Very popular these days is the idea of a “blameless post-mortem.” After all, as Dr. Paul Batalden liked to remind us, “Every system is perfectly designed to get the results it gets.” Don’t blame the people; blame the system.
I am all for blameless postmortems. When performed honestly, they offer the kind of psychological safety that is crucial for discovering which parts of the system contributed to failure. This safety is important because systems are the results of human decisions.
Part of your system includes your company values, and how those values are modeled, discussed, and rewarded by the company leadership. Your system includes every human-created artifact that might show up on a Lean Six Sigma process map. Your system includes the automated processes that were designed and implemented by people.
When the system leads to bad outcomes, the system needs to change. And that means people need to change.
Wherever you find yourself in the leadership hierarchy, consider the role you may have in perpetuating the flaws of the current system. And as you identify areas that may need to change, remember that those who implemented those systems did the best they could in their environment with the knowledge they had. Be explicit in separating the deficiency of the system for today’s conditions from any blame on the original creators, while also acknowledging people’s responsibility to correct their part of the system.
If you’d like to explore the enforcement of responsibility without blame in your situation, let’s talk. Visit stevedwire.com/talk to start the conversation.
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