Following up my post about not blaming a bartender, here's another look at learning to cast aside our old habit of blaming individuals… this time, baseball related.
Modern organizations (in healthcare and business) tend to blame an individual when something goes wrong. It's commonplace in our societies and it's, basically, human nature to blame. But, Lean and the Toyota Production System teaches us to NOT blame individuals and to, instead, look at the system. Dr. Deming, who influenced Toyota greatly, said that 94% of problems are due to the system. The exact percentage is unknowable, but the point is to not jump to blame.
So what happened in Major League Baseball last week?
Texas Rangers Fans
Fans of the Texas Rangers (or maybe, more broadly, attendees of the Rangers' opening day game) were accused of being thoughtless jerks for littering and piling up beer cans around a statue that was placed outside the stadium honor a fan who died when he tragically fell from the stands a few seasons ago.
A number of tweets were sent around that blamed the fans for being “disgusting” and “not having common courtesy” as if they were intentionally dishonoring the man who fell.
We could write off people as being jerks, or we could think about the system they're a part of. What are some of the factors:
- Beers inside the stadium are very expensive (which probably drives people to drink outside before the game, whether they should or not)
- As some people stated in online comments, there weren't enough trash cans outside the stadium (because people aren't supposed to be drinking that much outside and there are security concerns about bombs that lead to trash cans being scarce)
So, do we blame the team for charging high prices for beer (they probably should, to help reduce drinking and driving)?
Do we blame the terrorists?
Do we blame overreactions to terrorist threats, such as removing trash cans?
I don't think I'm “making excuses for people,” if you want to call it that.
I'm just trying to exercise that part of my brain that asks, “What are possible systemic causes?” instead of just asking “Why are people such jerks?” I'm not there in Arlington, so I can't “go to the gemba” (the actual place) to investigate first hand… but I think asking questions can be a good start. Maybe I can ask my friend and fellow blogger/podcaster Ron Pereira, who is local and a Rangers' fan, to check this out. Are there enough trash cans outside the ballpark?
When we make it easy for people to do the right thing, it tends to happen. Hospitals love to lecture staff about washing their hands, but the gel or foam dispensers in the hallways are empty far too often. Do we blame the people or understand the system so we can fix it?
Would another set of fans, put in the same situation, do the same thing (leaving trash around)? If so, it's likely a systemic problem (and I'll choose to not blame society).
Cubs Outfielder Junior Lake
I long for the simple days when baseball teams had TWO uniforms – home whites and road greys… sort of like my hometown Detroit Tigers still wear today. Nowadays, teams have dark jersey tops, alternate uniforms, throwback hats, etc. There are many combinations that a team might wear throughout the season.
The different uniform combinations are a mistake waiting to happen.
And it happened this week (ESPN story). Junior Lake, at left, wore the wrong road jersey to start the day.
It's easy for broadcasters and fans to pick on Lake for “his mistake.” You can hear the blaming in the headlines, articles, and tweets… “Junior Lake's Jersey Snafu,” his “mistake,” etc.
Was it Lake's fault? Did he pack incorrectly for the trip? Of course not. His job is to focus on baseball. The team has a support staff who is supposed to take care of this — a system.
After the Pirates' final out in the bottom of the first inning, Lake immediately went into the clubhouse to change. He said he got confused because both jerseys were hanging in his locker, and he chose the wrong one.
You could ask, “How hard is it to pick the right one?” but I could ask, “Why would you hang two different jerseys in a locker?”
This isn't Junior Lake's fault. This was a systemic error.
Why did they even have the wrong uniform with them that day? According to Paul Lukas and Uni-Watch.com:
I posed that question to a Cubs PR rep, who got back to me with the following: “We had both uniforms packed, since each day's starting pitcher may decide which uniform the team wears while on the road.” So there you go.
Would you blame a nurse for grabbing the wrong medication out of a drawer, when the med wasn't even supposed to be there and when the support system failed to put the right thing in the right place? Hospitals do this all the time and it's not fair to the people working in the system.
Good factories, like Toyota, have great systems in place to make sure the right part gets to the right place at the right time. Hospitals (and baseball teams, apparently), not so much.
Would another nurse (or another player) make the same mistake in the same situation? If so, it's a systemic problem.
Multiple nurses gave the wrong medication to the Quaid twins over the course of a day. That screams “system problem” to me.
Other players have worn the wrong jersey before (including last year). System problem! I agree with Lukas' assessment that this will happen again, since the Cubs have 13 different uniform combinations.
How can we shift organizations away from blaming individuals? We can probably start by looking in the mirror. I try to be better about it myself. Maybe we can all try to set that good example — look for the system problem, not the individual problem.
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The danger in what you are trying to convey is that we might stop taking on our own personal responsibility and just blame everything on the system. It’s gotten that way when it comes to lawsuits. People spill hot coffee on them selves and go after the system or supplier because it’s hot.
There’s danger in always blaming an individual for a workplace problem.
There’s danger in never taking personal responsibility.
That’s why I think Dr. Deming’s “94%” number is helpful. Many organizations jump to automatically blame an individual 94% of the time (if not 100%). Blame the person, unless proven otherwise.
I think it’s more reasonable (and overall less harmful) to first blame the system… unless proven otherwise.
The Just Culture algorithm does a good job of fleshing this out. It’s not always “the system.”
As for the McDonald’s coffee incident and lawsuit, this documentary was really eye-opening: “Hot Coffee” — the woman’s lawsuit isn’t as ridiculous as it might have seemed in the news and late-night talk shows. The coffee wasn’t just “hot” (in the normal sense), but the brewer put out and served coffee that was far hotter than the normal safe temperature range. McDonald’s had previous complaints and hadn’t taken action to adjust the temperature.
I think the sheer act of blame period is wrong, whether it’s at a person or system. We should stop saying it’s the fault of [insert cause here] without figuring out the best way to make sure such a cause cannot happen again. Root cause analysis + error-minimization (if not error-proofing).
Simply blaming a person isn’t right. Blindly blaming a system isn’t right either. Proper diagnosis of the cause is the right thing to do. Laying blame is so quick and semi-soothing but still doesn’t solve the problem.
“When we make it easy for people to do the right thing…”
Best phrase in the entire post. Every manager/engineer should start with this phrase when they want to improve performance of frontline workers. It falls in line with the common phrase of “removing barriers to success.”
And more blame being shared, this time in NASCAR…
http://espn.go.com/dallas/story/_/id/10722523/nascar-puts-tire-pressure-drivers-teams-not-goodyear
It seems pretty clear to me that a NASCAR team that inflates the tires BELOW the Goodyear recommended range has no one to blame but themselves.
But, blame is a tempting thing to try and people will blame without thinking about it or because they think they can get away with it.
Thanks for sharing.
Another baseball game this weekend that made me think of Lean is the infield covering being left off the field overnight in Oakland leading to the A’s-Mariners game being cancelled Friday night.
Goodness gracious.
Here is an article about that.
The article didn’t blame anybody, other than, I guess the grounds crew as a group.
This article has a little more detail, blaming a bad weather forecast:
I hope they can learn from this and prevent that from happening again! They have had a lot of problems in that stadium (sewage in the clubhouses, etc.).
Hi Mark,
Great piece. It led me to another question: what are the root causes of the blaming culture? I haven’t thought through this one yet, but it’s undoubtedly a mix of the structural, cultural, and inner world views of people.