There Are No Accidents

Accidents or, better still, incidents (accidents and near-misses) are effects. Effects are neither good nor bad; they are what they are, they are neutral. In fact, they only obtain meaning once we assess their implication on our lives and attribute a commensurate value to them. Furthermore, effects do not materialize by themselves as by magic, they have a trigger, a source of origin, or a (root) cause. It’s important to know that countless effects are in fact different manifestations of one-and-the-same root cause.

Because root causes are rarely immediately obvious, responsible managers need to make a deliberate decision to diagnose unintended and unwanted effects. To diagnose means to identify the operative cause and effect relationship, which explains and predicts a certain outcome from a specific course of action. After all, the only guarantee for eliminating unintended and unwanted effects is implementing a solution that negates their root cause(s). All else is merely trial-and-error.

Stupid is as Stupid Does

Oh, I can hear you say you’re not telling us anything we didn’t already know, and you’re right. After all, what do you do when your body manifests unwanted symptoms or effects? Of course, you go see the doctor for a diagnosis and a solution―a prescription for medication and a recommendation for what to do and not to do.

Yet, I’m stupefied by the number and frequency by which business advisors, consultants, coaches, authors, speakers, and teachers advocate anything but conducting a thorough root cause analysis. They reason, if that is your pain than this is your prescription. Hence, you are in luck if such a prescription actually does anything to address the underlying root cause of your unintended and unwanted effects.

Prescription of most, if not all of these solutions are justified with a forecast of increased bottom line results. However, chasing unintended and unwanted effects with solutions of which you believe they will raise bottom line results, while failing to diagnose the root cause of those effects is like mopping a flooded floor with the tap still running. Why is any solution promising to increase bottom line results more attractive than finding a solution for unintended and unwanted results that are draining bottom line results?

Is it true that leaders see diagnosing root causes, studying the system, as a weakness, an acknowledgement of a lack of talent, knowledge and credibility? Do they cover up their insecurity with a display of bravado by acting on instinct and hoping for the best?

The challenge facing decision makers who choose any prescribed n-step solution is the assumption that they already fully understand how their business functions as a singular, unique, integrated, and open system. Unfortunately, studies show that’s not the case!

Tampering; the Compounding of Errors

Lloyd S. Nelson, statistician and founding editor of the Journal of Quality Technology, is known for his funnel experiment, as explained in the video below.

He demonstrated that a stable system will show random variation. The fact that a system is stable—no results exceed plus or minus three times the standard deviation—indicates the system is in statistical control and the outcome of work processes is predictable. Albeit, this does not mean there are no unintended and unwanted effects.

Because unintended and unwanted effects are created by the exact same system that creates the intended and wanted effects, creating more of the latter and fewer of the former effects requires a systemic approach known as Continual Improvement.

Decision makers who choose to solve any of the countless manifestations of one-and-the-same root cause separately and without diagnosis of its underlying root cause, are compounding errors, introducing more variation, causing them to correct previous corrections, thus making matters worse rather than better. This all too common phenomenon is known as Tampering with a Stable System.

Thunder is Impressive . . .

Mark Twain said: “Thunder is good, thunder is impressive; but it is lightning that does the work.” Similarly, technology, strategy, agility, onboarding, A-teams, and any other leadership and coaching practice is good and some are even impressive; but it are the business’ work processes that do the work.

In his famous book Zen and the Art of Motorcycle maintenance, Robert Pirsig makes a distinction between riding a motorcycle and motorcycle maintenance. Yes, how you ride a motorcycle will have an effect on the need and frequency for motorcycle maintenance. But, a lack of motorcycle maintenance cannot be compensated by more motorcycle riding skills.

Statistics show that ninety-four percent of ALL business results—all (un)intended and (un)wanted effects—are systemic in nature. Therefore, how you operate the system, how you direct the system towards realization of its intended purpose, how good you are at conducting your inter-personal relationships with employees and all other stakeholders, offers hardly any compensation or solution for acute and latent errors within the business system’s design, structure or organization, operation or implementation, maintenance, and management. You just cannot expect the system to out-perform its own capability and capacity, period!

Creating Systemic Solutions

If you experience unintended and unwanted effects, and no matter what you do they keep popping up left and right like playing a game of whack-a-mole, you are experiencing a systemic problem, which requires a systemic solution. Creating systemic solutions require understanding of a system on the level of process. As Dr. W. Edwards Deming said, If you cannot explain what you’re doing on the level of process, you don’t know what you’re doing.

Remember the wise words from Benjamin Franklin: “Being ignorant is not so much a shame, as being unwilling to learn.” Are you embracing prescribed one-size-fits-all silver bullet solutions because you’re unwilling to learn how your business system functions as a singular, unique, integrated, and open system? Is that why you choose not to conduct root cause analyses? At least you now know why tampering is bad for business and thus for your career. Board members are showing less tolerance for under-performing executives.

The Root Cause: Rethink Your Approach To Solving Stubborn Enterprise-Wide Problems  explains how you can gain CEO Effectiveness™ with Business Mechanics™ provided you’re willing to change your level of thinking, which allows you to make different decisions, which result in different outcomes. Who can argue with that!

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