it’s not lined up with what actually works it’s a waste of time.”

A Royal Commission is looking into the practice of care:

A royal commission into South Australia’s child protection system has begun formal investigations. The inquiry was announced in August after a Families SA care worker was charged with unlawful sexual intercourse with seven preschool children under his care at a residential facility. Families SA has since suspended 25 carers from working one-on-one with children following an audit of internal staff records, while a further 77 staff have been identified as being of high concern”.

These are big issues in some sense. There are smaller challenges like getting a dental checkup for all the children in care. To make sure that they are all educated. To enable them to develop friendships while in care. How can we design systems so that brothers and sisters are not separated from the families that they are removed from? Or the Royal Commission into Child Abuse:

AND it is important that claims of systemic failures by institutions in relation to allegations and incidents of child sexual abuse and any related unlawful or improper treatment of children be fully explored, and that best practice is identified so that it may be followed in the future both to protect against the occurrence of child sexual abuse and to respond appropriately when any allegations and incidents of child sexual abuse occur, including holding perpetrators to account and providing justice to victims. AND it is important that those sexually abused as a child in an Australian institution can share their experiences to assist with healing and to inform the development of strategies and reforms that your inquiry will seek to identify.

The fiasco of the Home Insulation Scheme, which had another Royal Commission appointed.

But Mr Rudd said he took ultimate responsibility” for the deep tragedy” of his government’s failed $2.8 billion insulation scheme which resulted in the deaths of four installers, one of whom was only 16.

The roll-out of the National Disability Insurance Scheme is something that I am following with a lot of interest. This is the overhaul of the disability sector in Australia including new ways of providing services, new principles of care and lot more money to deliver these. However, this is a massive program rolling out all over the country starting with a few sites.

July 2013 launch locations The initial four NDIS launch sites included: Hunter area, NSW (for those aged up to 65 years) Barwon area, Vic  (for those aged up to 65 years) South Australia (for children aged 0-5) and Tasmania (for young people aged 15-24)

I recently attended the South Australian review meetings where after a year if implementation there is a lot of learnings to be had and I saw a healthy atmosphere of trying to understand what is working, what is not and what can be improved. I have much hopes for this and that it will be implemented with much more care and focus on learning.


_Real knowledge is to know the extent of one’s ignorance - __Confucius_


To go about implementing these kinds of services are not very different from Toyota rolling out a new care or expanding in a new country. Fundamentally, there are two ways we can do this.

  • One, we believe that we can design organisations, policies, systems that work well right at the start and deliver the promises.
  • Two, we understand the nature of complex systems. It is not about being right at the start but to be able to create a learning organisation that uses the scientific method and follows a continuous learning process to reach the goal.

In my experience; the public expectation, the politics, the managerial decisions are all targeted towards the first way of doing this. However, we know through the experience of successful organisations like Toyota or Alcoa or the Mayo Clinic that the key to achieving the high standards set for us is through the idea of learning by doing. Steven Spear in his book The High Velocity Organisation where he decodes the principles and practices of the Toyota production system and applied them in various industries including hospitals talks about the challenge faced by designing safety in a organisation like Alcoa. High Velocity Org - Alcoa Safety   There is no reason to think why we can actually deliver services in complex situations in the same way - there is no brain trust that can make this happen. The challenge is to start with the right principles and keep learning by doing. This creates the innovation and improvement momentum to reach the high standards of social services we want for ourselves. I recently read an article (can’t find the link right now) where the author talks about the fall of Berlin wall 25 years ago. It is clear to everyone that centrally planned economies are not going to work. However, after the 25 years, in economies like Australia which are not centrally planned there is a growing interest to design organisations or implement policies in a centrally planned way. We cannot build and deliver on policies and organisations that deliver on day 1. What is required is a culture that accepts that we are not superhuman, that the way forward is to learn as we go, to expect politicians to understand the same and more importantly educate the citizens that we are focussed on the ultimate outcome but we will learn as we go. Our goal is to minimise the mistakes as much as possible but at the start of course, we will make small mistakes and these will help us learn to build systems that are robust and will deliver the outcomes we want with less and less mistakes in the future. We can substitute mistake” here with cost reduction, employee satisfaction or any other goal. All of this starts with humility - to be humble enough to say that this is work is complex and I am not going to get this right the first time.


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