Some time ago, a company asked for a review of their manufacturing environment. Immediately it was noticed that management did not allow a manager to blame an employee’s actions as the root cause in a safety or quality incident investigation – even if the employee blatantly violated a procedure or rule. Certainly, this follows Dr. W. Edwards Deming’s principles.
In one example uncovered, an employee was grinding metal without wearing safety glasses and got injured when a metal fragment got in his eye. The accident’s root cause was not that the employee was ignoring the rules. Not following the safety rules was the cause of the accident, but not its root cause.
The accident’s root cause was that the employee was not motivated to follow the safety procedure. The accident investigation becomes much more meaningful when the investigator attempts to find the deeper root causes that resulted in this person doing something unsafe. Tackling this deeper and more difficult question led to more effective corrective action.
What could be some possible root causes of this situation? Maybe the employee never followed safety procedures and management was fine with that until the person got hurt. Maybe the person was in a hurry to support the flow of production and the environment actually motivated the person to put grinding the metal quickly ahead of creating a safe work environment. It could be that local management, maybe unknowingly, rewards people for doing complex tasks fast, but fails to properly reward people for working safely.
People generally stray from following important safety and quality procedures because management has created an environment where people are motivated by factors other than safety and quality. The reality is that in some organizations many factors are valued more highly than quality and safety.
How about your organization? Are you more likely to be rewarded for hitting a challenging ship date or satisfying a customer? Are you more likely to be rewarded for making heroic efforts to address customer complaints about quality rather than making heroic efforts to make sure the products the customer receives are defect-free? When releasing new products, does your organization celebrate the completion of exhaustive quality testing or gigantic efforts to ship the first product?
Maybe employees, despite what management says, violate safety and quality procedures because quality and safety are not the highest valued operating principles. If so, that is misguided. It is wrong from an ethical perspective as well as from a business perspective.
Let’s look at this from the viewpoint of the customer. Would a customer rather receive a high-quality product a few days late or a defective product on time? Would a customer rather have great customer service from a company, or never need to make a service call? Would a customer rather have a thoroughly tested new leading-edge product after extensive testing or a shortened testing period now?
It's been my experience that customers put quality above the other factors. Because customers ultimately decide which companies will succeed, quality really should be the underlying core culture.
While it can be challenging to understand why other factors displace quality and safety as true core values, there seems to be two main reasons. The first is that many businesses have a short-term focus. They are often motivated by short-sighted leaders who focus on positive revenues and profits right now. Their approach is to collect the money now and deal with quality problems later (or maybe someone else will have to deal with the fallout after they have moved on).
The second reason is that management is reluctant to blame themselves for the root causes of quality and safety issues. The employee and or their supervisor who did not follow the procedure is a scapegoat to hide behind when the fictional quality and safety culture that management is responsible for is put to the test.
Managers must continually work to improve their quality system, which is the driving force that encourages everyone to take responsibility for doing things right for all the right reasons. Root cause investigation must uncover and correct environmental cracks which result in inaccurate procedures or allow them not to be followed.
Recall the teachings of the great quality leaders. Rather than be upset at someone not following the procedure accurately, we need to ask what factors have crept into the system and then address those issues effectively. If we do that well, we will be successful in realizing that quality is core to our business strategy. The end result will be a significant edge compared to our competitors which, in turn, will have a dramatic effect on the bottom line profitability in which everyone wins!
