In the Lean methodology, building upon the teachings of Dr. W. Edwards Deming, we work hard to shift away from “naming, blaming, and shaming.” Dr. John Toussaint is one of many who provide alternatives to the “blame and shame” approach that's, sadly, so common in healthcare.
When I teach about focusing more on fixing systems and processes (instead of blaming individuals), I talk about workplace scenarios where things go wrong. As Deming taught (and I believe strongly, from my own experience), roughly 94% of problems are caused by the system.
I often say that it's human nature to blame others. It's easier to lecture and say, “Don't blame,” than to practice this in our daily lives. I'm not perfect, but I try.
I sometimes say, “You might not stop blaming people, but you can be better at being aware of when you're blaming… and you can shift your thinking to the system–hopefully before you say something out loud.”
Yesterday, while traveling, I was looking to get a light dinner at the airport. There was a wine bar at the airport that I knew had good light snacks that paired nicely with a glass of wine. That's all I needed instead of a full meal.
Being alone, I grabbed a wooden stool with a back and tried sitting on it at the bar.
The base of the stool had some loose or weak joints, and as I sat on it, it felt like it was about to collapse backward and out from under me. So, I grabbed the stool next to me instead, and I thought I had some obligation (for the safety of other customers) to say something to the bartender about it.
I politely said, “Excuse me, this stool is about to come apart… I was afraid it was going to fall out from under me.”
The bartender wasn't really busy — there weren't any other customers at the bar, and he was drying or polishing a glass.
He replied, without even really looking at me, “Yeah, we're due for an update… they're all sort of like that. Sorry.”
I said, “Well, it seems like somebody could get hurt…”
The bartender interrupted and said curtly, “WE KNOW,” and continued polishing his glass. I took that to mean, “So, shut up about it and order something.”
So I thought, “Jerk,” and I got up and left, muttering to myself about how rude the bartender was and that I'd give my business to somebody else.
And then I realized… wait, maybe I'm just blaming the individual here.
As Dr. Deming said (or is quoted as saying):
1) “If you really have to blame someone, blame the people responsible for the system.”
I tried to put myself in the shoes of the bartender. It's quite possible that somebody tells him about the lousy stools multiple times a day. Maybe he has been told by management (locally or by the corporate parent of the chain) that he can't do anything about the chairs, since removing the worst ones (without a replacement) might reduce the capacity and revenue of the bar.
Maybe the bartender has asked and begged and pleaded for better stools (taking pride in his work and worrying about his own tips), but he hasn't gotten a response or any help.
How would I feel in that situation? I'd probably be frustrated and maybe a bit bitter. I might snap at a customer if I'm constantly being told about a problem he couldn't fix.
The jerk in this situation might have been me (there might have been some confirmation bias on my part since people in this unnamed state sometimes have a reputation for being rude or combative). Or, it might be the bartender who is indeed a jerk (a 6% chance, per Deming?)… or neither of us.
Can you think of situations where you blamed an individual when it was really a system problem? Have you tried to be more mindful about this? How has this played out in your personal life or in the workplace?
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As a shop floor quality leader in a large multi-national conglomerate, it didn’t take me long to realize that my machinists were just like that bar tender. They felt helpless to improve because nobody in management ever listened to them. Simple gestures on my part, simple improvements were enough to really change their attitude and the way they engaged–with me at least. My “non-Deming” boss, on the other hand, balanced out my efforts.
I had very similar experiences on the shop floor at GM. While everybody in Detroit tended to blame the UAW for everything, I learned that a vast majority of the UAW workers wanted to do quality work and management usually wouldn’t let them… they weren’t allowed to stop machines to change tooling on schedule… yet they got blamed when the tools (predictably!) broke in an unplanned way and caused downtime. I could go on and on. I learned most of the workers weren’t “jerks” – they had been beaten down by a bad system.
Although no expert in this field, I believe Friedrich and Finer (PDF article) provides insight into this matter and in part provides a rational answer to this subject.
If Deming is correct when suggesting “94% of problems are caused by the system”, –the system a standard toward which the professional endeavours to reach to achieve the goal– it would be unreasonable to hold a professional accountable for those problems: but not unreasonable to hold them responsible if they fail to act accordingly to highlight areas of concern in the system that could lead to problems occurring (risk assessment).
Holding systems to account (blaming) is unproductive, as systems are inanimate and have no feelings; holding to account those who created the system too is unproductive, as they have probably been promoted for creating such a wonderful system based on theories learnt in the class-room, which bare no resemblance to reality.
In risk assessment I learnt that accidents just don’t happen, problems don’t just occur. They do happen as a result of a culmination of small, apparently insignificant, occurrences being ignored that eventually lead to the problem.
Systems fail or the same reason. Poor risk assessment, quality control, education and training, and audit to mention a few.
If you have to hold anyone to account for system failings, hold those who allowed the systems to be put in place without fully understanding the implications of the system processes.
If you have to hold anyone responsible for system failings, look no further than you: for blindly following the system; for not knowing what you didn’t know; for not challenging the system.
Following system processes verbatim is no excuse, as clearly demonstrated during the Nuremberg trials (1945-46).
Thanks for your thoughts, Richard.
I think “the system” is not defined as “a standard toward which the professional endeavours to reach to achieve the goal.”
There might be a standard (such as doing a surgical procedure a certain way or a standard that says to not harm the patient), but that exists within a system.
The system includes the policies, equipment, staffing levels, technology, etc. that a person works within.
It’s not a matter of “blaming” the system, but recognizing that “the system” is responsible for most errors. Dr. Deming said (and I agree) that senior management is responsible for the system, whether they designed it or (more likely in healthcare) just allowed it to evolve.
I don’t know if Dr. Deming’s 94% is always correct (we could never know a number that precisely). I think the number is meant to counter the traditional management mindset that 94% of problems (or more) would be an individual’s fault.
I think when the person working in the system has a high degree of professional stature and autonomy (like a surgeon), they have more of a responsibility to speak up and protest a “bad system” (although I’ve read news reports while in the UK recently about even doctors being afraid to speak up about hospital problems due to a fear of retribution). A bartender… I can excuse him or her for not “speaking up” and just keeping their head down because they really need that job. A doctor or a surgeon, arguably, has much more of a professional and moral obligation to say, for example, “I’m not going to be pressured into starting this case because such and such isn’t ready. Management isn’t going to bully me into keeping on schedule at all costs.”
Similar to your challenging opportunities recently with the cable company, mine involves an every-other-month crucial conversation with ATT/Direct TV and the surprise billing changes. It seems with moves and past experience with ATT that my bias begins the conversations rather strongly when the person on the phone is only a part of the system. Our monthly billing changes every other month with a surprise. Whether it was some special offer that ran out or discount or ??? It’s hard to keep up with. When you call they calm you with another discount or something that will run out at a determined time. It eats up hours of their time and mine. How about just sticking with a standard. Yet, although ATT and Direct TV are the same family now the billing representatives are not and you get switched back and forth between the two without much being accomplished until another surprise bill shows up and you’ve not changed anything in your plan for a year. It is the system. What to do? Per our study this year on crucial conversations; keep it safe, understand their story and mine, keep to the facts and work towards a mutual purpose. Fun times and Friday I’ll be having another one because our bill surprisingly jumped up 20%. I could change services but in our location there isn’t an alternative. :-)
You might appreciate this story then, Rick:
https://www.leanblog.org/2012/05/directv-makes-it-hard-to-cancel-move/