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Failure-Proofing Government

Comprehensive performance management is the key for the long term. But for the short term, there's nothing wrong with a Band-Aid.

No public official envisions his or her career being defined by a spectacular failure that occurs when something or someone drops between the cracks of a government organization's processes. Yet that's exactly what happens too often, when something bad ends up on the front page or leads the 6 o'clock news. In the end, it isn't the likely career destruction that is the principle concern; it's the people who suffer because of an inadequate process.

Government work involves human lives, valuable property and the overarching responsibility for stewarding taxpayers' money. Finding and plugging the cracks in the enormously complex organizational processes of today's government demands a comprehensive performance-management system that puts in place measures to drive every employee's action. Human beings manage the vast majority of risks, and those humans closest to the possible point of breakdown are those best equipped to steer off the failure. Building out controls to this level takes a serious, long-term leadership commitment of resources and time.

But is there a way to plug the high-risk holes in the short term? Can these catastrophic failures be avoided without all the work of systemic and comprehensive performance management?

Not completely. Only a comprehensive and continuously improved system of performance management offers the best chance to manage the faults inherent in any system. But witnessing first-hand several public-confidence-rocking issues got me thinking about what I would do if I were asked to head a large agency or if I were elected as a mayor, county manager or governor. What could I do in the short-term to lessen the risk of something going terribly wrong before I addressed the longer-term issue?

My career developed during the quality revolution of the 1980s, an era that forever changed the course of American manufacturing, initially and most remarkably in the automotive sector. The growing application of lean concepts in government today is a direct descendent of that movement, and the lessons learned since continue to increase its relevance to government.

During that time I learned and used a methodology known as "Failure Mode Effects Analysis" (FMEA). Its purpose is to systematically assess four aspects of failure: What kinds of bad things could happen? What processes would have to fail for a bad thing to happen? What would cause or allow the failure? And how bad would it be if it failed?

This assessment leads to a prioritized list of what needs to be improved to reduce the chance that the bad thing will happen. An ideal fix? No. A Band-Aid? Yes. But Band-Aids can buy time, and time is a good thing.

So, where do you start to find and patch the holes -- to fill those organizational cracks?

I would suggest you find people trained in the FMEA methodology to examine the kinds of processes where failure would have the following effects: death, serious injury or harm, emotional trauma, abuse, serious property damage or destruction, significant disruption to normal living and working, material harm to the environment, or a significant waste of taxpayers dollars.

Working through the four questions leads to rating and ranking processes in order to prioritize which cracks need to be filled first. The cracks are plugged through process changes that, ideally, eliminate the possibility that a failure can occur and through measures that ensure that the quality of processes is visibly managed.

While FMEA can spot the big holes, it's ultimately a culture and system of performance that is needed to cover the broad base of risk. Cultures in which facts drive thinking, accountability is clear, results are measured, transparency is healthy, and processes are continuously improved are the ones that best manage risk. If people are afraid to point out the problems for fear of being embarrassed or punished, then the risk is high that the problems will never see the light of day -- until something bad happens.

The business of leadership is all about trade-offs; every day we have to decide what matters and where we will put our organization's resources and energy. Only shifting to a results-driven system of performance management will fill the cracks in an organization's processes, the cracks everyone dreads discovering only after someone or something drops through them.

Senior fellow, Governing Institute
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