The Procedure Didn't Fail. The System Did.
A different way to think about procedures, people, and system design.
THINKING DIFFERENTLY
There's a phrase I've heard for years.
"People don't follow procedures."
Sometimes it comes up in a quality meeting.
Other times during an audit.
Sometimes after an accident or a customer complaint.
The phrase is almost always followed by the same conclusion.
"We need to retrain them."
And the meeting moves on.
For a long time, that explanation seemed perfectly reasonable to me.
After all, if a procedure exists and someone chooses not to follow it, it seems logical to assume the problem lies with the person.
Over the years, though, I began to suspect that reality was a little more complex.
Because most people don't come to work intending to do a bad job.
No one wakes up in the morning thinking:
"Today I'm going to ignore the procedure and create a problem."
So the question stopped being:
Who didn't follow the procedure?
And became something else.
What caused an otherwise responsible person to stop following it?
That question changes the entire conversation.
Sometimes we discover that the procedure is simply too long.
Or that it hasn't been updated in years.
Or that it describes a reality that no longer exists.
Other times we find something even more interesting.
Following the procedure makes the job harder than not following it.
And when that happens, people begin to improvise.
Not because they're irresponsible.
Because the system teaches them, every single day, that there's an easier way to survive.
That's when I realized something I had never considered before.
When one person doesn't follow a procedure, we may have a discipline problem.
When many people stop following the exact same procedure, we probably have a design problem.
And those two problems require very different solutions.
One tries to change people.
The other tries to learn from the system.
Since then, whenever I hear someone say,
"People don't follow procedures."
I try to ask a different question.
What do people know about this job today that the procedure doesn't know yet?
Because sometimes the procedure didn't fail.
It simply stopped learning before the people did.