{"id":1712,"date":"2026-10-26T08:56:29","date_gmt":"2026-10-26T08:56:29","guid":{"rendered":"https:\/\/expand-strategy.com\/?p=1712"},"modified":"2026-10-26T12:29:10","modified_gmt":"2026-10-26T12:29:10","slug":"quando-o-alerta-nao-muda-a-decisao","status":"publish","type":"post","link":"https:\/\/expand-strategy.com\/en\/2026\/10\/26\/quando-o-alerta-nao-muda-a-decisao\/","title":{"rendered":"When the Warning Does Not Change the Decision."},"content":{"rendered":"

Compliance Does Not Guarantee the Quality of a Decision<\/strong><\/p>\n

Institutions do not fail only when they are unaware of a problem. They may fail when relevant information is available, when professionals recognise warning signs, or when an investigation identifies the causes of an event, yet the knowledge produced does not sufficiently alter the decision or the conditions under which it is made.<\/p>\n

This distinction matters because formal compliance and institutional capacity are not equivalent. Procedures establish rules, allocate responsibilities and make scrutiny possible. They do not, in themselves, guarantee that relevant information will be considered, that warnings will carry sufficient weight in decision-making, or that identified problems will lead to meaningful change.<\/p>\n

In complex organisations, knowledge is often distributed across different units, specialisms and hierarchical levels. The authority to decide may lie apart from those who observe a problem; responsibility for implementation may not coincide with the ability to change the conditions that shape it. It is within this distance between knowledge, authority and action that certain failures cease to be isolated episodes and begin to reveal institutional limitations.<\/p>\n

The Challenger <\/em>and Columbia<\/em> space shuttle accidents, research into failures in hospital work processes, and the OECD\u2019s analysis of government capabilities provide different contexts in which to examine this question. The scale and consequences of these events are not comparable. Their analytical value lies in a shared question: under what conditions can an institution turn relevant information into a decision, and an acknowledged failure into change?<\/p>\n

Challenger: <\/strong><\/em>When Knowledge Fails to Shape the Decision<\/strong><\/p>\n

On 28 January 1986, the space shuttle Challenger<\/em> broke apart 73 seconds after lift-off. All seven crew members died. The Presidential Commission identified the failure of the pressure seal in a joint on the right solid rocket booster as the physical cause of the accident. The low temperatures forecast for launch raised significant technical concerns because of their potential effect on the performance of the sealing rings, known as O-rings.<\/p>\n

On the eve of the launch, engineers at Morton Thiokol, the company responsible for the solid rocket boosters, raised concerns about the safety of the anticipated conditions and initially recommended that the launch should not proceed. During discussions with officials at the Marshall Space Flight Center, the technical objections were challenged, and Morton Thiokol\u2019s management ultimately reversed its initial recommendation. Information about the engineers\u2019 original opposition and the company\u2019s initial recommendation did not reach the programme\u2019s senior decision-makers in full (Presidential Commission on the Space Shuttle Challenger Accident, 1986).<\/p>\n

The Commission concluded that the decision-making process had failed on several levels: communication problems had led to a decision based on incomplete and, at times, misleading information; engineering data had come into conflict with management judgements; and NASA\u2019s management structure allowed flight-safety concerns to bypass key programme officials (Presidential Commission on the Space Shuttle Challenger Accident, 1986).<\/p>\n

The accident cannot be explained solely by the failure of a component. The investigation also showed that the way information was communicated and considered shaped the decision. The technical knowledge existed, but it did not exert sufficient influence to prevent the launch.<\/p>\n

In her subsequent analysis, Diane Vaughan (1996) developed the concept of the normalization of deviance<\/em>: practices that gradually depart from expected safety standards may come to be regarded as acceptable when they do not produce immediate adverse consequences. The repetition of deviations without visible consequences can alter the way an organisation interprets risk, until what should prompt reconsideration becomes part of routine practice.<\/p>\n

Vaughan\u2019s analysis helps explain why the accumulation of warning signs does not necessarily lead to change. The question is not simply whether information exists, but how an institution interprets it, what authority it gives that information, and under what conditions it allows it to challenge expectations, deadlines or decisions already taken.<\/p>\n

In Hospitals: When Working Around a Failure Does Not Fix the System<\/strong><\/p>\n

Research into organisational failures in hospitals makes it possible to examine this problem beyond the context of a major accident. In their study \u201cWhy Hospitals Don\u2019t Learn from Failures\u201d, Tucker and Edmondson (2003) analysed 239 hours of observation involving 26 nurses across nine hospitals, examining how these professionals responded to failures in work processes.<\/p>\n

The authors distinguished between two types of process failure: errors, understood as the incorrect or unnecessary execution of a task, and problems that impede the proper performance of work. Their research examined how professionals respond to these situations and the implications of those responses for process improvement and organisational change (Tucker & Edmondson, 2003).<\/p>\n

When a professional lacks a necessary item, information or working condition at the point it is needed, they may find an alternative, turn to colleagues or reorganise the sequence of tasks. The immediate problem is overcome and the service continues. Yet if the failure is not examined and corrected at its source, it may recur, once again requiring the time, attention and effort of staff.<\/p>\n

This example illustrates the dynamic under discussion; it is not a description of a specific clinical incident reported in the study. The research identifies organisational patterns and does not justify attributing a uniform response to all hospitals or professionals.<\/p>\n

The institutional problem emerges when professionals\u2019 capacity to improvise repeatedly absorbs the consequences of inadequate processes. An organisation may appear to function because its staff compensate for its shortcomings. That continuity, however, can conceal costs, vulnerabilities and opportunities for improvement. The failure may become insufficiently visible to trigger systemic correction precisely because someone has managed to resolve its immediate consequences.<\/p>\n

Tucker and Edmondson (2003) describe an illusory equilibrium in which small process failures erode organisational effectiveness rather than driving learning and change. A local response allows work to continue, but it does not guarantee that the conditions that gave rise to the problem will be altered.<\/p>\n

The significance of this study lies neither in holding nurses responsible for problems beyond their control nor in presenting improvisation as evidence of incompetence. Rather, it shows that the experience of professionals who identify and compensate for failures does not necessarily translate into an institution\u2019s capacity to eliminate them. Those who recognise a problem may lack the authority to change the process; those who hold that authority may not receive sufficiently structured information about recurring failures; and those who assess performance may observe the continuity of service without recognising the effort required to sustain it.<\/p>\n

This dynamic raises a central question for the governance of healthcare organisations: is the system correcting the conditions that produce failures, or is it merely relying on professionals\u2019 ability to work around them?<\/p>\n

The distinction has implications for management, safety and the quality of care. Organisational learning requires recurring problems to be recognised, communicated and examined, and that this analysis should be meaningfully connected to decisions about resources, processes, responsibilities and working conditions. Without that connection, experience accumulates, but change may not follow.<\/p>\n

Columbia: <\/em>When Investigation Does Not Translate into Institutional Change<\/strong><\/p>\n

Seventeen years after Challenger<\/em>, the Columbia<\/em> accident again brought the relationship between physical causes, organisational culture and safety into focus. Comparing the two cases makes it possible to examine the extent to which the lessons of an investigation translate into effective changes in the institutional conditions that shape decisions.<\/p>\n

On 1 February 2003, the space shuttle Columbia<\/em> broke apart during atmospheric re-entry, killing all seven crew members. The investigation identified a breach in the thermal protection system on the left wing as the physical cause, resulting from the impact, during ascent, of insulating foam from the external tank. The foam detached from an attachment area on the tank and struck the shuttle\u2019s wing after lift-off (Columbia Accident Investigation Board, 2003).<\/p>\n

The Columbia Accident Investigation Board did not confine its analysis to the physical sequence of the accident. It also examined the programme\u2019s history, priorities, schedule pressures and the organisational culture that shaped communication and risk assessment.<\/p>\n

The report concluded that the physical and organisational causes carried equivalent weight, and that NASA\u2019s organisational culture contributed to the accident as much as the foam that struck the wing during ascent (Columbia Accident Investigation Board, 2003).<\/p>\n

The investigation identified organisational problems that hindered the effective communication of critical information, constrained the expression of professional disagreement and encouraged decisions based on assumptions insufficiently supported by engineering evidence. The report linked these factors to the history and culture of the space programme, including schedule pressures, shifting priorities and barriers to the integration of safety information.<\/p>\n

The comparison with Challenger<\/em> does not mean that the two accidents had identical technical causes. It shows that, beyond the differences in the physical sequences of events, organisational weaknesses persisted and continued to affect safety and the quality of decision-making processes.<\/p>\n

This is where the question of institutional learning becomes particularly demanding. An organisation may investigate an event, publish findings, formulate recommendations and revise procedures without sufficiently changing the mechanisms that shape future decisions. The production of knowledge is one stage of learning; it does not, in itself, demonstrate that learning has been embedded.<\/p>\n

The issue is not simply whether an organisation has identified the causes of an accident. It is whether the knowledge produced has changed the practices, authority relationships, assessment criteria and decision-making processes that influence the possibility of recurrence.<\/p>\n

Decision Architecture and Institutional Capacity<\/strong><\/p>\n

The three cases reveal different problems, but they allow a common question about the organisation of decision-making to be formulated. In Challenger<\/em>, the investigation identified failures in communication and in the consideration of relevant technical information before launch. In the hospitals studied by Tucker and Edmondson, the local resolution of problems could coexist with the persistence of the conditions that produced them. In Columbia<\/em>, the investigation again identified organisational factors that shaped safety and risk management.<\/p>\n

These situations should not be treated as equivalent. A space shuttle accident, a failure in a hospital work process and a limitation in public governance have different contexts, consequences and evidential requirements. Their juxtaposition is analytical: each case makes it possible to examine the relationship between available information, the organisation of decision-making and the capacity to correct action.<\/p>\n

In this sense, decision architecture provides a relevant analytical lens for the study of institutions. The concept directs attention to how decisions are organised: how information circulates, how different levels of authority interact, how disagreements are considered, and how decisions relate to their implementation. It does not assume that all institutions operate according to the same model. Rather, it examines how the configuration of their processes shapes the use of available knowledge.<\/p>\n

Institutional capacity, in turn, concerns the conditions that enable an institution to formulate and implement decisions, coordinate actors, mobilise resources and respond to the results of its actions. It is not synonymous with decision architecture, although it may be shaped by it. A decision-making process may integrate information inadequately; an institution may correctly recognise a problem yet lack the resources, skills or coordination mechanisms needed to resolve it.<\/p>\n

Organisational learning is a related but distinct dimension. It refers to the capacity to interpret experience, reconsider assumptions and modify practices. The existence of reports, evaluations or recommendations does not, in itself, demonstrate that learning has been embedded in institutional routines and mechanisms.<\/p>\n

This distinction is particularly relevant to public governance. Cross-cutting challenges, spanning ministries, services and policy areas, require more than specialist information or individual expertise. They require mechanisms that can align priorities, integrate technical contributions, coordinate responsibilities and monitor implementation.<\/p>\n

The OECD\u2019s 2026 report on centre-of-government capabilities examines six countries, including Portugal, and considers the conditions needed to steer, coordinate and sustain complex priorities. In the Portuguese case, the analysis focuses on the relationship between political and technical levels (OECD, 2026).<\/p>\n

This framework makes it possible to relate decision architecture to the mechanisms through which public priorities are coordinated, planned and implemented. The quality of public decisions depends not only on the individual competence of decision-makers or the availability of specialist information, but also on the institutional conditions under which information is integrated, interdependencies are managed and implementation is monitored.<\/p>\n

Decision architecture does not, on its own, explain every institutional failure. It does, however, provide a way to examine a fundamental dimension: how the organisation of decision-making facilitates or constrains the transition from knowledge to action. This relationship makes it possible to analyse the connections between decision architecture, institutional capacity and learning without reducing one concept to another.<\/p>\n

From Identifying Failure to Institutional Change<\/strong><\/p>\n

The cases examined show that recognising a failure and changing the conditions that produce it are distinct processes. Information may exist without influencing a decision; professionals may resolve problems without being able to eliminate their causes; and an investigation may produce recommendations without ensuring that they translate into different institutional practices.<\/p>\n

The answer does not lie in multiplying procedures, reports or control mechanisms without examining their relationship to decision-making. It lies in understanding whether an institution can identify relevant information, give it appropriate weight, align responsibilities and translate the knowledge acquired into verifiable changes.<\/p>\n

In public administration and healthcare organisations, this requirement has particular significance. Continuity of activity may be mistaken for effectiveness, formal compliance for quality, and the existence of evaluations for learning. Yet the absence of disruption does not demonstrate that problems have been resolved; it may simply mean that someone has managed to absorb their consequences.<\/p>\n

Institutional responsibility therefore begins before the final assessment of outcomes. It includes how warnings are received, how disagreements are handled, how recurring problems are communicated and how decisions can be reconsidered in the light of new information. It also requires recognition of the limits of the authority held by those who identify a failure, and of the responsibility borne by those with the capacity to change the conditions in which it occurs.<\/p>\n

An institution demonstrates capacity not only when it implements decisions consistently, but also when it can question assumptions, correct processes and incorporate experience into the way it operates. The decisive test is not whether knowledge of a failure exists. It is whether that knowledge can change the decision and the conditions that made the failure possible.<\/p>\n

An institution reveals its capacity not only in how it makes decisions, but in what it can change once it recognises that a decision was wrong.<\/p>\n","protected":false},"excerpt":{"rendered":"

Compliance Does Not Guarantee the Quality of a Decision Institutions do not fail only when they are unaware of a problem. They may fail when relevant information is available, when professionals recognise warning signs, or when an investigation identifies the causes of an event, yet the knowledge produced does not sufficiently alter the decision or […]<\/p>\n","protected":false},"author":3,"featured_media":1718,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"footnotes":""},"categories":[62,61],"tags":[],"autor":[42],"entrevistado":[],"local":[],"class_list":["post-1712","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-analises","category-analises-ensaios","autor-daniela-teixeira"],"yoast_head":"\nWhen the Warning Does Not Change the Decision.<\/title>\n<meta name=\"description\" content=\"How do institutions transform information into decisions? 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