This document discusses how change initiatives often focus on superficial improvements rather than addressing root causes. It notes that after a royal visit, signs and infrastructure along the route were temporarily improved but have since deteriorated. Similarly, many continuous improvement efforts paint "just the outside of the process" rather than fixing underlying problems. This allows old practices to return over time. The document identifies two reasons for this: 1) the culture was never truly changed, and 2) the root causes were never identified and addressed. It argues that finding root causes requires investigating "why" things are done and may necessitate cultural shifts within teams. Superficial changes alone will not create sustainable benefits.