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Blameless Post Mortem

What a stunning way to identify this issue. Post mortem...

In my profession, a post mortem is just that, it means someone died. And, someone is ultimately held accountable.

First I am furious you would borrow from the medical profession such a sobering incident and then go on to make light of it. Until you have actually witnessed a post mortem as a family or professional, you have no idea what the lasting impact can be on future.

And, to think you have the attitude that no one deserves a reprimand or stern rebuke is utter nonsense. How do you expect them to learn responsibility? This is more of the 'everyone-deserves-a-trophy' attitude and you let them play fast and loose with the economic futures of your sellers.

What a bunch of utter nonsense. I grew up when you were taught responsibility, respect and you didn't screw with someone's income they were depending on. You did your level best to be a good employee, you hoped that you didn't screw up and if you did get called in, you learned a lesson.

Post mortem...in my field, people lose professional standing, licenses, are sued and jailed for 'screwing up'. You have no idea what all that entails until you are dragged into court. No one gets a three arm 'ha-ha' sweater.

With your attempt at quelling the comments by Chad, you just efficiently lowered my respect for etsy, the CEO, the Board of Directors for letting this go on and all of the administration for covering a**es when needed.

Your explanation cheapened etsy, the sellers that have strived to do the best to make it a unique and wonderful place to shop and made it look like the silliest techno experiment on the net.

I can only hope you get caught in the next big internet debacle and topple off that pedastal you have all put yourselves on. Maybe if you actually have to work for a living instead of playing, you will get it right the second time.

Playing with code and entering it 30 times a day to see 'what happens', should not be allowed. Only when you formulate some standards will you be able to forget these follies and concentrate on actually fixing the site. Tell them to work on the problems at hand, don't let them run amok and ruin a good thing. Sometimes the word 'no' can be a great motivator.

And, don't tell me you are doing post mortems. You really want to see and hear one first hand, join me in a casualty debriefing or a medical error resulting in death. Then, and only then, will you truly understand the meaning of that phrase.

1 Highlighted Response

Sue:

I'm sorry you're having a tough time with the explanation. The intention is not to be flip in any way. On the contrary, we take incidents, mistakes, outages, and errors very seriously. Again: no one gets OFF the hook for contributing to a negative outcome. They are arguably more on the hook than if they were in an organization whose response is simply a stern "Don't do that again!" or "Be more careful!"

Why? Because unless we have some understanding on why someone thought an action was ok to make (when hindsight shows that it wasn't ok) then we will never understand how to prevent that action from happening. The person who made a mistake *did* think it was ok, because otherwise they wouldn't have done it.

The larger post with greater detail is here: codeascraft.etsy.com/2012/05/22/blameless-postmortems/

The idea of a blameless postmortem isn't an Etsy one at all; it actually comes from the field of patient safety in healthcare. it's not an excuse to make people feel better when they make mistakes. It is to *increase* accountability, not decrease it.

The concept is known in the healthcare (patient safety) and aviation safety industries as a "Just Culture", and is practiced in an increasing number of arenas. The reference for it is "Just Culture" by Sidney Dekker: www.amazon.com/Just-Culture-Balancing-Safety-Accountability/dp/0754... which may give some background on the ideas.

Alternatively, a video of Dr. Dekker is here, giving an explanation, possibly better than I did: www.youtube.com/watch?v=t81sDiYjKUk

As to how we approach making changes to begin with, and how we aim to gain confidence in any of those changes, this was some detail I gave in a different thread: www.etsy.com/teams/7714/ideas/discuss/10636565/page/7/?post_id=1346...

For sure: Etsy takes this seriously, and is not intended to be flip.

The idea of a blameless postmortem is to emphasize *learning* from mistakes by getting at details of them, not waste time and distract from that learning by punishing someone, which doesn't actually prevent the mistakes in the future.

I hope this might help.

198 Responses

'Post mortem' is used in a lot of places. I work in the design packaging industry and it is used to look at jobs that didn't do very well and figure out what happened.

It has many definitions not just a medical one:
dictionary.reference.com/browse/postmortem

I thought their explanation was great. But I work in the same kind of atmosphere that Etsy tries to sustain and I enjoy it. I love going to work.

I'm pretty sure that if someone did something malicioius and caused issues - I'm sure Etsy wouldn't keep them on or give them a 3 armed sweater.
Wow.

I'm a programmer, when someone screws up we give them our department rock to sit on their desk until the next person screws up, then they get the rock. Programming (as in the etsy website) isn't life or death. People make mistakes and no one loses a life or limb. Don't get your knickers in a twist.
the whole interview seems a bit childlike to me...maybe its a culture difference but i dont like mollycoddling
I liked that admin took the uproar about the tech warrior language seriously enough to communicate about it, I thought it showed respect for peoples' objections to do so.
What was the original issue here?

And for the record, I see "postmortem" used in all kinds of contexts. The Oxford Online Dictionary defines it as:

"an analysis or discussion of an event held soon after it has occurred, especially in order to determine why it was a failure: example: an election post-mortem on why the party lost"
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Inactive Etsy Member 8:51 pm Jul 19, 2012 EDT
I am on etsy every day and I have NO idea what this is about..... Can someone explain?
www.etsy.com/teams/7716/announcements/discuss/10641726/page/1/
ByGoneYears from ByGoneYears says

Wow.

I'm a programmer, when someone screws up we give them our department rock to sit on their desk until the next person screws up, then they get the rock. Programming (as in the etsy website) isn't life or death. People make mistakes and no one loses a life or limb. Don't get your knickers in a twist.
...............................................
I couldn't have said it better.
Next time you deal with the medical profession (where we are expected to be 'professional'), think about etsy's approach to a serious job that deals with other people's incomes and how they pay their bills.

If the nurse comes in and is flip about your pain, your IV that is hurting, your incision that is leaking, check to see if the hospital has now adopted a 'no harm, no foul' policy and we can all say, 'Welcome to the new world of three armed sweaters'.

ByGoneYears: Did you ever think that their mistake might cost someone their ability to pay for their health insurance, house payment or groceries. That to me is serious. It is not a joke.
Hospitals are well into the computer technology era and NO ONE is allowed to play with the programs. The IT people must be the best, background checked and met certain standards to work with the systems. The patients' electronic record is used by nurses, doctors, pharmacy, OT, PT, RT, emergency, receiving hospitals, the list is endless....do you want your records or that of a family members lost in space because someone decided to play with code?
There is no excuse for this kind of behavior when people depend on this site to provide an income for themselves or a family.
If it was a gaming site or a social site, I could care less....

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