Where were the pre-mortems for Covid-19?

As we continue to adjust and respond to the COVID-19 crisis, it can often feel like policy responses are buffeted by what the most pressing concerns are at the time; they are made reactively rather than proactively. In this post, Dr Andrew Joyce and Celia Green offer a new way of thinking about how it is that we go about investigating better ways of doing decision making in times of crisis.

A number of investigations have or are about to take place related to decision making failures in government management of COVID-19. The Ruby Princess investigation has taken place, the inquiry into the Hotel Quarantine failures in Victoria is about to commence and there is an investigation planned into the Aged Care tragedy. What if there was a simple decision-making process that could have been used to help prevent some or all of the missteps which occurred. Rather than conducting ‘post-mortems’ what if the teams responsible had conducted pre-mortems?

What if there was a simple decision-making process that could have been used to help prevent some or all of the missteps which occurred. Rather than conducting ‘post-mortems’ what if the teams responsible had conducted pre-mortems? Image: Upsplash

What if there was a simple decision-making process that could have been used to help prevent some or all of the missteps which occurred. Rather than conducting ‘post-mortems’ what if the teams responsible had conducted pre-mortems? Image: Upsplash

There is considerable research demonstrating that human decision making deviates from logical expectations in quite consistent patterns. This research has shown how we routinely over attend to some pieces of information (e.g. novel information) and neglect other sources (e.g. base rates) when we make decisions and are somewhat poorer at probabilistic type decisions than we realise. Confidence in a judgement relates to the ease with which the information is retrieved and our perception of whether events seem causally related. All these biases influence how we understand and act on Covid-19.

A recent piece from the UK earlier this year discussed how cognitive biases can be problematic for political decision in the context of Covid-19. It was concluded there is little that can be done to prevent these decision making biases from occurring and the best we can hope for is greater government transparency. While increased transparency is a worthy goal and seen as a current problem in relation to COVID 19 in Australia, the conclusions understated currently used strategies for mitigating human decision making biases.

At the level of individual decision making it is very difficult to alter these biases although recent research has shown it could be possible. However, there is an established body of work showing how in a group setting, there are processes that can be used to reduce bias and improve decision making. This research has been applied in corporate environments at a board and managerial level with various decision making structures recommended to mitigate decision making bias. One of the challenges is the difficulty in accessing political elites for this type of research to understand what type of biases they are bringing to different topics and thus what particular strategies might be valuable. Consequently, this research does not seem to have been applied to governmental level decision making structures.

One of the strategies being applied in business environments is the pre-mortem technique developed by Gary Klein. This process involves a team imagining that in the future a particular project has been a disaster and then considering all the reasons why things went wrong. This strategy has been used effectively in business and project management to visibly understand and plan for risks.  Utilising a similar process for the management of hotel quarantine in Australia could have helped identify risks associated with the strategies being employed. The creator of the pre-mortem technique has already written about how it could be applied to Covid-19 alongside other decision making tools.

Rather than utilising a simple pre-mortem decision making tool, Australian governments are focused on conducting ‘post-mortems’. This can create unnecessary stress for staff already working in very difficult circumstances and the focus should instead be on how to create the most supportive decision making processes possible. Further, the terms of reference of these inquiries such as the inquiry into hotel quarantine are too narrowly defined around the specific policies which should have been employed. This will result in some important recommendations on changes to decision processes and policies for those specific areas but is unlikely to lead to the implementation of improved decision-making structures and process across other government departments and policy areas. The current inquiries need to explore how decision making structures can be improved, for example could a pre-mortem have helped. The focus of these inquiries should include an examination of whether the decision making processes exacerbated or mitigated human cognitive biases.

The Australian Covid-19 inquires could help establish the types of decisions making processes that could be integrated into departmental structures and routinely used for complex policy and program decisions. For example, academics have highlighted how the application of science driven decision making used in the context of Covid 19 should be applied to climate change. Presumably the risk modelling undertaken to inform lockdown measures used some of the worst-case scenario planning akin to a pre-mortem process. Learning from Covid-19 decision making failures is a unique opportunity to apply this knowledge to climate change. The necessity of implementing improved decision making structures at all levels of government using the best available cognitive science research cannot be overstated. These reforms are vital in the continuing efforts to combat Covid 19 and respond appropriately to the threat of climate change.

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