A culture in which people are blamed for their failures and mistakes is highly damaging for innovation and for learning. If staff are worried that the finger will be pointed at them for trying things that don’t work then they will not try them. And if people are scared of recriminations they will not own up to errors and mistakes which means that an opportunity for improvement and learning is missed.
This problem is particularly acute in the health care sector where a blame culture can discourage whistle-blowers and individuals who want to report errors – their own or those made by others.
The Daily Telegraph reported that in 2002 Dr Gary Kaplan, Chief Executive of the Virginia Mason hospital in Seattle visited a Toyota factory in Japan where he was surprised to see at first hand the company’s remarkable ‘stop the line’ philosophy. Any worker on the multi-million pound production line can stop the line if he or she experiences an unexpected problem or difficulty. Senior technicians and managers rush over – not to berate the worker but to help them and to learn. That way they can improve the process for all workers and all Toyota plants. It is all part of the company’s famous ‘kaizen’ or continuous improvement concept.
Dr Kaplan wanted to introduce a similar process at the hospital so that staff would immediately report any incident which could be harmful to a patient. But he ran into opposition. The existing culture was ingrained. People did not want to go over the heads of doctors or to report things that might get colleagues into trouble. Doctors feared that admitting mistakes might lead to lawsuits.
It took a dramatic accident in November 2004 to trigger the change. A 69 year-old mother of four tragically died after she was injected with the wrong medication. The hospital immediately issued an apology and took full responsibility.
It made staff realise that Kaplan’s policies were designed to save patients and not to chastise staff. There are now about 800 safety reports every month revealing everything from tiny defects to major mix-ups. The reports are acted upon with the aim of improving the process so that the mistake cannot occur again. Blame and fear have been replaced with learning an improvement. The result is that Virginia Mason is now recognised as one of the safest of hospitals. Remarkably the change to an ‘owning up’ culture has led to a 75% reduction in lawsuits and a corresponding reduction in the cost of liability insurance premiums.
Two pertinent lessons for innovative leaders are clear from the story of Dr Kaplan and his hospital. First, a great way to innovate is to copy an idea from an entirely different field – in this case automobile assembly. Secondly, corporate cultures are remarkably resistant to change and it often takes dramatic actions to alter them.
If you have a blame culture in your organisation and you want to change it to one of transparency and honesty then here are some practical steps you can take.
- Focus the message on the benefits of innovation and continuous improvement and on the risks inherent in covering up failures.
- Senior executives and managers should lead the way by pointing out mistakes they have made and how similar errors can be avoided in the future.
- Whistle-blowers who point out serious flaws and failings should be singled out for praise (unless they wish to remain anonymous).
- You could invite an external speaker from an entirely different industry (e.g. Toyota) to tell their story.
Transparency will shine a spotlight on reckless or incompetent individuals. But that is not its primary purpose which is to enable continuous improvement based on all the little fears, problems and errors that clog the current systems and stop us from being more efficient and more innovative.