Lean Thinking for Solving Systemic Problems

By Jon Miller Updated on June 8th, 2020

People are marching worldwide in protest of police violence. They are demanding wide-ranging changes to law enforcement and criminal justice. This is bringing the systemic problem of institutional racism into mainstream consciousness. Systemic problems persist not due to a lack of effort or concern but often due to misdirected efforts. Actions such as more training, additional oversight, or reallocation of funds to and from programs are rarely enough to address systemic problems. They require a different approach. What insights can Lean thinking offer for solving systemic problems?

What is a Systemic Problem?

Systemic problems are flaws, imperfections or issues that are ingrained or essential characteristics of an overall system. In other words, such problems are not due to specific, individual or isolated causes. Rather, they are the result of general background conditions of the system itself. They’re a feature, not a bug. Systemic problems require changes to the structure, organization or policies that govern the system. It’s no use trying to reduce user error when the software has been coded in such a way to crash under routine operating conditions. In the quality improvement world, we call such conditions common causes.

The Temptation of Special Causes

Even when recognize a problem as systemic, it’s easy to fall into the trap of addressing its superficial aspects. We may add technology safeguards, punish the bad apples, update policies or associated penalties, or audit adherence to the rules more carefully for a time. We want to find the bug in the system and fix it. This works up to a point. Sometimes we need to upgrade the whole system.

When problem solving, we use a fishbone diagram to identify the man, machine, material, method, and measurement factors. These are what are known as special causes. They are inputs to the process that fail unpredictably and intermittently. While they shouldn’t be ignored, when we focus problem-solving efforts on special causes, we leave common cause unexamined, systemic roots unaddressed.

Common Causes and System Performance

Common cause factors lead to failures even when the inputs of people, equipment, methods are perfectly adequate. There is random variation inherent in the performance of any system due to common cause factors. Because common causes are those factors that result from policies, norms, culture, and the broader environment, change requires action at the leadership level.

How much of the problems with a systemic are due to common cause variation and how much due to special cause variation? The rule of thumb is the 80/20 principle. In other words, for one special cause failure there are four common cause failures. For every police officer who commits a malicious act of violence against a civilian there may be four who hold no hate in their hearts but who stand by and allow it, simply going along with the norms of their system.

Common cause variation is a measure of a process’ potential to perform properly when special cause variation is removed. In other words, even if every violent racist was removed from the police force, it is not enough. The common causes conditions that generate these behaviors in otherwise well-intentioned people must also be removed.

Lean Principles for Facing Our Systemic Problems

Whether we are solving society-wide problems or issues within our own organization, here are a few Lean principles that help us when facing systemic problems.

Break down the problem. This is normally the second of eights steps in problem solving, after clarifying the problem and writing a concise problem statement. For some systemic problems, writing a clear and concise problem statement can be hard at first. Systemic problems by nature can be big and vague. It’s not rare to cycle through steps one through four of a few times between breaking down a big problem into its smaller components, rewriting a narrower problem statement, and setting an attainable target.

Visualize the whole system and its interactions. In any type of problem solving it’s tempting to zero in on solutions and get to work right away. When facing systemic problems, it’s more important than ever to grasp the overall scope. This is hard because it requires looking at the big picture, the detailed parts, and also their interactions. It may also require broadening our examining to include interactions with adjacent systems. When grappling with complexity, we have to resist our urge to settle on simple answers. The simplest solutions often come as a result the deeper look at an issue’s complexity.

Become the part and walk the process. When creating a map to visualize the system it’s useful to physically walk through the processes in question. For a healthcare problem, walk through it as if we were the patient. For delivery of goods, as if we were the product. If the process is justice, we may need to do this not only from the viewpoint of the police officer and the civilian but also the victim. Walking the process in these shoes helps us develop empathy for each person who experiences the process. This helps us to see the system as it is, rather than as we believe it to be.

Agree on the ideal state of the system. A good rule of thumb for business is that ideal processes deliver what the customer wants, when they want it, one at a time, at a low cost, right the first time, safely and so forth. These things are hard to argue with. They are not immediately achievable. But they provide a sort of True North reference point on the journey. This is nearly impossible to do if we are addressing it at the detail level of specific countermeasures to specific complaints. To avoid argument over details, we need to start with a high-level agreement on the outputs an ideal system would provide so that we can compare it to where we are and see the gaps.

Lean Approaches to Correcting Systemic Problems

There are a few Lean principles for taking corrective action once we have an understanding of the true picture of the current state, an ideal state and the gaps to close.

Build a model line. Piecemeal solutions very rarely fix systemic problems. But neither are all-at-once transformations likely to succeed. Time, attention, resources and support for improvements are all in limited supply. It’s best to concentrate resources, attention and efforts on building one or more small but shining examples of success. The model embodies as many of the “ideal state” notions as possible. These model areas become laboratories for rapid experimentation and learning. This allows us to correct failed ideas without too much expense or embarrassment, and to copy successes rapidly.

Empower the gemba. The people closest to the work often know best how to improve it. We need people to own the solutions, rather than feel owned by them. There is no room for blame when correcting systemic problems. Community members and the police officers must jointly develop solutions. Pushing big, top-down change is inherently slow. With changes at the top, policies may be reversed. Pulling small, local change is more likely to survive leadership changes. People are more likely to maintain and protect what they had a hand in building.

Start the 60% solution today. Try out simple, low-cost solutions immediately, even if they are only partial improvements. When demanding drastic changes to address systemic problems, we sometimes fall into the trap of waiting for the 100% solution. Such a thing rarely exists, and when it does it comes late and with a big price tag. If we can make a 60% improvement and make it stick, we can build on that.

We Shall Overcome, Some Day

Take a long-term perspective. Systemic problems take time to fix. This can be difficult to accept when painful systemic problems have been with us for so long. As with all systems and processes, they don’t stay fixed on their own. The gains we make today erode tomorrow, without upkeep. Conditions change, resulting in new special causes. We we raise our standards we may see new common causes and norms that need challenging. Correcting systemic flaws requires patience and persistence, a long-term perspective.  There is always room for improvement.

  1. James La Trobe-Bateman

    June 8, 2020 - 8:19 am

    The world needs all approaches to fixing these systemic problems. Like the way you put this from a lean angle. Well said and a clear way forward.

    • Jon Miller

      June 23, 2020 - 3:04 pm

      Amen to that.


    June 11, 2020 - 6:28 pm

    Appropriately explained. Illustrations and examples could further enrich the content further

    • Jon Miller

      June 23, 2020 - 3:04 pm

      Thanks for your suggestions Umaprasad. I’ll keep them in mind.

  3. Eric Budd

    June 23, 2020 - 1:29 pm

    “What would be the aim of the system?”was Deming’s response when asked to discuss improving education. He taught that without an aim there is no system. One of the significant challenges we face when working on systemic change is the multitude of aims that people have in mind when they begin work on changes aimed at improvement. This is why everyone doing their best is never enough. We must know what we are working towards and then do our best.

    • Jon Miller

      June 23, 2020 - 3:05 pm

      Good reminder Eric. Thank you

  4. Christopher R Chapman

    July 6, 2020 - 7:40 am

    To be frank, this is a very naive perspective. Social/political problems are not the same as those we encounter in an organization when trying to improve processes: They are inherently intractable and do not yield easily to efforts to “tame” them – they are, as Rittel and Webber observed, “wicked problems”.

    For example, the first difficulty we’d encounter would be agreeing on operational definitions of the problems we want to resolve, eg. What is the problem we’re trying to solve? What do solutions look like? How will we know when to stop?

    It’s even problematic to say, “Well, we’ll look for special causes of variation.” Oh? Define special cause /and/ variation in this domain. As Rittel & Webber observed, the domain quickly goes fractal because every wicked problem can be described as the symptom of other wicked problems.

    So what’s the way forward? Changing thinking in Industry, Government, and Education as Dr. Deming observed. Otherwise, you may as well try desalinating the ocean with a brita filter jug.

    • Jon Miller

      July 6, 2020 - 10:52 am

      Hello Christopher

      Thanks for your comment. I agree it would be naive to say “solve the entire problem at once”. This is not what I am saying. I espouse a form of practical problem solving that starts by 1) clarifying the problem, and 2) breaking down the problem, then 3) setting agreed targets for improvement based on #2, and only then 4) looking for root causes. Wicked problems are only wicked when we don’t break them down.

      Changing thinking across the wide swath of society as you describe is the very definition of boiling the ocean. While this is admirable and people should not stop trying to do so, addressing large, complex problems as a collection of small practical problems has led to progress in my experience. We can expose people to enlightened ideas but as long as incentives and other system elements remain, their behaviors will default to those the system rewards.

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