Hi Reader,
Leadership teams pride themselves on being problem solvers. It is one of the reasons they exist. But even the strongest teams struggle with something far more foundational: accurately identifying what their real problems are in the first place.
From our experience working with hundreds of executive teams, we’d argue that most teams do not have a problem-solving problem. They have a problem-diagnosis problem.
And when teams misdiagnose the cause, they unintentionally revisit the same problems over and over, making improvements on the margins, but rarely truly solve the actual problem.
Few real-world events illustrate this better than the UK Post Office Horizon scandal, a devastating example of what happens when leaders get the cause wrong. The story is tragic, but the lesson is incredibly practical for leadership teams today.
A Cautionary Case Study: The UK Post Office Horizon Scandal
In her book Blindspotting, Kristin Ferguson highlights the story of the UK Post Office Scandal. For nearly twenty years, the UK Post Office believed a troubling narrative. Sub-postmasters across the country appeared to be losing money from their branches. The organization saw deficits and assumed fraud or theft. Hundreds of workers were accused of criminal behavior. Many were fired. Some went to prison. Dozens of lives were shattered.
There was only one problem. None of it was true.
The losses were caused by Horizon, a faulty IT system riddled with errors. The technology was malfunctioning, but leadership clung to a belief that the system could not be wrong. They trusted the software and distrusted the people.
Instead of investigating the system, they investigated the individuals. Instead of asking what might be causing these discrepancies, they asked who was to blame. This was attribution bias at its worst. A tragic example of leaders assuming human failure when the real failure was its systems.
The Lesson: Most Recurring Problems Are System Problems
And while most leadership teams will never face stakes as catastrophic as the UK Post Office scandal, they are still at risk of making similar mistakes on a smaller scale every week. When a problem keeps returning, it is almost never just about someone’s character, effort, or competence. It is rarely as simple as someone “not getting it” or “not being a culture fit.” Sure, that could be a part of it, but if leaders stop their analysis there, they are nearly guaranteed to see the same symptoms emerge later.
Recurring problems almost always indicate that something in the system isn’t working as it should. But just like the Post Office, leadership teams rarely stop to consider the role the systems people are working within are impacting the results.
This is exactly what Dan Heath describes in Upstream. We become fixated on the visible pain points rather than the invisible structures causing them. This is also what we describe in chapter one of At the Heart of Work. In nearly every significant recurring problem organizations face, it's both systems and people that are playing a role. The key shift is to begin moving upstream to better understand the role each are playing. Only then can you begin to solve them.
Why Teams Miss the Real Cause
1. Attribution Bias
When something goes wrong, people are the easiest thing to see. Leaders instinctively blame attitude, effort, or motivation instead of asking what expectations, incentives, or gaps in clarity shaped the behavior. It feels quicker to point to a person than examine the system, which almost always leads to misdiagnosis.
2. Systems Can Be Elusive
Most systems live in routines, workflows, and unspoken norms, which makes them seem invisible. When issues surface, teams focus on the visible moment or individual, usually not the underlying systems. The system shapes behavior daily, but because it hides in plain sight, it often goes unexamined.
3. The System Feels Fixed
Even when leaders notice a structural issue, they often assume it is too entrenched to change. Longstanding processes feel immovable, so teams accept them as “how things work around here.” That belief keeps recurring problems firmly in place.
4. A Firefighting Culture
When teams operate in constant urgency, they react to symptoms rather than explore causes. Things get patched, not understood. The system remains untouched, guaranteeing the problem returns. The pace of firefighting prevents upstream thinking.
5. It Requires Us to Face Our Role
Going upstream often reveals that leadership contributed to the problem, through missing clarity, inconsistent expectations, or undefined processes. That level of introspection is uncomfortable, so teams avoid it. But without it, blind spots stay hidden and issues persist.
How to Reduce Your Team’s Blind Spots
If you want your team to consistently identify the real causes of recurring problems, you cannot rely on instinct alone. You need agreements and rhythms that deliberately create space for upstream thinking. As you embrace these agreements, bring the At the Heart norm to each one to help you move upstream. Anyone on the team can ask, “What’s at the heart of this issue? Is it a people or systems issue, or perhaps both?”
Agreement 1: Our weekly leadership team meeting will always save space to explore causes of recurring issues.
Any member of the team should feel empowered to name a recurring problem that deserves deeper exploration. When everyone knows this space exists, leaders do not wait for the “right” moment or assume someone else will raise the concern. They surface patterns early, while the signals are still small and manageable.
This agreement shifts the culture from reactive to reflective. It ensures the team is not only reviewing updates but also studying the underlying forces that produce those updates.
Agreement 2: We will regularly step back for a deeper retrospective to understand our most significant recurring problems.
Whether monthly or quarterly, leadership teams need intentional time to pause, zoom out, and examine the challenges that persist. This is not optional. Without structured step-back time, teams stay trapped in firefighting mode. They solve symptoms instead of causes.
A deeper retrospective creates the breathing room leaders need to examine patterns, evaluate assumptions, and connect issues across the organization that may share a common root.
These agreements create the foundation for diagnosing accurately. Once they are in place, teams can use two natural settings to practice upstream thinking.
Agreement 3: Propose and Experiment.
To overcome the forces of the “System Feels Fixed” and the “Systems Feels Elusive,” teams can propose experiments for new ways of working. The great thing about treating them as experiments is that you can always adjust based on what you learn.
Treating changes as experiments reinforces the idea that learning and improvement is what you are after. It also helps to quell the concerns of people that might feel resistant to making the change, because you can always adjust it based on what you learn.
1. Use Your Weekly Leadership Team Meeting
During your open discussion block, identify emerging issues that keep returning. Then slow the conversation down long enough to explore upstream questions:
- What exactly is the problem we are seeing?
- What pattern is emerging across weeks or months?
- What assumptions are we making about the cause?
- What system, expectation, or structure might be reinforcing this issue?
- What information or clarity might be missing for the people closest to the issue?
Even ten to fifteen minutes spent reframing the problem upstream can prevent months of downstream rework.
2. Use Your Quarterly Sync for Deep Diagnostic Work
Your Quarterly Sync is the perfect environment for deeper investigation. Step back and ask:
- What problem keeps returning, regardless of who is involved?
- What have we tried, and why has it not worked?
- What system or rhythm might be unintentionally producing this result?
- What expectations or incentives might be misaligned?
- What upstream intervention would make this problem less likely to happen again?
Quarterly Syncs provide the perspective leadership teams need. They help you see connections, break old cycles, and redesign the structures that are shaping behavior.
Closing Thought
The UK Post Office scandal is a heartbreaking reminder of what happens when leaders trust their assumptions more than the people experiencing the problem. Most leadership teams will never face consequences that severe. But every team faces the risk of searching in the wrong place for the wrong cause.
Your recurring problems are not evidence of failure. They are signals. Signals that something in the system needs to be seen and understood. Blind spots shrink when teams slow down, question their assumptions, and use their collective wisdom to see more clearly.
-Shaun & Joe
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