Dealing with the hindrances so forthrightly may call into question what the outcomes of the program should be, and it’s perfectly fine to go back and change the outcomes in light of what is discussed around hindrances.

If one has not internalized the concept of quality matching and the problems of change in chain-link systems, then Marco’s explanation of his actions may seem banal—he identified the three problems and worked on them in turn. But if one has these concepts, then Marco’s statement is dense with meaning.

The first logical problem in chain-link situations is to identify the bottlenecks, and Marco did that—quality, sales’ technical competence, and cost. The second, and greatest, problem is that incremental change may not pay off and may even make things worse. That is why systems get stuck. Marco’s solution to this problem was to take personal responsibility for the final result and direct others’ attention to the three bottlenecks, one after another…

… Marco avoided this problem by shutting down the normal system of local measurement and reward, refocusing on change itself as the objective…

Instead, Marco described a turnaround in which he provided the overall definition of what had to be done and in which he anticipated and absorbed the costs of change. In any organization there is always a managed tension between the need for decentralized autonomous action and the need for centralized direction and coordination. To produce a turnaround of a chain-link system, Marco Tinelli tipped the balance, at least for a while, strongly toward central direction and coordination.

A system for innovation

How do you increase the chances that a failed adhesive turns into a brilliant product? With a system designed to bring curious risk-takers together. Encourage and celebrate boundary spanning. Provide resources and slack time. Normalize intelligent failure and celebrate pivots. Declare that you want a significant portion of your company’s revenues (or school’s curricula or family’s activities) to come from new and different products, courses, or experiences. Successful innovation does not come from the lone genius. Importantly, each of these familiar elements of innovation is reinforced by each of the others. The whole is more than the sum of the parts.

“Use Systems Thinking to Change How We Think about Error …

Rely on inquiry

So Morath faced a challenge: How to help people to see and accept their hospital’s failures? Rather than doubling down on her logic—You work in a complex error-prone system, don’t you see? Things will go wrong!—she instead invited clinicians to reflect on their experiences that week with their patients, then prompted, “Was everything as safe as you would have liked it to have been?” Her aspirational question opened the floodgates. Most people had been in what Morath called “a health-care situation where something did not go well,” and

once they reflected on the many problems they had noticed, they became eager to talk about what had happened and how they might improve…

New language

Another element of the patient safety system was what Morath called Words to Work By—a roster of suggested terms designed to help shift mindsets from blaming to learning. Morath substituted neutral-sounding words such as study for the more threatening word investigation, which put people on the defensive…

Synergy…

As with the system at 3M that supported people’s intelligent failures in ways that encouraged product innovation, and the system at Toyota that made quality improvement second nature, Children’s Minnesota built a robust learning system that turned everyone into an active participant in patient safety. Morath’s approach reminds us that system design is more than simply coming into an organization and flipping a single switch. It’s flipping multiple switches understanding how they work as a system.

So often the problem is in the system, not in the people. If you put good people in bad systems, you get bad results. You have to water the flowers you want to grow.