One of the most interesting practices at Etsy is the use of blameless postmortems to learn from mistakes and create processes that prevent them from being repeated. If I could take only one thing from Etsy and implement in other organizations, it would be the concept of a Just Culture:
Having a Just Culture means that you’re making effort to balance safety and accountability. It means that by investigating mistakes in a way that focuses on the situational aspects of a failure’s mechanism and the decision-making process of individuals proximate to the failure, an organization can come out safer than it would normally be if it had simply punished the actors involved as a remediation.
One of the most important aspect of the blameless postmortem process is that it’s an effort to overcome hindsight bias. When we look back on past mistakes, it’s all to easy to make the mistake of thinking that the information we have now is the information we had when the mistake occurred. This makes it extremely difficult to analyze the mistake and prevent similar mistakes in the future.
A big part of a postmortem is constructing a timeline of what happened. When you get to the moment when the mistake occurred, the person whose action caused the mistake is asked to think back and remember exactly what they expected to happen at the time the mistake was made, so that the gap between the expected outcome and the actual outcome can be revealed and the organization can work on preventing it in the future. The key is focusing on what information was available at the time of the incident.
Lately I’ve been trying to keep a journal of the decisions I’ve made at work and what they were based on, with the thought that when I’m trying to evaluate the quality of those decisions in the future, I’ll be able to go back and see what the rationale was at the time. When you look back three months or six months on a decision you made, it’s easy to forget what information you based that decision on, so I’m trying to write it down.
Not only do I often have to explain decisions I made to other people, but I also have to review them for my own good. We’ll see if the journal helps out.