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Your purpose is to identify where in the process things go wrong, not who messed up. Look for systemic causes, not culprits.
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the system that people work in and the interaction with people may account for 90 or 95 percent of performance.
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If I were to command a general to turn into a seagull, and if the general did not obey, that would not be the general's fault. It would be mine.
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