It is interesting that in teaching students how to complete a process of root cause analysis I often come to a point where people want to start pointing fingers. Employees are lazy, stupid, uncommitted, oblivious, ignorant and the list goes on.
I have a different point of view. My perspective is significantly impacted by Shigeo Shingo. No I have never met the man but his perspective that the worker deserves respect plays like a lyric straight out of my quality hero Edwards Deming’s 12 points of quality song sheet. You see I believe the worker deserves to take pride in the work they do. They deserve to operate in an environment where fear doesn’t rule the day but dignity, respect and learning temper accountability and the drive for results.
Mistakes are good. Yes they are. I don’t care how you were conditioned, mistakes are good.
they give us an opportunity to see first hand what we have always known. Our processes are just not that good. In fact wrong is easier than right in our processes. Its no wonder mistakes get made. The process is so complicated and we are asking our employees to go ever faster. It is almost inevitable that mistakes get made.
And yet they are a good thing
Make “RIGHT” Easy…
You see a mistake made and considered an opportunity to learn gives us a chance to improve the process. A chance to make right the easier answer or at very least wrong more difficult.
We need to change our mindset and begin to embrace the mistake as the opportunity it truly is. Learning the tandem skills of root cause analysis and mistake proofing enables us to eliminate mistakes all together. Yup I am not saying mistakes should be tolerated and hence repeated. I am saying they should be mandatory opportunities for learning.
Earlier in my journey into root cause analysis I was often stymied by the 5 Why process. It always seemed to bog down and get no where. It took a while but I finally figured something profound out. Blame and shame have no place in the RCA journey. Blaming a worker only leads to a dead end and the need for punishment.
There are certainly times when a worker needs a swift kick to get back on the straight and narrow. However I believe these events are truly few and far between if you have a clue how to manage people with dignity and respect.
The process of RCA should necessarily focus first on process and how the process can be enhanced to make it more reliable. If you aren’t buying my argument this might be a good time to stop reading and go back to fear and intimidation as motivational tools. Not a fan think they are dumb and so 1950’s.
Focus first on process. Recognize that the employees behavior is a product of your processes robustness. Yes they interact with it and may not be capable of the highest performance levels but ahh you or your predecessor hired um so yes look in the mirror again for the source of the real problem.
Fix the process smart guy!
So the next time you are digging into a 5 Why and someone comes even remotely close to blaming the operator as an answer to the why question, push back make them take a process focus first.
We can always deal with individual performance when we are more certain our process is good. By the way the FEW employees you have that like to blame everything but themselves (yup wonder where they got that negative behavior from) when mistakes are made, yes you know the ones. Well guess what if the process is effective and robust they have less places to hide poor performance and eventually have to either accept responsibility or accept discipline.
Either way we end up with employees able to perform at a higher level. Only difference is those 1950’s bonehead managers are still under performing as their employees are fearful for their job and my employees are performing at a high level willing to take small risks to find even better levels of performance.
Your choice… Now go make some mistakes and fix your process!