“In our highly disjointed world at VeraComm, where functions don’t communicate well and don’t significantly collaborate, we fail to improve as a whole. Everybody seeks opportunities for improvement, but because we’re separated from each other, the best we can do is improve our individual step in the process and no more. We fail to understand that problems at one step can be caused by fundamental issues at another. And with learning cycles as slow as ours–pretty much equal to the frequency of releasing, every eight or ten months–we just can’t learn. Cause and effect are so widely separated from each other on the timeline that we simply cannot connect the dots. •”