The absence of a Director of Nursing at the time of Lehman's admittance, a post that had been vacant for over a year, also signals that the medical and clinical teams did not adequately appreciate the interdependence and complexity of their work.
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Workarounds can occur when workers do not feel safe enough to speak up and make suggestions to improve the system.
For instance, an in-depth investigation of Nokia's rise and fall in the smartphone industry between 2005 and 2010, which included interviews with 76 managers and engineers at Nokia, concluded that the company lost the smartphone battle not as a result of poor vision or a few bad managers but at least partly due to a “fearful emotional climate” that created company-wide inertia, especially in response to threats from powerful competitors.
The regulators were, in a sense, disabled from effectively carrying out their regulatory duties by a culture of fear and deference.
I don't mean to imply that working in a fearless organization takes more effort or a tremendously difficult undertaking. It doesn't. But initially, when we've been entrenched in fear and its attendant mental frameworks, it's not always obvious.
For instance, I've studied senior management teams in which a lack of psychological safety contributed to long-winded conversations (indirect statements, with veiled criticisms and personal innuendo, take longer than candid ones), elongated meetings, and an inability to come to a resolution about crucial strategic issues. Decisions that could have been resolved in hours stretched over months.