Grant Harris, founder of GTH Consulting, leads with one line: fix your process, not your people. Then a cold inbound speaking lead arrived with the budget approved and the association’s president already sold on him, and instead of taking the offer, he proposed a leadership session and extras before and after the talk. The planner had to reopen an approved budget and review a second proposal, and he was not selected — rightfully so, he says.
Listen:
Check out all episodes on the My Favorite Mistake main page.
My guest for Episode #370 of the My Favorite Mistake podcast is Grant Harris, founder and president of GTH Consulting, who works with leaders on what he calls human-centered performance. His tagline is “Fix Your Process, Not Your People,” and his work starts from the observation that organizations keep blaming people for problems the process created. Grant is a Certified Diversity Executive, a corporate board member, and a three-time published author who has worked with organizations including The Washington Post, the U.S. Department of Agriculture, and ASICS.
His favorite mistake is recent. A cold inbound lead arrived in his LinkedIn inbox: an association with budget approved, a president who had seen him on LinkedIn and wanted him, and a fee close to the number he hoped for. The job of a speaker, as Grant puts it, is to be the easiest best choice for the decision maker. Instead of accepting the offer, he proposed a leadership session and extras before and after the talk. What he missed was the work his proposal created on the other side: the president had to go back with new questions, review a second proposal, and reopen a budget that was already approved.
He was not selected, and he says rightfully so. He did not ask why, because in his experience that question gets no answer or a partial one. He ran his usual debrief instead, asking what went well and what was weakest, and talked it through with mentors. The relationship with the planner survived, and he is still in touch about future events. What he took from it: showing value is his job, not the client’s, but it belongs in discovery questions up front and in the conversation after a successful engagement, not stacked onto an offer already on the table.
We also get into what Grant calls accurate accountability: when the same problem shows up with different people under the same conditions, stop blaming the person and inspect the process, and it is not automatically the leader’s fault either. He offers one question to replace the statement “Sally messed up”: what part of the process made this outcome possible? He talks about where process friction hides (talent decisions, feedback loops, communication norms), why retraining alone rarely fixes a process problem, and how a late autism diagnosis shaped his view of capable people mislabeled as rigid, aloof, or disengaged. I bring in Deming’s estimate that most problems come from the system, the Just Culture replacement test, and a recent wrong-medication case where the harm traced back to a mislabeled vial rather than the nurse who gave the injection.
Themes and Questions:
- Why an extra the buyer never asked for reads as friction, and how to tell adding value from adding steps
- How to debrief a lost deal without asking “why not me”: what went well, what was weakest, and who to ask
- Where discovery questions belong: up front, and after a successful engagement, not bolted onto an offer that is already on the table
- What accurate accountability means: the same failure across different people under the same conditions points at the process, not the person
- The question that replaces “Sally messed up”: what part of the process made this outcome possible?
- Where process friction hides: talent decisions, feedback loops, and communication norms
- Why retraining alone rarely fixes a process problem, and what a restorative response looks like instead
- How a late autism diagnosis shaped Grant’s view of capable people mislabeled as rigid, aloof, or disengaged
Scroll down to find:
- Video version of the episode
- How to subscribe
- Quotes
- Full transcript
Find Grant on social media:
Watch the Episode:
Memorable Moments from the Conversation:
Click on an image for a larger view
Subscribe, Follow, Support, Rate, and Review!
Please follow, rate, and review via Apple Podcasts, Podchaser, or your favorite app—that helps others find this content, and you'll be sure to get future episodes as they are released.
Don't miss an episode! You can sign up to receive new episodes via email.
This podcast is part of the Lean Communicators network.

Other Ways to Subscribe or Follow — Apps & Email
Episode #370: Grant Harris, Fix Your Process, Not Your People
Meet Grant Harris: Human-Centered Performance and GTH Consulting
Mark Graban: Hi, welcome to My Favorite Mistake. I’m your host, Mark Graban. Our guest today is Grant Harris. He is the founder of GTH Consulting, and he works with leaders on what he calls human-centered performance. His core message is one that I think a lot of you will recognize, the idea of fix your process, not your people. So we’re definitely going to talk about that today. Grant has worked with organizations including The Washington Post, the US Department of Agriculture, and ASICS. We’ll hear about his favorite mistake, and we’ll talk about how capable people, sadly I’d say, get labeled as difficult or disengaged when the real problem is the work around them. So Grant, thanks for being here today. How are you?
Grant Harris: Awesome. Thank you for having me. Looking forward to the conversation.
Mark Graban: Yeah. I think we have a great conversation ahead. A lot of the topics that you work on are near and dear to me and I think a lot of the audience here. But first things first, what’s your favorite mistake?
Grant’s Favorite Mistake: Creating the Friction He Teaches Others to Remove
Grant Harris: Oh man, I have so many mistakes, because honestly I like to say I’m full of sayings. I like to say I’m perfect six days a week and today is my day off. But that’s not true, because I make plenty of mistakes. But my favorite mistake is one that came in the last several months. This is August now, so it’s fresh. It’s less than a year old. I am a speaker and a consultant, and this particular mistake had to do with building my speaking business. And I created the friction that I teach, speak about, write about, coach, and train others to avoid. So I created the friction that I help other people fix. And in that moment I didn’t see it that way, but ultimately hindsight did.
So here’s the setup. I got a cold inbound lead, which, anybody in business, that’s what you want. I didn’t do anything for it that I could attribute to something specific. I didn’t buy an ad. I didn’t know these people or this association or this decision maker. They showed up in my LinkedIn inbox and said, “Hey, I’ve got a speaking opportunity. We have budget. We saw you. We want you.” That is the perfect storm of what you want as a speaker.
Mark Graban: Right. That’s great.
Grant Harris: And the goal of being a speaker at any level, in any way, shape, or form, whether you’re paid a dollar, $1,000, a million dollars, is to be the easiest speaker for a decision maker to choose. Again, reducing the friction. That’s the job. Be the easiest, best choice. I was the best choice at the moment, but I didn’t make myself the easiest, and I created that friction. And then the question is, how did I do that?
The Inbound Speaking Lead and the Extras Nobody Asked For
Grant Harris: So it was handed to me on a silver platter. It was very close to my happy price in terms of what I would love to see to be paid for my work. Everything was taken care of. The president of this organization was on board. She saw me do a thing on LinkedIn and was like, “Yeah, we need you.” Everything was good. And then I decided to create value.
Unfortunately, a lot of times professionals, and people in the speaking business as well, want to create value, and they think they’re adding something on that is important, that is necessary, but ultimately, in hindsight, it’s just adding more friction and noise. So instead of taking the offer that I was given, I decided to take that and then try to build in a leadership session and build in extras before and after that I thought were valuable, that I thought might be valuable to the audience. But at the end of the day, when I looked at it in hindsight, that just added more process friction to the decision makers.
Now she had to go back and ask another question. Now they had to review another proposal. Now they had to look at the budget again after the budget was already approved, and you know that’s a hell of a process to get there in the first place. So now I’m introducing something that I think is valuable to me, but to the client, unfortunately, it was adding process friction. And this is exactly what I tell leaders and tell people to eliminate: look at the friction in the process and fix those conditions and remove those conditions so that you can get to a state of flow. And flow is being the easiest choice to make at the moment.
So that was in my near recent past, and I have learned from that. But I believe it’s a favorite mistake of mine as I grow in not only my speaking, but my business as a whole. I created the friction that I tell everybody to stop creating in their work. So that’s my favorite mistake.
Blind Spots, and Why This Happens to Experts Too
Mark Graban: Well, thank you for sharing that. And isn’t it funny how we have blind spots? There’s a reason for the old expression, the cobbler’s children have no shoes. This happens to a lot of people, right, Grant?
Grant Harris: It does, more often than we know, subconsciously and consciously. Subconsciously, again, I wasn’t creating friction in my mind. I was like, “Oh man, I’ve got a great opportunity, and let me add value here,” because I want to be a value add to the client, and obviously on the back end I want a great testimonial, and I want to be able to use that to build my business. But in the moment, I wasn’t thinking of all the admin things in the back end that go into making a decision, that go into a president of an association, an event planner, the decisions that they have to make to get to the point of saying, “You’re the person we want. Here’s this offer.” And then I come back with a whole bunch of stuff, and they’re like, “Oh, that’s nice. That’s great, but that’s not what we were looking for.” So yeah, it happens. It happens.
Not Selected, but the Relationship Survived
Mark Graban: Did it blow up the whole deal then, where they said, “Okay, well, we can’t get approvals for all that”?
Grant Harris: It did not happen. I was not selected, and I’m not surprised. However, in this work, and in my business, I am much more interested in relationships than transactions. Especially in this business of speaking of any sort, for pay, it pays to have relationships. So I still have a relationship with that planner, with that association. I have had conversations with them after that time. I’m following up with them, which is a big part of this game, after the event that’s happening this fall. So there’s still a relationship there, and I believe, based on the responses, that they’re still interested in me as a professional, at some point in time, to come and speak to their members. And that might be the first gig of the next year or the next cycle or the next season. You don’t know. So no, I did not get that gig, and rightfully so. But I still have that relationship, and that’s what’s most important in moving from a friction state to a flow state: building and keeping and maintaining important relationships along the way.
Mark Graban: Yeah. Well, it sounds like they didn’t say no. It was maybe more of a not now, and maybe we’ll find a time and opportunity in the future, which is also… it’s not ideal, but it’s a pretty good place to be, like you said, in terms of the relationship and all.
Grant Harris: Yes. Correct.
Why He Did Not Ask “Why Not Me?”: The Post-Debrief
Mark Graban: When did you come to realize what had happened here about putting in the friction? Were they real direct with the no, or did you have to piece things together? Because one thing I’ve found as a consultant and a speaker is that sometimes people don’t want to elaborate on why they selected somebody else. It’s kind of awkward or uncomfortable for somebody to want to do that. They kind of want to move on. It’s hard to tell somebody no. But how’d you piece that together?
Grant Harris: So I did not, and I do not suggest or recommend that anyone at any point in their professional lives ask, “Well, why didn’t you pick me? Why not me?” That’s not necessarily the question you want to ask, because, one, you’re either not going to get an answer, or you’re not going to get the whole truthful answer. So I didn’t ask, “Why not me?” I just accepted it. Sometimes you have to lick your wounds. I accepted it, and I went back, as I do with every interaction that I have in my business, to say, “Well, what went well? What was the weakest part of that interaction?” I do a post-debrief.
And in that, I came to see, and in conversation with mentors, people that have been doing this a lot longer and deeper and better than me, I could see that I was adding on these layers of administration that were unnecessary in order to get to the deal, which, again, most of the work was done for me in that particular instance.
It was in my post-brief. I wasn’t upset. I was disappointed that I created this friction, but hey, I’m a person too. I can coach and train and teach other people that don’t have what I have in terms of the personal or lived experience, and I don’t have what other people have. But now I can add this to my vault of personal experience to say, “Hey, maybe if you are looking at all the value that you believe that you are creating, maybe take a step back, maybe take a beat, maybe take a pause, and say, am I really creating value? Or am I actually creating friction in this process that is going to be the obstacle from this person saying yes and getting the deal done?” So it was definitely an after-action debrief that allowed me to think about my thinking.
Mark Graban: Well, I think that’s really the key. I appreciate, Grant, that you’re telling the story in a way that shares your reflections and lessons learned, but then how you’re processing that and thinking through how to share that or apply it, not just here today on the podcast, but as you’re working with others. It definitely comes through that you learned from this. It’s experience.
Discovery Questions Instead of Add-Ons: Where Value Belongs
Mark Graban: In the future, I wonder, how do you find the balance of asking if there are other ways that you can add value, as opposed to… it sounds like you really proposed something, as opposed to inquiring, “While I’m working with you, are there any other things?” Maybe that would give them an off-ramp to say, “Well, no, we really want you to do what we proposed.” And okay, great. I wonder about that, because holding back an opportunity to add value to the client could be a mistake in the other direction, for you and the client.
Grant Harris: It could. That’s what I like to call paralysis by analysis. So I’ve never been a fan of asking a client how I can display value for them. That’s my job, not their job. I have always been a fan of asking clients good questions that help me sniff out where that value might apply, and when that value might apply, and to whom that value might apply. So that comes in two instances. One, at the beginning of that relationship, with discovery, and many of your listeners might be familiar with that.
And also on the back end. So you may think, as an entrepreneur or founder, “Hey, I want to build all this value up front because I might not be able to get this client again. I want to put out this new product or service or offering. I want to test something,” these kinds of things. But all of that is about you, and not about the client or their need, or the people that you are serving and their need.
The other way that I have done that is on the back end. After a successful, whatever that is defined as in the relationship and in the agreement, after that, in that debrief conversation, that’s where I have targeted questions. “Okay, who else does this conversation need to be had with? Where else can this apply? You saw what was done in session A. Well, let’s talk about how we get to session B.” So if there is proof and evidence in quote-unquote session A, then it’s easier to throw out things for session B. And, “Session B.1, we could add maybe this, because I’m hearing this.” That’s repeating to the client what they are saying, and if you are putting the client in position to sell for you, then that’s the ultimate place to be in, versus trying to sell to them or at them.
So for me, that happens in those two places. One, up front, asking those targeted discovery questions. But after successfully adjudicating an event, an opportunity, then, with that proof positive, you have more opportunity to open the landscape and talk about other things on the back end. That’s been successful for me. Certainly there are others that do this work better than I ever will, but that’s been my personal experience.
Fix Your Process, Not Your People: Where the Line Comes From
Mark Graban: Yeah. Well, again, we’re joined by Grant Harris. There’ll be links to Grant’s website and more in the show notes. Let’s dig into the work and other topics here, Grant. “Fix your process, not your people,” the line you lead with. It’s powerful. Where did you learn that mindset?
Grant Harris: So first and foremost, fix your process, not your people, is a practical leadership lens. And it is a way to spot process friction, some of the friction that we’ve been talking about, before capable people get mislabeled as a performance problem. And this is especially relevant in HR, L&D, and in some ERG environments. You mentioned human-centered performance before. This is about looking not at the person, and blaming and labeling the person for the failure, the missed deadline, the broken handoff, the miscommunication. All those things happen because we are people, and people are fallible. However, too often, many organizations and the people leaders within them lay blame only at the feet of the person. It is Grant’s fault, it’s Mark’s fault, Eduardo, Raheem, Sally, Jane, whoever. It is them and they. And unfortunately, that does three things. One, that affects time, that affects talent, and it ultimately negatively affects value that the organization provides for its internal and external shareholders.
So my stance and my approach is that organizations continue to blame people for the problems that their processes create. And ultimately, my work is to inspect the conditions around the work before we judge the person. And when that happens, you start looking at the friction in the process, and then when you alleviate and fix those conditions in the process, you get to a flow state where everyone, at the end of the day, is able to perform at their best and to give their best. So that is fix your process, not your people.
A Late Autism Diagnosis and Being Mislabeled at Work
Grant Harris: And that has shown up in more than one way for me, particularly because I happen to be an autistic person, a late-recognized, late-diagnosed autistic person. I was diagnosed in my late 30s, and most people get diagnosed by the age of six. So I spent most of my personal and professional life not fully aware of my traits and how I show up. And many times I was mislabeled and misjudged and misunderstood in the workplace for how I showed up, and mislabeled as rigid or aloof or disengaged, these types of things, when the opposite was true. I was locked in, but locked in in the way that I show up.
So that’s where this work stems from. It stems from me being an autistic person who is also a self-proclaimed introvert in every way, shape, or form. I knew about being an introvert long before I ever knew that I was autistic. So those stigmas and those biases that show up against introverted people, then you combine that with an autism diagnosis. That’s where I started looking at processes versus how people are labeled and blamed for the breaks and the breakdowns in work.
Mark Graban: So before coming back to the work and the process, since you brought this up, I’m curious to unpack a little bit around your late diagnosis. On some level that seems like, I don’t know, a collective mistake of the medical community or doctors you’ve had through your life. What have you learned about why a diagnosis might be late coming? Was it a matter of, I imagine, doing well in school and not having any real problems that would lead to investigation that might lead to a diagnosis?
Grant Harris: So, a couple of things, and thank you for that question. The way that I approach this work is through a neurodiversity lens, but it is not the front door, so to speak. I call it the side door, because neurodiversity is only one way that this work shows up. Disability is a large umbrella, and there are many disabled people in the workplace that are not neurodivergent. So it is only a lens through which I do this work. That’s on the professional side.
On the personal side, no, I don’t blame the medical field for missing something. The generation I grew up in, my parents weren’t inclined to get me tested for something because, yes, I seemingly was operating at a high level. What most people would call high-functioning. I do not use that term, because if something or someone is high-functioning, thereby someone else has to be low-functioning. And who makes that judgment about who is high or low? And again, looking at the process versus the people. So I don’t use that term, high-functioning, but that is something that many people are familiar with.
There was no reason in my parents’ or family’s mind to get me tested for something. I am the first person in my family to be diagnosed with autism, to be recognized as neurodivergent. Now, I am not the only disabled person in my family. Disability is the only category that any person at any point in time can become disabled, and that can change for a person, but you can’t really change the other categories. So no, it was not a failure of the medical system in any way, shape, or form.
And I owe it to my wife, which I’ve told this story many times. She’s ADHD, and she saw something in me and said, “Hey, you should probably read this article. It might apply to you.” And it was titled something like “10 Traits of Your Partner Who Might Be Autistic.” And I immediately identified with at least eight, and nine was a toss-up. So I said, “Hey, this might be something.” And, long story short, I went through the process, which I was very privileged to be able to do. I understand that I was privileged to be able to get that diagnosis. But from that fulcrum, from that point, and it took me a couple of years to talk about it publicly. The first time that I posted about being autistic was about two years after my diagnosis.
And since then, I have been able to, again, shift the focus from people being the problem and how they show up, to processes being the friction that keep those people from performing at their highest level. So that’s really where that story aligns and intersects.
Leaders Own the Process: Accountability Without Blame in Either Direction
Mark Graban: Okay. Well, thank you for sharing, and thanks for letting us dig into that a little bit. Back to process. One thing I’ve seen in different industries and different settings is that it’s so much easier for a leader to blame a person, because that’s offloading responsibility. I’m of a school where I was taught, yes, we need to focus on the process, and who ultimately owns the process? It’s leaders, right? So to say that there’s a problem with the process requires some humility and some ability to look in the mirror instead of pointing the finger at others, right?
Grant Harris: So that’s a slippery slope, because of a couple of things. If I walk into a room of leaders, people leaders, whatever the title may or may not be, they have gotten there by certain means. They’ve made sacrifices with time, with their family, with their money, et cetera. In more cases than not, in most cases, they’ve earned the right to be there. And for me to come in and say, “Everything is your fault because you have this title,” is not the way to go. It’s not necessarily received the right way.
Mark Graban: Sure. Of course.
Grant Harris: So the way that I approach that conversation, the accountability conversation, is this. Most of the time, accountability is seen as punitive. You’re accountable for this, and if it fails, then you failed. And that’s not always the best case and way to look at accountability. But I like to look at accurate accountability. Accountability is important. People mess up. Individuals drop the ball. Individuals miss that. Individuals miss this. So it’s not about excusing the person and excusing their accountability. It’s about accurate accountability. Is the person accountable for the right thing at this point in time? Meaning that if we see the same problem happening with different people under the same conditions, at different points in the work, then we need to stop blaming that person and putting the accountability on that person, and we need to start inspecting the process.
So excusing accountability is never okay. Blaming managers and people leaders just because they have the title and authority is not okay. What is okay is accurate accountability, to say, “Yep, Grant, in this instance, all these conditions were met, all these things were here. You had all the tools. We had all the communication. We gave you feedback, and you still dropped the ball. I should hold that accountability.” However, more often than not, many, or at least one, if not three, of those things that I just mentioned, those process friction categories, as I like to call them, were not met, or did not happen, or weren’t clear, or weren’t complete. And if that’s the case, then it’s not the person, it’s the process. And the person, meaning both ways, Mark. It’s not the manager or the leader, it’s not the subordinate or the follower, it’s the process between those two. So that’s how I look at and approach the conversation when it comes to accountability, meaning that it’s not all the leader’s fault all the time. And it’s certainly not all the worker’s fault all the time. More often than not, it is mostly the process most of the time.
Deming, Just Culture, and When It Is Fair to Hold Someone Accountable
Mark Graban: Sure. One of my influences when it comes to quality and leadership, he passed away 30 years ago, but I think he’s still pretty influential today, Dr. W. Edwards Deming, would throw numbers around of, roughly, 90% of the time problems are caused by the system. He never said 100%, but I think he was trying to swing the pendulum back. I’ve seen sometimes leaders say, “Well, hey, 90% of the time,” or, “Unless proven otherwise, I’m going to default to thinking it’s a person problem.” So I love that phrase, accurate accountability. That makes me think of a lot of things. In healthcare in particular, there’s a framework that’s often referred to as Just Culture in a workplace. The longer version of the phrase is, well, let’s be fair and just. It’s a framework to think through when it is appropriate and fair to hold an individual accountable. Were they truly making a bad decision where they knew better, and they knew the outcome was going to be bad, and nothing in the system was forcing them to do it? There’s a time to punish, let’s say, intentional acts, as opposed to slip-ups, or people being pressured into making what in hindsight seems like a bad decision. There are differences there, and I think that Just Culture framework lines up conceptually with what you’re describing. It’s not always the system, it’s not always the person, but let’s have a framework for figuring out when that happens.
Ask a Question, Not a Statement: What Part of the Process Made This Possible?
Grant Harris: And that’s the inspection. That’s why I say inspect. I do not suggest that your listeners become Sherlock Holmes in any way, shape, or form, although I’m a fan. If you’re familiar with Sherlock Holmes, I am a Benedict Cumberbatch Sherlock version fan. My sister likes previous versions. But I’m not suggesting that your audience become Sherlock Holmes in their inspection. I am suggesting that they stop and think and ask a different question instead of making a statement.
I make the statement that John or Joe or Sally or Sue, they messed up. That’s a statement. So we want to flip that and ask a question, and that question is, what part of the process made this outcome possible?
Mark Graban: Exactly.
Grant Harris: So Sally, Sue, Ricardo, whoever, may have, on the surface, messed up. It’s there. It’s a thing. You can see it. But below that surface, and behind the layers of that onion as you peel them, you start to see that there were three different handoffs that failed. That there were two deadlines that shifted. That there was no charter or intent at the beginning. That people made it up along the way, and then they’re holding the bag, they’re holding the bucket, and then you say, “Oh, it’s them.”
And not just the individual. This also applies to teams, to groups, to departments, to divisions. That team over there isn’t doing what they need to do. This team over here always does this. Those are all labels, at the individual and the collective, and they’re all statements, and they’re not questions. And the question is, what part of this process made this outcome possible? And if you’re a leader listening to this, if you’re a people manager listening to this, if you start asking that question, you are already ahead of the game. You are already doing the right thing, because you are no longer just labeling the person. You are trying to inspect the process of how it got to that person or those people.
Where Process Friction Hides: Talent Decisions, Feedback Loops, Communication Norms
Mark Graban: Right. And that’s how you prevent mistakes instead of just responding to them well. You can ask those questions proactively, thinking what could go wrong, instead of just waiting to learn from the things that do go wrong.
Grant Harris: Correct. Because if you’re always in react mode, if you’re always putting out fires, then you’re never going to build a forest. You’re always putting out these fires that are just burning down your trees that you’re trying to build. So you’re reacting. And there are six to seven different categories that I talk about in terms of where process friction hides. I’ll just give examples of three of them: in talent decisions, in feedback loops, in communication norms. Just those three. You could spend hours, days, weeks, months, quarters in just those three out of the six or seven to say, what part of that process is bleeding value? How am I losing money? How am I losing my talent? And then you have to pay two times a person’s salary in order to re-recruit and rehire, versus keeping that talent that you have and expanding that talent. Because most talent that is within organizations right now is either mislabeled or misused. And I don’t mean misused in terms of abuse, but I mean underutilized. They aren’t maximizing that potential, because people are disengaged, because they are ultimately disillusioned, and the leader, unfortunately, sees that disengagement as, well, they’re not talking, they’re not showing up, they’re off camera, thereby they just don’t care.
Mark Graban: That assumption.
Grant Harris: Yeah. And that, across the board, is usually not the case for all people, but specifically neurodivergent people. Neurodivergent people are some of the most caring employees, because they are the people that get hit first and get hit most when it comes to the negative aspects of this process friction. So these are the things that I talk about with leaders. This is how I hold leaders accountable, but accurately, because it’s not always their fault. And it certainly, sure enough, isn’t always the employee’s fault.
A Wrong-Medication Case: Start With the Fact, Not the Person
Mark Graban: Yeah. I want to come back a little bit to this statement. Let’s say there’s an incident in the workplace, a quality problem. I’ll use a healthcare example: something affects a patient. And if that first statement is, “Sally messed up,” that’s already jumping. That’s making such an assumption. It’s making such a leap. This is my engineer training, my manufacturing training: it’s better to start with the fact. The factual, observable statement is, the patient received the wrong medication. That says nothing about the cause. If we start there, then we can ask the questions you’re asking, the questions I’ve been taught: what made it possible for the patient to receive the wrong medication?
There was a case recently that was in the news from Nashville, where four different patients the same day getting knee replacement surgeries were injected with the wrong medication, and it paralyzed at least one of the patients. We don’t know about the other three. One of the patient’s family went to the news media.
Grant Harris: Wow.
Mark Graban: It would be such a mistake to blame… Well, who injected the patient? That might have been Sally. But it was a clear liquid in a vial that was labeled incorrectly. So Sally didn’t make the mistake. Somebody, and I use that word with a bit of a cringe, somebody in the pharmacy mislabeled a vial of clear liquid, which looks like every other clear liquid that could have been in a vial. And then we can step back and ask those questions, instead of saying, “Well, Ricardo in the pharmacy messed up.” What made it possible to mislabel or put the wrong medication into the vial? And so, well, the pharmacist didn’t catch it. The pharmacist didn’t know. They can’t smell the clear liquid and know it was wrong. So it’s just this cascading effect of, I would say, process causes. And I think when things like this get reported, the pressure and the question from people in society is, at the hospital, who did you punish?
Grant Harris: And that’s a great example, and I love how you were digging, pulling the…
Mark Graban: Oh, I’m sorry. You kind of froze up a little bit there. Say that again.
Grant Harris: Yeah, I think we had a little lag. I think I caught the last of it.
Restorative, Not Punitive: Why Retraining Alone Fails
Grant Harris: And that’s an excellent example of, one, asking a better question up front and inspecting the process and not jumping, like you said, directly to the person. But you said a word a couple of times here that I want to inspect. You said “punish” a handful of times. And in my work, I never want this to be punitive, because ultimately, all those layers that you talked about, there are people in those layers, and it could get down to the base layer, that this is the person at that base layer, the person that created that label, the person that put that label on that sticker in that bin. There could be, and there may be in many cases, an ultimate person who is accountable for that thing. That’s not the bad part. The bad part is when you finally do the inspection to get to that person, you still treat that person as a problem instead of an opportunity to say, “Well, let’s give this person what they need.” And that’s different than training. I want to make a clear distinction that I am not suggesting that we just train away. Training is good, but many research studies will show you that just trying to train away a problem is throwing money down the toilet.
So it’s not about the training, because if you train the wrong way, again, a bad process is going to create a bad result. So it’s not just about retraining that person. It is about holding the person accurately accountable, and then looking at all the comprehensive ways of what that person was given, how that person was given those things, when they were given those things, and with fidelity saying, “Okay, well, this probably isn’t the best way to do it.” And that changes across industries. I’m not a healthcare expert. Those leading practices change from industry to industry. But what does not change from industry to industry is the inspection process, and those friction layers that hide right underneath your nose. Because I give you credit that if you’re digging that many layers down to find the 12th person that may have… that’s where you want to go, because you’re not just saying, “Oh, this person at the top, you’re done. You’re fired,” or, “You’re demoted,” or, “Your pay is docked.” You’re digging down to see, well, how can we adjudicate this particular situation, but how can we ensure that this doesn’t happen again, and we mitigate that risk? So it’s not about punishment, and I understand when you use that word, but I try to stay away from punitive. And I try to look at restorative. How do we restore the people that are part of this process, and how do we rectify the process so that we mitigate this from happening again, outside of standard human error?
The Replacement Test and the Training Trap
Mark Graban: Yeah. We’re totally on the same page there. I agree with you. If it’s unfair and unjust and an employee gets fired for something that was a process problem, back to the Just Culture framework for a minute, there’s a concept in there called the replacement test. If you were to swap out an equally skilled, equally trained person and put them in that same situation, would they have likely made the same decision, or possibly made the same mistake? If true, that’s a process problem. And there are so many layers of cost when an employee gets fired. There’s a cost to that individual. There’s a cost to the organization, as you’ve stated, in terms of hiring a replacement. And I’ve got a collection of stories of bringing in a new person without fixing the process. It’s a matter of time before now the organization may, unfortunately, get punitive on someone else.
And the training trap. Some organizations will say, “Okay, well, we’re not going to fire the person.” I know a lot of people in healthcare…
Grant Harris: We’re just going to train the hell out of them until they become a zombie.
Mark Graban: We’re going to retrain them. And so, well, if they were never trained to begin with, I would say that’s a process problem.
Grant Harris: Correct.
Mark Graban: And if they were trained, and it didn’t prevent them from being involved in the problem, why retrain them? I’d do the math: two times zero equals zero. Right?
Grant Harris: I was not a math major. I was a psychology major and a philosophy minor, but I can even do that math. If you ask me to count to 10 twice, I might mess up twice, but I can do that math. Retraining, training the hell out of people, is not where to go. Educating people, all day. Educating people is the way to go. But just training them in a way that you, as the organization and the people leaders within them, think is productive just because it either cuts cost or because it cuts time… cutting costs and cutting time can be good and healthy things. But if it leads to unhealthy things like rework, escalation, execution drag, if you’re not getting the job, the project, the task done on time, in scope, and within budget, you’re executing with drag, and then you’re going to lose value quarter after quarter. Slowly in most cases, but in other cases quickly.
So yeah, these are things that I could talk about all day. And I try to talk about them in a way that is accessible, that people can understand in plain language, that they can see that these things are practical, and on Monday they can go back and they can ask that question. They can do that thing. It doesn’t cost anything other than your mental capacity. And, you know, you might have to pay to bring me in, but that’s okay. So it doesn’t cost anything. And it doesn’t blow up your whole infrastructure with a new implementation and a new program and these kinds of things. You just stop making a statement and start asking a question, and that will permeate, especially if you’re in a position to be a leader with authority and responsibility. That will permeate to your teams. It will change the way you do business.
How to Find Grant and Get the Free Friction Signal Check
Mark Graban: Well, Grant, thank you so much for sharing your story, your reflections, a lot of insights here today. Again, Grant Harris, the founder of GTH Consulting. Check out the show notes for links to his website. As we wrap up, tell us more about how people can find you, and the Process Before People Scorecard.
Grant Harris: Yeah, certainly. So you can find me on LinkedIn, Grant Harris, the number five, and I post there regularly. I interact there regularly. You can DM me directly, “Scorecard,” and I will send you a free, what I call a friction signal. It’s all anonymous, doesn’t cost anything, data doesn’t go anywhere, but it will give you a quick, in-the-moment signal check to see where your friction factors might be showing up. So if you DM me “Scorecard,” I will get that to you for free. And the scorecard in and of itself, the full scorecard, is a seven-question diagnosis. And from those seven questions, they are based on the categories that we’ve been discussing. Some of them I mentioned to you earlier. And you get a score, you score yourself, and then you have the opportunity to target specific areas in your friction factor, along with my facilitation and along with the work that I do, and bring them together, and that’s where it starts, with that scorecard. So that scorecard is free. The signal check is not a diagnostic, but the full scorecard is. So if you are interested, again, you can DM me on LinkedIn, and I will get you that free signal check.
Mark Graban: All right. Sounds great. I’m going to check that out and take a look too. So, Grant, thanks again for joining us here today. Really appreciate it.
Grant Harris: Excellent. Thank you. Appreciate it.
Mark Graban: Thanks.

