We needed to improve quality. Not just once, but all the time. And we needed to do it across over 100 teams, each of which had a different context and different quality problems. The problem that impacted the greatest number of teams impacted only 6Â â€” and more than 70% of the problems affected only one team.
No central plan could help with either of these. We needed a systematic solution, a strategy. But not a central plan. We needed a practice, a habitÂ â€” something that combined funding with problem fixing, while reinforcing local ownership.
That’s when we invented Safeguarding. That was more than a year ago; teams are owning their quality and actively making things better.
Another company had consistent risk aversion. Commonly, people identified the option with the highest expected value…and then did something else. In that environment, the personal costs of even tiny failures were too high. So everyone consistently chose the lowest-risk option, even when that was a guaranteed bad outcome. Psychological safety was totally missing. And yet each relationship was different, with different risks.
Safeguarding was also an effective strategy for creating Psychological Safety.
Continue reading “Safeguarding – Culture is a Process, not a Single Change”
Assume you cut your hand in the kitchen, then didn’t notice for an hour and had to be rushed to the ER. You do this 3 times per day.
You spend most of your time in the ER and very little time cooking. You want to fix that.
TheÂ improve testingÂ strategy says “we’re going to cut ourselves all the time. How could we notice that so that we don’t bleed out?”
So we write something that will check every minute to see whether we’ve cut our hand in any of the specific places we’ve cut ourselves before. Of course, if we cut ourselves in the leg, we still don’t notice it and we end up in the ER.
And then we start checking our leg. Over time we are catching many our cuts in time to put on a bandage. We spend less time in the ER, but we’re still all covered in bandages and spend a lot of time looking for wounds.
SafeguardingÂ would instead ask “why are we cutting ourselves 3 times a day? Why is this kitchen so unsafe?”
So we look and realize that the tilted counters are causing knives to slide off, people lunge for them so that the knife isn’t ruined on the floor, and then they cut themselves.
Safeguarding is to flatten the counter top.