Many organizations aspire to become a learning organization. Continuous improvement and learning from our mistakes often is their credo. In such an organization you may observe the following scene. Picture a quality laboratory, testing the quality of a pharmaceutical end-product. In the analytical procedures one of the first steps is to crush 10 tablets in a jar. During a daily standup meeting the issue was raised that sometimes 9 or 11 instead of 10 tablets were crushed, yielding incorrect results. While searching for the root cause of the problem, the team excluded defects in the SOP or knowledge of the lab technician performing the task as the root cause. The team finally concluded that this was a typical case of a human error. People do make counting errors every now and then and that is just part of who we are. Since that company was actively living up to their aspiration of not having a blame culture, the case was left at that. The lab technician, let’s call him Jack, was forgiven for this mistake. Jack promised to pay better attention in the future and things were said like: “It could have happened to me as well” This was said with the undertone of, I am glad it was you instead of me.
And that was the end of it. At least for the team. Jack still felt blame towards himself. How could I have been so stupid. I won’t let this happen again. And although there was no blame towards Jack expressed, he found himself blaming himself for his mistake. Jack felt more stress doing his job because he was afraid, he would make the same mistake again. He was probably most afraid of the team finding out he made that mistake a second time. It made him feel insecure and he started double checking his counting of the tablets to make sure he did not repeat his mistake. Jack was not in a happy place.
A ‘no-blame’ culture in this instance has resulted in a self-blame situation. A no-blame culture often has the tendency to accept human mistakes as a given, however we do not blame you for that. It is accepted that this is the situation, and you are not accountable.
A ‘no-blame’ culture... has resulted in a self-blame situation.
I’d like to mirror that with what is called a ‘Just Culture.’ A just culture works from three premises: 1) mistakes are regarded as a product of the organizational culture or the systems employees have to use to get the work done, 2) we need to create a work environment built on trust where it is safe to share what actually happens, and 3) people are held accountable for willful misconduct or gross negligence. In that line of thinking, mistakes or human errors have a cause and these causes can be addressed. If the organizational culture tells you that we accept that all people make mistakes, people will often treat human errors as the root causes of a problem. However, when the organizational culture tells you that we regard a human error as a symptom of the work environment, we place human errors in a different perspective. Now we have the process to blame rather than the person. We therefore need to understand what can be changed in the process to prevent or reduce this occurrence of human error.
In our case, Jack made a counting mistake. We know Jack can count so there is no additional training for that needed. But we also know that miscounting can happen. The key question to answer here is, can we change the process to get rid of the counting step. How can we get 10 tablets in a jar every time without counting? The solution was to take a piece of Perspex and drill 10 holes in it. Filling these holes automatically gives you 10 tablets, without counting. This change in the process eliminates this so-called ‘human error’ all together.
My question to you is, how are you treating human errors in your organization? Are human errors regarded as a legitimate cause? what are the implications and how can we start building a just culture?
I would love to see your responses in the chat.