It’s the Process not the Person

We Don’t Wake Up Scheming to Make Defects at Work (Most of Us)

My mentor, Rodger Lewis, drilled this one into my head from our first meeting.  While we love to blame people for outcomes, the truth is that the process is the culprit.  Most of us don’t wake up in the morning and think, “How can I cause a problem at work today?”  We don’t brush our teeth and ponder ways to create defects. In fact, most of us go to work thinking, maybe even hoping, that nothing goes wrong.  But, for some reason, we act like – therefore at least at that moment, we believe that – people are planning to do wrong at work.

We don’t wake up scheming evil at work.  Just our problem employees do.


I often find myself quoting another great friend and colleague, Dr. Rick Kunkle, a retired emergency medicine physician and healthcare executive.  Rick (“Doc”) Kunkle says, “The process is perfectly designed to give you precisely the result you are getting.”  When a defect surfaces, the process produces it.

Some will argue in favor of human error, to which I’d just reply, “Your process allowed the error.”

Med Error or Human Error: Process or Person?

I was working with a nursing manager a few years ago. She had 60 plus direct reports. As her organization hoisted lean on her without preparing her mind and heart, she saw it as a heavy burden. When problems surfaced on her team, she quickly ran herself ragged working offensively to contain them.  She was just doing what had been successful for her: firefighting.   When she couldn’t contain them all, she slipped back into her default defensive mode: blaming. First, she’d blame her leaders for forcing her to change, and then she’d blame her team.  One day, a serious medication error alerted the unit to the potential harm they were doing to their patients.  Instead of blaming people, she took a team with her to solve the problem. As she went from the point of recognition (the patient got the wrong med) to the point of cause (when the nurse was pouring the med), she realized that in the spirit of not harming anyone else, any one of her team could have made the same error.

Why?  Because the process allowed the error to be made.

Fatigue, distractions, confusing med names, similar patient names all create the potential for errors.

Waking up in the morning and devising evil plans to fail?  Not so much.

The distractions at the point of cause were many.  Their med dispensing unit had been located in the midst of their nursing station – the hub of all things on the unit – because power and internet cabling was readily available there.  They were thinking cost savings over safety.  It made sense to the nursing manager because so much of the nurse’s work away from the patients was done there at the hub.  They were putting productivity before safety.  When they observed nurses being interrupted endlessly whiling pouring meds, they knew they had put that step in the process, pouring critically controlled meds, in the wrong place.

As a new containment, the nurses would don fluorescent orange and yellow safety vests – the kind you’d see in a factory or on the highway – when they poured meds in the busy area.  It was a visual signal to not interrupt me when I’m pouring these meds.

Re-Thinking How We Think: it’s the process not the person

So, how does a wise leader correct his or her defensive thinking?

First, take every leadership thought captive to the principle: it’s not the person, it’s the process.  As much as your heart wants to believe that John Doe is an idiot or, worse, an evil person planning to make defects on purpose, let common sense prevail.  Sure, John Doe’s personality may make him hard to manage, but the process delivered precisely what it was designed to do.

Second, begin to practice error proofing.  There are four levels of error proofing: elimination, prevention, detection and loss control. Eventually, the nurse manager I mentioned was able to move the medication dispensing unit.  Her containment worked as a form of prevention, but by moving the dispenser to a quiet, non-traveled area, she eliminated distractions coming from the unit nursing station.  Yes, the nurse pouring a med still was responding to call signals and pager calls, but at least the manager had eliminated some of the distractions.  To her credit, the nurse manager rounded the pdCA cycle and began to work on solving the next med error distraction problem: group pages that didn’t require a nurse to stop pouring a med.

Lastly, lead your team into this new mindset.  It’s so easy to get caught up blaming someone else.  For some reason, we believe that we are better if we can compare ourselves to others failures.  Truth and transparency prove otherwise.  Remember how our nurse manager realized that anyone could have created the med error with the process as it was? Lead your team into humility by practicing humility as you lead them.

Rodger and Doc knew the principle and lived it: it IS the process NOT the person.  The sooner we believe that the sooner we find our way to sustainable gains and a safer place for our patients and our team.