The design, collection, and synthesis of work so that it is actionable is always difficult, but is particularly so within the white spaces of organizations. Limited resources, perceptual biases, and the dynamics of most environments all complicate what is already a challenging communications situation. Yet extracting, understanding, and summarizing gaps in responsibilities, information, and capacity always represents the best opportunities for learning within any work setting. Leaders need to focus on the most important issues competing for their attention, and determine where and how to deploy the scarce resources available to them. They then need to enhance returns in both the short and long term. It is always easy to second-guess decisions made by others, especially when given weeks rather than seconds to reach a judgment. Leaders considering such responses must in turn develop effective listening skills, and encourage collaboration across organizational boundaries when it can be lead to more effective responses to problems.

Teams must learn to describe their challenges to leadership accurately and succinctly, so something can be done about it. For leaders to be able to devote attention to such concerns, workers must learn to summarize their plans and status effectively. A balance of analytic skills and intuition are required for each of these situations, to seek the sweet spot between adequate controls and insulating bureaucracy. Those assigned to resolve gaps need to crisply distill and effectively apply their knowledge and personal experience, and describe the boundaries they must operate within, and the constraints which they are working to overcome.

In the book Know What You Don’t Know, Michael Roberto defines the skills required to effectively accelerate problem detection and resolution within an organization.  Organizations can't solve problems that are invisible or when the messenger is punished for talking. It is basic human nature to act differently when someone is watching than when they aren't. The author describes the underlying accountability challenges for effective problem in the following way:

When we examine the challenges of diagnosing and responding to such problems from a human factors perspective, we realize that representations of information will generally only capture our attention when:

• the environment we operate within is consistent with our experience and expectations
• the information itself is presented in a coherent and meaningful way
• sufficient time is provided to correctly process this information
• the connections of this information to our areas of responsibility are well established
• rehearsals and practice reinforce desired behaviors.

Too often, cross-functional responsibilities, planning and status reporting are not designed to support these characteristics. As a result, information which should command immediate action may be ignored, and have limited usefulness, and assessments that are not timely or sufficiently robust can easily erode in value with time. And when goals are unfocused or overly abstract, status reports can easily degrade into 'dog and pony' shows that consume precious resources, without catalyzing any meaningful learning or follow-up.

Reviewing the failure practices of other organizations can provide a useful benchmark to evaluate ones own behaviors against. As an example, consider this reflection of events surrounding 9-11; many such analyses took years to be developed, and emphasized the need to 'connect the dots' from available information sources in a timely and effective manner. Yet despite extensive investments in infrastructure for such data collection and synthesis, underlying security objectives remain unsatisfied; the right balance of reliability and cost-effectiveness remains a matter of open debate. Contrast this with a different response to a complex situation - a partial outage of Amazon's cloud services product offering - a situation affecting millions of users, and thousands of businesses, which occurred during a network upgrade. Despite the rapid response by Amazon, their response is less a result of their troubleshooting skills than of failure containment principles and practices that originated within their design processes and which anticipated exactly this kind of an event.

Planning, process management, and meaningful facts and data are crucial in such determinations, as they provide an essential context for our critical thinking, and for designing management systems that are resiliant. With the cognitive and behavioral framing which each of these disciplines should establish, we must learn how to boil down issues to their key essence, and provide the relevant information about those issues to those that need to act on it. Situations must be represented accurately, and their discovery should be used as a learning opportunity, rather than a public accountability drill. This is not easy, since twenty-twenty hindsight can draw us into spending far more time after a problem has occurred than we had to analyze it before it occurred. Were we just unlucky? Should we have been more diligent? These are difficult questions to answer without context or experience.

Peer reviews of after-action results by practitioners that are based upon an adequate foundation, provided with sufficient access to relevant details, and that draw from experience in organizational patterns will be more likely to consider a system's performance under both normal operations and under failur conditions. One profession which has learned to do this well is the medical community. Teaching hospitals have weekly and monthly reviews which are designed to deliberately codify and communicate institutional responses to unusual situations. These reviews deliberately focus on 'mortality' and 'morbidity', since such scenarios trigger the greatest harm to patients, the institution, and its practitioners. At regular, cascading meetings, this community uses these reviews to dive deep into the mistakes they made, and shares what was learned from these mistakes. The best of these presentations are then reviewed in a broader, monthly ‘Grand Rounds’ seminar, which draws practitioners from surrounding hospitals, which indicates the cultural 'pull' for such information… the atmosphere is serious and somber, with a focus on avoiding such failures in the future. These reviews are mutli-disciplinary, with different services bringing their most noteworthy cases forward, and unfolding a narrative that describes how facts and data were revealed within each case over time. Each review involves an earnest assessment of the unique characteristics of that situation, describes the cascading chain of events which led to the outcomes, and identifies how future responses can be improved.

The reason these meetings have 'stuck' within the medical profession is the evidence-based culture that permeates medical practice. Cultures must embrace their most important failures (rather than pretending they aren't happening, blaming others, or losing sight of priorities). A community's information gathering and reasoning skills will enhance its understanding of the importance of decision-making on value, schedule, cost, quality, and safety, but will only be possible from a perspective which facilitates meaningful reflection to be performed. From such understanding, the community can thus learn to develop realistic, mitigating actions, and describe and share those to others. Without such a framework, and corresponding community acceptance, discussion of failures may instead devolve to whining, as if karma itself makes them inevitable.