Want to understand an organization's culture and leadership with one question? Jeffery Pfeffer and Robert Sutton, in their classic book Hard Facts, Dangerous Half-Truths And Total Nonsense: Profiting From Evidence-Based Management
"What happens when people fail?"
Pfeffer and Sutton reported on research by Anita Tucker and Amy Edmondson that explored why hospitals are not often successful at finding and fixing recurrent problems. Their research has implications for you and your organization.
Tucker and Edmondson found that nurses found a way around most problems and errors as they happened, and did not report them. In fact, nurses contacted a physician or manager for help only seven percent of the time.
One problem with that approach is that the organization (hospital) loses the opportunity to learn from the problems and prevent them in the future. Another problem is that the nurses' quick fixes often created new problems elsewhere.
Why didn't nurses seek help to fix the root causes of problems? The authors reported that,
"Seventy percent of the nurses we interviewed commented that they believed their manager expected them to work through the daily disruptions on their own. Speaking up about a problem or asking for help was likely to be seen as a sign of incompetence. " (page 16)
Tucker and Edmondson's suggestions for improvement
Provide management support. Be available for your front line workers, so you are more likely to hear about problems and errors. Provide resources to think beyond the quick fix. Teach front line workers to search for the root cause.
Create an environment in which it is safe to admit problems and errors. As a leader, admit your own mistakes and weaknesses. Ask front line workers to speak up when problems occur. The ideal employee may not be the one who quietly solves problems on her own. Rather, the ideal employee is probably the "noisy complainer."
Respond to worker concerns, and do something about them. When the root cause is outside an individual worker's control, management must step in and provide the leadership to the problem.
If you are engaged in an organizational change effort, I recommend reading Tucker and Edmondson's paper in full.
In the meantime, what happens at your place when people fail?
[Drawing copied from page 29 of Tucker and Edmondson's paper.]
