This is the nature of management. Decisions are made, usually for good reasons, which in turn prompt other decisions. So when problems arise - and they always do - disentangling them is not as simple as correcting the original error. Often, finding a solution is a multi-step endeavor. There is the problem you know you are trying to solve - think of that as an oak tree - and then there are all the other problems - think of these as saplings - that sprouted from the acorns that fell around it. And these problems remain after you cut the oak tree down.

There is a crucial yet hard-to-understand concept here. Most people grasp the need to set priorities; they put the biggest problems at the top, with smaller problems beneath them. There are simply too many small problems to consider them all. So they draw a horizontal line beneath which they will not tread, directing all their energies to those above the line. I believe there is another approach: If we allow more people to solve problems without permission, and if we tolerate (and don’t vilify) their mistakes, then we enable a much larger set of problems to be addressed. When a random problem pops up in this scenario, it causes no panic, because the threat of failure has been defanged. The individual or the organization responds with its best thinking, because the organization is not frozen, fearful, waiting for approval. Mistakes will still be made, but in my experience, they are fewer and farther between and are caught at an earlier stage.

Boston University professor Anita Tucker and I studied nurses carrying out the dozens of tasks that occupied them throughout long hospital shifts. Taking detailed notes, complete with time stamps, to document the work of these dedicated caregivers at nine hospitals, Anita observed that nurses confronted “process failures” surprisingly often—almost one an hour. A process failure was anything that disrupted a nurse’s ability to complete a task, such as an unexpected supply shortage in bed linens or medications. The nurses were acutely aware of these frustrating daily hurdles. Their jobs were hard enough! On average nurses were working an extra (unpaid) forty-five minutes simply to tie up loose ends before leaving the hospital.

We can easily understand why busy nurses rarely engaged in second-order problem-solving. But this left them vulnerable to continued frustration because the work-arounds didn’t reduce the frequency of future process failures. The average time a nurse spent on work-arounds (a few minutes here, a few minutes there) added up to about half an hour per shift—a substantial waste of skilled professionals’ time. Like all quick fixes, the nurses’ work-arounds created an illusion of effectiveness. Confront a problem, implement a work-around, get on with your day. End of story.

The person closest to the problem often has the most accurate information about it. What they tend to lack is a broader perspective. The person working on the line at McDonald’s knows how to fix a recurring problem at their restaurant better than a person merely analyzing some data. What they don’t know is how it fits into the bigger picture. They don’t know whether the problem exists everywhere, or whether the solution wold cause more harm than good if implemented globally, or how to roll the idea out to everyone.