“That makes sense,” Luke said. “It was a little outside our normal behavior, giving nurses the authority to question a doctor about hand washing.”

“That’s the problem with normal,” I replied. “Normal is just repeated behavior regardless of the outcome. It’s the desired outcome we have to pay attention to, not what is normal.”

“I agree,” Luke nodded. “Likely, we would never make that decision without looking at mortality rates. It was only when we asked the nurses, that things became clear.”

“When you examine systems, you have to figure out how that system emerged. Was it designed to produce an outcome, or did it arrive out of repeated behaviors, ingrained as habits, without regard for the outcome?” I stopped. “A not-so-intelligent system makes even competent people (surgeons and nurses) look dumb. Eventually, competent people will overcome a not-so-intelligent system, if you give them permission, better yet, ask them.”