At first I thought this post was stretching this week’s blog theme of applying Lean principles in everyday life, but I think it actually does fit quite well, at least for those of us for whom sports is a part of our daily life.
Last night, I was able to attend the Fiesta Bowl game in Arizona (my father-in-law is an Oklahoma State alum and fan). Yes, that’s a marching band picture since I’m a former college marching band drummer at Northwestern.
It was a crazy game in many ways and it looked like Stanford would win as they lined up to kick a relatively easy 35-yard field goal. The kicker, redshirt freshman Jordan Williamson, missed the kick, hooking it very wide left (photo or video), so the game went into overtime. Williamson then missed a 43 yard attempt in overtime (again, wide left – his third miss of the night) and Oklahoma State made a field goal to win the game.
Stanford fans probably cursed the kicker, blaming the kicker for the loss. But, in keeping with the lessons taught by Dr. W. Edwards Deming and the Toyota Production System, can we simply blame the kicker?
Jordan Williamson is part of a team, as we all are at work. As Dr. Deming taught, we all work in a system. The Lean philosophy, as an extension of Deming’s work, teaches us to first look at the system and processes before just blaming and punishing an individual. This is a lesson that’s also being applied to the improvement of patient safety in healthcare.
Dr. Deming wrote:
“American management is quick to assign blame to an individual when the problem, is in fact, a fault in the system.”
Williamson, as the kicker, is the most obvious “goat” in this situation. He’s the equivalent to the nurse who administers the adult dose of the drug heparin to a baby in the Neonatal ICU (as happened in the case of actor Dennis Quaid’s twins). The kicker is at the “sharp end” of the system, as they would say in the patient safety movement. There are a lot of pieces to the system.
Does anybody blame Stanford’s star quarterback Andrew Luck (the expected #1 pick in the upcoming NFL draft) or the offense for not scoring a touchdown toward the end of the game? Does anybody blame the head coach for being somewhat conservative in the last minute once Stanford was in field goal range? I believe they didn’t take even one shot for the end zone passing, as many teams would do. Does anybody blame the defense for allowing Oklahoma State to score 35 points or to tie the game with just over two minutes left?
It’s human nature to blame an individual. It’s the kicker’s fault. Or is it? Williamson was a semifinalist for the annual Lou Groza award that honors the best college kicker, so he’s deemed to be one of the top 20 in his position (out of about 120 starting kickers in the top tier of college football). So, let’s grant that he’s at least an above average kicker. But, he’s a young kicker, so they tend to be nervous in pressure nationally televised situations (or it’s understandable that they would be). Good kickers miss kicks. It happens. Williamson had missed just three kicks all season, then he missed three in yesterday’s game.
But how often do good kickers miss two in a row (including the overtime kick)?
Williamson’s teammates came to his defense, as shown in this article:
Daniel Zychlinski made the most out of a low snap but not enough to spin the laces out of the way. Williamson hooked it left again.
“I told him to keep his head up,” fullback Ryan Hewitt said. “He’s still the best kicker I know.”
When they got their turn, the Cowboys needed just two plays to get to the Stanford 1. That led to a 22-yard field goal attempt for Quinn Sharp. He nailed it.
“It’s not an easy feeling,” Sharp said. “Everything comes down to you. You are the last one. It’s on the line. And people can look at any plays throughout the game. But most of the time when a situation like that happens, they don’t look at those plays. They look at it as the kicker messed up or the kicker did this. It was his fault.”
One by one, Williamson’s teammates came over to his locker. Senior wide receiver Chris Owusu spent extra time embracing Williamson, whispering words of encouragement into his ear.
A field goal attempt involves all 11 players. There’s the long snapper, the holder, and the kicker. There are eight other players blocking the other team. If any one of those pieces falls apart, the kick fails. As mentioned above, the ball was placed by the holder for the overtime kick so that the laces of the ball were facing the kicker (see photo). The ideal placement of the ball has the laces pointed away from the kicker, as kicking the laces reduces the distance of a kick and can make it hook or slice more wildly after contact.
Nobody says “blame the snapper!” or “blame the holder!” unless there is an obvious mistake, and that wasn’t the case on the overtime kick.
A friend on Facebook made an insightful comment, looking at the role of the coaches:
The young man (kicker) clearly wasn’t mentally prepared for such a situation. He obviously has the physical ability to make both of the kicks he missed…but you could see the fear in his eyes and body language. The Georgia kicker had the exact same look. So, to me, the special teams coach and head coach need to figure out how to ensure all their players are ready for those pressure packed situations. That’s why I blame management. Ha!
He wasn’t really serious about blaming management. Situations like this aren’t about blaming the kicker or blaming the coach (nor is improving healthcare quality about blaming the nurse or blaming the managers). It’s about understanding the system and recognizing what can be done to prevent future errors. I’m not sure what Stanford’s countermeasures will be. I know they won’t be reacting by punishing the kicker and making him run extra laps. That would be stupid and demoralizing. I’m sure Jordan Williamson feels bad enough. But, he has three more seasons to redeem himself.
In situations like the medication error that injured the Quaid twins, it’s common for the nurse who administered the medication to take the fall. But, the nurse is like the kicker. You need a good snap, a good hold, and good blocking. If a nurse gives a medication that’s not even supposed to be in the NICU to a baby, the nurse isn’t solely at fault. The system failed the nurse, just as it failed the babies.
Does the kicker (or the nurse) deserve SOME blame? Sure. But all of the blame? No way.
p.s. Thanks to ePatient Dave for prodding me to blog about this after being part of the private Facebook conversation.
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the Chief Improvement Officer for the technology company KaiNexus.