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Blame Processes, Not People

Posted by Greg Jacobson

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Oct 28, 2014 9:02:00 AM

4818952324_a2cce9be1b_mAs part of our efforts to share valuable Lean practices with our readers, we've created a series of education videos. Each video covers an improvement principle in 2-3 minutes, providing you with a quick nugget of best practice information. This video discusses why you should blame processes, not people. Don't forget to share with your staff and colleagues!



In this video:

Lean thinkers and safety experts agree that most problems and errors are actually caused by deficiencies in our processes and systems. These system thinking concepts apply in manufacturing, healthcare, software companies, and more. 

Be hard on the process, not the people. Remember the case a few years back when the actor Dennis Quaid’s twins were given an adult dose of a blood thinning medication in the NICU? Would it make sense to simply reprimand the nurses? The twins were actually given the wrong dose by three different nurses over a 24 hour period. They weren’t 3 bad nurses; the situation points to having a number of systematic errors in the pharmacy and the NICU that even allowed the adult dose to be there in the first place. In the same way, if your organization accidentally ships an empty box out, instead of blaming the individual, we need to look at the process. Why was it possible to send an empty box out in the first place? Would a different person in the same job be likely to make the same mistake?

Modern safety principles emphasize the need to prevent errors and harm by focusing on our processes, not just getting rid of the so called bad alpples. Dr. Deming, one of the foremost experts on process improvement, famously estimated that 94% of problems and defects are caused by the systems, not by the individuals.

So here’s your call to action - as you go through your daily work, proactively look for things that could go wrong, and don’t ever sweep a near miss under the rug. We need to be proactive to help prevent problems, not just react after a bad event. When you see one of these risks or potential problems, take a minute to log in to KaiNexus to report the opportunity for improvement, whether you have an idea for a proposed solution or not. Let’s say you discover that two medications with similar names also have very similar packaging, that’s an opportunity for improvement. Or, if you work in a factory and there’s a piece of machine guarding that’s about to come off, report the problem. Identifying problems and risk factors is the first step in process improvement. It’s an important step in moving toward zero defects as a goal.

Watch more videos from the KaiNexus Education Video series.

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