Often when problems occur, we seek to figure out who is to blame for the problem. This is not an effective management strategy as Dr. Deming made clear, and I have discussed before: Attributing Fault to the Person Without Considering the System, Distorting the System, Distorting the Data or Improving the System, Lessons From the Red Bead Experiment with Dr. Deming, 94% Belongs to the System.
From my previous post Find the Root Cause Instead of the Person to Blame:
Often, if you ask why we have this problem or defect, people will point to some error by someone. So, you can blame that person… [but] 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 an improvement strategy (PDSA) 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 improvements, and many more, are sustainable and can be built upon over time.
In addition, the psychological effects of seeing people as the source of errors and defects 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.
This video takes a look at how to manage effectively by fixing systemic problems.
In order to have high quality goods and services the entire system has to be highly efficient and focused on quality. And [it must] have a system in place that can produce that high quality product or service.