Persistent business problems are rarely caused by one person, one tool, or one bad decision.

They usually come from a system that makes the wrong behavior easier than the right one.

• The workflow is unclear.
• Ownership is ambiguous.
• Knowledge lives in someone's head.
• The technology does not match the process.
• The scoreboard measures activity instead of results.
• Managers compensate for broken systems through personal effort.

Good operators make the system visible. Then they improve it.