Too busy to read?

This initial failure to perceive and not tolerate problems did not happen for lack of caring; it happened because most of the people in the process paid more attention to getting the tasks done than assessing whether the goals were being achieved. They had become more like rubber stampers than craftsmen, while the top people who were supposed to "taste the soup" to make sure it was excellent were focused on other things.

It is literally impossible to produce a consistent result in a business that depends on extraordinary people. No business can do it for long. And no extraordinary business tries to!

Watch out for the "Frog in the Boiling Water Syndrome." Apparently, if you throw a frog into a pot of boiling water it will jump out immediately, but if you put it in room-temperature water and gradually bring it to a boil, it will stay in the pot until it dies. Whether or not that's true of frogs, I see something similar happen to managers all the time. People have a strong tendency to slowly get used to unacceptable things that would shock them if they saw them with fresh eyes.

"Taste the soup." Think of yourself as a chef and taste the soup before it goes out to the customers. Is it too salty or too bland? Managers need to do that too, or have someone in their machine do it for them, for every outcome they're responsible for. People who are delegated this task are called "taste testers."