Fundamental attribution error: attribute fault or defect to the individual without first considering the systemic effect.
When we fall into this trap the system is not improved. What we want to do is when we find poor results is think about how the system can be improved to consistently produce better results. By using management improvement concepts such as (all of these are present in David’s short example): operational definition, shared vision of desired outcome, process improvement, visual management, flowchart, continual improvement, respect for people, coaching, 5 whys… we can find ways to change that will result in consistently better results.
Blaming people is a low yield (often negative yield) strategy. Figure out why the results were not good and figure out how to change the process so that it reliably produces better results.
The punishments will continue until motivation improves. Nobody is really looking at why…
It is much more effective to determine why the system is causing people to behave in ways that are seen as “motivation” problems. Exploring to determine how the system can be improved so that people don’t get de-motivated is a better use of management’s time. The “motivation” problems are normally a symptom of an underlying weakness in the management system.
My challenge to everybody in this room is don’t wait. Start applying the philosophy today: start and don’t stop. The more you learn, the more you apply, the more you will gain and that is what the PDSA cycle is all about. Make a plan, do your plan, did that plan work? Think about it. What is my new plan? Go again.