Most leaders can point to a dashboard full of strong departmental KPIs and still feel a quiet discomfort: the business is busy, talented people are working hard, and customers still experience friction.
The mismatch is usually structural.
Here, we describe a pattern we have seen in corporate roles and client work: teams optimise locally, handovers fail quietly, and leadership decisions slow down because visibility is weak. The result looks like “execution problems” on the surface, but the cause is usually misalignment across people, process, and systems.
This is the belief that if each department hits its own targets, the organisation will thrive.
What happened before: improving e-commerce picking productivity created downstream pressure, increased damage, and worsened customer experience. The metric improved. The system degraded.
This is a known risk in measurement: when a measure becomes a target, it can distort behaviour and reduce the value of the measure. This is often summarised as Goodhart’s Law.
Most customer journeys are built from transitions: lead to sales, sales to onboarding, onboarding to delivery, delivery to support. Those are the points where businesses drop context, repeat work, and create delays.
Another example of this is a handover experience from a former client: an executive search firm collecting the same information three times. This is a classic handover failure: the customer experiences it as disorganisation, and the business experiences it as waste.
Handover breakdowns are well evidenced in other high-stakes environments like healthcare, where communication failures during handoffs are linked to errors and adverse outcomes. The domain is different, but the mechanism is the same: information loss, ambiguity, and inconsistent execution.
Leaders often cannot answer basic questions with confidence:
When executives do not trust the numbers, decisions slow down and meetings become debates over whose spreadsheet is correct.
This is where “shadow systems” appear: spreadsheets and side tools created to fill gaps left by disconnected systems. Research on shadow systems and shadow IT shows how often they emerge alongside ERPs and how they create data inconsistencies and control issues over time.
What starts as process friction often ends as culture friction.
When processes are hard to follow or systems do not support the work, people adapt:
There is solid research on workaround behaviour when information systems do not support employees’ tasks adequately, including how policy and attitudes interact with these workarounds.
Over time, the organisation normalises the workaround and then defends it. That is how operational issues become “how we do things here.”
We recommend two practical lenses:
The Five Whys is a simple root-cause technique popularised through Toyota’s problem-solving culture, often attributed to Taiichi Ohno’s description of repeatedly asking “why” to reach underlying causes.
It works best when it is applied to a specific, observable problem and the answers are grounded in evidence, not opinion.
If you map a process and only optimise what happens inside departments, you miss the highest-friction zones. Handover points are frequently where information, accountability, and customer experience degrade.
A reliable question in workshops is: “Where does work slow down, and where do you feel the most frustration? "That is usually where value leaks.
Remove steps before improving them.
A practical sequence looks like:
This matters because automation can scale confusion just as easily as it scales efficiency.
People think transformation is a technology project. Transformation is interconnected work, with everyone involved. Questions to ask:
The “Making Toast” exercise is intentionally simple: draw the process step-by-step using visuals, one step per sticky note, with multiple people mapping independently.
The value is not the drawings. The value is what becomes obvious:
It is a quick method for surfacing variance before investing in tools and change programmes.
Operational excellence is not achieved by making one department brilliant. It is achieved by getting the system to behave as one system.
KPIs still matter. They create focus and accountability. The shift is designing them to reinforce the customer journey and shared outcomes, so local wins do not create global damage.