When a serious incident occurs, our instinct is to look for someone to hold responsible. But solving problems isn’t about finding a person to blame. It’s about finding ways to prevent the same thing from happening again. In the vast majority of cases, breakdowns aren’t caused by carelessness or malice. They’re the result of a process that made failure possible.
So instead of asking, “Who messed up?” what if we asked, “How did the work process break down?”
That approach is what led to one of the most effective improvements in modern healthcare.
People Know Where Processes Fail
In the early 2000s, Central Line-Associated Bloodstream Infections (CLABSI) were commonplace and sometimes fatal. Clinicians knew the best practices to prevent these infections. But the best practices weren’t reliably followed due to time pressure, unclear roles, and a lack of readily available supplies.
At Johns Hopkins Hospital, Dr. Peter Pronovost and his team1 approached the problem of CLABSI by focusing on the process of placing central lines. They examined the actual steps clinicians followed, the decisions they had to make in the moment, and the conditions they were working in. By digging into the process, Pronovost and his team identified five critical steps that were often skipped:
- Wash hands
- Clean the site with antiseptic
- Cover the patient with sterile drapes
- Wear sterile hat, gloves, and gown
- Apply sterile dressing
The team turned these steps into a simple checklist and built in feedback loops to track its effectiveness. This low-cost intervention led to dramatic results. Across more than 100 intensive care units in Michigan, central line infections dropped by two-thirds. Within the first 18 months, the initiative2 saved more than 1,500 lives and nearly $200 million.
Focusing on Process Allows You to Dig Deeper
When an incident occurs involving someone performing a task, there’s often an inherent bias to search for the specific error the person made. Once that error is found, the investigation tends to stop. A step in the procedure wasn’t followed, and that becomes the explanation for the incident. But when we settle for generic explanations—especially ones that focus on the person—we also end up with generic actions that do little to mitigate risk.
In reality, “procedure not followed” is not a thorough explanation. It’s a signal that further analysis is needed in order to learn and improve. Getting specific details can be challenging, as it requires honest and open discussion with the people who actually do the work. That’s when you need to focus on the process. Instead of asking "Why didn’t you follow the procedure?", try asking:
- Which step in the task didn’t go well?
- What made it difficult to follow that step?
- What obstacles or anomalies did you have to account for?
- What was different this time versus other instances when this task is performed?
When we frame our questions around the task, we shift the focus away from the individual and highlight the other causes that contributed to the incident. These “other” causes are often overlooked, but that’s where you’ll find opportunities to manage results through the work process, rather than relying on solutions that focus on the individual.
Specificity is the key to meaningful improvement. The more precisely you understand where the breakdown occurred and the specific factors that contributed to the breakdown, the more actionable your solutions become. The checklist that helped reduce CLABSI rates didn’t just say “follow protocol better.” It pinpointed five exact steps that were being skipped and made them visible and repeatable.
Shared Accountability, Strengthened Reliability
Focusing on the process doesn’t mean letting people off the hook. It means holding the system and the people within it to a higher standard. Accountability becomes a shared effort to understand how the work is actually done, and how it can be done more reliably.
Any organization that handles complex tasks, under pressure, in changing conditions, can benefit from this shift. When problems occur, the most useful question isn’t “Who failed?” It’s “Where do we need to strengthen the process?”
That’s how reliability is built: not by fixing people, but by fixing the systems they work in.
