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In small / medium companies, the many policies / processes are still often adhoc, and handled on case to case basis. This often leads to confusion and allegations of favoritism.
Often in such organizations, the owner / promoter wants to approve everything, and hence delegation is absent. This removes the power from the hands of the managers, thereby making them puppets to simply "execute" what they are directed to do. This can lead to lack of ownership, and lack of long term commitment. This often, is the single biggest impediment to rapid decision making and delegation of powers. This also leads to senior people becoming unsatisfied and quitting the organization too soon.
Often, the budgets are low, thereby one has very less freedom in organizing employee events, training events, and freedom to engage with consultants etc is severely curtailed. This again makes day to day life difficult.
Often their investments in good softwares / tools / ERP packages are low, and therefore it makes many things manual, and regular systems remain absent.
Small budgets place a lot of pressure on the quality of people one can get, and this again hinders quality of work.