The Two Root Causes of Everything?


One thing I have enjoyed in the past few years is meeting and working with more people with direct experience working at Toyota (including here in San Antonio, my new home).

There are always gems and brilliant nuggets that come out of those chats. One I heard recently that make me chuckle and really think:

“My Japanese sensei said every problem had one of two causes: no management or bad management.”

The picture of the two turkeys is tongue in cheek (referencing Jack Welch and his comment about employees being “turkeys.“) Welch seemed insulting and dismissive. My Toyota friend was respectful in retelling the sensei's assessment.

It's not that managers are turkeys. We're talking about bad management practices or the lack of a management system. Much as we shouldn't blame frontline staff for being a part of a bad system, we should be careful about blaming individual managers for the beliefs and mental models that were taught to them. Now, some managers might just behave in odious ways – we might blame them for their behavior… or we can look for a deeper root cause.

The Toyota comment about “no management or bad management” reminds me of a quote from Gary Convis, a former high-ranking Toyota executive, when he said:

“You respect people… you listen to them, you work together. You don't blame them. Maybe the process was not set up well, so it was easy to make a mistake.”

This reminds me of Dr. Deming's view that quality starts at the top. Management owns the system and if the system is responsible for 94% of all errors… we can't blame frontline workers or call them “turkeys” — we need to improve the system. And that includes the way we manage, starting from the CEO on down.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. The problem with Toyota is that their contemporary management believes if they ignore an issue then the problems do not exist. This is especially true of the company’s performance on undercarriage corrosion which has been an issue since the 1980s. I still cannot believe that our late model Rav4 is being recalled due to suspension parts that can break due to corrosion. This is an issue which has been conquered by the Big 3 automakers 25 years ago, yet Toyota is still being nagged by this issue. Considering this is our car’s fourth recall (and the issue with the door panel switches has still not been addresses), I have lost total faith in “Toyota Quality.” This car’s quality feels more like that of an early 90’s American car instead of a late naughties vehicle.

  2. Your post speaks directly to the VSM ad I am running this week (7/28/2012) on LeanBlog! It highlights that in Lean, managers are not considered to be value-adders, and they can easily mess things up through their actions or inactions.

  3. Managers are people to and the Respect for People principle includes them. A point which I’m glad you make Mark. They work in a management system which has problems and which can be improved. Key as in everythng is to involve them and have them be part of the problem solving.

  4. Over 80 percent of first pass lean improvements in my organization have been to develop standards where none have existed before. I am sure we are typical of most.

    I am also sure that most CEOs have a higher awareness of standards for public restroom cleaning frequency than for most types of patient care. Too bad Ray Kroc chose hamburgers instead of hospitals.

  5. The purpose to focus on improving the system is that is the most effective way to improve results. It is also true blaming people can damage the system in many ways (even if say you had something were blame or something else were reasonably valid). Some people get thrown by thinking this “respect for people” goes too far when bad behavior doesn’t get blamed on the person doing the bad behavior. There are several things going on. First when you look systemically you often see that the system is encouraging the bad behavior. And even if not, the most effective way to improve is not to blame, it is to improve the system (focus on fixing causes not symptoms).

    • “… the system is encouraging the bad behavior…”

      Such as the current Olympic games, with the badminton players throwing matches to get a better paths toward the medal round. It’s poor sportsmanship and poor ethics, but I can understand the players being tempted to do that. The fact that more than one team saw the opportunity to do that tells me it’s a system problem… who designed that system of competition? Why wasn’t it just a double elimination tournament, so you have the incentive to win every match?

      “The Goal Is Winning Gold, Not Winning Every Match”

      Where exactly did the badminton players veer off into corruption?

      They did not organize the tournament. They did not arrange the draw.

      They simply looked at the information that was presented to them, looked at their ultimate goal and went in the direction that seemed to have the best chance of leading them there. A loss in those matches, they decided, would give them a better path to winning a medal. How is this different from, say, a swimmer who coasts to the wall in a preliminary heat or a runner who jogs past the finish line in a semifinal to conserve energy for the final? Is it even that much different from a baseball player bunting?

      • I must admit I didn’t see the badminton and my first response is that seems lame. Did they break any rules and doing anything really dishonest, it doesn’t seem like it. For example, you know those bike races where they roll around the sloped track – the competitors don’t try to go fast, they try to setup the right conditions (they practically stop sometimes).

        Then I read a bit more and maybe it was justified (I guess refs even interrupted the play to say – quit that… the fans were booing…). But yeah setting up the rules the way they did was crazy. It shouldn’t be you create an incentive to do worse in one game in order to do better overall.

        Setting up the rules to make someone looking at the best system outcome will come from sub-optimizing how I play in this game isn’t great.

        to a much much less degree other competitors have to sub-optimize current games to see the big picture (swimmers and track athletes have to swim fast enough to make the next round but not tire themselves out). Granted those swimmers don’t benefit from losing. But they benefit from not trying their hardest at all times.

        That situation with the gymnast also could be risky. Only 2 on a team are allowed to compete for the overall individual. The best USA person (I guess) was beat out they came in 4th overall but 3rd on the USA in qualifying. It would be hard for an individual to give up, but I can imagine it would happen if #3 of the team did great but knew they didn’t have a shot really (in the finals) and the country superstar hero was going to be shut out by them doing well in the last event… Hard for the USA to image, I think, but for perspective in the USA, say if Michael Jordan would be denied a chance, the pressure on #3 to let Michael go through would be significant.

  6. Great example Mark. I need to file that one away. I believe the healthcare organizations that have done the best with lean scuttled their “management by objective” type of incentives early on.

  7. Hi All

    Mark thanks for sharing the thoughts and comments.

    Firstly we all know that bad behaviour regardless of who does it has to be dealt with, or inreality you do not respect people because you allowed someone to show disrespect to others.

    Bad management and no management are big problems we face to today in business. And there is someone to blame anyone the owns part of any business. Owners are the top of the organizational pile. Bad systems, bad management, no management, unethical behaviour, backstabbing, etc. are all symptoms of bad ownership. There are two types of bad owners, those that foster the wrong type of systems and behaviour, because they want short term results and they do not care how they are obtained, or how much damage they cause. The second are the lazy we own it, but we do not care to be active in running it owners they hire and over compensate executives to deliver short-term results. The unfortunate part is that many of us fall into that second category, because we actively trade stock or mutual funds and all we look for is the rate of return over that last hour, day, week, month, or quarter.

    Until owners demand something more than a set of financial statements from their executives and board members (namely a long-term growth plan), we won’t change what is wrong. The key advantage of Toyota, Honda, Hyundai, LG, Samsung, and any Buffet owned enterprise is dominate ownwership that is more interested in the future than they are in the quarter or even the current year. You cannot fix most problems when they are driven, by an ownership system that is flawed and demands all the wrong things.

  8. Hi Mark

    Good topic. My guess is that what the Toyota person (if they were Japanese) meant by “management” was not “managers” but “the act of managing”. In other words “bad management” means poor process of setting and improving from standards, and “no management” mean no standards. If the management team irrationally refused to set or maintain standards it could mean “bad managers” but this is s true rarity.

    The other key insight from Toyota is that there is almost always more than one root cause. Multiple countermeasures should be taken at the lowest (root cause) levels, as experiments and not permanent solutions, because most problems arise from a complex mix of factors.

    • Yes, it was clear he meant “management” (actions and practices) – or else he would have said “managers” (the people).

      But, I could see where people would personalize the statement and think they were being blamed as individuals.

      Even managers work in a system.


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