How To Use Jeff Bezos' 5 Whys Technique To Find Root Causes In Your Clinic


Identifying and addressing the root cause is where you can make changes in outcomes as a business leader.

Pate Abilla is a a process guru, and I've added his post here on how Jeff Bezos uses a simple technique called "5 Why's" to find the root cause of a problem.

What is it that really sets Amazon apart from everyone else. I obviously don't know the definitive answer to that, but I can draw on some experience being an early employee at Amazon. 

I want to especially point to one experience that might, perhaps, demonstrate the way we were taught to think at Amazon.

The Conveyor Belt Accident

Back in 2004, I was part of rotational program at Amazon and at this particular time, I was in one of Amazon's massive fulfillment centers. During Q4, Jeff Bezos takes the time to visit several fulfillment centers to see how things are going and to lend a hand.

In a meeting with the senior team of which I was a part, we discussed metrics for that Q4. One of the metrics is related to safety. It was at this time the safety manager explained one of the accidents during that year at the fulfillment center. 

An associate had damaged his finger on a conveyor belt.

I immediately noticed Jeff Bezos' demeanor change from one of excitement because of the busy-ness of Q4 to one of serious concern.

Then he got up and went to the whiteboard. He then began to facilitate the following discussion:

Demonstration of 5 Whys by Jeff Bezos

Bezos wrote on the whiteboard the following and took us through an exercise right then and there (this is from memory).

  1. Question: Why did the associate damage his thumb?
    Answer: Because his thumb got caught in the conveyor.

  2. Question: Why did his thumb get caught in the conveyor?
    Answer: Because he was chasing his bag, which was on a running conveyor belt.

  3. Question: Why did he chase his bag?
    Answer: Because he placed his bag on the conveyor, but it then turned-on by surprise

  4. Question: Why was his bag on the conveyor?
    Answer: Because he used the conveyor as a table

Conclusion: So, the likely root cause of the associate’s damaged thumb is that he simply needed a table, there wasn’t one around, so he used a conveyor as a table. 

Countermeasure: To eliminate further safety incidences, we need to provide tables at the appropriate stations or provide portable, light tables for the associates to use, or place maintenance bags on the floor.

There are several things amazing about this experience:

  1. Jeff Bezos cared enough about an hourly associate and his family to spend time discussing his situation.

  2. Jeff properly facilitated the 5-why exercise to arrive at a root cause: he did not blame people or groups — no finger pointing.

  3. He involved a large group of stakeholders, demonstrated by example, and arrived at a root cause and he didn’t focus on symptoms of the problem.

  4. He is the founder and CEO of, yet he got involved in the dirt and sweat of his employees’ situation.

  5. In that simple moment, he taught all of us to focus on root causes — quickly. He did not heavily rely on data or over-analysis of the situation, and yet he was spot-on in identifying the root causes of the safety incident.


Remember, this was back in 2004. If the CEO can think this way, then clearly the entire company can. While Amazon isn't perfect in any way and Bezos isn't necessarily the poster boy for effective leadership, this particular situation is a really great example of how leaders can behave and how they can demonstrate clear thinking and quick problem solving.

If I were to point at one thing that sets Amazon apart, it's how their people think. And how they think is heavily influenced by Bezos and his example.