January 16, 2015

In the 1950s Japanese car manufacturers had a reputation for poor quality, but by 2014 Toyota attained podium-topping stature in resale value, according to Kelley Blue Book. What caused this transformation? Rabbi Dr. Dov Peretz Elkins’ parable on How We Become Wise, How We Change suggests that it depends on whether there is commitment to embrace mistakes as opportunities to learn:

After a long, hard climb up the mountain, a group of spiritual seekers finally found themselves in front of the great teacher.
Bowing deeply, they asked the question that had been burning inside of them for so long.
“How do we become wise?”
There was a long pause until the teacher emerged from the meditation. Finally, the reply came:
“Good choices.”
“But teacher, how do we know how to make good choices?”
“From experience,” said the wise one.
“And how do we gain experience?” they asked.
“Bad choices” smiled the teacher.

Under visionary leadership, Toyota initiated a continuous improvement system to identify the source of errors – the bad choices – in its manufacturing process. At the heart of Toyota’s success was their commitment to an all-stakeholder, non-blaming, forward-looking approach that generated countless suggestions from employees with a goal of ongoing review and refinement. Could a similar approach work in criminal justice?

Elements of a similar approach are already emerging in the justice system. The National Institute of Justice special report, Mending Justice: Sentinel Event Reviews, highlights the importance of adopting an all-stakeholder, non-blaming, forward-looking review process for examining system errors. The report urges us to view errors and bad choices, such as DNA exonerations and other organizational accidents, as treasures to be mined by police, prosecutors and other stakeholders for actionable wisdom.

But key questions about this approach remain unanswered. In particular: can criminal justice agencies adopt the kind of long-term commitment to an ongoing review like the one that made Toyota successful?

One way to develop an ongoing commitment to process improvement could be to look at more than just errors. Essential buy-in from apprehensive stakeholders perhaps could be more easily obtained when looking at near miss cases – situations where a more serious error or bad outcome was averted. These near miss sentinel events have the appeal of being cases where the system got it right, though maybe not at first or as quickly as possible. Consider a wrongful arrest and detention that is corrected after a few weeks, thus avoiding what might have later become a wrongful conviction. These near misses would provide powerful lessons based on what was done right and what might have been done better, allowing jurisdictions to implement and institutionalize the sentinel events approach outlined in Mending Justice.

As Toyota recognized, quality begins with commitment at the top; but it is achieved only through commitment throughout the organization, especially those who may feel they are most likely to be blamed when things go wrong. Mending Justice provides a road map for the criminal justice system to develop processes for learning from error and striving for continuous improvement. As in auto safety, airline safety and hospital infection control, we owe it to the people we serve and who depend on us for the safety of their loved ones to institutionalize processes to learn from events where things went wrong – and where we got it right.
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Mending Justice: Sentinel Event Reviews is now available to read online or download in e-book or PDF formats on NIJ.gov: http://www.nij.gov/topics/justice-system/pages/mending-justice.aspx.

Learn more about sentinel event reviews on NIJ’s Sentinel Events Initiative webpage: http://www.nij.gov/topics/justice-system/Pages/sentinel-events.aspx.

Interested in conducting research on sentinel event reviews in the criminal justice system? The National Institute of Justice is currently seeking proposals. https://www.ncjrs.gov/pdffiles1/nij/sl001132.pdf.

Robert Lipman served as a federal prosecutor and now designs and manages technical assistance programs to enhance the capacity of prosecutors and others overseas.
Note: The opinions and views expressed in this publication are those of the author(s) and do not necessarily reflect the views of the Department of Justice.