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The 5 Why's

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Blameless problem solving - Douglas O. Guffey

JW Way Fundamental #22: Practice Blameless Problem Solving 
"Blame has no place in our firm. Fix errors by focusing on solutions, not assessing blame. Learn from mistakes and use that knowledge to improve our processes. Mistakes are critical component of learning." 

It is natural to feel defensive when something goes wrong.  In many organizations, being constantly self-protective is a wise strategy, because any blame or black mark that attaches to an individual becomes the reason to not select that person for opportunity or advancement.  Some organizations even practice “scapegoating,” selecting the politically weakest member of the team to bear the blame and the adverse consequences of a failure.  Few behaviors have a greater negative effect on team cohesion and productivity than the feeling that you must “watch your back” when among your teammates and in your own work “home.”

At Jaburg Wilk, we have consciously chosen not to play the “blame game.”  When something goes wrong, we go beyond identifying the proximate, immediate cause to look for and identify any latent or systemic cause.  Human error is most frequently the proximate cause, but systemic deficiencies often increase the chance of human error.  None of us are careless; if we made a mistake there was a reason.  As team members at JW, we seek for that reason and improve our systems and ourselves to decrease the chance of error in the future.

One useful tool for identifying the root cause of a failure is called the “5-whys.”  On the surface, this is the simple process of asking “why” several times until you arrive at a basic element of the situation that you have the power to change and if changed will at least potentially alter the chance of future failures.  Here is an example used by CEO Jeff Bezos of Amazon during a visit to one of that company’s order fulfillment warehouses:

A worker had severely injured his thumb moments before Mr. Bezos’s arrival.  Upon learning of the incident, Bezos went to a whiteboard and began the following analysis: 

Q: Why did the worker damage his thumb?

A: Because his thumb got caught in the conveyor. 

Q: Why did his thumb get caught in the conveyor?

A: Because he was chasing his bag, which was on a running conveyor belt

Q: Why did he chase his bag?

A: Because he placed his bag on the conveyor, but it then turned-on by surprise 

Q: Why was his bag on the conveyor?

A: Because he used the conveyor as a table 

So, concluded Bezos, the likely root cause of the worker’s damaged thumb is that he simply needed a table; there wasn’t one around, so he used a conveyor as a table.  To eliminate further safety incidences, Bezos ordered the warehouse managers to provide tables at the appropriate stations or provide portable, light tables for the associates to use.  He also told them to update and give a greater focus to safety training.  

In addition to effective problem-solving techniques, several associated behaviors are necessary to making blameless problem solving effective:

  • Blameless does not mean unaccountable.  We are each accountable to ourselves and to each other for accomplishing our personal goals and the firm goals.  First and foremost, we must protect our clients’ interests.  We each must own up to what we have done and hide nothing, not from our clients, not from each other and, most important, not from ourselves.  Problems identified can be fixed.  Problems concealed will fester.
  • We must support each other when failures are examined.  Human error is human and a natural part of life.  We are in this together; we accept and prize each other.  When a problem arises, we will fix it together and act to pull everyone up, not push anyone down.
  • We make corrective changes fully and promptly.  A culture of blameless problem solving is not a license to ignore a systemic problem or continue a risky practice.  Identify it, analyze it, and fix it.

We admit our mistakes, we learn from them, and we fix them.  That is the JW Way.


About the Author: Douglas O. Guffey is a healthcare attorney and partner at the Phoenix law firm of Jaburg Wilk. He assists clients with the business of medicine.