IGNITE EXTENDED / LESSON 35
When does a repeated action become an internalized expectation?
A culture diagnosis with an intervention hypothesis.
On January 5, 2024, a door plug blew out of Alaska Airlines Flight 1282, a Boeing 737-9 MAX, in flight. On February 26, 2024, the FAA released the final report of an expert panel required by the Aircraft Certification, Safety and Accountability Act of 2020, passed after the two fatal 737 MAX crashes. Drawing on more than 4,000 pages of documents, seven surveys and over 250 interviews, the panel issued 27 findings and 53 recommendations. It described a disconnect between senior management and the rest of the organization on safety culture, 'inadequate and confusing implementation' of the components of a positive safety culture, and employees who questioned whether the Speak Up reporting system would protect them from retaliation. Boeing's safety management system procedures were formally sound but complex and frequently changing, and awareness of safety metrics was low at every level. Two days later the FAA Administrator gave Boeing 90 days to produce a comprehensive action plan covering quality control and its safety management system. The panel did not investigate the door plug event itself.
Sources: FAA: Review Panel's Final Report on Organization Designation Authorizations (ODA) · GlobalAir: FAA panel calls Boeing safety culture inadequate and confusing · Axios: Review finds disconnect between Boeing management and staff on safety · AviationPros: FAA Administrator says Boeing must commit to real and profound improvements
Boeing had written safety procedures and a reporting channel. Using the routine-versus-norm distinction, what would you need to observe to know whether employees now expect peers to stop the line and report a problem, and which management levers would have to change for that expectation to form?
A routine describes a sequence of actions. A norm describes behavior members regard as appropriate and expected. A manager can establish a routine through instruction and monitoring, while a norm can guide action even when the manager is absent.
The culture material uses hand hygiene as a historical organizational case. Its purpose here is to understand management systems and shared expectations, rather than to provide clinical instructions. The case asks why people fail to perform a known action and how an organization can change the pattern.
Failure to follow a routine can reflect missing supplies, an impractical process, lack of knowledge, conflicting incentives or a weak social expectation. A campaign aimed at the wrong mechanism can create activity without lasting change.
The source compares actions such as access to supplies, training, observation, feedback and accountability. These interventions perform different functions. Diagnose the conditions surrounding the behavior and test a plausible explanation before assuming that employees need more motivation.
A routine is a repeated pattern of activity. A norm is a shared expectation about how members should behave, often supported by social reactions.
A specified sequence of actions, often explicit, trained and monitored.
An expectation about appropriate behavior that can become internalized and reinforced by peers.
Illustrative application: attending the weekly customer review is a routine. Expecting colleagues to disclose bad news early, and challenging concealment even when a manager is absent, indicates a norm. The meeting may exist without that expectation if people learn to present only favorable results.
Observe peer expectations and consequences as well as the scheduled activity.
A routine becomes cultural when people share an expectation about the behavior and reinforce it with one another. A checklist alone does not establish that transition.
Management asks teams to review customer failures weekly. Initially the behavior may occur only because a meeting is scheduled and a manager asks for the report.
People observe what happens when they raise a problem. If managers reward early reporting and act on it, the routine gains a different meaning than if they punish the messenger.
Members come to expect that peers will surface a failure and help investigate it. The behavior becomes part of how a responsible colleague is understood to act.
Colleagues notice and respond when the expectation is met or violated. Look for behavior when the manager is absent to distinguish a shared norm from compliance alone.
Norm strength describes how widely and intensely the expectation is held. Whether the norm helps performance depends on its content and the work the organization must do.
Content is a separate question: a strong shared expectation can still be harmful or misaligned.
Content describes what people believe and expect. Agreement describes how widely those expectations are shared. Intensity describes how strongly members hold them. A culture can have high intensity within competing subgroups while lacking organization-wide agreement.
Strong culture therefore does not mean good culture. Members can share harmful expectations strongly. Evaluate the content, its consequences and its alignment with the strategy separately from its strength. The original matrix makes these dimensions visible.
The Vanderbilt discussion describes a set of mutually supporting actions, including leader modeling, transparent goals, peer observation and consistent accountability. The source interprets these through shared agreement and intensity around the behavior.
The mechanism concerns what members believe is right and what they expect others to do. It can reduce the need for continuous managerial supervision, but it can also create conformity or exclusion. Examine whether the change persists after special attention ends and whether people can challenge a harmful norm.
Culture can influence how people coordinate and how they direct effort. Explain the behavior connecting a shared expectation to an operating result.
People behave in ways that support the strategy’s requirements.
Shared meaning and expectations can support effort and compatible action with less explicit direction.
Illustrative application: an early-escalation norm may reduce repeated clarification about when to raise a release risk. It may also make people willing to spend effort documenting a problem. A norm that discourages dissent can coordinate action quickly while suppressing information the decision needs.
Strength does not establish usefulness. Evaluate the norm’s content, the task and the consequences it produces.
Click either page to read it at full size. In the reader, use ← → to switch between these two pages.
Selected reading: PDF pages 2, 3, 4
The selected pages describe a setting with explicit hygiene protocols and several barriers to consistent behavior. The organizational question is how knowledge, work design and peer expectations interact in everyday practice.
The historical case describes situations in which staff are expected to clean their hands. The desired behavior is more precise than a general statement about safety.
People with different roles and employment relationships share the care environment. A consistent expectation must cross those boundaries.
Workload, physical inconvenience and established habits can interfere with following a known rule. Equipment availability addresses only part of that difficulty.
Reluctance to challenge another person can let nonconformance continue. Peer response is part of the behavior system.
Selected reading: PDF pages 2, 3, 4
Awareness of a protocol does not establish that it happens reliably. Diagnose when behavior breaks down and which constraint explains the gap.
A shared norm involves expectations and social reinforcement. Following a rule only during observation can have a different mechanism.
This course uses the historical case for organizational analysis. Its clinical details and dated statistics are not instructions for current clinical practice.
The organizational case asks why a well-understood desired behavior can remain inconsistent. Carroll’s discussion contrasts training, monitoring, practical barriers, meaning and shared accountability. The lesson concerns organizational behavior, not a clinical protocol.
What would distinguish a stronger routine from an internalized norm?
Microsoft and LinkedIn's 2024 Work Trend Index, a survey of 31,000 people in 31 countries, reported that 75% of knowledge workers use generative AI at work and 78% of those users bring their own tools. When usage spreads bottom-up, the operative rules are peer norms, not the written policy.
In April 2023 Samsung engineers pasted internal source code into ChatGPT; the company responded in May 2023 by banning generative AI tools on work devices. A ban is a fast routine with monitoring costs. Whether people stop pasting sensitive data into consumer tools when no one checks depends on friction (is an approved tool available?) and on what peers expect.
At Relay, pasting a clinic's schedule into a consumer chatbot to debug a template is the same mechanism as the staging near-miss: a fast path that moves PHI outside agreements. The durable fix pairs an approved, BAA-covered tool with a team expectation that anyone can question an unsafe paste, and the application of HIPAA to a given tool needs legal review.
Sources: Microsoft and LinkedIn release the 2024 Work Trend Index on the state of AI at work · Forbes Australia: Samsung bans ChatGPT among employees after sensitive code leak
Fictional team: everyone is trained to record a handoff, but records are often missing. The tool is slow; managers sometimes skip it; a campaign improves compliance only while a supervisor watches.
Identify routine, friction, norms and leadership issues. Propose an intervention and evidence that would distinguish a temporary monitoring effect from a more durable change.
Month 11, team of 9 (illustrative: 3 remote). Relay's engineering culture prizes shipping fast. While testing a new reminder template, an engineer sends a message containing a patient's full name and appointment time to a wrong number; the staging environment had been seeded with a copy of real clinic records because synthetic test data did not exist. A HIPAA training module and a written policy against using real PHI in testing were already in place. Daniel himself has hot-fixed production templates on Friday nights. Nobody raised the practice before the incident.
Write a one-page culture diagnosis: classify each failure by mechanism (knowledge, friction, meaning, expectations, accountability), state whether 'no real PHI outside production' is a routine or a norm today, propose an intervention hypothesis, and name evidence that would distinguish durable change from a monitoring effect.
When people already know the rule, more training adds activity without change. Check friction, incentives and what leaders tolerate before building another course.
Announced audits and visible observers inflate compliance; the McLaws and Kwok wards show gaps of 25 to 66 points. Evidence of a norm comes from unannounced or automated observation after the campaign has ended.
One visible exception for a senior physician or a founder tells everyone the rule is negotiable by status. Vanderbilt's 'no exceptions for top MDs' was a design choice, not a slogan.
A culture diagnosis of Relay's PHI near-miss: mechanism classification, routine-versus-norm verdict, an intervention hypothesis led by friction removal and leader modeling, and an evidence plan based on unannounced audits.
Next lesson: Culture design & management levers
Check your understanding
Question 1
After a hospital campaign, observed compliance with a safety step rises from 60% to 92% during announced audits. Unannounced electronic monitoring in the same month shows 58%. What is the best interpretation?
Unobserved behavior barely moved (58% vs 60%), so the audited gain is a Hawthorne effect. The tempting answer treats measured compliance as the behavior itself; a norm is the behavior that persists when nobody is watching.
Question 2
At Relay, the written policy says no real PHI may be used outside production, and every engineer has completed HIPAA training. Staging still contains copied clinic records. Which mechanism should be addressed first?
Training is complete, so knowledge is not the binding constraint. As long as real records are the easiest test data, even well-intentioned engineers will copy them. Remove the friction first, then work on expectations and accountability.
Question 3
Which observation is the strongest evidence that 'report near-misses early' has become a norm at a 20-person software company?
A norm is enforced by peers, across status, without a manager present. Signatures show the routine exists, a rise under CEO attention may be monitoring, and zero incidents can mean concealment as easily as safety.
Question 4
A sales team strongly and unanimously believes 'never tell a client about a product defect until the contract is signed.' On the agreement-intensity matrix, what is this?
High agreement and high intensity define strength, so this is a strong culture. Its content conflicts with honest dealing and long-run retention. Treating strength as goodness is the misconception the matrix is designed to correct.
Question 5
Vanderbilt tied department chairs' discretionary funds to unit results, but staff themselves received no bonus for compliance. Why does that design make sense?
The program wanted staff to see the behavior as the right thing to do, enforced by peers. Paying for each observed act turns it back into a monitored routine. Leaders got consequences because they control resources, modeling and exceptions.
Question 6
Relay's CTO says: 'We have a privacy culture: it is in our values deck.' Engineers say privacy reviews are skipped whenever a customer demo is close. Which statement is most accurate?
Culture is what people expect, and what is rewarded or tolerated, when values conflict. A rule that gives way whenever a demo is close tells everyone which value wins. The values deck is evidence of what leaders intend, not of the norm.
Workbook
Module output: A culture diagnosis and a consistent set of management levers.
Library
10 appear in the slides with notes; the rest are kept here for reference.
Source S49 · Carroll · 7 pages
Source S04 · Feinberg · 10 pages
