Supervisors are hiding something from their managers.
They're hiding deliberate violations of operational
procedures by their employees. This happens when employees
are asked to follow procedures they find awkward or
inefficient. They don't want to follow them, and if you ask
them why, they will complain about managers devising
procedures for employees to follow that they don't have to
follow themselves. So employees devise their own procedures,
and the work gets done.
Supervisors see this occurring, yet they assure their
managers that proper procedures are being followed. But even
as they are giving these assurances, they are supervising
employees who are following different procedures. It's a
deception, and it occurs in most employment settings.
Things run smoothly, sometimes for years, but occasionally,
something goes terribly wrong. People get hurt and
businesses lose money. Investigators quickly assign blame:
proper procedures weren't followed. But often, they also
note that important changes in the work place occurred just
prior to the catastrophic event. They note it, but they
can't explain how such changes may have contributed to the
problem.
This curious presence of change attracted the attention of
Rangaraj Ramanujam, from Purdue University, who wondered if
change was a contributing cause of business disasters.
However, it was a difficult research question to answer, so
he framed his research around a different question, the
influence of change on the occurrence of deliberate
violations of procedures, the other contributing factor often
noted by investigators.
Ramanujam found a large financial services firm that had an
ongoing program of internal audits of company units. One
factor they rated was deliberate procedural errors. They
called them "latent" or "hidden" errors.
Ramanujam collected 80 of these audits and then noted the
presence of three kinds of change occurring just before the
audits. 1) organizational structure changes (reporting
relationships, and consolidating functions), 2) a new unit
manager, and 3) a change in technology such as new software.
These were deliberate changes, often intended to improve
operations. He also noted the risk in the unit's work, the
potential for harm if things go poorly.
Ramanujam found that low risk units with little change
revealed no increase in hidden errors in their audits. High
risk units with little change revealed even fewer hidden
errors. In the absence of change, few errors were detected,
but things were dramatically different when change had
occurred.
High risk units with the most change revealed four times as
many hidden errors as low risk units experiencing change.
This was a steep increase over past audits. They were powder
kegs waiting for a spark. They were out of control, and it
was change that caused the problem.
Ramanujam believes two things happen when change occurs.
1) People withdraw attention from routine operations to
implement the change, and 2) units lose shared memory that
helps prevent unauthorized procedures from turning out badly.
Shared memory involves the collective knowledge of everyone
in a unit about the routine procedures they follow. It's
like your spouse reminding you to lock the dead bolt on the
door when you leave because she knows you don't like to do
it. If you remove the spouse or occupy her with other
activities, you won't get reminded and the door will stay
unlocked. Probably, nothing will happen, unless a burglar
tries your door that day.
Four high risk units that experienced much change survived
their audits with no hidden errors at all. These four units
were different from the others, so Ramanujam investigated to
learn more.
He found that the managers of these error-free units acted to
stimulate and preserve the shared memory of their people
about their routine operations. Managers did this even as
they introduced significant changes. They actively involved
themselves in these routine operations. They read the
reports they received, and they knew what they said.
Ramanujam believes that managers should copy this example
when they introduce change, especially if the work is risky.
He also believes they should augment the shared memory in
their units by assigning people to monitor routine operations
during change and by conducting audits that look for
deviations from policy.
Reference: Ramanujam, Rangaraj (2003) The Effects of
Discontinuous Change on Latent Errors in Organizations; The
moderating Role of Risk. Academy of Management Journal, 46
(5), 608-617.
Business Practice Findings, by James Larsen, Ph.D.
Losing Control
Researcher discovers a surprising effect when changes are introduced.