ROI Case File No.263 | 'North American IT Company's Organizational Improvement'

Chapter One: Recurring Defects - The Limits of Treating Symptoms

The week following the resolution of Golden Wok Asia's 4P analysis case, a consultation arrived from North America regarding software development quality issues. Episode 263 of Volume 21 "Deepening Analysis" tells the story of pursuing the root causes hidden beneath surface phenomena.

"Detective, the same problems keep recurring. We fix bugs, but similar bugs appear again. We patch security holes, but vulnerabilities are found elsewhere. We're eternally playing whack-a-mole."

CodeStream Technologies' Quality Assurance Director, Sarah Chen from Seattle, visited 221B Baker Street with an exhausted expression. In her hands were extensive bug fix logs and reports of issues that, despite everything, wouldn't decrease.

"We develop enterprise SaaS platforms across North America. We have excellent engineers and employ the latest development methodologies. Yet quality issues simply won't improve."

CodeStream Technologies' Puzzling Vicious Cycle: - Founded: 2019 (Rapid-growth SaaS company) - Developer count: 180 - Client companies: 850 - Monthly bug reports: 320 (flat) - Emergency responses: Average 12 per month (late night/weekend work)

The numbers indicated chronic quality problems. Sarah's expression showed deep frustration.

"The problem is we're only addressing 'symptoms.' When bugs appear, we fix them. When vulnerabilities are found, we patch them. But we don't investigate why the bug was born or why the vulnerability was missed - we don't pursue root causes."

Chain of Symptom Treatment: - Problem: Login function bug → Response: Fixed relevant code - Problem: Payment processing error → Response: Added error handling - Problem: Database connection loss → Response: Implemented retry logic - Problem: Security hole discovered → Response: Fixed only that location - Result: Same type of problems recur elsewhere

"We're only fighting fires, not eliminating the source of the fires."

Chapter Two: Digging Deep with 5 Whys - The Power of Asking "Why" Five Times

"Ms. Chen, when problems occur, how is root cause analysis conducted?"

To my question, Sarah answered bitterly.

"Basically, we only identify the 'direct cause.' We end with surface-level causes like 'this code was bad' or 'this check was missed,' without touching the structural problems behind them. We don't have time."

Current Root Cause Analysis (Superficial):

Case: Customer Data Breach Incident - Occurrence: Authentication check missing in API, allowing other companies' data to be viewed - Cause analysis: "Engineer in charge forgot to implement authentication check" - Countermeasure: Added authentication check to relevant API - Result: Same problem recurred in different API after 2 months

I explained the importance of continuing to ask "why."

"'Forgot to implement' is not a cause - it's a phenomenon. Why did they forget? Why was it overlooked? By continuing to ask 'why' five times, the true cause becomes visible."

⬜️ ChatGPT | Catalyst of Concepts

"Eliminating symptoms doesn't cure the disease. Ask five times, dig to the root."

🟧 Claude | Alchemist of Narratives

"'Why' is a journey tracing roots deep underground. Looking only at the surface changes nothing."

🟦 Gemini | Compass of Reason

"5 Whys is the scalpel of causality. From surface to root cause, it reaches certainly."

The three members began their analysis. Gemini deployed the "Software Development-Specific 5 Whys Analysis" framework on the whiteboard.

5 Whys Principles: 1. Clearly describe the event 2. Repeat "why" at least 5 times 3. Don't blame people, question processes 4. Identify specific, measurable root causes 5. Take fundamental countermeasures against root causes

"Ms. Chen, let's dig down to the root causes of CodeStream's recurring problems using 5 Whys."

Chapter Three: Reaching the Root Cause - Five "Whys"

Phase 1: Practicing 5 Whys (1 month)

We applied 5 Whys to representative problems.

Case: Missing Authentication Check in API

Problem (What): API lacked authentication check implementation, resulting in customer data breach

Why 1: Why wasn't the authentication check implemented? → The engineer in charge forgot to implement it

Why 2: Why did they forget to implement it? → The implementation checklist didn't include an authentication check item

Why 3: Why wasn't it in the checklist? → The checklist was created 2 years ago and didn't reflect new security requirements

Why 4: Why wasn't the checklist updated? → No one was responsible for checklist management, so no one updated it

Why 5: Why was there no responsible person? → During rapid growth, engineers tripled but quality management process structure couldn't keep up

Root Cause: Quality management structure lagged behind organizational rapid growth

Difference from Symptom Treatment: - Surface countermeasure: Add authentication to relevant API (same problem recurs elsewhere) - Fundamental countermeasure: Establish quality management structure, establish checklist management process

Phase 2: Application to Multiple Problems (2 months)

We applied the same analysis to 20 major problems over the past 6 months. Common root causes emerged.

Root Cause Classification:

Root Cause 1: Process Absence (40%) - Vague code review standards - Test case creation methods not standardized - Pre-release checks dependent on individuals

Root Cause 2: Knowledge Concentration (30%) - Security expertise concentrated in a few engineers - No mechanism for technical transfer to new hires - Best practices not shared

Root Cause 3: Organizational Structure Deficiency (20%) - QA team not independent from development - Quality goals not established - No time secured for quality improvement activities

Root Cause 4: Technical Debt (10%) - Legacy code complexity - Insufficient test coverage - Documentation deficiency

Chapter Four: Implementing Solutions - Fundamental Countermeasures Against Root Causes

Phase 3: Implementing Fundamental Countermeasures (6 months)

We took systematic countermeasures against identified root causes.

Countermeasure 1: Process Establishment

Code Review Standards Codification: - Security checklist: 20 mandatory verification items - Performance checklist: 15 verification items - Review passing criteria: All items must be cleared - Result: Security bugs 45/month → 8/month (82% reduction)

Test Standards Establishment: - Unit test coverage: Minimum 80% required - Integration test scenarios: Standard templates created - E2E testing: 100% coverage of major flows - Result: Production bugs 120/month → 35/month (71% reduction)

Countermeasure 2: Knowledge Organization

Knowledge Sharing Mechanism: - Weekly technical sharing meetings: Share each team's learnings - Security study sessions: Held twice monthly - Code review record database: Past review points searchable - Result: Same-type bug recurrence rate 65% → 15%

Mentorship System: - Always assign senior engineer to new hires - Pair review all code for first 3 months - Visualize growth with technical skill matrix - Result: New-hire-caused bugs 28/month → 5/month (82% reduction)

Countermeasure 3: Organizational Structure Reconstruction

QA Independence: - Made QA team independent from development, placed directly under CTO - Granted release approval authority to QA team - Established right to refuse releases not meeting quality standards

Quality Goal Setting: - Monthly bug count: 320 → Under 80 - Emergency responses: 12/month → Under 3 - Customer satisfaction: 3.8 → Over 4.5

Results After 12 Months:

Dramatic Quality Metrics Improvement: - Monthly bug reports: 320 → 65 (80% reduction) - Emergency responses: 12/month → 1.5/month (87% reduction) - Security incidents: 8/year → 0 - Customer satisfaction: 3.8 → 4.7

Development Efficiency Improvement: - Bug fixing time: 35% of total development time → 12% - New feature development speed: +23% (due to reduced bug response) - Deploy frequency: Once/week → 3 times/day (enabled by quality improvement)

Business Results: - Customer churn rate: 18%/year → 6% - New contracts: +45% increase (improved quality reputation) - Engineer turnover: 25% → 8% (improved work environment from quality improvement)

Chapter Five: The Detective's 5 Whys Diagnosis - The Power of Questions

Holmes compiled the comprehensive analysis.

"Ms. Chen, the essence of 5 Whys is 'root cause pursuit.' Eliminating symptoms is easy, but that only repeats the same problems. By continuing to ask 'why' five times, you travel from surface phenomena to true causes. That courage and patience create fundamental improvement."

Final Report After 24 Months:

CodeStream Technologies transformed into a company boasting industry-top-level quality.

Final Results: - Monthly bugs: 320 → 25 (92% reduction) - Customer satisfaction: 3.8 → 4.9 (industry top) - Development productivity: 45% improvement - Market reputation: Established as "Most Reliable SaaS"

Sarah's letter contained profound insights:

"Through 5 Whys, we transformed from 'firefighters' to 'problem eliminators.' What mattered most was the stance of questioning processes, not blaming people. By continuously asking 'what's wrong' rather than 'whose fault,' the entire organization learned and grew. Now whenever problems occur, we see them as improvement opportunities."

The Detective's Perspective - Questions Illuminate Truth

That evening, I contemplated the essence of root cause analysis.

The true value of 5 Whys lies in its simplicity. Complex analysis methods can only be used by experts, but anyone can repeat "why" five times. However, few have the courage to truly repeat that simple question five times.

Don't be satisfied with surface causes - dig to the true cause. That patience becomes the power to fundamentally transform organizations.

"Questions are blades. They cut open surfaces and reach truth. Five questions strip away five layers of lies."

The next case will also depict the moment when deep analysis opens an organization's future.

"Continuing to ask 'why' is a journey to truth. Those who stop the journey midway will forever wander the surface." - From the Detective's Notes