many attributions for this saying, but Susan Carr, writing in the Patient Safety & Quality Healthcare e-newsletter, determined that it originated with Dr. Paul Batalden in the field of medicine.
When Ms. Carr contacted Dr. Batalden about his observation, he told her:
The observation invites personal reflection and awareness, the place where the lasting improvement of quality usually begins. By directing people's attention to design, the words offer a powerful invitation to deeply consider how the present situation was created and invites its re-creation.
Many fields of practice have systems to which this adage applies – the medical field where Dr. Batalden worked, the legal system, and organizational systems.
Because I’ve worked in Human Resources, not medicine, I think of the saying as an organizational design principle: Every organization is perfectly designed to get the results it gets. How many times have HR directors looked at employees’ behavior and shaken their heads, wondering why people behave the way they do? The answer is often that the organization incents people to behave that way.
For example, sales employees might be paid for dumping more product in customers’ stores than the customer can profitably sell. Or one manufacturing plant might hoard materials that could better be used in another plant, because they have learned that ordering new materials later takes too long.
Yes, every system is perfectly designed to get the result it gets. The only way to change the result is to change the system.
Some organizational systems are formal – the reporting relationships, the incentive plans, the company policies, etc. – and some are informal – the “attaboy” conversations, or the hallway meetings where the real work gets done.
As one leadership commentator said (in The Executive Perspective):
As discussed . . . here on our blog, you design your company system through the conversations that you are actively having as well as those that you have codified in employee manuals, procedures, plans. However, your design is also stuck in unspoken conversations that you should be having but you are not having. The classic example is of a company that wants to be innovative but does not reward risk taking.
Once you recognize that, you can now also see that if you want to change your results, and therefore the design of your team or company, you just have to change your conversations.
If you want to change the results, but don’t change the design of your organizational system, you are engaged in Albert Einstein’s definition of insanity: doing the same thing over and over again and expecting different results.
The changes you make to your organization may be small. In fact, you are probably better off trying small changes, rather than engaging in a wholesale re-design of your organization.
I’ve been a part of change initiatives that take the entire organization apart, task by task, trying to design the perfect organization to get a desired result. The problem with that approach is that organizations are complex. The larger the organization is, the more complex it is.
Most organizations are so complex that the law of unintended consequences takes over. There is no way you can anticipate every interaction between the organization’s members or parts. In dismantling an entire organization to re-structure it, you are as likely to create new dysfunctions as to fix the old problems.
So change. But change carefully.
When has a change caused unintended consequences in your organization?