Following up my post about not blaming a bartender, here’s another look at learning to cast aside our old habit of blaming individuals… this time, baseball related.
Modern organizations (in healthcare and business) tend to blame an individual when something goes wrong. It’s commonplace in our societies and it’s, basically, human nature to blame. But, Lean and the Toyota Production System teaches us to NOT blame individuals and to, instead, look at the system. Dr. Deming, who influenced Toyota greatly, said that 94% of problems are due to the system. The exact percentage is unknowable, but the point is to not jump to blame.
So what happened in Major League Baseball last week?
Texas Rangers Fans
Fans of the Texas Rangers (or maybe, more broadly, attendees of the Rangers’ opening day game) were accused of being thoughtless jerks for littering and piling up beer cans around a statue that was placed outside the stadium honor a fan who died when he tragically fell from the stands a few seasons ago.
See below and click on the image below for the full photo and article.
A number of tweets were sent around that blamed the fans for being “disgusting” and “not having common courtesy” as if they were intentionally dishonoring the man who fell.
We could write off people as being jerks, or we could think about the system they’re a part of. What are some of the factors:
- Beers inside the stadium are very expensive (which probably drives people to drink outside before the game, whether they should or not)
- As some people stated in online comments, there weren’t enough trash cans outside the stadium (because people aren’t supposed to be drinking that much outside and there are security concerns about bombs that lead to trash cans being scarce)
So, do we blame the team for charging high prices for beer (they probably should, to help reduce drinking and driving)?
Do we blame the terrorists?
Do we blame overreactions to terrorist threats, such as removing trash cans?
I don’t think I’m “making excuses for people,” if you want to call it that.
I’m just trying to exercise that part of my brain that asks, “What are possible systemic causes?” instead of just asking “Why are people such jerks?” I’m not there in Arlington, so I can’t “go to the gemba” (the actual place) to investigate first hand… but I think asking questions can be a good start. Maybe I can ask my friend and fellow blogger/podcaster Ron Pereira, who is local and a Rangers’ fan, to check this out. Are there enough trash cans outside the ballpark?
When we make it easy for people to do the right thing, it tends to happen. Hospitals love to lecture staff about washing their hands, but the gel or foam dispensers in the hallways are empty far too often. Do we blame the people or understand the system so we can fix it?
Would another set of fans, put in the same situation, do the same thing (leaving trash around)? If so, it’s likely a systemic problem (and I’ll choose to not blame society).
Cubs Outfielder Junior Lake
I long for the simple days when baseball teams had TWO uniforms – home whites and road greys… sort of like my hometown Detroit Tigers still wear today. Nowadays, teams have dark jersey tops, alternate uniforms, throwback hats, etc. There are many combinations that a team might wear throughout the season.
The different uniform combinations are a mistake waiting to happen.
And it happened this week (click on the photo for an ESPN story). Junior Lake, at left, wore the wrong road jersey to start the day (the correct jersey is shown at right).
Was it Lake’s fault? Did he pack incorrectly for the trip? Of course not. His job is to focus on baseball. The team has a support staff who is supposed to take care of this — a system.
After the Pirates’ final out in the bottom of the first inning, Lake immediately went into the clubhouse to change. He said he got confused because both jerseys were hanging in his locker, and he chose the wrong one.
You could ask, “How hard is it to pick the right one?” but I could ask, “Why would you hang two different jerseys in a locker?”
This isn’t Junior Lake’s fault. This was a systemic error.
Why did they even have the wrong uniform with them that day? According to Paul Lukas and Uni-Watch.com:
I posed that question to a Cubs PR rep, who got back to me with the following: “We had both uniforms packed, since each day’s starting pitcher may decide which uniform the team wears while on the road.” So there you go.
Would you blame a nurse for grabbing the wrong medication out of a drawer, when the med wasn’t even supposed to be there and when the support system failed to put the right thing in the right place? Hospitals do this all the time and it’s not fair to the people working in the system.
Good factories, like Toyota, have great systems in place to make sure the right part gets to the right place at the right time. Hospitals (and baseball teams, apparently), not so much.
Would another nurse (or another player) make the same mistake in the same situation? If so, it’s a systemic problem.
Multiple nurses gave the wrong medication to the Quaid twins over the course of a day. That screams “system problem” to me.
Other players have worn the wrong jersey before (including last year). System problem! I agree with Lukas’ assessment that this will happen again, since the Cubs have 13 different uniform combinations.
How can we shift organizations away from blaming individuals? We can probably start by looking in the mirror. I try to be better about it myself. Maybe we can all try to set that good example — look for the system problem, not the individual problem.
About LeanBlog.org: Mark Graban’s passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all.
Mark is a consultant, author, and speaker in the “Lean healthcare” methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. Mark is also the
VP of Customer Success for the technology company KaiNexus.