standardizing work steps (which is where actions often seem to culminate). By the end, however, the need for a more complex, entirely different solution might become clear. Rather than focusing on intuitive answers such as shortening travel distances or eliminating steps where waste is most visible, greater scrutiny shows that creating lasting, more meaningful solutions comes from looking farther and deeper toward upstream challenges, organizational and information disconnects, or other sources of lag that cause disruption to accumulate.