Blame the Road – Not the Person
Posted on August 19, 2009 Comments (4)
The system is responsible for
90, 92, 94, 97% of problems – W. Edwards Deming. Fix the system, don’t blame the people. When you seek system fixes you approach situations differently than if you search for people to blame.
By the way, I am often asked about the data supporting Deming’s contention that the system was responsible for 97% of the problems. This statement was not based on a set of data but on Dr. Deming’s decades of experience. And he increased the percentage over time – as he learned more.
Your streets are designed to kill people.
Vision Zero started about 30 years ago, when traffic safety researcher Claes Tingvall got the idea that we didn’t have to accept road traffic deaths as a fact of life. Tingvall and his colleagues said that these deaths were not “accidents’’ but were predictable and preventable. And they set out to prove it.
One of the ways they began to protect people was to put barriers down the center of two-lane roads. They showed that this could be done cheaply. When Mylar – a strong polyester film – is supported by closely spaced plastic poles, it can keep cars from crossing the median. When the Swedes used this type of center barrier to separate the traffic going in opposite directions, they effectively prevented head-on collisions and the death rate on these roads fell by 70 percent to 80 percent.
Global health research shows more improvements can save lives. For example, Ghana put in rumble strips – small bumps spaced closely together – across all the roads leading into the capital city of Accra, reducing fatalities by 35 percent. Research has shown that speed bumps on roads are one of the “best buys” in all of global health.
Most people think we are doing all that can be done to keep our roads safe. They are wrong. Road traffic injuries kill more than a million people a year worldwide, including 40,000 a year in the United States.
Is a situation killing 40,000 people in the USA a year a health care issue? It sure seems to me it would be. It probably isn’t a disease management issue though (some might try to say bad roads are a disease but I wouldn’t say that). I think this is one, of many examples, that shows that we have a disease and injury management system not a health care system (in addition to illustrating systems thinking, effective root cause analysis, PDSA, innovation, respect for people…).
Related: Find the Root Cause Instead of the Person to Blame – Traffic Congestion and a Non-Solution – Checklists Save Lives – Saving Lives: US Health Care Improvement – The Economic Benefits of Walkable Communities – SWAT Raid Signs of Systemic Failures – System Improvement to Respond to the Dynamics of Crowd Disasters – The Leading Causes of Death