What Swiss Cheese Can Teach Us About Good Governance
- Kelly Gray
- 2 days ago
- 2 min read
When was the last time your governance processes made your organisation better, not just more compliant?
Somewhere along the way, governance acquired an image problem. For many organisations, it has become something to get through rather than something that helps them get better. But governance was never meant to be a tick-box exercise. The goal was never just to pass audits, complete reports or reduce risk.
Working in the not-for-profit sector, compliance should protect our purpose, not replace it. Governance should create the conditions for good decisions, not simply provide evidence they were made.
A colleague recently introduced me to James Reason's Swiss Cheese Model, a framework originally developed to explain why accidents occur in complex systems.
Imagine several slices of Swiss cheese stacked together. Each slice represents a layer of defence. Every slice has holes which are small weaknesses, human errors or system flaws. Most of the time, those holes don't matter because the other layers compensate.
But every now and then, the holes align, and that's when failures occur. This analogy got me thinking and I realised it is transferrable to thinking about governance, in particular clinical governance.
Like the Swiss Cheese model, there are a range of factors which determine good governance in organisations. These layers of ‘defence', include organisational factors such as capable leadership, a healthy organisational culture, clear structures, learning and development, adequate resources, and systems that support good decision making. And then there are the ‘holes' in the layers. There can be hidden system flaws such as job design and understaffing, and these holes often represent the humans operating in the existing organisational system.
We spend enormous amounts of time designing policies, processes and structures, but often forget to ask people what it feels like to experience them. A system only works if it works for the humans inside it.
Behind every policy is a person trying to interpret it.
Behind every process is a person trying to navigate it.
Behind every incident is a human making the best decision they could with the information, resources and pressures they had at the time.
Organisations are not machines, they are networks of humans with different experiences, motivations, fears and competing priorities. If we ignore that reality, we'll never truly understand why the holes appear. Good governance doesn't eliminate human error. It anticipates it. It's about designing systems that expect humans to be human.
The beauty of the Swiss Cheese Model is that it replaces blame with curiosity. Instead of asking, "Who made the mistake?" it encourages us to ask, "What conditions made this mistake possible?"
Governance isn't at its strongest when incidents never happen, its strongest when organisations are curious enough to learn from them.
Because a healthy governance culture doesn't live in policies, audit reports or committee papers, it lives in the everyday decisions people make when no one is watching.
The next time something goes wrong in your organisation, what’s the first question you ask?
“Who made the mistake?”
Or...
“What allowed the holes to align?”
If this article has sparked your curiosity, I've developed a free Lessons Learnt Exploration Tool to help organisations move beyond blame and towards learning. You can download it here.
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