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Many of you know the story of Ray Crock. He took McDonald’s from one location in San Bernadino, California to over 40,000 sites around the world. And if there is one thing we can say about McDonalds, it’s that it is consistent. McDonald’s may not win the world’s best hamburger award, but when a family of five is traveling cross country looking for a safe and predictable spot for lunch, McDonalds will do just the trick.

Design Reliability versus Actual Reliability
Every system, like McDonald’s, has an inherent design reliability. That is, if properly managed, it can only be as good as its system will allow. Perfection is not in the cards. But with managers and staff all making the right choices, achieving design reliability is the result. And that applies from service to safety, from environmental protection to creating an inclusive workplace. The design of your system, from equipment to procedures, sets the maximum reliability you can achieve.

Yet, for those of us who have spent too much time buying happy meals for a group of six-year-olds, we can readily detect differences between stores. At one store, the staff are fast and friendly, the tables and restrooms are clean, and the food is hot and fresh. Occasionally, though, you’ll find a McDonald’s that is not producing the typically predictable, highly-reliable results we’ve come to expect from McDonald’s 40,000 stores. Slow service, dirty tables, missing items in your order. Is it that these team members are working in a different system? No. Different processes and procedures? No. It is that the team, managers and staff, are engaging in less optimal choices. It is here that culture resides. The theory goes that you cannot do much better than the inherent design reliability of your system, but you can do worse. And doing worse than what’s possible is most fundamentally tied to the quality of the choices being collectively made by the team.

McDonald’s is built around consistency, speed, and low cost. It will try to excel at protecting these values. Admittedly, McDonald’s is not quite designed to be a fine dinner house nor a health food store. Like every business, McDonald’s had to decide what it was going to be good at, and what it would not.

Three Markers

In our Just Culture Improvement Index (JCII), we survey culture across the protection of seven common values across businesses.1 To understand an organization’s improvement around these values, we ask survey team members about system design, and two aspects of behavioral choices. Are we continuously designing better systems? If team members see that systems are being continuously improved, it is a sign the design reliability is likely to increase, whether that be tied to service or safety. Are we engaging in peer-to-peer coaching? If team members are willing to coach each other, we see that as an indicator of the team’s willingness to protect the design reliability of the system, to minimize the natural drift inherent to human decision-making. Are we showing an intolerance for highly culpable conduct (theft, harassment, discrimination)? High reliability is, in part, tied to removing employees who do not share the values being protected by the organization (think of the ousted Boeing executives). Three markers: designing better systems, peer to peer coaching, and an intolerance for highly culpable choices – all directly tied to protecting organizational values.2

Tracking Survey Data to Real-World Results

Our performance around these three markers will dictate the results.  As some evidence, we can look to injuries reported to the Bureau of Labor Statistics to compare these three markers in relation to improvements in reliability.  As shown in the chart at right, where employees within an industry report seeing systems being redesigned, peers coaching peers, and an intolerance for culpable behavior, those industries made progress. 

The six industries scoring highest in a composite of the three behaviors across our seven benchmark values saw a five-year 17.1% reduction in injuries, whereas the six lowest performing industries saw a 1.2% increase in injury rates.  That 1.2% increase was saved by university education seeing a 29% reduction in injuries during that timeframe.  Take university education out of the bottom six, and the rest averaged a 7.4% increase in injury rate.

There is an old adage that every system is designed to achieve the results it gets.  That is partially true.  System design sets design reliability.  This determines what is achievable.  Our management (or mis-management) within those systems produces the gap between what we can achieve (design reliability) and what we do achieve (actual reliability).  If you don’t believe that, go visit a few high performing McDonalds and a few low performing McDonalds.  To what do you attribute the differences?

Cite as: Huntsman, D., & Marx, D. (2024). McDonald’s Golden Arches: Three Simple Markers of Improving System Reliability. The Data Series, (4), 1–2.

1 The Just Culture Benchmark Survey is a device for evaluating workplace culture using nine key behavioral markers tied to seven generally universal organizational values: customer service; patient/customer safety; employee safety; financial stewardship; data privacy and protection; environmental protection; and diversity, equity, and inclusion.  We use the survey, and its associated Just Culture Improvement Index, as key measurement tools aiding organizations’ implementation of Just Culture.

2 What is important to recognize is that seeing these behaviors in an organization does not tell us the absolute reliability being achieved, any more than we know a person’s weight simply by knowing that they are eating better and exercising more.  Our benchmark behaviors evaluate change, to see that an organization is moving in the right direction.

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