Many leaders in healthcare (including John Toussaint, Paul Levy, and others) are working to eliminate the “name, blame, and shame” culture that often exists in hospitals. This push (in my mind) started with W. Edwards Deming, who taught that 94% of problems are caused by the system, and continued to the modern patient safety movement, which also teaches a systems-based view of what’s needed to prevent errors, not just punish an individual after the fact.
With a hat tip to Patrick Vlaskovits, I saw this post online, related to software development:
My short answer would be: “You probably can’t.” Does a blaming leopard change its spots?
There were a lot of great comments, mainly from programmers and developers who seem to understand systems better than many of the managers do.
The poster of the question added:
My arguments that this will decrease morale, increase finger-pointing and would not account for missing/misunderstood features reported as bug have gone unheard.
Adding “who” to blame doesn’t seem like a move that would increase teamwork or improve morale in any setting. Is a software defect something that’s truly an individual error, or, like healthcare, are the results of a system the result of all of the interactions and different moving pieces and processes? Not being a software developer, I wonder, though, if Dr. Deming’s 94% principle would still apply… maybe 6% of bugs are caused by a sole person’s individual error?
The default view of blaming managers seems to be that an individual is the root cause of a problem unless proven otherwise.
I think the more correct view is to assume it’s the system unless proven otherwise – whether it’s a software bug or a medication error.
I’d also predict, in a software setting, that the number of reported bugs would go down in a “shame and blame” culture… mirroring the underreporting of medical errors in such cultures.
Anyway, check out the discussion there and I’m curious to hear your comments about “shame and blame” cultures and any steps you’ve been able to take to reduce it in your organization.
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 VP of Innovation and Improvement Services for KaiNexus.