Two key points deserve consideration:
1. What is failing, rather than who is failing? The treatise on To Err Is Human reflected on analysis of process failure, on which much of Deming’s Total Quality Management was based. Although both works were rapidly pureed into buzzword bingo in their various implementations, they were founded on solid principles. Deming proposed that 85% of manufacturing bad outcomes were due to process failure; 15% due to individual error. Yet the trend has been to personalize blame, find the bad apple, shift blame and scurry out of the line of fire, to practice CYA medicine. If it is axiomatic from the get-go that a failure is due to a blameworthy person, then blame will be attributed to that person. Consider Lt. Calley, the bad apple in Vietnam, or the various bad apples in Baghram Prison who wound up doing time.
It is much more embarrassing to analyze systemic failures, and systemic failures merit systemic corrections. If we must take it as an axiom that the Emperor is not naked, then we will reach the requisite conclusion that some one or ones are disrespectful of his finery. If we are not allowed to question the premise that this is the best of all medical systems, but undercut by bad people, we are off to another round of bad and horrible consolidation of power under the principle of purging the counterrevolutionaries and wreckers.
2. Is it a symptom of corruption, rather than bad implementation? Corruption is the systemic erosion of moral principles of communication in an interpersonal process. A terrific treatise was written by two faculty of the Army War College on corruption within military communications. The work is Lying to Ourselves: Dishonesty in the Army Profession, authored by Dr. Leonard Wong & Dr. Stephen J. Gerras, (link), it is an ABSOLUTE MUST READ for anyone involved in medical process.
“Untruthfulness is surprisingly common in the U.S. military even though members of the profession are loath to admit it. Further, much of the deception and dishonesty that occurs in the profession of arms is actually encouraged and sanctioned by the military institution. The end result is a profession whose members often hold and propagate a false sense of integrity that prevents the profession from addressing—or even acknowledging—the duplicity and deceit throughout the formation. It takes remarkable courage and candor for leaders to admit the gritty shortcomings and embarrassing frailties of the military as an organization in order to better the military as a profession. Such a discussion, however, is both essential and necessary for the health of the military profession.”
Medicine is racing along at lightspeed to catch up with the military and American business in its “internal relativism.” In the military, arbitrary and impossible expectations are placed on the lower echelons of command by elitist and distant commanders, uninterested in, and truly unfamiliar with, day-to-day operations in the field. By expectation, the field operations staff do not anticipate these instructions and orders to be in any way useful. Usually, they are just paper-flailing methods for the senior command to defer responsibility down the chain. In the business world, HR instructional videos are not usually constructed for the provision of useful information to an employee; rather, they are potential evidentiary exhibits, coupled with signed affidavits from employees, that they WERE instructed on this-or-that, so that responsibility can be kicked down the ladder.
The protests of Wong and Gerras are not mere fussing over the sad lack of morals in military command; they are worried about the corrosive effect of unreliability in the field. If enormous numbers of assignments are made, that no rational commander could schedule to be done – well, they are “paper-whipped.” For example, field troops deployed in combat areas in Iraq and Afghanistan were ordered to undergo a 32-hour seminar on gender sensitivity training in the military – something that the various branches have not done well at in the past. Nevertheless, standing down combat troops for a week-long seminar at home base seems a poor prioritization of time. Most commanders summarized the course to “don’t sexually abuse people,” and checked off the box. In that case, who was The Bad Guy? Well, legally, the field commander. That’s all the enterprise cares for, who to blame.
Another ritual in business and the military which is accepted, that a new commander takes over a shop, wing, base, whatever, and executes a drill-down performance audit that gives dismal grades. That same commander continues an ongoing audit, and over time, the shop, base, wing, whatever steadily improves until it’s an all-green-flag, top-notch unit when the two or four year stint which that commander winds up and marches off. Naturally, the next commander comes in, and tears the place down, and finds utter failure and incompetence, which she/he steadily improves, etc. There is no intent of “punishing” the outgoing commander; it’s all part of the charade of promotion.
What disappears is reality. What if two bases need to be deployed? One is in shambles, and the other is tip-top. Of course, these terms mean nothing in reality; it has more to do with where the commanding officer is on her/his deployment cycle. Except for soldiers getting killed unnecessarily, waiting for relief that they will never get, except for that the system works perfectly. You just have to redefine the term “work.”