Don’t Shoot the Messenger

Blaming and shaming employees for bringing up quality concerns is an antiquated way of thinking.

As a quality manager, I have had employees come into my office and confidentially pour their hearts out to me about a quality concern over a certain process. In these instances, I’d start an investigation to address the issue and alert the management in that area of the lab without disclosing the name of the employee. The next thing I knew, a group of employees would be in senior management or executive leadership’s office being interrogated to get to the bottom of who reported the concern.

I would overhear, “Who told Quality that?”

If the managers were successful in figuring out who brought the concern forward, that person would be bullied and informally punished. This happens more often than we’d like to admit.

Reporting Culture

As they have an intimate knowledge about their work, employees have information about the happenings in their area that management does not. In order to get staff to bring this important information forward willingly, the staff needs to be able to trust their management. Without this trust, there will be incomplete reporting of non-conforming events and the lab will suffer. Management should never “shoot the messenger!”

A heavy emphasis should be placed on a “reporting culture.” Management should want to know about things that go wrong, could have gone wrong or could be done better. The staff should be encouraged and empowered to report and are rewarded for doing so. It should not be the goal of management to “catch” people making mistakes, but rather to foster a culture in which the staff voluntarily brings up issues and opportunities for improvement so that the lab can improve.

If it is your goal to sneak around and point out people’s errors, I guarantee that your staff will do everything they can to hide issues from you. If you treat issues as opportunities for improvement and work collaboratively with staff to correct them, reporting will be much better.

The front line staff is integral in reporting. They have the knowledge of operations and the best improvement ideas. They know their work best.  In Lean Six Sigma, the saying is to “Go to the Gemba,” meaning to go to the people who actually do the work. Managers often have a tendency to want to devise corrective action plans without involving staff-which, more often than not, leads to a lack of buy-in and perhaps failure. If the person designing a corrective action does not understand the processes they are correcting thoroughly, the corrective action is destined to fail. The quality department, lab section and operations management working together with front line staff is a winning formula for management of a non-conforming event and corrective action.

A reporting culture requires management’s commitment to take all “events” seriously. This establishes trust and gives credibility to their message. If management doesn’t follow up, staff will lose trust and reporting will diminish.

If a lab is going to take advantage of the benefits of a reporting culture and non-conforming event management system, it is important to encourage reporting of near misses. A near miss is an event that could have occurred, but didn’t. Before an event actually occurs, employees will often recognize holes or potential failures in the system. Being proactive requires us to take care of issues before they become a problem for patients, employees and the business.

Inevitably, though, if you ask employees to tell you about problems they have or mistakes made by others or even themselves, you will get questions like: “Are you going to blame me?” or “Are you going to punish me?” From my experience, they have a right to be concerned. Historically, management’s tendency is usually to blame an individual and/or punish them. I have seen this firsthand in my previous roles.

Just Culture

This is where the idea of Just Culture TM comes in. Just Culture balances a blame-free culture and accountability. It sets management free from the propensity to find a culprit and allows you to focus on finding and eliminating the root cause. There is even an algorithm to provide framework for determining management course of action following an event. This provides fairness and justice, which is something the staff wants. They do not want to be blamed for those things that are not “their fault.” Staff wants negligent people to be held accountable. Just Culture provides message credibility and establishes trust as it ensures consistency and fairness in handling of events.

This is a fairly progressive way of thinking and does take some training and practice, but both the management and the staff respond very well to it. More information can be found by going to They have all sorts of training options and resources, as well as a very good in-person course to become a certified Just Culture Champion.

I believe that 99.9% of employees in the lab want to do the right thing. By and large, lab professionals work in the lab because they want to help people. It only follows that it is not appropriate to automatically assume that these well-meaning employees are to “blame” if something goes wrong. Thinking in a systems mentality frees us from the tendency to blame people-instead, focusing on the flaws in the system that allowed that event to occur.

The only way to correct a flaw in a system is to redesign the system so the error cannot occur again. The strongest response to an event is the elimination of the root cause through a new policy, procedure or process. The weakest responses to events, which are employed most frequently, are placing blame, disciplining in every instance, retraining on a broken or error-prone system and “reminding” people to do things over and over. The systems thinking approach takes a lot of the fear out of reporting events, which in turn establishes trust and empowers employees to report.

*A caveat to systems thinking and Just Culture is where negligence and recklessness is involved. When an employee is negligent or reckless, discipline is appropriate. Negligent acts include falsification of data, unethical practices and knowingly causing harm. This is rare and requires a different approach.     

Blaming and shaming employees for bringing forth quality concerns and opportunities for improvement is an antiquated way of thinking. Fostering a reporting culture through embracing the concepts of Just Culture and systems thinking enables your laboratory to fully benefit from its most important source of continuous improvement ideas: its staff.