Assigning blame where it belongs

Steve Duin, a columnist in the Oregonian, wrote today about a settlement with the family of a man who died as a result of his actions and those of public officials after his arrest. Many were involved including the arresting officers, jail staff, and the ambulance personnel. The columnist worries that without the exercise of a trial that will assign blame, there will be no motivation to change. I think there should be accountability in the system, but does assigning blame motivate employees to change?

An audit steps back and looks at the structure that allowed employees to make bad decisions. When I meet with auditees, I always tell them we are auditing a program's or service's performance, not the employee's performance. What was the tone at the top or the climate that allowed police to believe that a man urinating in a trendy neighborhood required a forceful police reaction? Are police trained to recognize that sometimes a person's actions can be the result of mental illness? Do personnel treat all medical emergencies with the same urgency and care? What is the procedure for medical personnel at the jail to make medical decisions? Should medical personnel at the jail and police reassess a person's medical condition before transporting to a hospital to determine the current urgency of the situation? Training, procedures, and the management climate can make for better outcomes. An audit would review all of those and assign blame, but not to the individual, instead to the services that failed. Then maybe there would be change.