Have you ever made a mistake at work? How about in life? I generally don’t go more than 30 minutes without doing something pretty dumb; so, if you’re anything like me, the answer to both questions is a resounding yes. If you’re human, you make mistakes. Mistakes are one of the most productive ways we learn and adapt. If you’re human and you work, you make mistakes at work.
For an employer, that mistake might be costly in a bunch of different ways. It can cost an employer a great deal of time, money, credibility, and effort to correct employee mistakes. Do you know what’s even more costly than fixing a mistake? Blaming employees for making them.
“But, Jay, what about accountability?” Accountability and blame are two different things, with accountability being the much more difficult path. Accountability means looking at the complexity of the error, not just the person who happened to make it. Accountability means looking at the many systematic interactions that lead to a fault, identifying where they can be improved, and then putting the proper structures in place to fix them. That takes A LOT of work.
Because accountability is so labor intensive, most organizations default to blame. It’s far easier to point out the person who made the mistake as the sole cause of an error than it is to zoom out and take the macro view of the system.
“Joe was the last person to use the toilet before it overflowed; it’s obviously his fault, and he’s responsible for all this damage.” Simple, no further thought required.
Joe gets reprimanded (aka “held accountable”), but do we really have accountability? No, we don’t, all we did was blame Joe, and close the book. And by blaming Joe, we closed the feedback loop that could potentially avert future errors.
Do you think Joe (or any of his co-workers) are going to be willing to speak-up next time they almost make a mistake? Nope. As a matter of fact, the next time they make a mistake, they probably consider trying to hide it so that they don’t open themselves up to blame and punishment. This is known as a “closed loop system.” A work environment where mistakes, near misses, lessons learned, and opportunities for improvement, are be buried for fear of blame and punishment. Buried for now, but destined to pop up again later, just hopefully not on Joe’s watch.
The better solution is the “open loop system.” These are the types of transparent and engaged work environments where the goal is not punishment and blame, but reduction in error and improvement of outcomes. The end goal is high reliability. Open loop systems are what turned around the safety records of industries like aviation, medicine, and nuclear power. They are known has HRO’s or High Reliability Organizations: workplaces where operations have high risk and small errors have enormous impacts.
Those fancy organizations are still run by humans, and guess what…humans make errors. How do mitigate the risk of human errors? By removing blame and taking accountability. Human error is assumed in the system, so leaders care little about WHO made the mistake, instead they care much more about WHY, the mistake happened. Leadership recognizes that it is their job to take the hard path towards accountability, instead of the easy blame game route. It is leadership’s job to ensure workflows are simplified, ergonomic, safe, redundant, and thoughtfully laid out. They empower employees to proactively report errors, near misses, or concerns.
In hospitals, the most junior nurse is empowered to stop the most senior surgeon, by “stopping the line,” “arching up a concern.” Literally, those words cut through all hierarchy and dogma and allow junior employees to address a concern on the spot. These actions are built into the culture because they are supported by policy and management systems and modeled by leaders.
Safety reviews in aviation are anonymous. Self-reporting an error is protected by “safety privilege” which cannot be used in civil, criminal, or disciplinary proceedings. Further, if you proactively report a mistake and it gets investigated by the FAA, any finding against you is deferred (as long as you haven’t used “safety privilege” in the past 5 years) and eventually redacted from your record.
I’m certain that if you pulled out your organization’s mission and vision statement, there will be some catchy passage about “accountability or transparency,” but if the description of the “closed loop system” sounds more like your daily life, then “accountability” and “transparency” are not your organizations goals.
There are lots of people, smarter than I, who have intimate knowledge of the change in management process within an HRO and how to get an organization to adopt HRO principles/culture. Matthew Syed wrote a fantastic book about the above topics called “Black Box Thinking.” If you’re interested, you can find it here. He also has a ton of resources on his website.
If your employer has rolled out fancy new surveillance systems but hasn’t offered any explanation as to how they are going to improve the system beyond “holding people accountable,” beware. They are setting up a closed loop system, and they are squandering their investment by not offering protection for mistakes.
Every employee and employer stand to benefit from adopting HRO principles and reducing blame. In the public sector, taxpayers will see greater efficiency for their dollars, and in the private sector, profits will increase.
If you feel like you’re working in the closed loop system and want some help, give Nutmeg a call. We want to help your employer adopt a culture of high reliability. It’s better for everyone.