The Root Cause

Rethink Your Approach To Solving Stubborn Enterprise-Wide Problems

Who IS The Enemy?

Who is “HE” in the Pogo cartoon?

                HE is the enemy!
HE is an opposing force that makes the simple difficult and the difficult seemingly impossible.

            Where does HE make his presence most frequently known?
At the cutting edge; right there at the interface between your front line people and the public at large―your buyers, vendors, suppliers, regulators, and the media.

            This is what THEY like to label as Human Error; but is it?
That depends entirely on your definition of the term, as either:

  • Humans making mistakes
  • A symptom of a failing system

Humans Making Mistakes

            All unintended and unwanted results―mistakes―are generated by the exact same business system that generates the intended and wanted results. Moreover, Dr. W. Edwards Deming concluded that only some six percent of all outcomes—both (un)intended and (un)wanted results—are directly attributable to an individual or a group of people.

Symptom of a Failing System

            Dr. W. Edwards Deming said that 94 percent of all results are systemic in nature, which means they are inherent to the business system’s design, organization or structure, implementation or operation, maintenance, and management.

Also, a Dutch study into marine incidents—accidents and near-misses—found that:

  • Seventy-five to 96 percent of all marine incidents involve human error.
  • Each incident has 7 to 58 distinct causes.
  • Fifty percent of those incidents have at least 23 causes.
  • Each incident involves two or more people, each making two mistakes.

            British psychologist James Reason—author of a seminal study of human error—describes human error as a chain reaction. Fortunately, many incidents of human error never result in a full-blown accident because a single link in the chain reaction was thwarted, thus preventing the entire chain reaction from running its course. Such incidents are called near misses. The Dutch study into marine incidents found there were 600 near misses for every accident.

Who IS the Enemy?

            The enemy of business performance is systemic problems. And, given the statistics, we must conclude that employees are NOT the force opposing business performance, as they are so often made out to be.

            Regular employees can hardly be held responsible for systemic problems BECAUSE they have NO authority to change the system. Rather, employees are set-up to fail when their work environment is plagued with systemic problems.

            Then, who has ultimate authority to change the system—solve systemic problems—and therefore carries ultimate responsibility for success AND failure? Right, executives; the verb―to execute―is even in their title!

Better Executive Development

            Researching academic programs of executive development, I notice a heavy emphasis on finance and leadership. Yet, finance and leadership are just the faucet; NOT the water. Water is UNDERSATNDING the work flow passing through every business function and all processes, including finance and leadership. And, better flow translates into better business performance. Executives need to UNDERSTAND how a business functions as a singular, unique, integrated, and open SYSTEM.

            Focusing students’ minds on single silos of specialized knowledge―such as finance and leadership―inhibits perception of business as an organic whole. Attempts at understanding a system perceived through the lens of one of its component parts only leads to confusion and disorder. Does anyone need me to provide examples? Follow the news!

            What do executives—people with ULTIMATE authority to change work flow, and thus ULTIMATE responsibility for success and failure—actually learn to DO to reduce or eliminate the forces opposing business performance???

            Why are executives perplexed and bewildered by business system complexity? Why are they overwhelmed when systemic problems disrupt system integrity?

            Because I believe that executive education is failing current and future executives, I wrote the book The Root Cause: Rethink You Approach To Solving Stubborn Enterprise-Wide Problems, published by McGraw Hill. You can take a peek inside Here or go to the book’s dedicated site Here.

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