The No. 1 Root Cause
Let’s call the participant Andy. Andy is going to start a shirt factory. I sketch out on a flipchart how Andy is going to set up his company based on well-established practices (Figure 4.1). Andy is the boss and he decides that there will be a department for designing shirts, and he is hiring four designers. He also wants a head of design reporting to him. I draw this with Xs as illustrated in Figure 4.1. Then, he’s going to hire some cloth cutters, so I put four more employees under the cloth-cutting department, and then a department of sleeve attachers, and a department of assemblers who sew the shirts. Andy has now structured a 4 × 4 matrix, and he is ready to go. Then, the first customer buys a shirt and guess what? The first shirt out of Andy’s factory is poorly made. Its collar is poorly attached, some buttons are missing, and the cloth easily rips after the first wash. Andy promises to fix things. Now, if you go back to your fifthgrade math, that 4 × 4 matrix structure built by Andy has 64 boundaries,
or 64 interfaces among 16 employees in 4 departments where liabilities can occur, 64 areas of white space. Andy needs to look at those 64 opportunities to determine the root cause (Figure 4.2).