The Same Root, Five Times

When every root cause analysis terminates at the same point, you are either looking at a methodological artefact or a structural truth. In Modena, it was a structural truth.

DMAIC's third phase — Analyse — uses tools like the fishbone diagram to trace a problem back to its root cause. You start with the visible effect and ask "why" until you reach the structural origin.

In Modena, across five different problem domains — air quality, traffic, waste, housing, and public safety — every fishbone analysis ended at the same place: no institution had the mandate to optimise the whole system. Each department optimised its piece. The pieces did not add up. The gaps between them were where the damage lived.

The traffic system was fragmented across four departments. The health system across constitutional boundaries. The waste system between operator and regulator. The safety system split between three police forces with no integrated analysis. The water system required five institutions to approve a canal redesign — an engineer who could draw the solution in an hour spent twelve years and 127 emails trying to get it built.

Is that a finding about Modena, or is it a feature of the analytical method? If you use a tool designed to find root causes, perhaps it always finds one — and perhaps "governance fragmentation" is just a conveniently abstract place to stop drilling.

So you test it. If governance fragmentation is the real root cause, then cities that reduced it should show measurably better outcomes.

Copenhagen consolidated cycling, transit, and urban planning under a single mobility authority. Its car mode share dropped from 33% to 25% in fifteen years while Modena's held at 63%. Vienna integrated housing, vacancy activation, and social infrastructure under one entity. Its vacancy rate sits below 2%. Ljubljana merged waste collection, processing, and circular economy functions into a single municipal company. It went from landfilling 80% to landfilling less than 5% in a decade.

The convergence is not a methodological artefact. It is an empirical regularity — the same one that systems theorists from Donella Meadows to Elinor Ostrom identified: when complex problems span multiple institutional jurisdictions, fragmentation is not incidental to the failure. It is the failure.

The fifth discipline: follow the root cause even when it leads somewhere uncomfortable. Especially then.