What Business Analysts Can Learn From Swiss Cheese

Swiss cheese has holes in various places on different slices of cheese when you cut it up. Let’s imagine these holes reflect weaknesses in the system where mistakes can pass through, afterall no system is perfect. One mistake passing through a hole in one slice of cheese might remain unnoticed and not lead to a business catastrophe, if it's corrected. If the mistake slips through all the holes however, across all the layers of cheese (defences) when all the holes are in alignment, a catatrosphe might result.

The Swiss cheese effect, also known as the “cumulative act effect”, is based on the contribution of James Reason, a psychologist who explained systemic failure using four levels of human error: preconditions for unsafe acts, unsafe acts, organizational factors/influences and unsafe supervision. The principle of the Swiss cheese model has been successfully applied to safety engineering and healthcare practices across the world.

Human systems are likened to multiple slices of swiss cheese. The idea is that since each slice of cheese acts as a layer of defence, it would take a lot for an error to pass through the system before it’s noticed and resolved. Though there are many holes in the cheese, they rarely line up to create a clear passage through it.
 
These holes may be due to "active failures" or "latent conditions”.
 
The problems in an organization may be latent, for example, they may be related to culture, bad management, poor communication, etc. due to the way the organization is run. Other errors may be as a result of mistakes or unsafe acts (active failures) in the system such as an employee making a bad judgment call or ignoring procedure. Latent conditions can be highlighted and corrected via effective risk management before problems manifest in the system. Incidents within an organization may arise due to a combination of both latent conditions and active failures.

Applying the Swiss cheese model is a form of proactive risk management that should be practised to prevent disaster. Though defence layers may be put in place to prevent disaster, what is also critically important is how these layers interact.

How does this affect business analysts?
 
Failures can come from any section of an organization and they may be interconnected. A failed software implementation may have happened for multiple reasons like bad project management, inaccurate requirements, poor training, etc. If organizational problems or failures are thoroughly analyzed and addressed from multiple angles, they can be resolved completely and provide learning opportunities for project teams.

So also, in solving a problem, the BA should look at it from multiple angles and propose as many recommendations as are needed. One solution may not address the business problems you see. Systemic solutions are often needed to bring about widespread and positive change in the long term.

Another key takeaway from this is that when designing processes or systems, it’s important to build in multiple layers of checks (or defences), especially when there’s a lot at stake, e.g. review and approval of payment vouchers above a certain amount may need to be done by more than one person in the responsible business unit.

What’s your opinion of the Swiss cheese model?