Blame is Alive and Well While Systems Thinking Takes a Back Seat

September 27, 2012 § Leave a comment

A nurse, in an Ohio Hospital, accidentally discarded a kidney that was awaiting a transplant and had been provided by a living donor.  The nurse had been on break, had been replaced by a different nurse, and was therefore unaware the kidney was submerged in an ice filled sludge.  She purposely disposed of the contents into a disposal hopper thinking the kidney was still in the operating room because “that’s what usually happens.”

The hospital suspended the two nurses after the incident; one was later fired, and the other resigned.  Furthermore, a surgeon was stripped of his title as director of some surgical services.  What a tragedy on many levels.

The nurse who discarded the kidney had walked past a doctor and other nurses carrying the container.  Should someone have noticed?  Should someone have said something?  How was she to know?   She was fired!  Does that make sense?

In the light of our typical industrial age model of management that focuses on holding people accountable for results it makes total sense.  Why? Because, someone must be at fault!   That’s the philosophy with which we were raised.  That’s the philosophy that dominates our schools and our organizations, i.e. someone must be held accountable for the results.

In 1950 Dr. W. Edwards Deming explained his philosophy of systems thinking to the Japanese leadership.  The Japanese proceeded to implement Deming’s philosophy of Profound Knowledge.  By the late 1960’s Japan was dominating the manufacturing of electronics including televisions, radios, and stereos.  By the end of the 1970’s the gap in quality between Japan and the USA was reaching a crisis.  The philosophy of focusing on the improvement of the system was winning the competitive edge.  Costs were lower and quality was higher.  The age of blaming people for mistakes was dead.  At least it was in Japan.  Unfortunately it is still very much alive today in America.

Today we still tend to blame people for mistakes.  Unfortunately, according to Dr. Deming’s philosophy probably 94% of all mistakes come from the system and processes and only 6% from the people.  There were probably a dozen or more hand-offs that occurred in that operating room between the surgery preparation time and the time the nurse returned from her break.  Each of those hand-offs was an opportunity to have good quality or poor quality.  Information about the location of the kidney was a hand-off.  What to do with the slush was a hand-off.  Each of those hand-offs was a process that could be improved.  To blame her does nothing to improve those hand-offs and therefore, nothing to prevent a reoccurrence.

Today our children are failing to learn reading and math skills at their respective grade levels, yet we continue to embrace standardized testing and performance evaluations for teachers.  We continue to attempt to improve the individuals by judging, grading, blaming, and firing them.  We fail to fully recognize that our system of grading students destroys their passion for learning and steals their willingness to take responsibility for their own learning progress.  We continue with the same flawed processes and hand-offs that make up the entire dysfunctional system. We blame and then expect different results.

If we fired every nurse and every teacher in the country and replaced them all with highly trained substitutes would we improve anything?  Couldn’t we expect that the same number of students would fail and the same number of kidneys would be discarded?  Unless we embrace a systems view of the world and stop blaming we will continue to see these tragedies.  If blame is alive, improvement and systems thinking will take a back seat.


Are You a Traditional Manager or Self-Management Facilitator?

April 17, 2012 § Leave a comment

Are you a traditional manager or self-management facilitator?   Perhaps you recognize the need to change and you are making the transition.   Some organizations will be able to delay the transformation and others will need to change now or die.  I believe we will all need to make this transition at some point (some sooner than later) because the traditional manager and his/her current skill set are going the way of the Dodo bird.

The current management model that requires managers to “drive” results, and evaluate performance is not fast enough to keep up with changes occurring in the global economy.  There is a need for instant adaptability and traditional managers, as smart as they may be, cannot respond or plan fast enough.  The need to adapt to change is one of the dynamics creating a need for organizations to self-organize or self-manage.

Besides the need to adapt to the speed of change, managers must also be able to create environments that engage people naturally and not force so called engagement with bribes and threats.  Many traditional managers use so called “new” motivational initiatives to create employee engagement but these programs are really just the same old traditional management with fancy digital bells and whistles.

An environment of employee engagement is needed for adaptability.  Employee engagement is also needed for innovation.  It is impossible for bribes and threats of the traditional management policies, such as pay for performance and the traditional performance review, to encourage optimal innovation and creativity.  Managers are conducting performance reviews poorly because those policies are no longer able to meet neither the needs of the organization nor the needs of engaged employees.  Like the Dodo and the Dinosaur, the environment has changed and they are going extinct.

Our traditional manager is put in a position of needing to be omnipotent and omniscient.  The complexity of today’s global competition and speed of change make fulfilling this role completely impossible.  No wonder the traditional manager is so stressed and is performing poorly.  Only 29% of employees are engaged.  Less that 50% of employees trust management and less than 50% believe their organizations are able to effectively adapt to change.

How do you know you are making the transition to a self-managing facilitator?  Here are a few thoughts to consider.  First, are you a systems thinker?   In the face of problems or mistakes do you step back and ask questions about how the system is impacting the results and the individual behaviors?  Do you understand and appreciate variation such that you don’t look for root causes unless you are sure the problem is outside the normal variation?

Do you avoid blaming individuals for problems because you know that the performance of an individual worker is the product of the system they work within?  Do you appreciate that the individual worker works in the system and it is your job to work on the system?

Have you clarified a specific context of trust and do you have a process to continuously reinforce it by clarifying and living the values, the mission, and the vision that has been embraced by the entire organization?

Do you continuously build trust and reinforce trust with your people and do you provide them with tools and resources that allow them to also manage trust?

Are you able to provide the tools that enable your people to create self-managing teams which make more and more of the decisions close to the work?  Do you provide them with the tools and the data they need to track their own performance in a collaborative way (without competition)?

Are you helping to facilitate the continuous improvement of everyone’s hand offs?  Hand offs are the information and products delivered internally in an organization that build value for the external customers.  The faster and the higher the quality of hand offs the more profit the organization can make and the happier the external customer will be.

Are you personally developing, and offering opportunities for your people to develop the following skills of emotional intelligence, quality interpersonal interactions, quality system interactions, dialogue, critical thinking skills and systems thinking skills?

The traditional manager has a difficult job but the future self-management facilitator is even more skilled with a completely new set of sophisticated skills.  Are you making the transition?  Are you getting the help you need to make the transformation?  If not, watch out for the Dodo.  You might see it cross the street in front of you very soon.

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