How Leaders Decide a Change is Needed

in Improvement Science, Knowledge, Leadership, Quality as a Business Strategy (QBS), Systems

By David M. Williams, Ph.D.

Photo by Tetiana SHYSHKINA on Unsplash

Have you ever searched your computer hard drive only to be surprised by the number of files and multiple versions of a similar theme? I have hundreds of Microsoft PowerPoint presentations from client engagements, trainings, and conferences I’ve delivered and dozens of Microsoft Word documents of blog posts, articles, peer-reviewed papers, and book chapters I’ve published over the last 25 years. The science of improvement, quality as an organizational strategy, measurement, scientific problem solving, improvement methods, and a host of linked topics.  Each thoughtfully prepared to tap into the rationale brain of an audience or reader and with the intent to introduce concepts, digest data, and invite learning and change. I wonder how many leaders acted differently as a result? Any predictions?

Chine and Benne (1969) wrote there are three strategies to effect change in social systems: coercive, rational, and normative. 

Coercive strategies are pretty familiar. A penalty or consequence is established by someone with power or authority that demands compliance. You can see how this may have an effect but it doesn’t feel good and untoward effects are likely. 

Rational strategies are familiar too. We make a business case or argument for change. We hope to build will by conveying new ideas or data. We try to convince you and hope you will change. My many files reflect this approach. In a recent Zoom call, John Seddon, founder of the Vanguard Group and co-author of the recently published Beyond Command and Control (2019), helped me appreciate the shortcomings of this approach.

Every day workers make mistakes. A nurse gives a medication incorrectly, a teacher struggles to get a classroom focused on the lesson, a firefighter backs over a mailbox with a fire truck. Every day a leader in these human systems will give feedback to these workers based on a mental model that people make mistakes and helping them see the mistake and providing feedback will improve their performance for the future. Reasonable? 

Stacks of studies and books make a compelling argument the leader’s approach may do more harm than good. Why? In each case, the system of work is designed to allow the well-meaning person to make the mistake. The fact we see them make the mistake leads us to attribute the error to their knowledge or understanding or maybe to their attention to detail but the system is what allowed it to happen. It’s natural to want to react to the event but leaders need to fix the system so the event doesn’t happen going forward. Or at least it is much less likely.

I can present a case example of the situation, talk about my professional experience, and I can even include citations of key papers carefully adhering to the Chicago Style at the bottom of the slide. But, if the information I am trying to rationalize conflicts with a leader’s experience or deeply held mental models, a likely reaction is to resist, question, or say you understand but dismiss it applies in this case. No matter how hard I try, how convincing my case, or how good of a communicator I am, if you don’t see it for yourself or if you were not in search of this insight already, my rational strategy will not affect change.

Normative strategies take a different approach to effecting change. It invites you as a leader to learn for yourself using a double loop learning approach. In this approach, you go see how work really happens, to observe it with your own eyes, and study what’s actually happening. 

Tampa General Hospital CEO John Couris knows the best way to learn what patients and families are experiencing is to go to where they are served; to experience and see how the work gets done. He regularly partners with his team in food service, housekeeping, and patient transport, dons their uniforms, and works alongside them. This is not secret shopping or sneakily playing undercover boss, he openly wants to do the work with them to experience what it’s like. First-hand, he experiences the design and reliability of the system they work in, what hinders their ability to do the right work well, and he sees and hears from his team and his customers. What he sees can not be unseen and guides his continuous efforts to build a more perfect system.

Another tactic for leaders is to follow a process several times. A sample of five cases may be just enough to appreciate what’s not clear about what you are trying to accomplish, how your process is (or isn’t) aligned with the needs of customers, and whether that process is good enough to reliability deliver predictable results. This small sample creates awareness for change which should be followed up with a deeper dive to understand the process, identify change ideas, and come up with a plan to test those ideas to develop a more perfect process.

Quality leaders I’ve studied are curious. They go to the point of service to learn how the system is set up to meet the needs of customers and relentlessly look for opportunities for improvement. Once they see something that needs improvement, they can’t unsee it. They could choose to do nothing and let the waste and errors persist but instead, they act. The normative strategy of engaging leaders is a powerful method for building the will to improve and to affect change.

I think of all of those presentations and papers on my hard drive. I’m hopeful they opened some eyes and encouraged leaders to learn and act differently. I also know the rational strategy likely didn’t move many. To effect change in a human system, leaders need to see it for themselves, be uncomfortable with the gap between what is and what should be, and have the will to act differently to change the system and get a better result.



Chine, R & K.D. Benne. (1969). General strategies for effecting in change in human systems in Bennis, WG et al. The planning of change (2nd Ed). New Your: Holt, Rinehart, and Winston, INC.

Seddon, J, Ibrar Hussain, Toby Rubbra, and Barry Wrighton. (2019). Beyond command and control. United Kingdom: Vanguard Group.

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