It's just context - a story about my ignorance

· June 11, 2015

I have a story to tell you. It’s mostly about me and my ignorance, I’m sad to say.

But thinking about this have thought me a lot and I hope that you will learn a little as well. During the YOW conference at Perth I probably told this story 5-8 times (to different people mind you). Every time there was fruitful discussions.

This is NOT a post about THEM and (or versus) ME. It’s a post about me, and my reasoning. The story is just context as you soon will realize. Don’t worry there’s plenty of room for personal reflection throughout the post - should you grow tired of me.

The story

When we first got to work with the hospitals here in Indonesia we found something that made us very surprised and scared. At one of our hospitals the nurses was not washing their hands between patients visits. This is a practice that’s know to save lives in health care since 1820-ies. Even I knew that washing your hands is a good practice in health care.

So we asked the nurses and sure enough: “Yes, we know. We really should do that. We start now.”

No change.

We thought that maybe this was a manager problem, so we went to the head nurse and told her that “your nurses are not washing their hands.”. She of course knew that this was a problem and she would look into it. “We will change that!”

No change.

We went higher up the ladder. To the hospital director, a doctor. She also knew about washing your hands as a good practice. She was also appalled that this was not done properly in her hospital. The director made a public address to all staff. We had special “wash-your-hands properly”-training. Everyone was in agreement that this needs to change. Now!.

No change.

At this point I was at a loss. I had no higher authority to go to. All people involved was in agreement. But they didn’t change.

What do you think now?

When you see this heading, in the post, stop for a second or two and reflect about what you are thinking now; At this point what do you think? About the situation and about the people involved? Why?

I tell you what I thought. I’m ashamed to do so but I’ll do it anyway:

They are stupid! Or at least do not care one bit about their work. Lazy. And that's being nice.

But I was wrong. Let’s continue our story

Standard operating procedure

The director did something that I didn’t even think about. She updated the SOP (Standard Operating Procedure). One new line:

Wash hands between patient visits

Bom! The day after - everyone did it correctly. Now not really, it took a few days, but it makes for better dramatic effect, don’t you agree? The change was very apparent throughout the hospital.

What do you think now?

I tell you what I thought:

They ARE stupid. They are not using their brains. They are only following WHAT's written. Knowing that it was better to do what it didn't say.

Context - the organization

I was in this stage for an embarrassing number of months. But then I overheard a couple of conversations and email exchange that started to shift my perspective.

It turns out that it’s common practice and even encouraged, in the organization I’m currently in, to tell people off (read: YELL!) and even punish them financially (?!!!) for not following the SOP.

Yes, it’s true. I’ve heard and seen it a number of times. And the people doing the yelling and suggesting the penalties ALSO know that it’s better for the nurses to wash their hands.

What do you think now?

I tell you what I thought:

This is a stupid system. It's more about control and compliance than getting good work done

But in fact, letting people think for themselves is a big threat to a hierarchical system. To the system, mind you. Not the people in it. Nor the outcome of the activities in the system.

In the excellent Reinventing organizations Frederic Laloux has a liberating presentation of the different historical paradigms of organizations and when they are a good fit. The model for a strict hierarchical organization is a old-school army. You know the ones on display in Braveheart.

In this setting you absolutely DO NOT want people in the front line to start to think for themselves. Going another way, or running away. That would cause havoc in the army, the force behind the attack would be gone and the generals with the strategies loose all control.

Sadly… this kind of structure has often been used as a model for other organizations, where thinking for yourself is a good thing. Like most modern workplaces for example. This is less than successful, of course. I know - because I’m in one right now. And have been in others too.

The symptoms are that it’s very slow execution, people on the “floor” have a lot of responsibilities but no authority. There’s a lot of document outlining how to behave and act, and should the document not apply in a situation we stop and write new policies. Most people lower down in the hierarchy are not engaged and often feel that “i’m not doing anything useful” but follow procedure without thinking. People at the top are super busy and often feel that execution is slow.

In most of these organizations that I’ve been in everyone knows that this is a problem. Everyone knows that. Very few do anything to change it. Or even question the current system.

What do you think now?

I tell you what … this is getting old.

Why doesn't anyone just ask WHY and try to do better?

This has to do with context again, of course. Culture even is a better word for it. Let me tell you two stories more:


My co-worker Anton, here in Indonesia, is 2 years older than me. 45 in other words. He told me that when he was a child it was common practice that children that asked “Why?” got smacked. By parents, teachers and others.

What kind of people does that create? Asking WHY is not only not appreciated - it’s punished.

If no one is looking for better, challenging the status quo - how will improvements happen? From the top of course, as the system is set up. The people at the top think - the people at the bottom executes. And do NOT ask questions.

The culture is (were?) holding the improvements back.


I gave a presentation about lean and more specifically about limiting work in process to a group of middle level managers in a big insurance company in Sweden.

We played the game (see link above) and discussed the implications. All of a sudden the penny dropped for one of the managers:

Ah - I see. This would make us more productive, more effective. But I do *not* want you to tell my employees this. Please don't.

Why did he say that? Because his salary was calculate on how many hours his employee paid. The higher percentage of busy-ness the more pay for him.

The organizational system were (is?) holding improvements back.


And the solution to all of this is …. Eh… don’t know yet.

But I do know that people in general is not stupid. I very often miss or am ignorant about the context and culture in which they operate, though. There’s most often a reason for people to behave, or not behave in a certain way.

You should not change people, you should change the system in which they operate. This will give the people in the system a chance to be better version of themselves. And in doing so they will help the organization better.

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