Thursday, March 29, 2012

Examine the System, Don't Look to Blame a Person

Stress Solutions, Not Blame by Kevin Meyer
A couple years ago I told you how the organization had created a nonpunitive reporting system for air traffic controllers to report incidents. That led to a dramatic change, which might initially be seen as a scary negative but as most of us immediately realize is a huge positive:
New numbers released by the Federal Aviation Administration show reports of air-traffic errors have nearly doubled in three years. The number of reported incidents in 2007 was 1040, and that number rose to 1887 in 2010, an 81 percent increase. This cultural change in safety reporting has produced a wealth of information to help the FAA identify potential risks in the system and take swift action to address them.
The point of using in-process and process result measures on well functioning processes is often overlooked. You don't want to spend too many resources collecting data that has little value, but proper process measures are very useful and should be monitored. Also this helps when you decide to improve (or radically change something somewhat related) and can catch things (unintended consequences) very quickly. The point of understanding the data (in context) is critical. Brian Joiner did a very good job of emphasizing this idea I think. If you want to reduce complaints it is usually pretty easy to do so, by making it really hard to complain. When you really care about customer focus, understanding if complaints are up do to better processes to encourage complaints or because your service is lousy is critical. Related: Find the Root Cause Instead of the Person to Blame - Dr. Deming, 94% belongs to the system (responsibility of management) 6% special - European Blackout: Not Human Error (System Failures)

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