The Academy Awards Add an Inspector, Practice “Andon Cord Pulls,” Avoid Another Mixup


Tomorrow, my post will be about headlines that scream about ratings for The Oscars being “down from last year” or “the lowest in X years.” As I've blogged about before, I'm always skeptical of such simplistic comparisons that might mask the real underlying trend. Two data points are (usually) not a trend.

But first, could the Academy avoid last year's embarrassing mixup?

As I blogged about, the 2017 Academy Awards (a.k.a. “The Oscars”) will always be remembered for the process problem that led to the wrong Best Picture winner being announced.

The Oscars, An Embarrassing Preventable Error, #Lean, and Process Improvement

This year, Warren Beatty and Faye Dunaway were given a chance to read the winner properly (not that it was their fault last year, since they read the card that was mistakenly given to them and the “Best Actress” label was small and hard to read, as shown in my blog post from last year).

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Does Blame Really Help?

You can read a column that previewed this year's ceremony, blaming an individual for last year's mistake, although I'd label it a “systems problem.”

“{PwC's] Cullinan was not fired, but he became persona non grata for a while in the movie community — which is almost the same as death.”

The column also wrongly blames Beatty for not noticing it was the wrong envelope and also blames him for not calling timeout. It's always easier to blame and replace people than it is to fix the process, systems, or culture. But, fixing systems is more effective blame (as some in healthcare have learned).

Does Adding More Inspection Help?

The magazine Variety wrote about tightening “envelope procedures.

The Academy has added a third person to the backstage team.

Sadly, that reminds me of the way healthcare often adds additional inspection steps to processes like medication administration. It would be better to design a process that's “mistake proofed” where it's impossible for an error to occur. Relying on inspectors to catch mistakes isn't 100% effective — again, look at healthcare (or book editing).

Oh, and in addition to the third person, PwC's chairman “will be personally involved with Oscar operations this year.”

Does a hospital respond to a medical error by having the CEO get involved in double checking medications?? Thankfully, not.

In either setting, the CEO is responsible for systems and culture there is, therefore responsible for the results that the systems generate. But the CEO shouldn't have to be involved in micromanaging the daily work.

The article then has a bit more about the inspection — be more careful! Is that always effective? No!

“The new procedure also provides that both the celebrity presenter and a stage manager will confirm that they've been given the correct envelope for the category they are about to present.”

I hope they made that text bigger and more clear to make that inspection easier.

Toyota assembly lines DO have final inspection areas, which might shock some readers.

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Toyota doesn't yet have a perfect process, so they've decided (like every automaker) that the cost of inspection is better than letting a defect slip through to the customer. But 100% inspection is never 100% effective. They do, however, make sure the areas are extremely well lit. That makes inspection easier.

The Academy needed to also make things easier for the backstage team and presenters… and if there's a problem…

An Andon Process (& Leadership)

I do like this countermeasure that was mentioned in the article. It was something I suggested last year:

“Additionally, the three balloting partners will attend show rehearsals and practice what to do if something goes wrong.”

It sounds like they were instituting a process that we'd call an “andon cord pull” in the Lean methodology.

An effective andon cord or process provides:

  • a mechanism for people to speak up,
  • a culture where it's professionally safe to speak up, and
  • managers who respond and provide assistance as needed

Virginia Mason Medical Center has successfully adopted the andon concept. They call it the “Patient Safety Alert System.”

More Procedure Changes (?)

This next newly instituted rule confused me since I thought the PwC partners weren't supposed to be using social media already… Cullinan violating that rule was one of the contributors to the error, but they added (??) a rule. Or maybe they threatened or promised to enforce the rule. Looking at the process along the way instead of “naming, blaming, and shaming” after they got a bad result. Managing the right process the right way leads to the right results…

“The Academy of Motion Picture Arts and Sciences instituted a rule last year after the Oscar flub that PwC partners are prohibited from using cellphones or social media during the show.”

Maybe the Academy needs to add more “cell phone inspectors” backstage?

Come back tomorrow for a post that looks at this week's headlines and faulty analysis (from this week and over time) about the TV ratings.  My post will show a better way — process behavior charts (the topic of my upcoming book Measures of Success). 

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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