When something goes wrong, we look for the person who did it wrong. That is the natural reaction — and the wrong one. W. Edwards Deming estimated that over 94% of all quality problems are due to the system, not the individuals. That calls for a different kind of leadership.
The instinct that costs dearly
An order arrives late. A customer complains about a fault. An employee makes the same mistake twice. The first management reaction is almost always the same: who was responsible? Who made the mistake? What do we do about that person?
It's understandable. We're used to thinking in individual causes and individual solutions. But the question has a problem: it leads us to where the answer rarely is. Most problems in an organisation are not people problems. They are system problems.
Deming's observation
W. Edwards Deming spent most of his career documenting what most managers didn't want to hear: that the overwhelming part of the variation in an organisation's results stems from the system — not from the individuals who work within it. His estimate — that at least 85-94% of problems are due to the system — is often cited but rarely taken fully seriously. Deming himself expressed frustration that industry spent too much energy finding scapegoats and too little examining the systems, processes and structures that created the faults. He called it "the superstition of performance evaluation": the belief that you improve an organisation by rewarding the best and punishing the worst, rather than redesigning the system they all work in.
"It is the system that governs the performance of people. The system is the responsibility of management."
— W. Edwards Deming
What it means in practice
When a mistake is made, the correct question is not: "Who made the mistake?" It is: "What in our system made that mistake possible — and what do we do to remove that possibility?" That is a fundamentally different logic. It is not lax or responsibility-dissolving. It is far more demanding — because it places the responsibility with those who can actually change the system: management.
This way of thinking is the core of the Toyota Production System and of all good operational leadership. When a problem arises, the reflex of Toyota leaders is to go to the processes, not to the person. Was the standard clear enough? Was there time to do it correctly? Was the fault visible before it reached the next step? These are questions that lead to system improvements. And system improvements hold.
The opposite fails
Organisations that mainly react with individual accountability — warnings, reassignment, intensified monitoring — see a characteristic pattern: the same faults return with new faces. That is the strongest sign that the cause is in the system. You can swap out the person; you can't swap out the system by swapping out the person.
This is not an excuse for a lack of individual accountability — it is a clarification of what accountability should look like at the two levels. Employees are accountable for following the standards and procedures they've been given. Managers are accountable for ensuring the standards are clear, realistic and possible to follow. Standard work is the concrete tool for making the latter visible and operational.
✓The most important takeaways
- →Over 94% of quality problems are due to the system, not the individuals — Deming's estimate is still underrated.
- →Don't ask "who did it wrong?" Ask "what in the system allowed it?"
- →Organisations that mainly react with individual accountability see the same faults return with new faces.
- →Managers are accountable for the system. That is a far more demanding — and more productive — logic of accountability than hunting individuals.
Sources
- Deming, W. E. (1986). Out of the Crisis. MIT Press. — see The W. Edwards Deming Institute.
- Liker, J. K. (2004). The Toyota Way. McGraw-Hill.
- Shook, J. (2010). How to Change a Culture: Lessons from NUMMI. MIT Sloan Management Review, 51(2).
The references show the professional basis. Sources are reproduced in their original language.