Interesting read Mike. The fundamental logic, call it common sense, that is systems thinking is unfortunately far from common. Systemic change in an organisation starts with management thinking i.e. the assumptions that drive behavior (read:the system- the way the work works). Challenging and changing assumptions gives the whole systems perspective a very psychological aspect. Please allow me to recommend the book ‘Freedom from Command and Control- A better way to make the work work’ by John Seddon to get an initial idea of what quality by design in organisations look like.