Why outcomes matter

BP oil disaster of 2010.
This is the largest accidental marine oil spill in the history of the petroleum industry.
The accident was blamed on a series of cost-cutting decisions and the lack of a system to ensure well safety. It was also concluded that the spill was not an isolated incident caused by "rogue industry or government officials", but that "The root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur".
BP also had the highest number of explosions and other incidents at its US refineries.
A single outcome can destroy an organisation, and a number of smaller incidents can be indicative of serious underlying problems.

About outcomes

  • The entire performance of an organisation is often judged on outcomes alone.
  • Smaller problems may be indicative of bigger underlying problems.
  • An entire year’s work or even many years of work can be overshadowed by a single incident.
  • The CQC inspections are outcomes focused.

Managing outcomes

  • Dealing effectively with smaller incidents helps promote better safety and prevents bigger more serious problems.
  • Any negative outcome needs to be dealt with quickly and effectively. Festering problems will escalate and more problems may be occurring during any delay.
  • Regular reviews and interviews of staff and patients are useful to catch anything your system might have missed. A despondent patient might have given up on complaining because the complaints system in itself is so badly managed, they don’t think it is worth it. This means that problems get hidden and out of sight for longer.
  • Regular reviews of what goes wrong and how to fix it are essential.
  • Celebrating what goes right is equally important to allow us to play on strengths, and reinforce good practices.
  • Managing risk and managing outcomes must be the cornerstone of your compliance system.


"The man who makes no mistakes does not usually make anything"

About outcomes:-

  • No one can guarantee that nothing will go wrong.
  • It is about minimising negative outcomes not necessarily eliminating them altogether.
  • If something goes wrong, you must know about it and do something about it.
  • The acid test for all legal action will be whether you took reasonable steps.
  • Record positive outcomes. How many times you got it right is just as important.

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