Failure teaches best when blame is hard to pin down, study finds
August 26, 2015
For more information, contact: Ben Haimowitz , (718) 398-7642, email@example.com
Which company problem is more likely to get fixed – one attributable
to a particular person or department or one with wider roots? Common sense
would suggest the former, since the solution in that case may involve nothing
more complicated than changing the way a single unit is run or setting an
individual or a few people straight.
But some new research casts doubt on this reasoning, obvious
though it may seem.
In the words of a paper in the current issue of the Academy of Management Journal,"concentrated failures prompt narrower
attributions of responsibility which, whether accurate or not, ultimately lead
to less thorough investigations and fewer of the system wide changes that are
typically required to address organizational performance problems.”
The study goes on to explain that, “following multiple failures at
the same location or involving the same individuals, organizational leaders
have a well-recognized tendency to merely dismiss culpable parties or make
other relatively localized changes. While these simple changes may be
sufficient in some cases, the present study suggests the need for deeper
The paper, by Vinit Desai, an associate professor of management at
the University of Colorado Denver, comes to these conclusions through an
analysis of failures that are literally a matter of life and death – the improvement
or lack of it in death rates resulting from cardiac-bypass surgery in more than
115 hospitals in California, where the state gathers copious data on these
surgeries. The hospitals that made the greatest strides were those in which
deaths were dispersed among patients of a number of surgeons rather than being
concentrated in patients of one or just a few. The chance that the degree of concentration
did not influence death rates was less than 5%.
Asked for specific examples, Prof. Desai hesitates to draw
conclusions about the results of any single institution as distinct from the
sample as a whole. With this caveat, he cites the case of a hospital where over
a two-year period about half the surgeons lost patients who underwent this
procedure, called Coronary Artery Bypass Graft (CABG).
According to the hospital, it responded with broad procedural changes that
involved "[putting] evidence-based protocols in place, [providing]
educational and skills-based training for staff, and [forming]
multidisciplinary committees to identify and resolve quality issues." The
following year, no patients died following CABG at the hospital, even though
about the usual number of procedures was carried out.
What about hospitals where bypass deaths were
concentrated among a small minority of surgeons? How the departure of subpar
physicians affected such institutions individually would be difficult to tell,
the professor says. But outcomes were quite clear for the study sample as a
whole: greater concentration of failures was associated with more
subsequent departures but not with reduced CABG deaths. In
short, the exit of less competent surgeons did not, in general, solve the
Research, the study notes, “has identified a
pervasive tendency to overweight individual or dispositional factors and
underweight situational ones…When repeated failures primarily involve the same
group or employee, organizational decision-makers might suspect that the
involved party played a causal or at least a contributory role. This may
initially seem reasonable, given the frequency of failures involving this party
and the relative rarity of failures involving others within the organization.
However, work on defensive attributions would suggest the tendency for
decision-makers in this situation to ignore or undervalue any contributing
situational factors, and even to overweight the importance of individual or
The paper is based on the performance of 116
to 118 hospitals (the number varies over the length of the study) in two-year
segments of the period 2003 through 2010. A mean of about five surgeons per
hospital, but as many as 10, performed CABG operations, with the doctors
averaging about 63 such procedures per year. A little less than three percent
of patients died during or after surgery.
Desai analyzed the relationship between
failure concentration (how failure was apportioned among surgeons) in one
period, say 2003-04, and the change in the incidence of CABG deaths between
those two years and the following two years, say 2005-06. In all, the analysis
embraced 468 hospital-period observations, with findings including the
■ The more
concentrated failure was in one period, the greater the failure rate in the
■ This relationship was stronger in larger
hospitals, where concentrations of poor performers stood out more than in
smaller places. It was weaker in institutions with CABG death rates either well
above or well below the average, the former group being highly motivated to
improve their results and the latter group to perpetuate their superiority.
failure was associated, too, with increased incidence of surgeon departures and
fewer hospital efforts to refine CABG procedures.
Asked to sum up the study’s principal lesson,
Prof. Desai says, “Don’t be too quick to assign blame. In all likelihood, there
is more to be lost in doing so than there is in looking for a deeper cause.
Difficult though they may be, deep searches for underlying structural solutions
or procedural changes can pay off in a big way even in high-functioning
Indeed, in a 2011 study of the global
launch-vehicle industry published in the Academy of Management Journal, Prof. Desai and Peter Madsen of Brigham Young
University had occasion to cite a catastrophic instance of this – the tragic
loss of seven astronauts aboard the Columbia space shuttle from a structural
flaw that had been noticed in a previous shuttle liftoff but went uncorrected
because the earlier flight was successful. Organizations, the study concluded,
learn more effectively from failure than from success. Now the new research
takes the matter a step further, identifying the circumstances in which failure
teaches most effectively.
The paper, “Learning through the Distribution
of Failures within an Organization: Evidence from Heart Bypass Surgery
Performance," is in the August/September issue of the Academy of Management Journal. This peer-reviewed publication is
published every other month by the Academy, which, with close to 20,000 members
in 115 countries, is the largest organization in the world devoted to
management research and teaching. The Academy's other publications are Academy
of Management Review, Academy of Management Perspectives, Academy of
Management Learning and Education, Academy of Management Annals, and Academy
of Management Discoveries.