Tag Archives: blame

Peter Scholtes on Teams and Viewing the Organization as a System

In this presentation Peter Scholtes provides an explanation of teams within the context of understanding an organization of a system:

We will not improve our ability to achieve our purpose by empowering people or holding people accountable. I know that those are fashionable words but what they have in common that I think is the wrong approach is that they still are focused on the people and not on the systems and processes. I’m sure that will trigger quite a bit of conversation and perhaps some questions.

He is right, though those are difficult old thoughts to break from for many. He does a good job of explaining how to seek better methods to achieve more success in this presentation and in the Leader’s Handbook. Following the links in the quote above will also provide more details on Peter’s thoughts.

Peter includes a description of the creation of the “organization chart” (which Peter calls “train wreck management”) that we are all familiar with today; it was created in the Whistler report on a Western Railroad accident in 1841.

Almost a direct quote from the Whistler report: “so when something goes wrong we know who was derelict in his duty.” The premise behind the traditional organizational chart is that systems are ok (if we indeed recognize that there are such things as systems) things are ok if everyone would do his or her job. The cause of problems is dereliction of duty.

Peter then provides an image of W. Edwards Deming’s organization as a system diagram which provides a different way to view organizations.

In the old way of viewing organizations you look for culprits, in this way of viewing the organization you look for inadequacies in the system. In the old way of viewing the organization when you ask “whom should we please” the answer is your boss. In this way of viewing an organization when you ask “whom should we please” the answer is our customers.

This is an absolutely great presentation: I highly recommend it (as I highly recommend Peter’s book: The Leader’s Handbook).

Without understanding a systems view of an organization you can’t understand whats at the heart of the quality movement and therefore everything else you do, management interventions, ways of relating to people, will reflect more likely the old philosophy rather than the new one.

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Burning Toast: American Health System Style

Democrats and Republicans have created a health care system in the USA over the last 40 years that “burns toast” at an alarming rate. As the symptoms of their health care system are displayed they call in people to blame for burning toast.

Their participation in the “you burn, I’ll scrape” system is even worse than the normal burning then scraping process. They create a bad system over decades and ignore the burnt toast just telling people to put up with it. And when some burnt toast can’t be ignored any longer they then blame individuals for each piece of burnt toast.

They demand that those they bring before them to blame, scrape off the burnt toast. And they act shocked that the “toaster” burns toast. It is the same “toaster” they designed and maintain at the behest of those benefiting from burnt toast and of course it burns toast (those results are the natural outcome of the system they designed and maintain).

We need to fix the decades old broken toaster that the Democrats and Republicans built and have maintained. Dr. Deming called excessive healthcare costs a deadly disease decades ago yet Democrats and Republicans allowed it to continue harming us year after year and decade after decade.

We don’t need distractions blaming a few individual for what the two parties have created and maintained for decades. We need leaders to address the real issues and stop the distraction that those benefiting from the current system want to continue to see from those in Washington.

You don’t fix the system if all you do is blame individuals for each piece of burnt toast. Fixing blame on each piece of burnt toast is exactly what those that have continued to make sure the system is designed to continually burn toast love to see. It is a good way to make sure the fixes needed to the design of the toaster are not addressed. Both political parties have done well by those they receive payments from to ensure that the current toaster isn’t changed.

For decades the data shows the USA health care system costs are nearly double that of other rich countries with no better results. And we are not comparing to some perfect ideal, those efforts we compare to need much improvement themselves. So how bad much the USA health care system be to cost nearly twice as much as those systems that have plenty of room for improvement themselves?

Related: EpiPen Maker Also Hiked Prices on a Slew of Other MedicationsUSA Health-Care System Ranks 50th out of 55 CountriesDrug Prices in the USA, a system continually burning toast (2005)USA Heath Care System Needs Reform (2009)2015 Health Care Price Report – Costs in the USA and Elsewhere

Take Advantage of the Strengths Each Person Brings to Work

The players have weaknesses. But it is our job as coaches to find the strengths in what our guys do. They all have strengths, and that’s what we highlight. What really helps is having Russell. He is so committed to improving on the littlest things every day. I try to find a word for this sometimes, but I can’t … it’s his refusal to fail. No detail is too small, and he makes sure to stress that every day.”

Darrell Bevell, offensive coordinator of the world champion Seattle Seahawks and former quarterback of the Wisconsin Badgers provides a good guide for managers. “Russell” in the quote is Seattle’s quarterback Russel Wilson; also a UW-Madison alumni.

Street art in Singapore 4 people sitting and a kid

Street art in Singapore. Photo by John Hunter.

Managers should be setting up the organization to take maximum advantage of the strengths of the people in the organization while minimizing the impact of weaknesses.

“Refusing to fail” by saying you refuse and yelling and stomping around if you fail doesn’t work. But if you commit to improve, not just the exciting stuff but every important detail you can create a climate of success. You create a system that works and builds on the skills, ability and desire to do great work that your employees bring to work.

Sure you fix what is broken. But you also improve what is working well. You figure out where the system isn’t optimized for the abilities of the people and you address that by changing the system to take advantage of everyone’s capabilities while limiting the impact of people’s weaknesses.

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94% Belongs to the System

I should estimate that in my experience most troubles and most possibilities for improvement add up to the proportions something like this: 94% belongs to the system (responsibility of management), 6% special.

Page 315 of Out of the Crisis by Dr. W. Edwards Deming.

the system that people work in and the interaction with people may account for 90 or 95 percent of performance.

Dr. Deming’s quote from the introduction to the Team Handbook

I think, in looking at the total of Deming’s work, that the point he is trying to make is that looking to blame people is not a good strategy for improvement. The impact due solely to a person’s direct action (not including their interaction with the system and with others) is small in comparison to that of the system within which they work. So, Deming (and I) want people to focus on improving the system; which will achieve better results than searching for what people did wrong.

What did Deming want people to take from his statements?

Did he want us just to accept bad results? No. He was not saying it is the system there is nothing we can do just accept that this is how things are. He wanted us to focus on the most effective improvement strategies. He saw huge waste directed at blaming people for bad results. He wanted to focus the improvement on the area with the greatest possibility for results.

Did he want to say people are just cogs in the machine? No. Read or listen to most anything he said at any significant length (a full chapter of this book, a full article he wrote on management, an hour from one of his videos) and it is hard to maintain such a thought.

photo of forest trail

Pinetree Trail, Frasers Hill, Malaysia by John Hunter

Did he believe that people were not important? No. He was trying to direct the focus of improvement efforts to look not at the fault with one person but to look at the system. I believe strongly he was correct. If you blame a person as the root cause of a problem, my first, second and third reactions are why? why? why? It is possible the person is to blame and there is no benefit to exploring system improvement instead of settling for blaming the person. But that is rare.

I have written about the importance of developing people to build the capability of the organization. My father wrote about it previously, “American organizations could compete much better at home and abroad if they would learn to tap the potential information inherent in all processes and the creativity inherent in all employees.”

I wrote about the importance of the ideas behind Deming’s quotes here, back in 2006 – Find the Root Cause Instead of the Person to Blame

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How to Improve

My management philosophy is guided by the idea of seeking methods that will be most effective.* There are many ways to improve. Good management systems are about seeking systemic adoption of the most effective solutions. What this amounts to is learning about the ideas of Deming, Ackoff, Ohno, Chirstensen, Scholtes, Womack… and then adopting those ideas. In doing so learning about management tools and concepts as they are applied to your work.

Here is a simple example. Years ago, my boss was frustrated because an award was sent to the Director’s office to be signed and the awardee’s name was spelled wrong (the third time an awardee’s name had been spelled wrong in a short period). After the first attempts my boss suggested these be checked and double checked… Which they already were but…

I was assisting with efforts to adopt TQM and the time and when she told me the problem and I asked if the names were in the automated spell checker? They were not. I suggested we add them and use the system (automatic spell checking) designed to check for incorrect spelling to do the job. Shift from first looking to blame the worker to first seeing if there is way to improve the system is a simple but very helpful change to make.

This example is simple but it points to a nearly universal truth: if an improvement amounts to telling people to do their job better (pay attention more, don’t be careless, some useless slogan…) that is not likely to be as effective as improving the process. The example includes ideas such as poka-yoke (mistake proofing), respect for people and root cause thinking. I find it most effective to apply tools within an system that has some understand of the management concepts of Deming, lean, six sigma

The tools by themselves can be useful but it is much easier for them to be misapplied when there is not a more comprehensive understanding. If an organization wants to commit to a serious effort to improve that does not mean that improvement must wait for this education. But it does mean the most effect way forward is to initially strive to improve performance and at the same time build the capacity of the organization by building a broad understand of these ideas. Building that capacity is an investment that will pay off over the long term (and can be “funded” using the gains made using the tools and concepts).

* Update – in re-reading this my first sentence strikes me as a bit obvious, to the point that it is meaningless. Let me state it another way. I am not focused on getting the best result this minute, I am focused on finding the best methods that will produce the best results over the long term (predictable, repeatable system performance). I do not believe that the best management system is one that relies on heroic effort (fire fighting, large sacrifices…). That is most often the sign of failed management not successful management. CMMI covers this idea well.

European Blackout: Human Error-Not

German utility E.On says major European blackout was caused by human error [the broken link was removed]

Germany utility E.On AG said Wednesday that a European-wide blackout earlier this month that left millions without power was the result of human error and not any technical glitches.

The Duesseldorf-based company said the power outage, which led to blackouts in parts of Germany, France, Belgium, Italy, Portugal and Spain on Nov. 4, was not caused by a lack of proper maintenance or enough investment in transmission grids and facilities.

The blackout was caused after a high-voltage transmission line over a German river was turned off in an aborted attempt to allow a newly built Norwegian cruise ship to pass safely under it.

That triggered a blackout that briefly left 10 million people without power, stopping trains in their tracks and trapping people in elevators.

Ok, the focus seems to be that we didn’t do anything wrong, just some “human” made an error, which seems to be implied is out of their control. Why would the organization not be responsible for the people and the system working together? Management needs to create systems that work. That system includes people and equipment and process management and suppliers…

E.ON says human error responsible for Nov 4 power outage [the broken link was removed]:

It said that its control centre shut down part of an ultra-high voltage transmission line without checking whether the outage of a second transmission line might overload the power grid.

About half an hour later there was an outage at a second transmission line, which ultimately created a domino effect that led to the temporary disconnection of the European interconnected power grid.

The German utility said that all systems reacted in accordance with standard procedures, effectively preventing a complete blackout across Europe.

It seems obvious the process was not well designed if they believe a mistake was made that led to the tens of millions of people being without power. Failing to admit that the process was designed poorly and needs to be improved is troubling. Blaming “human error” does not help or help improve in the future (and is not a way to develop a culture that respects people). And it reinforces the notion that this event is due to one special cause (or 2…). It seems to me, even with this very little evidence at hand, that this is a system problem.

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Find the Root Cause Instead of the Person to Blame

When encountering a problem or defect the inclination of many is to find a person to blame. W. Edwards Deming believed that the system was responsible for 93% of the problems and over time he increased that number to at least 97%. Why did he see it that way, while so many others first inclination is to blame someone?

As I see it the issue has to do with what is the effective way to improve. Often if you ask why do we have this problem or defect, people will point to some error by someone. So you can blame that person (there are reasons this is not a very accurate way to view the situation often but even without accepting that premise the blaming a person strategy is not wise). The reason the blaming a person is a bad idea is that your organization will improve much more effectively if you keep asking why.

Why did they make that error? Why did the process let them make that error? When you follow the why chain a couple more steps you can find root causes that will allow you to find a much more effective solution. You can then pilot (PDSA) an improvement strategy that doesn’t just amount to “Do a better job Joe” or “that is it Joe we are replacing you with Mary.” Neither of those strategies turns out to be very effective.

But investigating a bit more to find a root cause can result in finding solutions that improve the performance of all the workers. What kinds of things? You can apply poka yoke (mistake proofing) concepts. You can institute standard practices so that everyone is using the best methods – not whatever methods they have developed over time. You can rearrange the process to simplify the steps and eliminate chances for errors. These improvement, and many more, are sustainable and can be built upon over time.

In addition, the psychology effects of seeing people as the source of errors and defect instead of seeing people as the source of improvements to process weaknesses are powerful. If you find yourself thinking a problem or defect is the fault of a person try asking why a couple more times and see if you can find a system improvement that would eliminate or mitigate such problems in the future. That is a much more effective improvement strategy.

I always have had a bias toward finding system improvements but over time that bias has increased as I have applied management improvement concepts. As you gain experience working on improving systems you gain experience showing the wisdom of Deming’s 93-97% figures. My belief is that he increased the percentage of problems attributable to the system over time as he experienced the same thing.