By R. Bruce Wright, CPCU
For most companies, especially smaller companies, learning from mistakes is the single most important management tool they can use to really improve the company's performance and profitability. Many of our clients will recall hearing us say that learning from mistakes may be the most effective improvement technique, although learning from other people’s mistakes is cheaper! This article is an effort to reinforce the technique of learning from mistakes using a real-life example taken from some work done many years ago by our founder, Dean Wisecarver.
Many years ago Dean did some safety management consulting for a small manufacturer located outside of Atlanta. This company made precision plastic injection molded parts for a variety of customers. It had about 120 employees, was reasonably well managed by people who understood that providing a good place to work and being successful as a profit-making enterprise somehow went hand-in-hand. The company had its share of employee injuries from cuts, burns, slips and falls, all from rather typical, even mundane "accidents" experienced generally in the plastic injection molding industry. He tried to encourage the management team to use those "accidents" as opportunities to recognize that something didn't go correctly in their operation, to see that each error that showed up as an employee injury was worth some investment to find out how they could change the process or change the training or change the physical setup; to do something that might give each and every employee a better chance to do the job right the first time without getting hurt.
Maybe you even recognize this conversation from past visits with a Synebar Solutions consultant! Like most of our contacts, these managers listened and nodded their heads, agreeing with the principle, but not really committed to the effort. They didn’t see what was in it for them, nor did they really get just how to go about improving based on what happened in “accidents,” that is, how to learn from things that go wrong.
Then, one day on a later follow up visit, Dean met with the company’s President. During their discussion, the President brought up an incident that happened just the preceding week. It seems a major customer called in a panic, needing some additional plastic parts to complete an order for one of its own customers on a rush basis. As a result, our client had to do a special rush run of the needed parts, which it was most willing to do for one of its most important customers. The run was done, the parts were packaged, and then shipped overnight to the customer. Only the next day did they discover that with all the rush and all the people who had to handle the request, the work order, the invoicing, and the shipping, something had gone badly awry. The entire shipment was sent to the wrong customer!
The President admitted it was a painfully embarrassing situation and he was mad. He went stomping after the shipping supervisor to chew him out for the mistake. When the President finally settled down enough to let the shipping person explain and show him the paperwork sent from the office, it became apparent it wasn't really the shipping supervisor's fault. The company President took the time to met one by one with everyone in the company who had anything to do with this special order. He quickly realized there wasn't anybody to be mad at or blame. Everyone involved was doing what they believed was right and good for the company. What he did discover was that there were flaws in the way that all the order processing at the plant was handled. Under normal circumstances, someone quietly took the initiative to correct errors on an order-by-order basis. When he asked why no one ever told him or other managers there was a problem, his people told him they thought it was no big deal or management would have changed it by now. The President admitted it was only because of the rush in this case that the problem didn't get fixed along the way. He said, "It's probably good this happened or we might never have realized we were doing things wrong."
Once the immediate situation settled down, he calmly "investigated" further, asking a variety of employees for their ideas and suggestions on how the process should be changed to reduce or eliminate similar errors in the future. He told me how, in the course of their assessment and idea-sharing, they all discovered better, more efficient ways of handling orders that brought improvements well beyond the original error. And the most significant thing he said he learned was that the problem was not with the people involved, but with the process. Changing and improving the process made his people better able to do each of their tasks correctly the first time around. He was absolutely bubbling with what this one incident did to improve his entire operation. Then he said something amazing!
He said that while he was reviewing the materials from previous consultations in preparation for this meeting, he re-read some of the things that had been sent to him about post accident reviews and he suddenly realized that that these suggestions had been encouraging them all along to do exactly what they did this time to solve the misdirected order problem. It struck him as ironic that they were willing to do that kind of analysis and assessment to fix a problem for a $1,500 order and a customer but they had, until now, been unwilling to do it when one of their own employees was physically injured.
So what does this have to do with the utility business? Well, everything, I hope! Simple errors often come to your attention only when someone gets hurt or when a consumer suffers some damage, events that cause someone to file a report. Without diminishing the importance of the injury or the damages themselves, the key to learning how to make things work better and more efficiently is really the error that was involved. The process of solving that error should become the catalyst for your people (and you) to find not only the most obvious error, but all the contributing errors that need to be fixed as you improve the work process. As the President of the company discussed above discovered, it usually isn't the people who are to blame for things that go wrong, but rather the process. Most people will really want to do a good job. If you set the tasks up correctly you give everyone the right tools, procedures, and opportunity to do the job right the first time every time!