Eight years ago today, I published a piece originally on LinkedIn as part of their “Influencers” series:
Here is the full text of that piece:
When any organization has quality problems or safety problems, this is clearly (to me) the responsibility of leaders and managers. When you're the boss, you are (like it or not) responsible for everything that happens in your organization, whether it's a restaurant, a factory, or a hospital. Sadly, many leaders think they can get away with blaming their employees when things go wrong. This behavior doesn't improve quality or safety.
My wife and I were about to go to a Mexican restaurant in San Antonio last weekend. We had been there once before and it was decent, if not good – but not great. More importantly, it was located pretty close to other places we needed to go on Sunday. My wife was looking up their hours online and, thankfully, found a report of a bad health department inspection (read here).
The news story said the restaurant:
… failed their inspection with 41 demerits.
A year ago this month, they failed with 51 demerits. Some of things that were a problem last April were a problem again.
What were some of these problems?
- Refrigerator at too high of a temperature
- Blood from raw meat dripping down into flour
- Moldy cutting boards
None of these problems are invisible. There's really no excuse for any of those problems happening, ever. If a restaurant hires well, trains well, ensures employees have safe food handling certifications, and manages well, these problems would never occur.
What's even worse is the owner and the manager of the restaurant did not correct serious problems found a year ago. Or the problems were “fixed” (in the short term) but were allowed to pop up again. Yuck. We would have never eaten there, had we known (and we found another restaurant that day).
As we see on TV shows like “Kitchen Nightmares” and “Bar Rescue,” these types of problems occur and fester due to a lack of leadership, plain and simple. You have absentee owners or weak leaders who don't look for problems or they just ignore them. These owners either don't see the problems (because they aren't looking) or they just don't know what to look for.
Sometimes TV cameras and a screaming guy show up – sometimes it's the health inspectors.
Back to the news article about our local restaurant:
The manager confirms that many of the same problems exist and he's called another all-hands-on-deck meeting to get the staff on the same page. He says their re-inspection was last week and went well.
This sounds like he is blaming the staff. Why weren't they “on the same page” to begin with? This is the owner's responsibility and the manager's duty. Did a manager get fired? What is the owner going to do to improve the system? They had one good inspection… but will the improvements last? Will people slip back into old bad habits?
If they had an “all-hands-on-deck meeting” before and quality didn't improve, why will this work this time?
Quality starts at the top because leaders are responsible for the design of the system. This includes hiring, training, and supervision – along with making sure people are aligned with the mission and values of the organization. Do employees feel appreciated? Do they have the time to do their work the right way or is the organization understaffed and overburdened
If you have a bad system and you fire all of the workers… you'll still have a bad system.
We often see similar things in healthcare, where the stakes can also be a matter of life or death (with outcomes worse than food poisoning). If you recall the case of the actor Dennis Quaid's twins being harmed by a preventable medication error at the famed Cedars-Sinai Medical Center, leaders blamed employees for systemic problems.
The Chief Medical Officer said:
This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai.
“There's no excuse”? There are plenty of “excuses” (or reasons or causes), including poorly designed work processes and a lack of understanding of human factors that led to multiple nurses making the same mistake with the same babies. The nurses gave an adult-dose medication to the neonatal ICU patients… a medication that wasn't even supposed to be there. So, the pharmacy made errors and nurses didn't catch an error that they weren't expecting could even happen (and the bottles of the two different medicines were very similar shades of blue… especially with the caps off and in a dark room at 2 am).
As one employee (at a different hospital) told me recently, “We aren't given the tools we need to do our job and then we get blamed for the problems that result.”
Far too often, when leaders talk about “accountability” and “holding people accountable,” they mean they are going to blame and punish employees. When problems are caused by systemic factors and poor processes, leaders need to look in the mirror and take actions that only they can take to improve the system.
As the great Paul O'Neill said (when he was CEO) after an Alcoa worker was killed in an accident:
“We're the leaders. Leaders are responsible for everything in an organization–especially what goes wrong. We killed him.”
Do you see examples in your own work where individuals are blamed for system problems? What actions do leaders take? Do you see leaders shirking or pawning off their own responsibility? Do these actions lead to improvement or do we need to try something new?
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