How to Damage Employee Engagement – Treat Human Error as a Cause

April 24, 2011 § Leave a comment

There is a difference between a mistake and willful sabotage and leaders who want to optimize engagement must appreciate and communicate the distinction not just with their words but also with their actions.   A mistake is understandable and sabotage is not.  

A Louisiana family was outraged after a major mix up left their loved one cremated instead of buried. Ruby Joseph of Lafayette, La., died.   She and another woman, Rose Alex, were both in the morgue at Lafayette General Medical Center.   According to the hospital, the two were labeled correctly, but Kinchen Funeral Home and Raphael and Sons Funeral Home picked up the wrong bodies.   Joseph’s daughter discovered the mistake when she opened the casket to say a final goodbye.   That’s when she when she found the body inside wasn’t her mother’s — it was the body of Alex.   “Why didn’t [they] look at the tag before [they] cremated the body?” asked Chaka Joseph.   “The saddest thing about that is it was our mother’s casket, our mother’s dress that we chose for our mother, on another lady’s body,”   Joseph’s son Kenneth said. Officials say the worker who picked up Joseph’s body did not check the wrist tag. He says when the hospital security guard had him sign an official release with the name of Ruby Joseph, he assumed he was leaving with the correct body.   The other worker from the other funeral home also failed to check the tag.

Is this a mistake or sabotage? Our decision will determine our action to “fix the problem.”   Fixing a problem almost always includes making amends for the impact the problem creates (such as the grief the family must have felt) and working to prevent the event from happening in the future. If the problem is truly a mistake, our actions might include a sophisticated root cause analysis.   If it is sabotage, we probably fire the employee.  

To decide our action strategy there are two questions to ask.   First, “Was this result willful?”   Secondly, “Could someone else have unknowingly done the same thing?”   If we answer “yes” to the first question and “no” to the second we probably should decide to fire the employee because sabotage is likely.   Any other combination means the problem is a mistake.  

If the result caused by the mistake is severe enough, we probably should embark on a sophisticated analysis to find the root cause.   Without this analysis we risk future loss.   Too often leaders will jump to the conclusion to fire the employee before answering these questions.   This “jumping to blame” predictably damages employee engagement.   The damage will not just be for the one employee but for all.   Studies show that blame for one employee causes all employees to assume the same could happen to them too. The root causes of mistakes are not just human error.

Mistakes are a result of a complex set of system interactions.   The human element is only one factor in a series of obvious and not so obvious factors.   The security guard had the funeral home employees sign the wrong paperwork. This was a factor.   Not looking at the wrist band was a factor.   Which one contributed more?  

A system is a complex series of processes that have multiple interactions.   It is a leader’s job to facilitate the variation in those system interactions and to enroll all employees to assist.   If another person could have taken the same action and contributed to the same result this probably means the overall system needs to be improved.   Firing the employee will NOT fix the system.   Firing the employee is always an option but it is the unsophisticated choice and will not guarantee avoiding the same result in the future.  

What can a leader do?

It is up to leaders to facilitate the improvement of system interactions.   It is up to the leader to help employee reduce this variation.   It is up to the leader to create an environment of trust and truth that enables the employee to speak up when he/she feels their processes are not optimal. When an undesirable outcome occurs leaders must first ask the two key questions.   Was it willful?   Could anyone else have done the same? Jumping too quickly to blame will risk damage to employee engagement and therefore risk damage to future productivity and future quality improvement.   Leaders who react will lose an opportunity, especially if the first reaction is, “How could he/she have been so stupid?”   Sincere employees who make mistakes are already suffering with the realization they caused pain for others.   There is no need to increase their suffering. Of course, those who truly did sabotage must be removed quickly and permanently.   Leaders must be able to spot sabotage and act quickly.

Leaders must also be able to swing into action a root cause analysis process.   Enrolling the employees in that process will optimize the probability of identifying all the root causes and increase the probability of avoiding the same mistake in the future even when the interactions are complex.   Leaders must avoid relying on “people dependent” actions to avoid problems. Instead, we need to look for system dependent processes. System dependent is more predictable because it doesn’t rely on humans and humans are imperfect.


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