Have you ever been in a situation where a decision in one area creates ripple effects far away? This is when a linear, “fix-the-symptom” approach to problem solving falls short. As organizations grow more complex, technology evolves, and teams become more interconnected, a different mindset is required.

This is where systems thinking comes in, which shows not just what is happening, but why, and how to design better outcomes by understanding the structures and behaviors beneath the surface. Let’s review the basics of systems thinking and provide some real-world examples to elaborate on how it can be implemented in any organization.

What Exactly Is a System?

A system is a collection of interconnected parts that together produce an outcome—often one we didn’t intend. In other words, when people, processes, policies, tools, and culture interact to create a result

Think of a hospital: clinicians, scheduling rules, medical record tools, and daily workflows collectively influence outcomes such as patient wait times, quality of care, and staff burnout.

Now swap the industry:

• In retail, staffing models, inventory systems, promotions, and customer behavior shape sales volume.
• In education, curriculum, testing schedules, funding, and teacher capacity determine equity gaps and graduation rates.
• In logistics, routing software, truck maintenance, weather, and driver incentives combine to influence on-time delivery.

The point is this: outcomes are rarely random—they’re produced by the system.

Why Your Organization Needs Systems Thinking

The strongest organizational problem solvers share a common trait: they zoom out before they zoom in. They look for patterns, not one-off events, and ask how culture, incentives, tools, and assumptions shape behavior.

There are three reasons systems thinking is essential to any organization:

1. Organizations are deeply interdependent.
   Decisions made in a single department can impact outcomes across the system. A hiring delay for nursing staff can increase patient wait times and lower satisfaction, and even small adjustments to shift schedules can influence staff fatigue, morale, and, ultimately, the quality of care delivered.
2. Feedback loops matter.
   A rushed software release creates bugs, which leads to customer complaints that need hotfixes and engineer burnout, and you guessed it…more bugs. Without a systems lens, leaders unintentionally reinforce the very problems they’re trying to solve.

Unintended consequences are everywhere.
A school district shortened lunch to maximize instruction time, only to discover a spike in afternoon behavioral issues due to hunger and fatigue.

Seeing Below the Waterline: The Iceberg Model

When leaders respond to problems, they typically react to what is immediately visible: events like a missed deadline, a spike in no-show appointments, or a frustrated email. While these events draw our attention, they are only the tip of the iceberg. Below the surface lie the:

1. Patterns that reveal whether an issue is recurring
2. Systems and structures that shape those patterns
3. Mental models—beliefs, assumptions, and norms—that hold the entire system in place

In a corporate setting, for example, a cycle of Monday-morning bottlenecks might not point to one employee’s disorganization. It may be caused by a system in which weekend inquiries accumulate because no clear process defines ownership of the inbox.

In healthcare, repeated delays in lab results might appear as isolated incidents, but a closer look could reveal a weekly trend tied to staffing schedules, which in turn stems from policies that were designed years earlier based on assumptions about workload and efficiency.

Another practical example comes from tech. Engineers may experience burnout repeatedly after major releases. At the event level, it’s a wave of exhaustion; at the pattern level, it’s predictable after every sprint. The systems level reveals the underlying issue: insufficient QA time and overloaded schedules. And at the mental model level, beliefs such as “speed is everything” or “we can fix bugs later” perpetuate the cycle.

By tracing events to patterns, patterns to structures, and structures to mental models, leaders can identify the roots of persistent challenges and design more durable, systemic solutions. With systems thinking, interventions become more strategic and effective by correcting the conditions that created the behavior in the first place.

The Inquisitive Approach: Root Cause Analysis

Many love the theory of systems thinking; however, in practice, conversations quickly become abstract. Teams nod along, and then they jump back into symptom-fixing.

Tools—simple, structured, visual—bridge the gap between theory and action. One tool that can help with  root cause analysis is known as “the 5 Whys.”

The “5 Whys” is simple, yet deceptively effective—if teams avoid blaming individuals and instead dig into underlying structures. The process is straightforward: ask the question “Why?” until the most basic cause is uncovered. This typically takes around five iterations of asking why, which is where the name comes from.

Here’s an example:

The Problem: Deteriorating stonework threatening the Lincoln Memorial’s integrity and visitor experience.

1. Why is the stone deteriorating? Because we wash it every two weeks.
2. Why are we washing every two weeks? Because of the bird droppings.
3. Why are there so many birds? They come to feed on the spiders.
4. Why are there so many spiders? The lights at night attract billions of insects.
5. Why do we shine lights on the memorial? To attract tourists who spend money in the city.

One Solution: Let’s turn the lights on later and off earlier.

Here’s a scenario from the corporate world:

The Problem: Customer support tickets keep increasing.

1. Why are there more customer support tickets? Because customers can’t find answers on the website.
2. Why can’t customers find the answers they need? The FAQ is outdated.
3. Why is the FAQ outdated? Product changes aren’t communicated.
4. Why aren’t product changes being communicated? There is no workflow between product and marketing.
5. Why is there no workflow between product and marketing? Each team assumes the other will handle updates.

One Solution: Create a clear update workflow instead of hiring more support staff.

Bringing It All Together: Four Questions to Shift Any System

When facing a problem, ask these four questions:

1. Events: What’s happening right now?
2. Patterns: Is this recurring?
3. Systems/Structures: What’s driving the pattern?
4. Mental Models: What beliefs maintain the system?

Ask them consistently and go from firefighting to redesigning.