The Just Audit team
RCA Part 7: Don't play the blame game
"Ownership: 'A commitment of the head, heart, and hands to fix the problem and never again affix the blame."
John G. Miller
Is there ever a time when blame is genuinely useful? Can we separate single incidents of blame from faults in an ongoing process that could be improved? And shouldn’t we look for opportunities for improvement in everything we do?
As you have read in previous articles in this series, organisations often stop at the most obvious causes of a problem. Not surprisingly this is usually someone who is an easy and obvious target for blame. However, blame is not helpful when it comes to learning lessons and ensuring an incident doesn’t repeat. Blame distracts from the bigger picture and causes people to close ranks and severely reduces the flow of vital information.
Great organisations don’t confuse ‘blame’ with ‘accountability’. Accountability not only means taking responsibility for any actions but also a willingness to give a frank account of any events and identifying steps that could be taken to reduce the likelihood of recurrence.
In order to ensure data (knowledge and information) flows freely, great organisations develop a culture that encourages error-makers (those who hold the knowledge and information we seek) to be transparent and explain why an event happened exactly as it did. If organisations jump too quickly to blame and punishment they reduce accountability and diminish their ability to uncover many of the deeper, systemic causes of the issue.
If you’ve ever worked in a blame culture you’ll know how sharply it contrasts with a culture of accountability. A blame culture is a short-sighted approach to productivity and usually a self-fulfilling prophecy. Looking over your shoulder with the threat of punishment, sanctions or job loss doesn’t motivate anyone to contribute their best work or brightest ideas.
Of course, many organisations appreciate the need to reduce blame. In order to avoid pointing the finger specifically at someone, some of these organisations resort to catch-all categories like ‘Human Error’. Whilst it’s a step forward, it doesn’t work in practice, because such terms are vague and can be interpreted in many different ways. Solutions can’t be found so it’s not very helpful.
Successful organisations work towards a ‘Just Culture’ or ‘Culture of Accountability’ through which they fully accept that people make errors. These organisations create environments where full and frank explanations can be volunteered safely and without fear of undue discipline. From here they can use this knowledge to successfully drill back to uncover the specific root causes that made their negative outcomes possible (or more likely). Effective actions can then be taken to make repeat or similar outcomes less likely or even impossible.
Additionally, working in a positive, enriching way, without fear or anxiety, promotes teamwork and a willingness to create the very best work environment.
Have you ‘drilled back’ to understand what made that person behave that way?
Are you helping your organisation to create a problem-solving culture?
All organisations are, at their core, data processing engines. They create data, attempt to understand it and then aim to improve activity. Any behaviour that encourages individuals to withhold information or close ranks will stem the flow of that data and can ultimately reduce performance.