A “bunch of guys sitting around and talking”. This is not just a common occurrence in everyday life; this is an important business phenomenon. It is not enough for leaders to act as cogs in a machine; they need to perform a valuable, useful service that benefits the organization as a whole. Reed, the director of Command and Leadership Studies at the United States Army War College in Carlisle and the person that coined the term “BOGSAT”, reiterates that systems are created by people; therefore, systems can fail if not maintained properly (2006). This regularly happens in the field of pharmacy when numerous committees, with good intentions, try to identify problems, but they fail to rectify the issues by implementing the necessary change. Reed also identified a common issue of many managers, where their own urgency displaces importance. Many pressures are placed on managers by multiple functional areas; these stressors often negatively affect management. The stressors take precedent over the immediate change that needs to happen in order to maintain basic daily operations.
Senge believes that organizations should not focus on making mistakes (1990). At the pharmacy, everything is date, time, and name stamped. If anyone makes a mistake, they were called out in a meeting by upper management and asked to identify what went wrong. This was good because it identifies the mistake, but at the same time, it shames the person that made the mistake. This does not make people feel comfortable and it does not foster a learning environment. This correlates with Senge’s concept of “the top leads and the local act”. Employees need to feel like they are a part of an organization. They need to feel like their thoughts count and that their talents are utilized appropriately. Pharmacies and other healthcare settings typically have a culture where the practitioner “knows all”.