What does a painted curb have to do with building a culture of safety? More than you might think.
Paul O'Neill, Value Capture's co-founder and non-executive chair, used this story often when coaching healthcare leaders. A person tripped on a curb in a parking lot at Alcoa and was injured. The person was cared for. Many organizations would stop there. At Alcoa, the problem was resolved. The reason the person fell was because they did not see the curb. The resolution was to paint it with bright yellow paint. And while most organizations that went this far would also stop here, Alcoa didn't. The learning was shared with everyone throughout the organization and led to preventive action. Leaders identified similar risks in their own areas and painted the curbs that were difficult to see. Learn the lesson one time. Prevent others from the same risk.
When reflecting with us about our work, he would sometimes ask us, “How are we helping them to paint the curbs?” With three simple words — "paint the curbs" — Paul was asking something much deeper: How are we helping people see and identify safety problems? How are we helping them share problems across the organization? How are we helping them solve not only this problem but every similar risk? These questions get to the heart of behaviors that promote a culture of safety and respect. Shingo describes the principle, “Respect every Individual” as a cultural enabler.
Respect Every Individual: Safety as the Ultimate Proof Point
Paul shared that organizations show respect for people when they focus on safety for everyone. Zero harm is always the goal. He lived this as a leader at Alcoa and at Value Capture and spent many years helping healthcare leaders aspire to the same. He often noted that many organizations claim people are their most important assets. His follow-up was simple and direct: "What is the proof? What are the workplace safety numbers?”
He guided us to respectfully advise people. "Don't get into a debate. What are the facts telling you?" I find it so helpful to work with people to understand the facts of the problem they are trying to solve, the performance measures of the work process, and the work design vulnerability.
Building on this, I had another mentor who frequently reminded me, "People have limitless potential." I find myself returning to this often by recommending that the people who do the work are the people who should improve their work. In problem-solving, when you get to the root cause and it's a person — keep digging. It's the process, not the person. In the many years I've worked on improvement, the system has never failed to have a vulnerability that caused the problem to occur. People solve the problem.
Embrace Scientific Thinking: What a Medication Experiment Taught Me About Failing Fast
I first learned about process improvement when I was a pharmacy manager in a large hospital. Like many hospitals, we used automated medication machines on the nursing units to store medications so nurses could administer them easily to patients. We refilled the machines every 24 hours and simultaneously housed large inventories of some medications while stocking out of others across our 53 machines. As a novice improver, I knew that more frequent refills would result in fewer stockouts and less inventory. What I did not realize was how little my team and I understood the work required to restock the machines.
We set out on an experiment to refill every two hours. We did this for six days. The technicians were overstressed. The pharmacists were pushed to check medications repeatedly — and because we didn't have enough time to complete all the work in two hours, we frequently had duplicate orders being dispensed and restocked. It was hard and frustrating.
On day six, my mentor came to town. He asked about the experiment. I told him what was happening and he asked me a simple question: "Lisa, is it worse than it was before?" I said, "Yes, absolutely." He said, "Then stop."
Those two words brought such relief. We stopped the experiment and went back to the regular 24-hour refill. A burden was lifted for everyone.
We went back to the drawing board and learned from one machine. We studied patient demand, the locations where the nurses wanted the medications to be stored, the work steps, and time necessary to replenish the machine. We started to gradually improve.
I learned so much about small experiments through that experience. It's okay to fail. Fail fast and learn faster. The beauty of the PDSA (Plan-Do-Study-Act) cycle is that studying what happened opens real options for what to do next: keep going if it's working, adjust if necessary, or abandon the experiment if it's worse. “Then stop”.
Root Cause as a Gift: The Rules in Use and the Daily Huddle
This is also where I learned about work design principles called the Rules in Use — from the foundational work of Kent Bowen and Steve Spear in "The DNA of the Toyota Production System." System vulnerabilities can be caused by the design of the work of an individual person (Activity), the design of how customers and suppliers connect or communicate (Connection), the design of a pathway — such as delivering a medication to a patient (Pathway) — or the design of how problems are identified and solved (Improvement).
As an advisor, I help people realize the root cause is a gift. When we find it, we can improve the design of the work and prevent the problem from happening again.
This shows up most vividly in the daily operating system. I have observed many rich discussions and learning through daily huddles. People come together to talk about plans for the day, problems they see, and what the team is doing to solve them. I have also observed that when there is no problem solving, there is nothing to talk about in the huddle. True to its name, a daily improvement huddle is a forum for learning about problem solving and continuous improvement. I can’t think of a better way to “embrace scientific thinking” than in real time, root-cause problem solving with the people who do the work.