The Co-Captain Theory- The Path to Organizational Homeostasis

There has been much discussion and rumination on the how a perfect organization should be structured. We have observed numerous examples of successful and deficient corporations and how their organizational structures contribute to both pathways, but when one must declare how the ideal organization should be designed one must first define what exactly an ideal organization is, and the qualities that are required. First, all the flourishing organizations we examined displayed a strong sense of shared purpose that was pervasive from the CEO to the front-line employees, leading those within the organization to believe in why and what they do to the deepest levels of their minds and to the higher levels of their needs hierarchies. Secondly, the organization must operate on “the edge of chaos” without the burden of “external sanctions” basically meaning that they cannot handcuff themselves to quarterly earnings or short-run sales goals, that the organization and its leaders must be focused instead on the long-run sustainability of their company. By no means are these two aspects an exhaustive list of what an organization needs to be successful but in a sense if people know what they are fighting for, and believe that it is worth fighting for they will always fight until they win, and often what is worth fighting for is not popular by any means nor is it ever easy. Even if these two aspects are met an organization may still falter if not structured properly to allow for maximum adaptability and continual learning, and therefore may fail.
Granted that these underlying qualities are met (especially in an organizations’ leadership) how then does one arrange their personnel to best achieve their purpose? The solution is simple and elegant, inspired by the authors’ main experiences in observing our natural world and on the athletic field. Instead of Executive Vice Presidents, or Heads of Divisions, there should be Co-Captains leading teams in tandem, providing a sense of balance in leadership to their departments and also providing dual feedback to their CEO, all enabling the company to function like a productive ecosystem, and a gracefully structured human body, and an exciting championship baseball team (Please refer to the attached diagram). This theory is in contrast to the individual spirit of accomplishment and burden we love here in the United States, but as stated before our organization requires those who populate it to be committed to the shared purpose, individual pursuits and selfish scheming have no place in the ideal organization and a CEO willing to institute the co-captain theory must not fear letting those whose commitment is shallow and egocentric find their place somewhere else.
So once the “right people are on the bus” how does one pair individuals in order to best utilize the co-captain theory? Well, since balance is a key goal of the theory one must carefully choose individuals that have different and complementing strengths and weaknesses. For example a choosing one captain that has a more risky business philosophy and pairing that individual with another that has a more conservative business philosophy. Or one whose greatest strength is their ability to communicate effectively while the others’ strength lies in numerical analysis. Rarely are there singular individuals who strengths are so wide and diverse that they do not need input and assistance from outside sources. And even if they don’t, such individuals are usually intelligent enough to realize that listening to all ideas only make one stronger. These co-captain pairs must be chosen carefully, therefore the CEO must directly observe individuals that they would consider candidates for the posts, and they must gather evidence from the candidates’ subordinates. The CEO must use their foresight to envision how a possible partnership would function. It is not necessary for these partnerships to be all sunshine and roses either, the co-captains must be able to constructively criticize each other without behaving defensively or immaturely, and their behaviors should always function to serve the organizations’ purpose. In this aspect the CEO must have zero tolerance otherwise the co-captain theory will not function properly. Meaning that if a captain the CEO assigned is behaving out of purpose that person must lose their position of authority immediately, at least temporarily, and if through this removal that individual does not recognize and amend their behavior then it is revealed that being a co-captain of their division is not in their interest nor in the best interest of the organization. Choosing the proper individuals for each co-captain position is a crucial beginning step, following the gathering of information, and the next one is for each individual and each co-captain team to understand and occupy their niche to perfection.
In an ecosystem when one describes a niche it refers to the environmental factors that influence the growth, survival, and reproduction of a species, it is not just a physical location of a certain organism or that organisms’ function and behaviors within that system. The niche an organism occupies is a result of their own morphology, as well as their morphology being a result of the niche they occupy. In a business organization it is recognizing that the decisions one makes are a result of functions of their division, and that the functions of their division are a result of their decisions. The size and shape of the beaks of Darwin’s Finches on the Galapagos Island are a result of the niche they occupy and they continue to occupy that niche because of the shapes of their beaks. Once one understands the reciprocal nature of a niche, then each co-captain can begin to better occupy that role. So each partnership must be aware of, comprehend, and be able to empathize with each other. Then when able to function properly in their niche (as individuals and a co-captain team) they can provide their influence on the system as best suited to the niche they occupy. Therefore it is not just the CEO’s responsibility to build functional teams, the co-captain teams themselves must identify and adapt to their environmental factors to maximize the growth, survival, and reproduction of their division.
Each co-captain will have different responsibilities in their niche operating ideally on opposite sides of feedback loops. Referring to the purpose of each co-captain should be ideally suited to governing either a reinforcing (or positive) feedback loop or a balancing (or negative) feedback loop. Obviously one’s personality and philosophy will reveal a penchant for governing one or the other and that individual should be assigned to that task. Though it is crucial for again for both individuals to understand and respect the others’ assignment as their niche cannot be occupied properly without the dual functioning. Arranging one’s organization to crux upon feedback loops will enable expedient changes of the revolutionary kind, and will also enable the small micro changes needed to correct volatile changes, both bringing the organization along their path of shared purpose and toward homeostasis. It is crucial to remember in a system which functions properly with positive and negative feedback loops input from both is constant, small adjustments are constantly being made from both sides. The co-captains must also not only provide proper input into the system below them but feedback in the co-captain system must travel upward as well. For the CEO is the like the brain which to function properly needs constant feedback from the body in order for it to make proper decisions to help the body survive, grow, and reproduce. Therefore the CEO must seek feedback from BOTH captains to acquire information, and must examine information both positive and negative (not related to the reinforcing or balancing feedback loops). And the organization that utilizes these loops of control, and information will be able to achieve that sustainable productivity and profitability.
Perhaps the co-captain theory is best explained through metaphor. Imagine your organization as a car, and the CEO is the brain of the driver, and the co-captains are the driver’s hands, one for the right and one for the left. Established is the fact that if the road is straight, and the car easily manageable, you may not need more than one hand, or no hands if you’re good with your knees, to keep the car between the lines. But rarely in the business world is the road straight and the car easily manageable. Most organizations are like an eighteen-wheeler, and most industries resemble Mt. Rose Highway. If you picture yourself driving an eighteen-wheeler up Mt. Rose, wouldn’t you want both hands on the steering wheel? Wouldn’t you want to be able to really crank it when you needed to get around a fifteen mph turn? Or wouldn’t you like to make those small corrections when a gust of wind causes your trailer to shimmy on a straightaway? Making it safely over the summit simply requires two hands working together. And an organization functioning smoothly requires the intelligent design of two individuals sharing responsibility for each department. Though the co-captain theory betrays the spirit of
Individualistic accomplishment we are so married to in this nation, it is something to be considered by those who wish their organization to function in the consistently shifting and incredibly competitive global business markets of the future.

ADDITIONAL NOTES ON IMPLEMENTING THE CO-CAPTAIN THEORY
· Co-Captains need not only exist at the top of the organization, one should disseminate co-leadership as far as possible. So if need be there should be Regional Co-Captains, then Area Co-Captains, then Local Co-Captains and so on.
· Co-captains should never directly govern teams larger than say 10 individuals. Example being Regional Co-Captains should govern a team of 10 Area Co-Captains, and each team of Area Co-Captains should govern a team of 10 Local Co-Captains.
· The Law of Rotation – Changes in those that occupy Co-Captain positions are encouraged. They should occur probably every few years, or upon request of the Co-Captain, to allow for fresh ideas to emerge
· Co-Captains – should be encouraged to run experiments, gain evidence, for possible changes in their division or to test the effectiveness of their feedback loops at generating the desired results.

Organizational Silence – Manifestation of Our Deepest Fears

Organizational silence, when an organization develops, or encourages, behaviors where employees, managers, and CEOs develop a case of tight lips in controversial situations results from deep insecurities that all human beings possess. Whether it be fear of looking unintelligent, or being rebuked by a colleague or boss, or losing grasp on one’s power, or fear of validating something one’s equals may consider lesser, all work in concert to produce an environment where people will not raise their voices when necessary. Morrison and Milliken state that organizational silence results from “top managers’ fear of receiving negative feedback from subordinates” and from managements’ view that “employees are self-interested and untrustworthy”. On the opposite hand employees fear retribution from their bosses, and past experiences also lead the employee to believe that their advice would be ignored by their superiors. Therefore silence is perpetuated and reinforced on both sides of the coin.
Organizational silence is not just prevalent in the business world but we grow up learning to keep silent as all of societies’ visible, and underlying, caste structures reinforce these same silence starting in grade school. Think of the bully picking on the nerd as you walked home from school. Or maybe you were the bully or the nerd. Anyway, fear of the bully causes you to walk right by pretending that you didn’t notice the hazing, and fear of the tattle-tale label causes you to stay silent when you get home and your mother asks you how your day was. Bullies, most would agree act from insecurity and fear, and maybe that bully down deep really wants someone to say something to them about their behavior because they crave attention or need help correcting a deeper problem. So really we are taught to “mind our own business” at a very young age, and this mindset pervades our work environment. Meaning that if we are doing well in our position we fear rocking the boat, cause unfortunately sometimes when a boat rocks we fall out. But is it really that bad to fall out of a boat? Not if you know how to swim.
Therefore begins the cure for organizational silence, which the authors state lies in managers not “shooting the messenger”, and employees having the courage to “rock the boat”. It helps one to feel comfortable rocking the boat if they have worked on their balance, are wearing a life-vest, and have of course fallen out of the boat on at least one previous occasion. The best way to show someone that falling out of the boat is no big deal, is to of course jump out yourself first. When I used to guide kayaking trips on Catalina Island we had groups of students from Los Angeles whose ideas of adventure were a new video game. So when we would go out kayaking in the ocean obviously for safety reasons we had to teach them how to self-rescue in case they happened to fall out, therefore at the start of every lesson, no matter how cold the water was one of the leaders would go overboard on purpose to show that it wasn’t a big deal, and that it was easy to get back in. So it is on managers to speak first, and maybe it would be most effective at breaking silence if they contradicted their own superiors in front of their subordinates. For example if a new policy directive came down that the manager thought certain aspect of were ineffective, he should first consult his own boss on those specific aspects, but then when relaying the new directive perhaps that manager should confide in his subordinates the aspects that he thinks aren’t effective and then in turn ask his team what they thought were ineffective. That way everyone’s opinion can be expressed and subordinates know that their manager was willing to risk their position to live on the edge of chaos and without external sanctions.
Through ignoring or removal of those external sanctions and not fearing actions without a net, we can learn to let go of our fears of speaking up. I’ll wager that those who read this and think that they would have said something if they saw the bully hazing the nerd in grade school, or possibly did say something in that context, have better communicative relationships with their bosses and subordinates today than those who did not comment. They have a long-time pattern of breaking organizational silence therefore must pass on how they learned to do so and teach others to overcome those fears as well. Organizations should seek out those individuals and learn from their communication skills regardless of their root. Also our society has moved in a positive direction concerning silence in situations, so hopefully as we continue to evolve into better people both in our personal lives and professional, lessons learned in grade school will be positive influences on our future behaviors.

Advanced Change Theory – Adaptation then Evolution, NOT Just Acclimatization

Quinn, Speitzer, and Brown, have developed a very sound theory on how to beget change in one’s organization calling it the Advanced Change Theory (ACT). They advocate that through committing to a series of relatively predictable, at least if one is familiar with previous works, such as The Fifth Discipline by Peter Senge, but explained in the language of histories greatest servant leadership advocates Jesus, Martin Luther King, and Ghandi. Using quotations from these three individuals is admittedly powerful, as is the behavioral examples elucidated upon. Some expected principles of ACT are of course examining oneself first, clarifying ones values and aligning behavior along those values, the all-powerful development of a common purpose (though presented with a new twist here), and developing partner-follower relationships. Though these principles are quite valid, their thinking was not as fresh, to me, as two of the other principles: first freeing oneself from the system of external sanctions, and second taking action to the edge of chaos. These two were particularly intriguing and clearly extremely difficult to master, though if one can practice what is right and learn to work without the safety net (of course in concert with all the others… sigh) one will be able to attain adaptive change easily, evolving ones organization into the most fit of their population for the long run, instead of just acclimatizing for the short run.
Obviously I am making a reference to terms that most would consider minor differences in semantics, as many would deem acclimatization and adaptation and evolution to be interchangeable terms. It should be no accident that Quinn, Speitzer, and Brown use the specific term adaptive change (somewhat redundant though) in describing the type of change the ACT produces. What they are advocating is perfectly understandable in biological terms as an adaptation is a trait favored by natural selection making the individual with it more fit than the competition, therefore the trait is passed on to the next generation, an inherited trait. As opposed to an acquired trait, or a “tool” an organism uses to acclimatize to their environment and acquires throughout their lifetime but does not pass on. The simplest example of an acquired trait would be the blacksmith who spends a lifetime pounding his anvil with the heavy hammer in his right hand. He builds a very muscular arm on a fit but asymmetrical frame, this trait makes him more fit as it helps him with his trade, providing food for his family, enabling him to reproduce more offspring. His children however will never be born with a huge right arm. Here lies the difference in traditional change theories, and the ACT. The authors state that “three-quarters” of changes attempted in organizations fail, or do not last, because there is a failure to change the human system. Meaning that corporations acclimatize, they do not adapt. And adaptive changes lead to evolutionary changes where a trait is so beneficial to fitness that it eventually perpetuates throughout the entire gene pool. But first begins adaptation and the ACT presents two interesting ways one’s organization can begin to adapt.
Imagine the first frog/fish-like animal to develop lungs to breathe outside the ocean. His frog/fish friends probably laughed at him hanging out up on the rocks, but when the bigger fish came up from below and ate those with no lungs they certainly weren’t laughing anymore. If that frog/fish had yielded to peer pressure, followed the norm, and not “freed [him]self from the system of external sanctions” where would we all be now. That freeing was crucial to making that adaptive change for the common good of the species. Just as George Zimmer puts his shareholders last in the list of his organizations priorities, and ignores the quarterly return rollercoaster in his decision making, so did the frog/fish. This freeing from external sanctions and influences is a marked quality of successful individuals and organizations, especially those who are successful at bringing about change such as Martin Luther King or Gary Loveman. This principle is especially important with regards to multinational corporations that are committed (supposedly) to social responsibility, such as Coca-Cola or Google. Coca-Cola when operating in countries with less-stringent or nonexistent labor and environmental laws, they should do the right thing and operate in the same manner they do on US soil because it is doing what is right. And when Google went into China they continued to operate their US-based search engine so that when Chinese people logged on in China they could then see what their government was filtering. Though Google did have to submit to censoring by the Chinese Government they came to the conclusion that any flow of information was an improvement, especially when couple with their original site so that citizens could then judge their governments’ actions themselves. These are the bold decisions required of business leaders, or frog/fish, and like Jesus allow public opinion, and short-term focus, to have little influence on them.
Along the same line of “freeing oneself from the system of external sanctions” is the authors’ idea of “taking action to the edge of chaos”, working without a safety net. Think of the risks the frog/fish took jumping out onto the rocks, not knowing what could have come of it, “building the bridge even as it is walked on”. Again evolution can illustrate the authors’ point as radical evolutionary changes have always occurred on the edge of chaos, violent climactic events like ice ages, or meteor collisions with earth. If the chaos is not sufficient enough change will be traditional and fleeting, an acclimatization not an adaptation. Look at our nation’s founding fathers who would have been hung as traitors had we lost the Revolutionary War, they were true ACT practitioners working without a safety net to give birth to their shared vision. This shared vision riding hell-bent on the edge of chaos allows those involved to “stretch themselves to behave according to that vision, they can become a revolutionary force.”
Here finally the authors again use biological terms that ease the understanding of their principles, and uniquely coin the word altruism in their description of vision for the common good principle. Interestingly altruism is a very common behavior shown in animal societies that operate extremely productive organizations, and Quinn, Speitzer, and Brown state that “sacrifice for a purpose when the role model is acting in an altruistic fashion” is essential to the ACT. None would argue that meerkat populations operate in a very common purpose oriented organization, as is their survival imperative, therefore one would not be surprised to see altruistic behavior such as a sentry cat acting as a decoy to draw predators away from a nursery den at great personal risk. Similarly if an employee can observe a CEO risking their own survival for a policy initiative, or a political leader risking re-election in his district to do the right thing for the population as a whole, that will inspire employees to do their job to the best of their ability in service of that vision and citizens to rise up to support what is right.
In conclusion it seems that business leaders have finally begun to learn from historical leaders and perhaps it is time to learn from scientific study, especially the biological sciences. Why should a corporation not function like an organism? Animals are regulated by feedback loops companies should be next. Why should businesses not organize like an ecosystem? A vertical, horizontal and circular inter and intra-dependence between, suppliers, vendors, customers, shareholders, employees, managers, departments and CEO’s. Moving forward as we begin to leave old ideals of paternalistic management styles, and business practices that have been proven short and near-sighted behind, perhaps Mother Nature should be the new business professor as she has truly endured long-term volatility all while sustaining substantial productivity, the basic goals of any business endeavor.

The Men's Warehouse - Tying it all together, and bringin' it home!

It has come to my attention that there are some threads common to the successful companies we’ve studied this semester. Now, there is a clear distinction between “good” case studies and “bad” case studies. For example, SAS Institute was obviously a good one, while Nordstrom was obviously a bad one. Of the case studies we’ve examined the good ones all seem to operate in a similar way, having congruous base philosophies on the way they manage their employees, their organization and their customer relationships. The Men’s Warehouse (MW) is a striking, and clear, illustration of these similar qualities, and practices, which I believe to be clutch to all the good case study companies’ thriving productivity, and include a focus on long-term value and sustainable growth, upper management participation in training the bottom rung employees, and most importantly valuing the unquantifiable and the intrinsic. These three focal points help each company go above and beyond expectations for customer service, as well as shareholder earnings, and employee satisfaction.
Akin to the SAS Institute, the Men’s Warehouse began as the brainchild of its chairman George Zimmer. At first a very modest operation, where Zimmer himself worked on the floor and served customers, it grew immensely in the 1990s because of the excellent customer service and the low prices offered. And since its inception Zimmer has always been focused on the long-term value. This is demonstrated by his statements regarding his company’s five stakeholder groups with employees being the most important with the customer, the vendor, the community, and finally the shareholder coming after. Obviously if one was only focused on that quarter, or the next, one would definitely not make a point of placing their shareholder last in their chain of focus. And in the case of The Men’s Warehouse their policies prove this standard to be valid and sincere. Versus Nordstrom who, despite a reputation for excellent customer service, espoused commitment for their employees but really instituted policies that were detrimental to employee satisfaction, possibly illegal, and whose true aim was maximizing quarterly earning numbers for investors. At SAS it was the private ownership that enabled the long-term focus, while at the Men’s Warehouse it is their hierarchy of stakeholder groups, combined with the charisma and sincerity of Zimmer and his top executives. If one is the lowliest employee at MW and hears the president talking about his appreciation and value for that individual in that position most likely because that is where they also started, that employee can believe those statements and carry it with them as they go about their daily activities. That sincerity provides a measure of inspiration to go above and beyond in one’s regularly for the customer because they know George Zimmer would do the same if he was in their position.
Hidden away within the commentary on each of these flourishing organizations is a management practice that reinforces and validates the rhetoric disseminating from the higher ranks. It is a practice common at Southwest Airlines, the SAS Institute, Harrah’s Entertainment, and of course The Men’s Warehouse. It is the direct involvement of upper management personnel in employee training in fact at the Men’s Warehouse “training was done almost exclusively by line managers and senior executives – there was relatively little specialized ‘training’ staff.” At The SAS Institute high-level executives welcomed new employees and ran new employee training sessions. Validity and sincerity in communications between upper levels of an organization and lower levels fosters an important team atmosphere and focuses all involved on the shared purpose of the organization, instead of an individual focus on my salary, my advancement, or my bonus/commission. Employees at large corporations, or even sizable regional companies, often have an ingrained skepticism or cynicism directed toward upper management personnel, almost a them versus us mentality most likely stemming from past histories of being “screwed” out of something like a bonus or benefits. Those on the Board, or the top management team, seem so removed from the daily struggle of the lowly employee, making it difficult to subscribe to initiatives that come down the chain of command both practically and intrinsically. But when that employee comes for their first day, or flies to their first Suits University, and their sales training is administered by their regions’ Vice President of Sales that employee is given the opportunity to stare that person in the face, learning from them directly, and therefore free to form their own opinion of that individual, instead of just trying to follow orders from a faceless title. It is a better utilization of power paradigms and is servant leadership in practice.
The employees at the companies we have studied this semester have all been in possession of something intangible, a quality that cannot be sufficiently described or measured, and that is never easily imitated, they all value the unquantifiable quality of human potential in their employees. At Southwest Airlines they are extremely careful to hire only those they know will fit into their culture but you ask someone what that is and they have difficulty answering they only know the type of personality required when they see it. At SAS Institute it is hiring employees with versatile skill sets, and independent streaks as micromanaging is a definite sin. SAS also provides employees with numerous benefits and perks, the effects of which on employee satisfaction cannot be quantified, and one only witnesses the effects in the continued blossoming of their stock value. This perspective of Men’s Warehouse management valuing highly the intangible and uncountable quality of human potential in their employees was fostered by the business philosophies subscribed to by George Zimmer. Zimmer is lucky enough to have an organization where he can apply his hippy liberal management style as the standard for the entire organization. He was probably ridiculed in business school for his flighty, uncountable, “soft” philosophies, but in the end he is able to laugh last and hardest because his approach proved exceptionally lucrative (especially considering the industry) and all should sit-up and pay attention, and if you want proof just look at the top line!

Harrah's Entertainment - Use that technology baby!

Competitive advantage is often discussed in business courses but it is a relatively undefined concept that can vary widely between industries and organizations. In the gaming industry the competitive advantage was long considered to be the ability to attract “high-rollers”, or high-value customers, because they visibly spent a much higher percentage of money gambling than the average every-day gambler. Harrah’s CEO Gary Loveman stated that there was an “if you build it, they will come” attitude in large casino business practices, which couple with the concentration on high-rollers, led Harrah’s to an earnings plateau in the 1990’s. The company’s then CEO, Phil Satre, had a unique vision for his organization and through savvy use of available computer technology the company recognized Harrah’s target customer base and then revolutionized the way they serviced them on their casino floors. This diversion in customer service proved extremely lucrative. The company also established a system of tracking customer information that can be utilized for years to come in retaining customers, all whom have such positive experiences at Harrah’s casinos that through sheer word of mouth Harrah’s can grow its customer base. Though Harrah’s experience was certainly ground breaking within their industry, the lessons they learned can be easily applied to other industries, because there is a quantitative basis to their operations which anyone could duplicate.
It is easy to see why business would want to focus on high-value clientele, as those customers spend more, utilize services more, usually have influential relationships that could increase one’s business, and because it is simply a sexy concept of closing a big dollar deal or ingratiating oneself to a high net worth individual. Many businesses do this such as banks, ski resorts, hotels, universities, and even governmental agencies; and most also have a measuring stick system to see who would fall into said category. Everyone wants a piece of the big players. Now truthfully in some businesses revenue streams are enhanced greatly by these individuals, or large percentages of revenues may come from this category, but in my opinion it is probably a much smaller percentage than realized. Harrah’s began their changes by thoroughly examining their numbers and realizing that 82% of their revenue came from 26% of their gamblers, and that it was everyday/weekly patrons who made up that 26%, not big spenders. This is something that most businesses would probably find true. There is a trend in the ski industry to become a destination resort (where one stays, eats, skis, shops etc. all in one location) because all the big-boy players are destinations. However many resorts just don’t have the terrain or traffic to achieve this and have seen better results catering to pass holders (every-day/weekend skiers) than attempting to bring in whales. Resorts have begun to offer their pass holders discounts on food, shopping, and in the bar (especially important to this season pass holder) as appreciation for being a loyal customer. And it has become more important to resort employees to recognize their frequent visitors which takes real skill when most people’s faces are covered with helmets and goggles. Businesses should do as Harrah’s did and really dive into their numbers to find exactly where their revenue is generated instead of adapting service methods and priorities just because it is what their competitors are doing, or is the industry standard. Though the concept is revisited weekly it seems, it is always good to remember that no sustainable competitive advantage is ever gained through something easily copied from someone else.
Currently those who learn to use the technology available, mine it properly, and utilize it properly within their organization will be at the top of their industry, regardless of what that is. As the gaming industry is largely computerized the technology involved offered Harrah’s a way to collect information on its customers gambling habits quite easily. This is something that can be duplicated in any industry simply by committing to growing their database properly throughout its activities, by for example collecting customer information each time a sale is made or repeated. However this is only the first step. For many years Harrah’s had this enormous database of customer information but were not utilizing it properly, a problem that many businesses have I’m sure. Under the leadership of Loveman they began to take unique interesting steps to slice and dice the data in such a way to gain the maximum benefit from it. They used information technology to establish automated systems that enabled them to further the advantage of collecting all that information. One of the most unique ways I found was their practice of sending a mailer, or tagging someone for a phone call, to someone who had spent at least $1000 and had not visited the casino in three months. Also they flagged those individuals who had lost money on their previous visit and targeted them for event invitations, so that individual would return under non-gambling circumstances and then perhaps (most likely) wet their whistle to begin pulling the one-armed bandit once again.
Importantly as well Harrah’s used their data and technology to drive customer service practices, and not just on the casino floor but everywhere within their casinos from the valet parking, to restaurants, to reception all employees were rewarded for providing good customer service. Not just as individuals either but as teams, therefore placing the onus on the managerial staff to instill a culture of excellent service within each of their departments, and then within their location as a whole. The practice of having pit bosses and casino floor supervisors paged when a customer activated their membership card in a machine, or at a table, is unbelievably ingenious. As a frequent gambler my total pet peeve is when I have to wait to get my free cocktails. As soon change my cash to chips at the blackjack table I would expect a cocktail waitress shortly, and if they do not appear soon I will get peeved. Now if I gambled at Harrah’s and gave my dealer my Rewards card which he would proceed to activate, there would a supervisor over there promptly and most likely calling over a cocktail waitress so Miss Burns can get her Corona with a lime. If that happened, I would be sure to return to Harrah’s more frequently than any other casino, period. Keeping all this in mind the next time that I have the inkling to play a little blackjack, I may just have to try my hand at Harrah’s and experience for myself just how wonderful their customer service is.

Evidence-Based Management – Not Just for Medicine and Business!

Reading Mr. Pfeffer and Mr. Sutton’s argument in favor of evidence-based management, I was struck by the apparent lack of the use of evidence in the implementation of systems throughout the business world. According to the authors most business management seems to institute systems, for compensation, performance evaluation, product design etc., without experimentation to test its viability or without adjustment to be successful in a specific organization. Instead they state that most organizations utilize outdated information, copy successful organizations’ systems, and regularly “buy-into” whatever is the newest trend. The cause of these tendencies, and the true aspects that needs to be tweaked in the business world to transition to evidence-based management, results from the continuing paradigm of the “hero/paternal leader” and the focus on short-term bottom-line numbers. Both of these lead to the endless circular implementation of ineffective, or less-than- triumphant, systems, and until paradigms are broken companies will continue to do this because it is quicker, and cheaper, therefore providing enough of a short-term success so that everyone involved (i.e. the CEO, the consulting company, the executive team) gets paid.
It almost seems counter-intuitive that companies employ systems without evidence of their success, but looking at the attitudes still displayed in many organizations it is not surprising. If an organization has a leader that believes himself (or herself) to be that infallible “source”, the oracle, the father to his people, than that leader will always take the approach that “father knows best.” And that individual will be negative and skeptical toward any system that he did not invent himself, or locate himself, or implement himself. Because if one is all-knowing then one cannot learn anything from evidence anyway, therefore the systems implemented must be correct and it is the people within the system that are not effectively utilizing it. For one to experiment with ideas before implementing them, seems ultra-simple, but is difficult for the oracle-leader because if the leader’s idea fails in the experiment that leader’s fallibility is then on display for the organization which could potentially weaken that leader’s mandate. The paradigm of the oracle-leader must first be broken before any movement toward evidence based management can occur, and this can be done through continued education and training within an organization, and increasing the visibility in the media of truly successful organizations that utilize the partner-leader mentality.
Pfeffer and Sutton use an interesting example for a successful organization, in the US Women’s Soccer Team. It is true they have experienced unparallel success in a competitive market, (though they did leave out the fact that growing up in the US affords our women greater opportunities to learn the game versus other countries) however when one delves deeper into the organization it is clear that there is a true partnership between players and coaches, and that no idea is discounted if there is evidence that it may be successful. For example following the 1999 win in the World Cup the team’s success began to slow, and Brandi Chastain (a valuable defensive player), had well-publicized conflicts with a the team’s head coach, and her own ideas about how the team was being run, and the system the coach insisted upon (mainly with her on the bench, but it is still valid). She voiced her opinions to the coach, and the media, and the resulting conflicts ended with her off the team. The coach making the fundamental attribution error, and putting her own ego (married to her ideas she implemented through new system design) at the forefront, and blaming the people instead of truly examining the effectiveness of her new system. However, following Chastain’s removal the team’s success was hampered by the new system and the coach’s unwillingness to amend the system, and reinstate Chastain, resulted in the loss of her position and a reinvention of the US Women’s game-play style, leading to a gold medal in Athens.
The necessity in our business world today for delivering immediate short-term results has been shown repeatedly to lead to ineffective systems that need to be overhauled every few years to keep up with top industry producers, or to jump on the bandwagon of a new performance evaluation philosophy, or simply because it is easier and cheaper than taking the time to design and conduct experimentation to determine a system that can be effective and sustainable for an organization. Becoming sustainable may also be regarded as developing a system that functions successfully while quickly and constantly adapting to needed changes (the author’s frame this as always treating one’s organization as an unfinished prototype). Focus on the short versus long-term can be compared to buying shoes. If one needs a pair of black open-toed sling-back heels one can go to Payless and buy fake leather ones that roll off an assembly line in China, are poorly stitched with inferior materials that maybe will last one a year if worn regularly. Or, one can go to Macy’s and spend ten times what one spends at Payless, but one will get a product constructed of the finest Italian leather, and hand-crafted with excellent stitching and materials. Now this shoe, if treated properly will last the owner for a lifetime. Like an organization the expensive shoe must be cared for, small adjustments such as inserts, or leather treatments, or re-cobbling, may be needed but one has a shoe for life, versus having to repurchase the same shoe every year (because one always needs a black sling-back heel in their closet). By focusing on the long term one will eventually save money on their shoes, and will have a better product to boot! Now it goes without saying that rigorous shopping trips to find the right design, and taking the time to try out the shoe in the store and at home if possible, are necessary for this system to work. And as far as following the current trend (viewed as important in shoe-buying as business) if one focuses on a classic style one will always be suitably attired, and as trends are circuitous, every five to eight years one’s shoes will again be on the cutting edge. No doubt causing all your competitors to run out and buy the same style, most likely on the cheap, therefore ensuring one continues to have the best product in your closet and on your feet.
Until businesses begin to truly employ partner-leader relationships within the hierarchies of their organizations, and not just spout the rhetoric of such ideals, and begin to focus on long-term success and sustainability evidence-based management will always be second to the cheap quick fix and newest trend. In my opinion, this may be an underlying problem with our society as a whole, with everyone in search of a quick buck so they can keep up with the Jones’, but the fact that professional educators and business trend-setters, such as Jeffrey Pfeffer, are advocating a new approach is hopeful. It will take time but these philosophies will eventually, one day, trickle down through our society so and we will reinvent our paradigms, starting in elementary school, showing the world what a successful organization looks like.

Steve Kaufman and Arrow Electronics – Is this how they teach someone to run a company at Harvard Business School?

The troubles discussed in Brian Hall’s study at Arrow Electronics, which arose from the evaluation system inaugurated by their CEO Steve Kaufman, was even frustrating for the reader, at least for this one! The CEO was fraught with misconception in the implementation of the system. The pervasive sales culture at Arrow would have been detrimental for any type of evaluation system that involved rating employees. And the way in Kaufman reacted to the initial results from the system he instituted displayed the lack of trust, and breached any already established trust, which upper management had for their employees. All the problems encountered by Arrow (lack of loyalty, lack of trust, rollercoaster sales numbers) may result from their industry, or from their business plan, and their competitors surely experience the same problems, however no company ever gained a “sustainable competitive advantage from something that is easily observed and readily imitated” (Pfeffer).
At Arrow the root of their issues stems from the ineptitude of their CEO. First his mentality that the job of the CEO is to motivate his people, instead of the approach that people are internally motivated, is his primary mistake. This leads him to believe that he can institute a system in which the achievement of high numbers is motivation enough for people to excel at their jobs. Then, foolishly Kaufman believes he can use these numbers to make decisions on promotions and raises. He puts a system in place without sincerely conveying to his managers that are completing the forms exactly what the purpose of them is, and what the company hopes to gain from them if managers complete them conscientiously. Then when they are returned to the executive offices and Kaufman doesn’t like the results, he makes the fundamental attribution error, and blames his people. Kaufman then tries to amend the results of the evaluations by further manipulating the system he introduced. This is where I became seriously flabbergasted by Kaufman’s behavior. He touted his system as a scientific approach to determining who deserved a promotion, or a raise, thinking he would just be able to look at those with high numbers and promote away. But he makes a crucial error in when he establishes benchmark requirements for certain percentages, this being a total corruption of the basic scientific process. You cannot start with the results and work backward to data collection! Elementary school children who perform projects for a science fair could tell you that. Kaufman even held a second training session, at who knows what cost, to further instruct his managers on how to properly manipulate the evaluations to result in the numbers he thought he should be seeing. Again missing an opportunity to sincerely convey to his people what he really wanted from them.
This poor communication from the upper levels of Arrow management down through the ranks is evidence of the cultural aspects at Arrow that are detrimental to the company’s long-term success, as well as sustained growth instead of the rollercoaster the company currently rides in the realm of sales and employee retention. It is clear from listening to the rhetoric spouted by its managers that Arrow employees are motivated solely by external forces, and lower hierarchy thinking, such as commission checks, short-term guarantees, and internal competition. This is illustrated in the comments made by the CEO believing that when an employee receives 4’s and 5’s on their evaluations they would say “’Oh, I got 5s and 4s – they love me!’ You don’t see the need to improve.” Logically though if that response is true, then wouldn’t Kaufman believe someone who received 2’s on their evaluation think, “Oh, I got all 2’s – they must hate me!”This is further evidence of Kaufman’s failure to find the proper attribution of systemic problems; he blames the employee for an improper reaction. Furthermore, neither situation leads to an employee that thinks, “Here is what I need to improve on, and this is how I do it.” This should be the purpose of performance evaluations. Then Arrow has an employee that scores well on the evaluation, thinking only “They love me!” which then fails to properly utilize that person’s skills for the benefit of the whole. The employees should instead feel “I am doing really well, how can I share my successful techniques to assist my colleagues in becoming more successful, therefore making the company more successful.” This is the kind of attitude that should be rewarded and encouraged, by promoting those that think for the good of the whole. However, one cannot determine these employees by filling in bubbles on an evaluation sheet. A change to this type of thinking may not be possible at a company like Arrow in the industry it resides in but it should be the goal of every organization to function on a level like this.
Arrow functions on such shallow measurements of success and failure, the difference between a two and four on a survey for example, that is a display of the lack of trust between upper management and employees. First the CEO does not trust the judgment of his managers in recommending people for promotion, or determining raises, to such a degree that he institutes a very expensive, complicated, system of evaluations so he can rely on the numbers (which as described above he falsely believes to be scientifically sound) to drive his decisions. Second the CEO doesn’t trust the managers enough to confide in them why he truly wants the surveys, sincerely informing them why it is important to him that the surveys are done accurately, why it is important to the company they are completed accurately, and most importantly why it is important to that manager that they do the evaluations accurately. To Kaufman’s credit he does attempt to do so, but after the fact, after he returned the evaluations to the company because they were too high! And when he does so even on paper he sounds insincere. Sharing information is a leader’s first step in building a successful partner-follower relationship with his people. Thirdly this lack of trusting employees on management’s part stems from the high turnover rate, though this is blamed on the industry. Personally I was not surprised that Arrow had turnover issues with their rollercoaster sales numbers. But jumping ship during times of low returns should be expected because I am sure that Arrow would not stand by its employees in tough times. Meaning that when sales are low Arrow employees could probably expect a pay cut, a lowering of commissions, or even a lay off. If the past behaviors of the company indicate this type of pattern why would an employee trust Arrow? Management, especially the CEO, blames the employee for being money-grubbing. But the employee sees it as cutting their losses, or breaking up with Arrow before they break up with me. Evidence of suspicious minds on both sides of the desk, and as Elvis says suspicious minds do not lead to successful long term relationships.
Overall the lack of trust in the organization’s system is truly the problem that needs to be addressed. An inept CEO can be replaced, but a system of poor communication rooted in a mistrustful organization, is something that cannot be easily remedied. To fix it Arrow might actually have to sacrifice some short term earnings goals for long term success, which few in today’s business world seem willing to do. And whatever happened to “If it ain’t broke, don’t fix it!” Meaning that the evaluation system Kaufman employed was definitely not crucial, possibly not even necessary. All he had to do was to trust and inform his managers by saying, “Our Company has gotten too big, hooray, for me to know everyone personally. I am having trouble figuring out who is performing well and who needs assistance. Can you help me to understand the best way to identify top performers to promote? Can you help me to understand the best way to identify those that need some assistance to improve their performance?” A really complicated and novel approach, huh?

Sins of Commission – Big Paychecks, Lack of Consequences, and Ethical Dilemmas

The essay written by Jeffrey Pfeffer, on the negative affects of commission based compensation systems, is a valid commentary on virtually all sales organizations that employ such a system. Most importantly he addresses the fact that these systems not only detrimentally impact customer service but also cause salespeople to compromise ethics and often legality in the pursuit of hefty commission checks. Unfortunately most of these systems are used in industries where a salesperson’s paycheck can be boosted by skirting corners, living in grey areas, or crossing black lines. I have witnessed the effects of these systems personally. It is a concept known as a “win not lose”, or scoreboard, mentality, where the goal becomes only winning and the final numbers on the scoreboard becomes the sole source of a person’s validation or failure. Often in these situations there is also a total lack of consequences as well which just exacerbates the unethical behaviors. If a business wants to run its sales departments ethically and legally, in my opinion, it needs to distance itself from this type of reward system unfortunately companies often benefit so hugely in the short run from these systems that they garner wide support across upper management, but in the long run these systems create shallow employees and therefore a shallow organization. Shallowness does not bring long-term success.
The scoreboard mentality is a concept most easily explained in the context of sports. Though I often use sports analogies in my comparisons in this instance it provides a clear illustration of the effects of such a situation. For example, a softball game is close and in late innings, a shortstop’s team is winning by one run, there is a runner on second base, and the batter hits a single through the infield that would score the runner. Now that runner must run right by the shortstop, and if that shortstop has an ethical choice; they can violate the rules and interfere with the runner stopping them from scoring thereby most likely ensuring a win, or they can follow the rules and the runner will score and tie the game. Now you couple this with the ability of the shortstop to interfere without being caught and punished, what is there to stop the shortstop from interfering? Only their own internal motivation. Following this if their only internal motivation is to win, or get a higher number on the scoreboard than their competition, the shortstop will interfere with the runner every time. Similarly imagine a mortgage salesperson paid on commission where each additional sale means a huge paycheck increase, and the crucial factor determining the closing of the sale is two points on a credit score. That loan officer is faced with the decision of following the law and losing out on thousands of dollars in commission, or whiting out and changing a credit score, which no one will ever notice and if they do no one will do anything about it because everyone’s paycheck is determined by the closing of this loan, to ensure their commission will come in huge. Too often people make the wrong choice, and as we are experiencing with our own current economy the long term repercussion of such systemic behavior are substantially damaging. Changing a credit score, or interfering with a runner, may seem like small things but they are representative of a break in values, a change in course that snowballs on those involved. The next time the same individuals are presented with similar situations there is a certainty that they will make the wrong choice again, and those small steps will become larger until one finds themselves falsifying entire W2’s or breaking someone’s leg with an unnecessary takeout slide.
Though ethically the choice ultimately comes down to a single individual the organization is responsible for the systems they institute and the effects that they create. Most organizations with ethical problems in the front line loudly spout rhetoric from the top levels about maintaining high ethical standards but the behaviors they show tell a different story. Managers know when someone is engaging in unethical behavior, or "gaming the system" to increase their paychecks, but they do nothing because often it is their top salespeople that are doing so and to punish that person or make them toe the line would be too detrimental to their own sales numbers, and so on up the chain. So the poor behavior is ignored, and often rewarded, just showing all the other salespeople (who undoubtedly know of the shady behavior) what it takes to be “successful” in this organization. They will then imitate the poor behavior (who wouldn’t? if it boosts your paycheck and gets you plaques on your desk and trips to Las Vegas for sales conferences) and like a virus it spreads throughout the whole establishment. Immediate consequences are the only way to combat this behavior. Like when a toddler hits another toddler for example, one must put that child in time out immediately or else they won’t learn that hitting is wrong, and they will do it again. Many companies have punishment procedures in place but the distance between the enforcers is so extreme that they are totally ineffective. If one waits for that same toddler’s father to come home from a business trip two weeks later before they are punished, that child will learn nothing and will adopt the attitude that they can only be punished when daddy is around if he hears about it at all. The lack of punishment, and the reinforcement of undesired behaviors, is crucial to commission systems breeding unethical and illegal behavior in a myriad of industries, and in our own government as well.
The most distressing thing that arose from my own experiences in “win not lose” environments was the total lack of realization of complicitness by the salespeople that were behaving in such ways. Organizations that utilize commission systems do a very good job of hiring those willing to compromise their ethics. Violating the law, or ethical guidelines, becomes so “old hat” for so many it is on par with speeding on the freeway. Living the commission lifestyle is like taking drugs, the high one gets when they are cut that first big check is huge, then every month after that one must get a bigger and bigger number on that check to achieve that original high. One can try and fool themselves into thinking, “I love my job because I help people buy their first homes”, but as soon as those big paychecks get removed, or decrease; one realizes how shallow and unfulfilling their working life has become. This may not be the belief of everyone, but it is mine, and by riding the rollercoaster of working commission in a booming market I experienced the extremely large paychecks, viewed and shared in the behavior compromises, and throughout was incredibly stressed, and ultimately left wanting. The best thing about my experiences was the realization that I personally require more from my career than paycheck, and this realization will drive my decisions for the future.

SAS Institute - More than Gravy

The success experienced by the SAS Institute is absolutely a result of their unique practices of compensation, personnel management and the culture fostered since the company’s inception in the higher education community. True, SAS has numerous competitive advantages that would be extremely difficult to duplicate or imitate, but they also do many important small things that validate the sincerity of management’s policies and rhetoric and that other companies in any industry can learn from to improve the job satisfaction of their own employees. SAS being privately held is a huge determining factor in all the strategy and policy they utilize, allowing great amounts of freedom for management to focus on long-term goals without the pressure of immediately pleasing stockholders and a board of directors. Obviously this is a factor not enjoyed by most of SAS’s competition, but the way SAS treats its employees is crucial to its sustained success and continuous innovation in an extremely competitive marketplace. SAS enacts a few very key benefits for its employees including a health center, day care, employer funded retirement, bonuses, task autonomy, and a touted health care plan. Combine these factors with the personal contact initiated by the upper management with their front line employees and it results in a family-like work environment where everyone has pride in their personal accomplishments and in turn the achievements of the company as a whole. On their website SAS states “If you treat employees as if they make a difference to the company, they will make a difference to the company.”
The success at SAS begins at the top. The upper management sets the tone for the entire company and not just through their rhetoric but through their actions as well. The company regards its employees as internal customers, and similar to their external customers when a request is made management takes it seriously and does their absolute most to satisfy that request. Having a CEO who is also the majority owner creates positive feelings in the employees at SAS because they realize that the company is the CEO’s baby and every decision he makes will be for the benefit of that baby providing a reassurance and stability unique to employees in the volatile software industry. SAS’s CEO, Jim Goodnight, also demonstrates his commitment to the company’s success through his actions of internalizing health care, providing day care, and adopting a hands-on approach to managing all aspects of his business. Goodnight states, “If you want something done right, own it and control it.” Therefore to provide his people with the best he chooses to outsource almost nothing. Goodnight commits also to reinvesting large percentages of earnings back into research and development pursuits to keep SAS on the cutting edge. As majority stockholder Goodnight could theoretically pay himself enormous dividends, take huge portions of these earnings and put them straight into his personal bank account, but he doesn’t. These actions prove to his people that he truly cares about the company’s mission and future. And it isn’t just Goodnight. SAS has the practice that senior managers run portions of their new employee trainings, so right off the bat front-line people have personal contact with upper management, further building that stability and trust relationship throughout the company. That way lower level employees’ trust that their superiors are making the right decisions, and management can be assured their employees are working their hardest to meet their obligations. Their CEO states, when discussing performance management, that “it should be a relationship instead of an infrastructure.” These relationships allow SAS to employ far fewer testers of their programming, relative to competitors, because of the rarity of mistakes made resulting in another advantage for SAS.
In any industry where brain-power is highly valued, as it is in the software industry, companies will recruit the most intelligent and accomplished minds they can as that individual could be responsible for the company’s next multi-million dollar product development. As we have previously examined intelligent people can be extremely difficult to manage. The commitment that SAS makes to giving its employees task autonomy is a very attractive work environment for an accomplished person. Importantly here too, SAS does not just use rhetoric, they take actions like providing every employee with their own private office. SAS believes strongly in intrinsic motivation, and this is where that comes into play. They allow their employees to motivate themselves they just provide them with the tools to make that possible. Also SAS allows their employees to move sideways through departments to amend their responsibilities, sometimes radically. Employees at SAS could theoretically move from the technical support department to research and development or sales. This has to be attractive to intelligent motivated people that often have many facets to their interests and skills. This practice would also cut down on burnout and complacency, both of which lead to the withdrawal behaviors of absenteeism and turnover, again saving the company in cost, but also increasing that intangible value of employee job satisfaction that drives performance. As a self-proclaimed intelligent person, I have experienced the burnout associated with the pressure of a sales position and would have welcomed the opportunity to flex different muscles in a product development capacity for a time. This flexibility demonstrated by SAS allows them to utilize every aspect of each employee to best impact the organization. I believe these two aspects of the culture at SAS are crucial to their employees’ happiness because all the rest of the benefits, i.e. health club, day care etc., are just gravy if the employee is not engaged in an activity they enjoy with the independence many adults require. And gravy, though yummy and requisite on certain dishes, is not very nutritious and is certainly not sustaining.
SAS can be compared further to a heaping plate of Thanksgiving dishes. The turkey, the real substance, comes from the private ownership since the company’s inception. The turkey is the reason for the holiday, just as the private ownership provides the means for SAS’s unique existence. On the side as the dressing is the CEO Goodnight, who must be stuffed in the bird to taste right, and you couldn’t wholly separate one from the other, ever. And also symbolizes the reinvestment of revenue into the company. You got mashed potatoes representing the company’s product which in the marketplace is not entirely unique, but for every person there is really one style they like the best, and SAS makes some pretty tasty mashed potatoes. Then you have the tangy cranberry sauce, representing the human resources practices, and since cranberry sauce must be eaten with every bite on the plate it is the glue that ties the dish together, and gives the cook (SAS) another opportunity for uniqueness. Finally, of course you have the gravy, all the perks, and at SAS that plate is smothered gravy. Conclusively it all sounds really tasty, and also like something one could eat repeatedly.

Nordstrom: The Evil Empire of Retail?

A most interesting point which occurred to me when examining the case of Nordstrom’s Department Store, and the legal troubles they had with their employees in the early 1990’s, was the similarity between the behaviors displayed by “Nordies” and the employees at Southwest Airlines. At both companies employees went above and beyond to serve their customers; they worked “off the clock”, they spent personal wages on parties for fellow employees, and they made personal luggage and purchase deliveries to homes. However employees at Southwest are almost spiritually devoted to their company and at Nordstrom a large percentage of workers sued the company. The real question is why such different reactions to similar expected behaviors? Why do we praise/accept one system and denigrate another when both encourage the same types of behaviors? The answer is that Nordstrom created a system to capitalize on its employees’ hard work, evolved a culture that implemented the system to perfection, while the executives spouted shallow rhetoric about “self-empowerment” and entrepreneurship, all resulting in a work environment that became increasingly toxic as the company reached a peak of sales success toward the end of 1980’s.
First one must agree that extraordinary activities done to service Nordstrom customers, or take care of the store, were not voluntary. The culture created by middle management, where “team players” frequently worked off the clock and were rewarded for it in many ways, enabled the compensation system to continue to work despite its unfairness and possible illegality. Upper management maintained throughout that if people were working off the clock then it was voluntary and isolated, when in fact it was pressured and pervasive. Positive punishment and negative reinforcement techniques were utilized, possibly unwittingly, by department and middle management to perpetuate the poor system. What is meant by positive punishment is the rewarding of undesirable behavior. In the case of Nordstrom, employees that left hours off of their timecards (albeit to boost their sales per hour and therefore their commissions, but according to upper management and the law for waged employees this was undesired) were rewarded by their managers extrinsically with the best floor hours and intrinsically with praise for being a team player and recognition in front of their colleagues etc. Conversely, employees that displayed the desired, and legal, behavior of reporting all the hours they worked on their timecards were negatively reinforced by their managers’ withholding of certain privileged hours. This would prove especially frustrating, and confusing, for employees as they were acting properly, displaying the proper behaviors, and were never reaping rewards. These employees were never receiving commission payouts either as validly reporting one’s hours led of course to a larger denominator, and therefore lower sales per hour number. Finally, it was these frustrations that led employees to take their case to the law.
One can see how the punishment and reinforcement techniques used at the department and store levels could drive the practices of not reporting work hours, this practice though was a result of the culture created through the usage of sales per hour (SPH) as a measuring stick for the entire operation. First you have a salesperson paid commissions on sales per hour providing the surface motivation for not reporting hours (coupled with the powerful techniques employed above). Then you have department managers that are measured on the SPH numbers of their salespeople, therefore motivating them into the reinforcement and punishment behaviors above. Allegedly certain managers even put “out of order” signs on time-clocks when their salespeople came in to do inventory on the weekend, so hours could not be reported. Sales floors became so competitive with a “win-not-lose” mentality that ethics were often compromised. Meaning that when one concentrates on winning at all costs it is nothing to steal a fellow employees’ sales numbers. Then above them you have store managers who are measured on the SPH numbers achieved by the different departments of their store, and who utilized those numbers to determine promotions. Therefore if one wanted to make hefty commissions, work the more lucrative floor hours, or get promoted at Nordstrom one had simply to play ball and not report all the hours they worked.
It is clear by the statements made by upper management that they realized how this system worked because when they first attempted to rectify and settle wage grievances they reinstituted the same practices in their system. Though sales activities were clarified further for employees, it remained that to achieve a healthy SPH one was still required to not report work hours. The unfortunate thing for one to observe is the lack of true engagement with the front line employees with upper management. Upper management relied on the systems they put in place, and turned a blind eye when it was apparent it resulted in unfair wage practices, chalking it up to voluntary activities which were as explained above truly involuntary. Nordstrom used its employees while deluding themselves into thinking that they were fostering entrepreneurial behaviors when in reality they were not imparting any ownership to their front line. This is where the true difference between Nordstrom and Southwest Airlines is illustrated. Importantly first the culture at Southwest was radically different, and was built on the foundation of teamwork and success of the whole. This culture was reinforced by the compensation systems the company put in place such as offering stock options for example which gives Southwest employees true ownership in the company and the stimulus for going above and beyond. Southwest is also very specific and purposeful in its hiring processes, and clear in its expectations of its front line employees. Nordstrom however, did not offer stock options to employees, and was intentionally deceptive about its sales per hour systems. Interviewed employees stated that “it becomes clear to most Nordstrom salespeople soon after they are hired that the store’s commission-selling program effectively penalizes any salesperson who insists on getting paid for every hour worked.” Employees should work hard at their jobs that is given, however when one is being paid hourly, not collecting a salary, it is the law that those employees be paid for the time they worked. Even if one is attempting to provide extraordinary customer service by for example driving a purchase over to a customer’s home in a bid to receive an Nordstrom “Customer Service All-Star” award it is clear that all that mattered was your SPH number. Providing excellent service was just management rhetoric. One eight year Nordstrom employee stated “In the end, really serving the customer, being an All-Star, meant nothing, if you had low sales per hour, you were forced out…”
This situation is common in many retail environments that track sales this way. One particular bank whose upper management team states repeatedly that their goal is always customer service, that they want their salespeople to operate on a need-based sales attitude, and that serving their long-time customers is primary to all their branches, employ similar systems that superficially reward customer service meanwhile the time needed by their front line employees to actually provide excellent service takes away from the time that employee needs to sell products in order to make commissions and retain their position. As at Nordstrom this bank’s employees are often frustrated by their inability to make sales numbers because all their time was spent assisting customers with issues where no sale was available. The same bank handed out numerous certificates, and offered praise, for high customer review numbers, but when paychecks came out and raises were extended, those excellent reviews were meaningless in the face of raw sales numbers.
It is not the focus on sales numbers that is particularly frustrating in these two cases (Nordstrom and the bank) it is the hypocritical attitude displayed by management throughout the organization. At Nordstrom upper management decried that they would ever require someone to work off the clock, but they instituted a system that resulted in that exact behavior and used the employees in the system to boost their sales numbers and reduce their costs, basically creating their competitive advantage through unfair labor practices. The system itself led to a culture that exacerbated and perpetuated these practices. In conclusion, Nordstrom deserved to be sued for back wages and in the future they should be more straightforward with their employees about what is expected and simply offer them the true ownership they claim to anyway in the form of stock options and salaries.

Twelve O'clock High - The Ultimate Leader

Twelve O’clock High chronicles the tale of a bomber regiment in World War II, headed by the incomparable General Frank Savage. Savage’s results as the leader of the 918th can be stated as nothing short of exceptional, and observing his behaviors and the relationships he builds throughout the war is a study in leadership under extremely difficult circumstances. Wartime is one of the most difficult environments a person can experience, and one where a person is challenged to perform extraordinary behaviors, but interestingly one where personality must not be a determining factor in performance, and that the system must function perfectly. Meaning simply that in war people are wounded and killed and someone must take their place and absorb their functions with immediacy and effectiveness not often required in the business world. Frank Savage’s personality is important to his success as the leader of the 918th but not crucial, evident in Major Stowall’s statement regarding the difference between Savage and Merrill being “two inches in height”; however they had disparate results with the same organization.
The film begins with the failure over a period of Colonel Davenport, original commander of the 918th, and pointedly the General in charge questions Davenport’s failure stating, “But he looks so good on paper… man like that can’t cut it, we’re in trouble.” As one would expect, the General is most assuredly receiving harsh criticism from his superiors due to the 918th’s troubles, but he regards the situation properly, does not make the fundamental attribution error and just blame Davenport, instead he grabs his hat and goes to speak directly with Davenport. Through skillfully approaching and questioning Davenport (the General simply states that “A man makes his own luck” and avoids blaming Davenport therefore diffusing the detrimental natural defensiveness one would display in Davenport’s position) about the errors made on his latest mission. The General realizes that Davenport had become too attached to his men and a change in command was needed, relieving his command with a brief “A man has only so much to give and you’ve given it”. Therefore he assigns Frank Savage to command the group. Savage behaved admirably throughout the entire development as he removed the rose-colored glasses to truly examine his friend Davenport’s performance, he brings his friend’s failings to the attention of his superior, and most importantly is prepared to assume Davenport’s position when he criticizes Davenport’s performance. This is crucial because Davenport is such an able person, and would typically become defensive of his efforts, which were substantial, probably lashing out at Savage with statements such as “Well, why don’t you take over then?” as most are want to do when put in Davenport’s shoes. As Savage is prepared to assume the reigns he feels more comfortable criticizing his friend (he also knows him well and is therefore less inclined to make the fundamental attribution error and more likely to turn his attention to the system) displaying excellent leadership skills.
Subsequently, Savage begins command of the 918th with his stated goal being to give them pride in their accomplishments, to achieve a group attitude that “the last thing a man will want is to be left on the ground.” However Frank knows that the system at Archbury is broken, otherwise his capable friend would not have been broken, and his approach is to redraw the black lines that the military intended on the base by becoming very strict. Savage adopts the opposite attitude of Davenport, who was buddy-buddy with his “boys”, as he sees discipline lacking on the base. He also reprimands personnel immediately, makes necessary personnel changes, and closes the saloon on the base, all to signal to the troops that a change in the failing system has begun, and that he intends to mold the group into a successful combat unit. Discipline is crucial in this situation because the safety of the troops depends entirely on their ability to maintain proper formation on their bombing runs, which of course would allow for zero buffer zone in the system, something that Davenport may have realized but because of his personal closeness with his men he could not see. This is illustrated in his refusal to replace his navigator. Interestingly the troops immediately attempt to rebel, but Savage has anticipated this knowing that if he can show them mission success and a safe return his men will begin to trust his judgment and actions. Though we are not privy to Savage’s personality in his previous command one can tell that Savage himself is not usually a strict disciplinarian, but he sees the problems in the system as resulting from a lack of discipline, therefore he amends his own personality enough to result in the disciplinarian behaviors required by his position at the moment. Gregory Peck does an excellent job of portraying this change when his character, Frank Savage, first arrives at Archbury, and he reprimands the gate guard for not checking his credentials.
Savage’s leadership skills, specifically his abilities as a contingent leader, are displayed through interactions with two of his soldiers Lt. Colonel Gately, and Lt. Bishop. Gately is the son and nephew of decorated high-ranking officers who, until Savage arrives, has been underachieving for his skill set. Instead of ignoring him, or cutting him loose, Savage skillfully berates Gately in private challenging his bravery and honor and then demotes him to commanding an airplane full of ‘failures’ ordering him to paint “Leper Colony” on the nose. By calling Gately “yellow” Savage flips the internal motivation switch for Gately. Gately knows he is brave, honorable, a well-trained experienced pilot, but because throughout his life people have always only seen his last name he hasn’t yet had the situation to prove to others what he knows about him. Because Savage treats him with an honesty, equality, and fairness he had yet to experience, Savage spurs him to action and Gately eventually rises to the challenges placed before him. The honest assessment Savage gives him in their first meeting, coupled with the commitment he makes to Gately to stick it out with him, proves beginning of the foundation of trust further setting the tone for Savages’ interactions with the entire group. Tailoring his leadership style to what is needed for each situation Savage’s conversation second private conversation with Bishop is key to group cohesion as he adeptly uses words like “we” and “us” displaying to Bishop that he is a partner leader, that he values Bishop’s opinion as an able mid-level leader. Again Savage shows the variability in his approach contingent to the situation, and Bishop hears what he needs from Savage to enable him to withdraw his original application for transfer.
The true transformation in the 918th comes when Savage pilots a plane on a mission where every group abandons their mission because of poor weather. Savage daringly ignores the command to return, feigning ignorance, and leads the group to an extremely successful result. Key to this mission was Savage’s putting himself at personal risk at the helm of a bomber, a behavior that validates him as a commander to his troops that were specifically skeptical of his abilities when he stayed on the ground. Not unlike Savage’s preparedness to assume command of the 918th his piloting of the bomber exampled his willingness to take the reigns in the face of his own criticism. Following the mission Savage displays a most important leadership characteristic in that he humbly requests commendation for his troops but not for himself. Humility in success is the way a leader can prove through action that he values the contributions of his personnel. This finally leads to Savage getting a cheer when he commends the group in a briefing; an action that prior to these actions elicited no response whatsoever.
In the film’s final act, Savage is temporarily broken. The death of certain personnel, and rigors of the wartime environment, finally starts to take its toll on the hero, and he breaks-down before leaving on a mission. The changes that Savage has made in the system at Archbury however stands true, and all the disciplinary action, personnel shifting, piloting missions, and even commendations made proves sufficient as the mission is successful even without its leader at the helm. Davenport makes a pointed comment proving that Savages’ changes in the system had been successful stating that “You’re riding in every crew station and in every cockpit.” Therefore his men remembered and embodied his teachings and system he established, they recalled the pride he had helped them generate in themselves, and they executed their mission to near perfection. This must be the goal of any leader regardless of the organization they are in, to establish a system that functions without the presence of their personality, and that their teachings are in the forefront of all their people’s minds so that each person can execute their function within the system to the best of their abilities.

The outside consultant and the case of the unhappy CEO...

Specialty Medical Chemicals (SMC) have found themselves in the position that every company eventually does, they are at the zenith of their growth curve (or are very close) and must make changes to their pathway not just to maintain their current position but to advance the company to a more competitive position where growth, profitability, and innovation can be sustained for the long run. SMC was founded on the genius of one man, Dr. Winthrop, and the intellectual property and patents resulting from his creations, of various chemical compounds used in the pharmaceutical industry, have nourished SMC since its birth. Barry Tompkins was made CEO of SMC following the company’s first growth spurt in the early 1980’s, and his expertise was crucial for driving the company further up the growth curve, however still on the shoulder of Dr. Winthrop’s innovations. Tompkins made many improvements at SMC in “streamlining the organization, putting in place financial controls, upgrading manufacturing processes, and installing systematic personnel practices.” Though Tompkins’ initiatives were important and necessary it was coupled with no influx of new ideas and inventions, no spending in the research and development labs of SMC, which of course resulted in a lack of growth. Tompkins own background, and his “big company type of manage[ment]” style was crucial to his successes. He choose to be very process oriented, and to devote concentration and money toward process improvements, improving the ‘business’ side of SMC. By focusing his efforts in that direction Tompkins failed to notice the “maturing” of SMC product lines and the innovation that is crucial in their industry was nonexistent at SMC because Tompkins’ modeled behavior for his leadership team was that he didn’t consider product development important. In a sense, the leadership at SMC though they worked effectively in the beginning stages of the company’s life cycle had begun to “rest on their laurels”, and were allowed to do so by Tompkins, and rely on the long-standing products and pipelines and long-practiced behaviors of protecting and engaging only in their own realm of responsibilities. It was clear at the time of Tompkins’ departure that the company lacked direction and purpose along with the strong leadership to guide them in that direction and lead them to that destination. The desire for new leadership resulted in the hiring of Carl Burke who was brought in to “reignite the growth” at SMC. Burke learned quickly through his observations that the manufacturing was state of the art, the sales team was populated with capable and dynamic individuals, yet there was something seriously lacking in the leadership team and change was needed. It must have been daunting for Burke unexpectedly discovering that the he had now embarked on a more difficult journey than anticipated and that SMC’s failures to grow stemmed from the chair he now occupied. Burke and the Board brought in an outside expert, Dr. Wells, to consult not only on how to change the psychology of the organization but to also on what, or more precisely who, to change. I think that anytime an outside individual becomes the leader of an organization and amendments to the established norms are required along with a shakeup of the personnel involved, it would be prudent to bring in an additional outsider to observe and recommend changes. This would be effective at relieving the new leader of some of the heat which is sure to accompany personnel modifications. An outside consultant, Dr. Wells in this case, should present a more objective view of the situation as well, especially in the case of SMC as Burke felt betrayed by the headhunters who found him, and was already jaded in his view of the leadership team.
The assessment process went smoothly with the leadership team and Dr. Wells was able to give constructive feedback. She was especially skilled at the “poo sandwich”. Meaning that when she addresses Burke with her somewhat negative observations she always remember to say something positive first and last then sandwiches the negative (the poo) in the middle, which can be a very successful way to diffuse defensiveness. Dr. Wells’ assessments were quite accurate in the designation that the VPs were entrenched in “functional silos” and her statement of the “wait and see” attitude displayed by the leadership team was especially astute. Lacking that strong leader with a vision for the direction of SMC, and the skills to steer the company at all, the VPs had turned their focuses inward and occupied themselves with the success of their own division with no bearing on the company as a hole. The “wait and see” attitude was a reflection of the company as a whole “resting on its laurels”. The leadership team had become complacent in the absence of a charismatic General. The behaviors displayed in the team meetings, such as the lack of conversation when general SMC growth is the topic, coupled with other behaviors, such as the admirable quality to which the factories are organized, lead one to believe that the leadership team is truly engaged and sincerely cares about their work at SMC, they just need someone to focus that energy properly. Perceptively, Dr. Wells noticed this as well, recommending to Burke that he “hold them [the leadership team] to stand” meaning that they need to take ownership of the company as a whole instead of just their division, and that Burke himself must “manage by setting broad strategies” that he must become the SMC’s needed visionary.
Radical changes are needed to shock complacent people into action, and Burke’s plan to reorganize SMC is the catalyst through which the company will embark on its next phase of growth. Relative to similar organizations in the pharmaceutical industry I cannot say whether Burke’s new organizational structure will be effective, however the changes needed to meet the new structure will provide the serious first step needed to stimulate the employees at SMC to see and follow their leader’s vision. It is this leader’s vision that SMC has lacked since its founder left, and Burke must also recognize the changes he needs to make personally to become the strong leader SMC needs. Following the restructuring, along with the needed personnel changes to satisfy the restructuring, Burke must develop a clear, concise, mission that the new leadership team must buy into, both for business and for personal reasons. Some of the leadership team needs new challenges. Burke must be an inspiring presence for his company, not unlike its founder, because in a sense SMC is being born-again yet they must remember the genius of their history to fuel their desire for future success. SMC was spawned from the mind of Dr. Winthrop, protecting and honoring his legacy is a powerful stimulant that can be utilized and embodied by Burke therefore providing a vehicle that can be steered along the company’s new path that he developed, and the leadership team can get onboard for the ride.

SPECIFIC NOTES AND PERSONNEL RECOMMENDATIONS FOR CARL BURKE:
- Michael Everett – New Pharmaceuticals GM – with his background in chemistry and creative skills he can guide this important division, this would give him his needed recognition.
- Roger Engleford – New Generics GM – proven competent to understand science involved in Generics, his multitasking and leadership abilities will help him to grow this department. He should also be involved with choosing and mentoring the new sales managers as his input is needed and this will make him feel important.
- Craig Carlson – Marketing Mgr Generics – he appears to be most effective underneath a strong charismatic mentor therefore best to have Engleford managing him.
- Jack Francis, and Roberta Janis – should both continue running their current departments as they are proven effective, but Burke needs to be proactive at involving them in SMC issues not allowing them to just occupy their silos. The best way to do this with Francis would be to approach him with the demeanor of one asking an elder for wisdom, and Janis can be appealed to through her like of “experimentation and testing of new ideas” perhaps Burke can allow her to run some mock-up proposals of her own design.
- David Rice – this is the one individual that I would give the ax. It seems as if he fell into the position not through merit but through cronyism. Perhaps he expected to be SMC’s next CEO but Burke was chosen instead. When weighing the pros and cons of his continued employment one finds the pros lacking. Seems he can be easily replaced by his assistant George who Rice seems to send to do his job anyway.

Our Brave New World Moving Toward Gattica

Companies in the US, especially private companies, in my opinion have the right to do whatever they wish as long as they are not causing harm. If Scott wishes to not employ people that have health risks be they smoking or obesity, that is their privilege, the government has no right to tell them who to hire or not to hire. And in turn the company will reap the benefits or consequences of such policy. Now once a person is employed by Scott, they must make their guidelines and policies totally clear so that employees can follow them easily and avoid extra expenses on health care and termination. I think Hagedorn’s drive to eradicate smoking from Scott is admirable; however I am just not that kind of person. I don’t feel like it is my position in life to dictate anyone’s lifestyle, as I do not wish mine to be dictated, and I would be concerned about the great candidates that I would be missing out on just because they smoke or eat fast food. Even if it were my company, I wouldn’t feel that I had the right to govern my employees’ lifestyles outside of work. All that being said I also feel that what they are doing, and it will be legally validated or invalidated through the Rodrigues case, is a slippery slope and as we gain more knowledge about genetics we will soon have the power to give probabilities of suffering certain diseases at birth and that knowledge could definitely be used by a company to refuse employment. BUT THEY ARE STILL PROBABILITIES!! Even if we read a genome at birth there is no way to say to a 100% certainty that that individual will suffer from alcoholism or diabetes because even if it is minute there is still the factor of environment. Therefore companies will continue to do the same as Scott, because corporations will ALWAYS want to cut costs, but as consumers we have the power to not buy Scott products or apply to work there because of their discriminatory practices. To summarize, Scott can do as it wishes to save money or get their employees in better health the government has no power to stop them as long as they are following a clear policy, but I consider it a dangerous precedence and an unfortunate commentary on the state of health care in the US.

The secondary debate where Jessica is concerned...

· The treatment of Jessica Santillan represents an excellent example of a debate on modern medicine and evolution. Jessica was diagnosed with restrictive cardiomyopathy, which I think is better described as a condition or a symptom, than an actual disease. Causes are stated as being unknown, but there are numerous diseases/conditions that lead to the heart muscle being stiff, and therefore ultimately ineffective (this is an abbreviated layperson’s description by the way). There are many causes that lead to the restrictive cardiomyopathy, however most of the time the cause remains unknown. In my opinion this means it is the result of genetic factors. Genetic diseases such as Gaucher’s and Fabry’s can lead to the condition. The mortality rate for these conditions is quite high, without extraordinary treatment (i.e. heart transplant). The debate is whether or not we are perpetuating certain diseases/conditions in our gene pool by extending extraordinary treatment to those with these diseases, as by doing so we are influencing the “survival of the fittest” by helping individuals to live, procreate, and pass on genetic defects who otherwise would not survive to reproduce? It is wonderful that we have made such incredible scientific advances that allow people like my diabetic mother to live longer and fuller than she would have 100 years ago, but what is the cost? Take the case of an individual with a fatal peanut allergy. If allowed to experience the world normally without taking extraordinary measures to protect this individual from peanuts that individual would almost certainly die before passing along their peanut allergy. Are the fittest individuals surviving in the world today? Does it even matter that one has genetic defects if they can be treated? To what lengths should we go to save someone who nature has marked as unfit? How does treatment/non-treatment affect our ability to evolve into a more fit biological state? And finally what is unfit? And who decides who is fit and who isn’t?

With regards to the death of Jessica Santillan

The death of Jessica resulted from preventable mistakes in the organ donor system, and from negligence on the part of the medical professionals involved. Reading the timeline dictating the actions of each individual involved with obtaining Jessica’s first donated lungs and heart, one finds it incredulous that her entire medical chart was not available, or obtained by, to the individuals “buying”, “selling”, and transporting her organs. In the series of events surrounding the transfer there were three opportunities to catch the mistake prior to entering surgery. First by the person at the New England Donor Bank, and second by the person at Carolina Donor Services; both operated on the assumption that neither would be asking for the organ if it wasn’t the right blood type but given the information that organs are sometimes placed to individuals off the “match-up” list, blood type should definitely be involved in the conversation. However these two persons are not medical professionals, and in the course of events the person who should have caught the mistake first was Shu Lin, a relatively experienced medical resident, who fetched the organs from Boston. The fact that this person in the chain was neither familiar with the patient’s medical history nor in possession of Jessica’s entire chart is where the system really breaks down. One would think there would be a form with boxes to check when one is picking up an organ. For example that individual should be able to look and say “Okay, Heart and Lungs? Check; Right Size? Check; Good Condition? Check; Cooler with Ice? Check; Blood Type? Check.” It seems asinine that this was not done by Mr. Lin, but checking the blood type was not a standard procedure. The last link in the chain however, is Dr. Jaggers the surgeon. The three prior failings, though avoidable through a little extra effort, were those of the system and Dr. Jaggers unfortunately placed 100% reliability on the system, which he should have known better than to do. He is the captain of his Surgery, and to not check on the statistics of the donated organ himself before beginning the procedure was his own personal failure. The attributions of this situation were of low consensus and consistency, and high distinctiveness. However, if one takes into account all the deaths resulting from hospital mistakes one would find a much higher consensus and consistency, and a much lower distinctiveness, somewhat assuaging Dr. Jaggers’ sole culpability in the matter of Jessica’s transplant.
These events reveal breakdowns and imperfections in the systems by which individuals receive treatment in the US, However it is my opinion that hospitals generally do a relatively good job (when compared with say the US auto industry, or the US government) of correcting the system when unfortunate things occur. The changes enacted because of Jessica’s death will save lives in the future, and though hindsight is always 20-20, there will always be personal failings because we are human and we make mistakes, and though it is unfortunate that this happened, the girl was undergoing a procedure to lengthen a life that nature deemed unlivable a long time prior (and according to Comorow’s article only 50% of heart-lung transplant patients live 5 years after surgery).
The events, statements, and feelings following her death are too difficult to unravel as it is unclear who said what but Dr. Jaggers is ultimately responsible and should bear all the accountability even if unfairly. Taking Jaggers' license or suing him and the hospital (especially when all the medical treatment the Santillans were receiving was free of cost) is frivolous because the hospital acted within an insufficient system, and the world needs doctors even those who may make one mistake. Dr. Jaggers' motivations are difficult to read but I think he was internally motivated to “cure” Jessica and especially after his initial mistake, he was too focused on his own internal sense of his professional success (and a really cynical person might say his own ego) to take close enough account of his patient’s condition and the high risk in a second transplant attempt in her weakened state. It was impossible to determine whether the hospital or the surgeon advocated for the second surgery but either way there should have been a closer assessment of Jessica’s condition prior to initiating the procedure. And it was this procedure that ultimately led to Jessica’s death.
Jessica’s family was motivated to cross borders and reside illegally in the US in order to obtain the best medical care for her in an attempt to prolong her life. One cannot blame them for the extraordinary actions they took on behalf of their child, a lot of parents take similar actions, however they should be grateful that their daughter lived to the age she did, and that a surgeon, the hospital he worked for, the community they lived in, and the taxpayers of this nation, donated their time and money to help them at all because this is help they wouldn’t have received in their home country. It is cruel to say “beggars can’t be choosers” in this situation, but it applies, and the Santillans taking out their wrath on the monies of Dr. Jaggers and Duke won’t assuage their anguish but knowing that the misfortune suffered by them will help to save numerous lives in the future will. Even if everything had gone perfectly with Jessica’s surgery there is only a 50% chance that she would be alive today. And revoking Jaggers’ license doesn’t help anyone; perhaps the world is better served if he was held accountable by donating his service to Doctors Without Borders or a similar organization in need of skilled professionals.
In conclusion what happened to Jessica was avoidable and tragic, but the fact remains that people die from mistakes made by hospital organization systems and the people that work within those systems everyday. The rare nature and mortality rates of individuals with congenital heart defects like Jessica make the individuals that suffer with these diseases miracles in themselves, and even had everything gone perfectly with her transplant her survival rate would still have been extremely low, and the lifestyle she would have been forced to live would have been as restrictive as it would have been expensive. Mistakes are made constantly, and consistently, by individuals populating imperfect systems, and until one can foresee the future we can only better our systems by doing as Duke has done and learning from our mistakes, making changes in systems to decrease the frequency to which mistakes occur because as long as human beings are involved there will be imperfections.