“I thought we had it fixed,” Luke shook his head. “We had a problem. We solved the problem. We implemented the fix. But, the fix caused two other problems.”

“It’s always something,” I smiled. “What did you just learn?”

“I learned that the steps in our process are not just a sequence of things one after another. The steps have an order, but each step has an impact on things around it.”

“And?” I asked.

“Two things,” Luke replied. “Each step has an impact on the work flow with what immediately precedes and comes after. But, a step might have an impact on something far away, that you cannot see or that you might not connect.”

“So, how do you most effectively make a change in your system?” I wanted to know.

“Obviously, our attention is riveted to the immediate area, but we also have to widen our picture to include the whole system and have metrics at key points that let us see unintended consequences.”