What worked at 15 people rarely works unchanged at 40. The team adapts informally. The official process drifts from reality. Eventually the workaround becomes the actual process.
When a new step requires more effort than the problem it prevents, people make a rational choice to skip it. Especially when nothing bad has happened yet.
Processes that are everyone's responsibility tend to become no one's. When something breaks, people fix the instance, not the pattern.
The goal is not a better-documented process. It is a process the team can actually follow without forcing it.
Starting from what people actually do, not what they are supposed to do. That is the baseline. Then improving from there.
Not a responsibility matrix. Just one person who knows when something goes wrong and has the standing to address it.
A simple check-in rhythm that keeps the official process close to reality, rather than a one-time redesign that starts to drift the next day.
If the same problem has been fixed more than once, or if new people take unusually long to become effective, that is usually worth looking at.
Start a Conversation