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A near miss means your processes need work. If you have any sort of reliable process, actual misses should be vanishingly rare and you'll need to look at proxie

A near miss means your processes need work. If you have any sort of reliable process, actual misses should be vanishingly rare and you'll need to look at proxies anyway to monitor for improvement, so why not use the best one available?

cadamsdotcom 2y ago
My point was there’s a nuance. The processes don’t need work - at an org level - because that near miss is noticed and addressed within the team. That’s the most cost effective place for it to happen. By analogy say you stumble while walking, that causes you to ask whether the concrete was uneven, or your shoes are the wrong size, or whatever else. Treating that trip as a “near miss” and “assessing at an org level”, by way of analogy, might be a bit like going to the doctor to ask if your legs are okay - that would be a disproportionate response.
- codr7 2y ago
  That however assumes a level of team autonomy that's not happening much from my experience. And the consequences from a disaster are very likely to affect the entire org.
- AlotOfReading 2y ago
  The problem is with your analogy here. Let's try two marginally less silly examples: 1) You're a sidewalk construction company. You monitor some of your sidewalks to see how often people trip and adjust the leveling or depth. 2) You coach a running team and your runners average 30s lost to stumbles per marathon. You think about better stride trainings or nutrition schedules to minimize that loss. These are still a bit silly, but far more analogous to actual software companies.
  - cadamsdotcom 2y ago
    These analogies are great for demonstrating a deeper nuance, I like them! So for 1) though, the sidewalk construction company is only incentivized to do monitoring and continuous improvement to the extent that a) they do it to compete or b) the client asks for it. And for 2) stumbles are likely to be quite obvious failures - but the obviousness of the failure doesn’t invalidate your example. To strengthen your point we could target something subtler than stumbles - let’s say 30s is lost to incomplete nutrition plans. In both cases only organizations that value excellence would consider these initiatives. Which actually aligns with the article, apart from a key difference that both examples given describe top-down searches for near-misses rather than bottom up flagging of them. I think ultimately this is about operational excellence - an org that really cares will actively look for near misses, but flagging them from the bottom up won’t make an org care unless it already did, because maybe they don’t have an incentive to care, or maybe they don’t see the value of that work or maybe they do care but haven’t addressed bigger issues yet or are too low margin of a business to afford to address them so it’s a yes-we-know-but-not-yet type of thing. And if bottom up flagging doesn’t work the best you can do is address it locally.

cadamsdotcom 2y ago

My point was there’s a nuance. The processes don’t need work - at an org level - because that near miss is noticed and addressed within the team. That’s the most cost effective place for it to happen. By analogy say you stumble while walking, that causes you to ask whether the concrete was uneven, or your shoes are the wrong size, or whatever else. Treating that trip as a “near miss” and “assessing at an org level”, by way of analogy, might be a bit like going to the doctor to ask if your legs are okay - that would be a disproportionate response.

codr7 2y ago
That however assumes a level of team autonomy that's not happening much from my experience. And the consequences from a disaster are very likely to affect the entire org.
AlotOfReading 2y ago
The problem is with your analogy here. Let's try two marginally less silly examples: 1) You're a sidewalk construction company. You monitor some of your sidewalks to see how often people trip and adjust the leveling or depth. 2) You coach a running team and your runners average 30s lost to stumbles per marathon. You think about better stride trainings or nutrition schedules to minimize that loss. These are still a bit silly, but far more analogous to actual software companies.
- cadamsdotcom 2y ago
  These analogies are great for demonstrating a deeper nuance, I like them! So for 1) though, the sidewalk construction company is only incentivized to do monitoring and continuous improvement to the extent that a) they do it to compete or b) the client asks for it. And for 2) stumbles are likely to be quite obvious failures - but the obviousness of the failure doesn’t invalidate your example. To strengthen your point we could target something subtler than stumbles - let’s say 30s is lost to incomplete nutrition plans. In both cases only organizations that value excellence would consider these initiatives. Which actually aligns with the article, apart from a key difference that both examples given describe top-down searches for near-misses rather than bottom up flagging of them. I think ultimately this is about operational excellence - an org that really cares will actively look for near misses, but flagging them from the bottom up won’t make an org care unless it already did, because maybe they don’t have an incentive to care, or maybe they don’t see the value of that work or maybe they do care but haven’t addressed bigger issues yet or are too low margin of a business to afford to address them so it’s a yes-we-know-but-not-yet type of thing. And if bottom up flagging doesn’t work the best you can do is address it locally.