The System is a Whole
So, what does this mean?
Although we are accustomed to having a checklist for everything, the problem is that the checklist will keep you thinking that each element has a separate and distinct impact on outcomes. It does, but it's more complex than that. This means some elements are very much tacit (in the background), and can be unspoken knowledge that is not being considered in decision making.
We could call it culture but but this word leads us to think about people without understanding it is the atmosphere filled with people, artefacts, technology, and social norms that is getting you the performance you see.