Finding the root cause for errors and preventing them from happening again is always good business. Your quality improves every time you prevent an error. Costs go down. And in some industries, like pharmaceuticals or medical devices, it's more than good business. It's the law. So there are plenty of incentives to find the root causes for errors.
Why then do we managers do such a poor job of investigating errors? Let's examine a typical case.
Jennifer is a new manager. Something has gone wrong and everybody knows it. Operations have come to a halt and it's her responsibility to investigate. She has to find out why this error occurred and make sure it doesn't happen again.
Being a typical manager she's been locked in a meeting room all morning, and by the time she gets back to her desk her email in-box is exploding out of her computer monitor. Not to worry. She can't see it anyway. There are sticky notes all over the monitor telling her to call everybody on the planet and explain the horror show that happened in her department while she was at the meeting.
She's in a pretty foul mood when she scurries out to the operations area. She tries to remain calm but her employees know she's not happy. They are head down and suddenly very interested in their work, wondering who is going to be interrogated.
She selects her quarry and the chase begins. "Where were you when it happened?" she asks.
"Oh, I was on break. I didn't see anything," comes the answer. And this victim manages to escape.
She pounces on another employee. "What do you know about it?" she asks.
"I just followed the instructions as they were written. I don't know anything," comes the answer. This quarry, too, escapes this day.
The chase continues until an inexperienced employee seriously thinks about her questions and answers truthfully. "Well, I saw something unusual. It seemed trivial at the time and I really didn't pay any attention to it."
Jennifer sees her chance and takes it. She scribbles on her notepad: "Employee needs to be more alert. Assigned to be retrained." Then she strides back to her desk to write her report, relieved that she could cross that job off her list so quickly.
But can Jennifer really cross it off? Not likely. It will surely come back again. Nothing really has changed except that the mind of one thinking employee has now been turned off. That's not all. Other employees who might have added thoughtful insights to the problem observed the interchange. And although they appeared to be so very absorbed in their work, they were learning a lesson.
Could this be you? When you go out to investigate errors in your organization, does your best source of information about the failure dry up because the employees fear repercussions? If this sounds familiar, can it be surprising that the same errors keep coming up over and over again?
Do you want to avoid this happening to you? Do you want to convince the employees to actively help you find solutions rather than to passively resist? The key is in recognizing that fear is motivating their behavior. Here are five time tested ways that will make any manager's life a little easier.
Brainstorm, don't blamestorm. When you investigate errors, focus on repairing the business process, not the people. Frame your questions around the assumption that there was a weakness in the system and some unlucky employees happened to fall into that trap. You should rally the employees to work as a team to figure out how the weakness occurred so it doesn't happen to them the next time.
After you have found the root cause of the error you need to implement corrective action to eliminate it so that the error never happens again. Always try to make your corrective action an engineering or procedural change. Constantly work to make your business process more resistant to input variability.
These kinds of corrective actions are much more effective and permanent than personnel indictments. And they have the added advantage that they don't create more fear in the employees. "Employee needs to be more alert" or "Employee assigned to be retrained" should be last resorts as corrective actions.
Develop a Standard Operation Procedure for investigating errors. If you have an SOP for investigations, then the employees know what's going to happen. Predictability allays fear. When you're asking all those questions, you're simply following the procedure.
The procedure doesn't have to be complicated. Start with the five W's: Who, What, When, Where, Why. Don't use names when filling in the Who. Use position titles.
The SOP should require that the investigator find the root cause for the error if at all possible. Corrective actions should be assigned to individuals with target dates. The SOP should also include means of verifying the effectiveness of the corrective actions.
Assume that all your employees want to do a good job. You'll be surprised how true that is. Sure, you might get disappointed at times, but those occasions will be rare. People will rise to your expectations. They will feel your attitude and will be more open to brainstorming solutions rather than covering up.
What if you really can't convince yourself that all your employees want to do a good job? Fake it. Act as if they do and play that role until the problem is solved. Your laser-like attention to fixing the business process will draw the employees in with you.
Drive out fear. W. Edwards Deming, the famous quality guru, insisted that managers must drive out fear. But in training seminars many managers would ask, "Why should employees fear me? I'm a nice guy, and besides, I'm just doing my job." Deming would respond that fear arises from the structure of the employee – manager relationship.
In the mind of the employee the manager has all the power in the relationship. The manager determines the employee's raise. The manager can hire. The manager can fire. When someone has that kind of power over anyone, it's natural for that person to have fear.
Even if you're a new manager walking in the door, sight unseen by the employees, there is fear in the workplace. Unless you do something active to drive it out, it will remain there. And it will inhibit your from rooting out the errors in your business processes.
So how do you drive out fear? You do it by earning the employees' trust on a daily basis. One good way is to always meet your commitments. If you say you're going to do something, you have to do it -- every time. If you say that you will meet an employee at a particular time to discuss something of concern to him, you'd better be there.
Sometimes you won't be able to make every commitment that you would like. There may be an employee who really wants, and deserves, a raise. How easy it is to say, "I'll take care of it."
This is a temptation that you have to resist tenaciously until you know for sure that you CAN take care of the problem. Because if you fail, you are now a liar. Remember, in the mind of the employee you are the boss and you have a lot of power. Better to under promise and over deliver.
It may be painful to only say, "I'll look into it," when employees make reasonable requests. But it will pay dividends when you have to investigate an error and you tell those involved that you're not out to find someone to hang.
Manage By Walking Around. Don't wait for the next crisis before getting up from your desk and out where your employees work. Sure you're overloaded. But if the only time your employees see you is when you storm out of your office with a problem and an attitude, they will be ducking for cover at first sight.
When your employees get used to the sight of you circulating around when there's no crisis to resolve, they'll be more open to brainstorming when the time comes to search for root causes for errors.
An added advantage is that by staying in touch with the people who actually do the work you'll know what's truly important in your department. When you have all the information, you can make better informed decisions about how to prioritize your work.
Follow these five principles and your error investigations will improve quickly. Your corrective actions will prevent similar errors from occurring. Each error prevented will create more time to research other errors and the process will feed back on itself.
Your employees will become more open with you in the error investigation process. Soon they will learn to take more of the responsibility on themselves. This will free you to take on additional responsibilities.
Call (734) 274-4680 or email us at Ask VCI to find out how VCI can help you.
Alternatively, call Dr. Norm Howe, Sr. Partner, directly at 734.740.9924