Chasing the Rabbit

by Steven J. Spear

Every time managers make a plan or take an action, it is based on some theory or mental model in the back of their minds that leads them to believe that the action being taken will lead to the desired result.

The problem is that managers are rarely aware of the theories they are using and often use the wrong theories for the situations in which they find themselves. It is the absence of conscious, trustworthy theories of cause and effect that makes success in building successful businesses seem random.

No matter what the task, Toyota had figured out how to do the work in such a way that individuals and groups kept learning how to do that work better. Good luck benchmarking that. Any snapshot would reveal where Toyota was today but not where it was headed.

The key for Alcoa, as we shall see in Chapter 4, was to realize that perfect safety could not be designed into its work from the start. No brain trust could ever figure out in advance all the little things that could go wrong. Instead, the trick was to do work, take immediate notice of any risks or potential risks in the work, and make changes so that the same risks did not reappear.

Low-velocity organizations, in contrast, are characterized by "siloization"—"You do your job and I'll do mine"—rather than integration and by endless workarounds and firefighting—"This'll do for now" or "Don't worry, this happens all the time"—rather than continual improvement, innovation, and invention.

Managers in high-velocity organizations make sure that a regular part of work is both the delivery of products and services and also the continual improvement of the processes by which those products and services are delivered. They teach people how to make continual improvement part of their jobs and provide them with enough time and resources to do so. Thus, the organization's ability to be both reliable and highly adaptive becomes self-reinforcing.

Information is not only contextual, it spoils; that is why it is so important to swarm problems.

You can argue that he should have checked, double-checked, and even triple-checked that he had the right medication, but there is overwhelming evidence that relying on vigilance, monitoring, and otherwise being careful is a poor defense against error.

Then he emphasized making changes so that maximum insight would be generated about the complex system of work. This was not a matter of making arbitrary modifications but of predicting clearly what was expected to occur before those alterations were made.

Maksimere learning

With cause and effect articulated—out in the open—if a modification did work, Dallis would truly understand why.