How to Establish a No Blame Work Environment

Blaming you. Anxious man judged by different people pointing fingers at him. Negative human emotions feeling

Focus on the Process is one of the Shingo Principles that highlights how all outcomes are the result of a process and consequently it is nearly impossible for people to consistently produce ideal results with a poor process. W. Edwards Deming captured this idea well when he said, “A bad system will beat a good person every time.” Understanding this is the first step to establishing a no blame work environment.

Like my colleague Stephanie Van Vreede’s reaction when asked to write about one of the Shingo Principles, I immediately jumped to my favorite, Focus on Process (I know, lean thinkers get excited about odd things don’t we?). When I was first exposed to lean thinking the phrase, “it’s the process, not the person” resonated with me because I feel that all too often people are accused of not doing their job when they were not at fault. And as one can imagine, this makes for a toxic environment. 

It is hard to avoid our natural, human tendency to blame the people involved when something goes wrong, so I would like to share with you some behaviors that can help you focus on process.

Define Processes Using Standard Work and Lean Tools

If you are going to focus on the process, you first must be sure that processes are well defined by standard work and that everyone is trained to the standard. This will give you a place to start when an issue or defect occurs.

For example, during my time as a director over a few surgical sub specialties we had an undefined process for determining surgical volumes for non-employed surgeons. It usually consisted of catching them on their way in or out of the operating room and having a quick conversation that went something like this, “You performed x amount of surgeries last year.  Do you think you will do that many this year? Can you increase by 5%?” Of course, arbitrarily coming up with targets during a conversation in passing is hardly a process, so when we would get questioned about why surgical volumes were not meeting target, and because we did not have any place to look all we could do was blame the people.

Go to the Gemba

Going to gemba is an essential behavior that demonstrates focusing on the process and helps to establish a no blame work environment. Observing the process and work conditions can be very telling about the root cause of a defect.

In my process improvement days, I often heard things like, “The OR start times are not meeting target because sterile processing isn’t delivering carts on time,” or “Surgery was delayed because the instrument tray did not have the things needed.” (The opposite of a no blame work environment). My wife, an operating room nurse and a first assist, would often share with me similar comments about sterile processing. I encouraged her to go to gemba and observe the work. After spending a few hours in the department, her thinking was changed.  She commented to me how the phone constantly rings, the staff is interrupted all the time, and preference cards were  different for the exact same cases.  She also observed how each tray had more instruments than they would ever need in the operating room and that all the cases seem to be scheduled at the same time.  It was an eye-opening experience for her and changed the way she thought about the people in sterile processing. This is all information that gave her an understanding of the processes and work environment that the department faced. She would never have obtained this level of understanding without going to see.

Seek to Understand

When an issue or defect occurs, seeking to understand rather than jumping to conclusions is another behavior that demonstrates focusing on the process. This means asking open-ended questions, collecting data, and listening to those involved in the process before reacting to the issue or defect.

One of the first questions a leader should ask is, “Is there a standard for this process?” If the answer is yes, then I always ask if the process was followed.  When standard work is followed and a defect is still produced I will start to track the reasons for the defect to see if this was a one-time occurrence or if trends start to develop. If the standard was not followed, then the question becomes whether everyone was trained to the standard and understands the importance of the steps, or if there was a specific reason to deviate from the standard.

Deming also said that people don’t like to make mistakes. The next time an issue or defect occurs, remember to focus on the process. To help establish a no blame work environment be sure to define processes using standard work and lean tools, go to the gemba, and seek to understand.


Chris Weisbrod, Network Manager


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