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When systems depend on human vigilance, they will fail. Build process you can trust. Don't look to past precedent when there isn't any.


Let me start with a quick personal story. I promise you will see how this relates to leadership and rapid change.

Let me begin.

It was a particularly busy day at the doctor’s office. It was a small practice of 2 pediatricians. One nurse was out that day and they were short one admin who was on vacation. Patients who had put off visits seemed to be all coming in at the same time. The office was shorthanded. Papers were pile on the fax and post it notes dotted every monitor in the office.

The fax machine began its high tone whirring as yet anther fax rolled out onto the pile that accumulated from the previous day.

The nurse grabbed the pile of papers that had accumulated on the fax from yesterday and began on the bottom with the oldest. This first one caught her attention immediately. It was a lab report for a 9 year old boy and the values were not good.


It was the results of a complete blood count which looks at red blood cells, white blood cells and platelets. The one number that jumped out at her, like a flashing red light was the white blood count.

White blood cells play a vital role in fighting off infections, viruses and other attacks on the body. When your body is fighting infection or disease the white blood counts go up. High WBC count suggests that the body is trying to fight out an infection or disease.

While White Blood Cells are fewer in number then red blood cells a normal WBC is about 8,000 per cubic ml of blood. When the body gets an infection the counts may climb to 15,000 to 18,000. If you are extremely ill your counts could get as high as 50,000 per cubic ml.

She stared at the report, blinked, inhaled, then exhaled. The white blood count was 183,000. And the data was 42 hours old. Things were happening fast. They quickly took another blood test. His count was now 250,000 per cubic ml.

She grabbed the doctor, showed him the results. The doctor quickly picked up the phone and called the child's parents. Still unsure what was causing this alarming rate of WBC, he had an idea. He knew it was very bad.

He barked into the phone. "Please take your son to the emergency room, right now. Don't stop for anything." He paused. "No, you can’t stop for breakfast. Please just go.”

This was a day when a perfect storm had all coalesced for this 9 year boy who just went in for a routine blood test.

The fax was date and time stamped more than 30 hours ago. It had been sitting on the fax machine for two days. The test was performed 12 hours before the fax was sent.

The boy was my youngest son. This happened 14 years ago.


Laboratory Medicine Best practices established by the CDC states that labs must have procedures in place for promptly conveying critical results to the doctor. A critical value is any imminent life-threatening result requiring immediate physician notification.

This white blood count was a critical value. The lab should have called the doctor immediately. They sent a fax. It sat on the fax machine overnight.

Eventually he was diagnosed with Acute Lymphoblastic Leukemia. This is a cancer of the bone marrow, mostly found in children. It affects the bone marrow yet shows up in the blood which manifests as the high white blood cell count. His body was trying to fight something off.

White blood cells protect you against illness and disease. Think of white blood cells as your immunity cells. In a sense, they are always at war. They flow through your bloodstream to fight viruses, bacteria, and other foreign invaders that threaten your health

However when there are this high in a patient, they do not function normally. As a result, the patient is at a much higher risk of many other infections.

This was a day when a perfect storm all coalesced around this 9 year boy who went in for a routine blood test. The fax was date and time stamped more than 30 hours ago. It had been sitting on the fax machine for two days.

Two systems broke down: the lab and the doctors office. In any organization, when systems break down, bad things can happen. In medicine, patients can die.

The speed at which the cancer was spreading was so fast, that the protocol of chemotherapy didn’t work right away. They called him a "slow responder".

Probably another medical euphemism they came up with so the parents don’t panic. Or the doctors for that matter.

Four days later, in the hospital his white blood count was 525,000 per cu/ml.

A fellow in Oncology wanted to do a manual blood transfusion at 4 am to keep him from having a stroke. He was drifting in and out of consciousness. At one point he grabbed my pointer finger, squeezed it and slide “Daddy don’t let me die”.

I was broken. Like in the movie the Exorcist, I screamed out the window “Take me!”. But lucky for all of us that didn’t happen.

Miraculously, after the fourth day, the chemo began to work and his counts began to turn. They threw everything at him. Five long years of chemotherapy, radiation and more chemicals than Dupont produces in a year,

He was a famous patient at Children's Hospital. When his counts turned, the lab at the hospital threw a party for him.

He did recover and went into remission. He is now considered “cured”. He is 21 today and is in the best shape of his life. He is a personal trainer.


The story about my son was triggered by a recent book I read by Michael Lewis called, The Premonition. It is the story of a group of medics and scientists who attempted to get the US government to take the pandemic response seriously.

The antagonist or malevolent force in The Premonition is "institutional malaise." Not any one person. The lessons of the book, tell us why bureaucracies and systems fail. And how system failures can become catastrophic. Something we have all experienced.

One big problem, Lewis observes, is that human brains and by extension complex organizations are simply not wired to grasp exponential growth. And complex is not limited to large organizations. A small organization can be complex without any sustainable process.

Exponential growth can result in change feeling initially slow and incremental. Then surprising when it later appears ‘suddenly’, becoming rapid and overwhelming. Like Covid.

To understand exponential growth, consider the metaphor of the Lilypond.

I tell you it will take 30 days to cover a lilypond completely with lilies until you cannot see the water. If one lily grows on day one and it doubles every day, on which day is the lilypond half full?

The 29th day.

Cognitive psychologists explain the difficulty of grasping exponential change as an “exponential growth bias”, where one treats this type of change as if it was linear.

And that is why no one initially believed the scientists who were begging the government to take the pandemic seriously. While exponential growth is not linear growth, our minds are wired to think in linear terms.


The tendency for our minds to treat exponential growth as if it was linear growth, is the key reason many organizations are under prepared for any scenario that moves this quickly.

Powerful leaders know that scenario planning is the strategic practice for helping people navigate deep uncertainty.

When done correctly it helps to address exponential growth bias. And it keeps a catastrophic failure from happening.

The conscious mind has a limited amount of information it can take in at any given time. For everything else, it acts as a reducing valve.

It reduces things to the smallest subset it can handle which is your Leadership Style or Archetype.

It is how we see the world. How we make decisions, how we work with our teams.

We tend to judge too many things by slapping a label on it. We end up pre-judging everything and experiencing very little.

When the pandemic first hit the United States in February 2020, decisions had to be made with very little data. There was no past precedence.

On March 2, 2020 there were 15 new cases per day.

By April 3rd there were 32,318 new cases per day.

By January 2021 there were 201,784 new cases in one single day.

The lilypond was full.

The scientists who could see this were thinking non-linearly. They were scenario planning. The decisions that had to be made in any given day in early February was based on data that was 2 weeks old.

The systems and the environments in which the scientists worked, which they had been encouraged to trust, had failed them.

“When you go into the details of the cases, you see it’s not bad people,” Lewis said. “It’s bad systems. When the systems depend on human vigilance, they will fail.”

My son nearly died by depending on human vigilance. Many businesses have gone bankrupt, many have managed to survive.

Covid has produced a profound collective trauma in the world this past year. These events will create cultural shifts and societal changes which we have never seen before. These changes can be exponential themselves.

If we depend on our systems or process to catch things, what happens when they don’t?

Every leader today has to make decisions based on rapidly changing scenarios.

Rapid change demands that we solve problems as quickly as possible. But that speed breaks down bad systems.

How do we formulate strategy in the face of uncertainty?

In my first book, “Leading Organizations from the Inside Out”, Bob Ivany, a general in the first Iraq war said the army coined a phrase that captured the dimensions of this type of problem.

We live in a VUCA world. Volatile, Uncertain, Complex and Ambiguous.

Leadership uncertainty comes from our inability to understand the present, because its not related to anything we’ve previously experienced.

When there are no analogies to the past, we have trouble picturing how things will play out in the future.

We are all overwhelmed with what I call the “tyranny of the immediate”.

We keep using our Brain Minds to think linearly. (This is the conscious mind)

However what if your business is dealing with a non-linear problem?

Then we must to tap into our sentience side, our Heart Minds, that finely tuned experience or intuition, we have all experienced at times. (This is the unconscious mind)

We are using our “brain minds” which can only solve linear problems. The brain keeps trying to use past precedent to solve future problems. But what if there is no past precedent?

We need to tap more into our sentience side, our “Heart Minds” so can we begin scenario planning and make decisions in a non-linear way.

This is why we are not going “back” to normal.

Right now, this is “normal”.

When times are uncertain, shorten your planning to the shortest time frame you can.

If you can't plan the year, start with six months or three months.

Even a week will do.

Try a day. An hour. Whatever works for you.

Don’t resist change. Embrace it.

Stay in the moment. Quiet the little voice in your head that never shuts up.

It’s creating, worry, fear and doubt about the future. And the future has not happened yet.

Worry is really just a story in your head that makes you feel like crap.

Sorry to burst your bubble, but feelings are not facts.

And the quality of your life, is in direct proportion to the amount of uncertainty you can live with at any given moment in time.

It’s a VUCA world folks.

If you would like to join a Mastery Roundtable Peer group, or get Executive Coaching please click here or call me at 415-935-1375. Look forward to hearing from you.


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