Today's Post in <50 words: Lean thinkers don't blame individuals who in a bad system, whether that's a presenter at Oscars, a kicker in a football game, or a healthcare professional in a hospital.
I'm still thinking about what happened at the Oscars last week. I wrote my original post on a pretty “real-time” basis that Sunday night as details were becoming known.
I'd like to write more about it, as I think there are MANY lessons to be learned from the Oscars mixup that are applicable to healthcare and other settings.
Analyzing that as a case study isn't about fixing the Oscars (although I'd answer a phone call from the Academy or PwC on this). It's about learning from the mistakes so we can improve processes that are a matter of life and death.
The Oscars, An Embarrassing Preventable Error, #Lean, and Process Improvement
Too many people, still, are blaming Warren Beatty and/or Faye Dunaway. That's really unfair. As with many healthcare errors, they were at the “sharp end of the needle,” as they say. There's a human tendency to “name, blame, and shame” the person who “made the error” instead of looking at the system and why the error could have occurred.
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Back in 2012, I wrote this blog post about not heaping blame solely on a football kicker who “lost the game:”
A football player is part of a team and a system. A kick might be missed because of a bad snap, or a bad hold… or because somebody blocked a kick. Or, a team might have made other mistakes that prevented them from winning by 11 points instead of having to kick a field goal at the end.
It's funny how the world works sometimes. I got a request on LinkedIn from a college student who is graduating and looking for careers in healthcare administration.
His name was James Cooper and he said he was OK with me sharing this story (and to have you check out his LinkedIn profile). As we were talking, he mentioned that he was a kicker for Temple University.
A video of him kicking an impressive 55 yarder in practice:
I shared a link to the blog post about not blaming the Stanford kicker, as a follow up to our chat about Lean.
It turns out that Jim had his own situation in his first game, as an 18 year old, where he missed some kicks in a game and got blamed for it. Temple lost 28-6, so there were more issues than missed kicks (had he made the kicks, they still would have lost 28-13).
I invited Jim to share his story as a blog post comment, which he did:
This is an absolutely great blog. Coming from someone who has lived the ups and downs of being a kicker at the division 1 level, it is refreshing to see someone with no known biases take on a view of kickers and the struggling athlete in general with such a wide lens.
Coming out of high school a US Army All-American, I went into my first ever college game versus the University of Notre Dame without ever really experiencing a troubling performance. Long story short, I missed my only two field goal attempts and had my only PAT attempt blocked.
From hecklers on Twitter, to receiving threats from people I never even talked to, it was clear I was receiving a large blame for the loss. Without a doubt I feel as though I should've made those kicks, which could have definitely changed the outcome of the game. But anyone who knows sports knows that usually a loss doesn't stem from the performance of one singular player.
This is a great comparison to lean and how it applies to the Health Care field. With all of that being said, no excuse for missing the kicks I did. Perfect snaps, perfect holds, and if they went in, my team would've been in a much better position to win the game. I'm sure the Stanford kicker feels the same way. Thanks for an article that definitely expresses how many athletes who have ever struggled have felt. I look forward to reading more of your work!
As I told Jim, I admire the maturity that it takes to be able to tell a story like that, to hold your head high, and to grow from it.
Again, he's looking for an entry-level healthcare administration job, particularly focused on the patient experience, so please check out his profile.
And, lesson learned to sports fans (not those of you who read this blog, I'm sure) — stop being jerks and abusing college players on Twitter (something that, sadly, happens too often).
As I told Jim, I'm sure he will take these lessons with him into his healthcare administration career. I bet he won't be as quick as others to blame an individual when something goes wrong.
As with the Oscars, we need to ask questions and investigate, looking for bad processes, not bad people.
And as readers, I hope you do the same in your daily work and encourage others to stop blaming individuals for systemic problems.
In a future post, I'll write about how it's unfair to blame Beatty and Dunaway, but I understand why the Academy won't allow the two PwC employees involved to work the Oscars again.
Now, removing them alone won't solve anything if they don't also improve the process. But, these two were the senior leaders involved from PwC… they had a hand in designing the process and they decided to not follow the process. Beatty and Dunaway were the “willing workers,” as Dr. Deming would have called them. More to come.
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I think Amazon’s response to their recent server failures stands as a good example of focusing on the process that allowed an individual to make an inadvertent mistake.
Keep putting out the good word!