From little things big things grow.

Systems – can’t live with them; can’t live without them.

“Everything must be made as simple as possible. But not simpler.”
― Albert Einstein


My day is organised and managed in accordance with a careful plan – I have a system. The underpinnings of this system have been more or less the same for a while now.
And in one or more respects this system always fails.

Lord Darzi said in his ISQua Global Leader Lecture in May this year that from the time he awoke on the morning of the Lecture to the time he stood to deliver it he had made perhaps half a dozen errors, no doubt despite the fact he had a plan, a system in mind for the day. All were minor, none was fatal but somehow the plan was imperfect (although it may have been as good as it could have been). We all experience this all the time.

But are these our failures or has ‘the system let us down’?

In thinking about this BLOG I scribbled down the following words late one night….:
‘All systems failure is human failure – why? – because people design the systems’

This seemed so blindingly obvious and simple (simplistic as it turned out) that I immediately assumed it was a well held and oft recited view and that I had read it somewhere and it had just percolated from my sub conscious to my conscious being. But GOOGLE all I like and I could not find a quote along these lines. So, if it is not a universal veritas then perhaps it is not so (mind you, it is well to remember that, in Roman mythology, Veritas, who was the goddess of truth, a daughter of Saturn and the mother of Virtue, hid in the bottom of a holy well because she was so elusive).

So, let’s see what we can find out….

SYSTEM………the word is so widely applied and misapplied it can mean almost anything that has more than one component to it. I have lamented the misuse of words, labels and ideas in my BLOG in the past, for example, ‘tipping point’, and system is one of the most misapplied I can think of.

I considered the definition ‘A group of interacting, interrelated or interdependent elements forming a complex whole’  . This does not convey the dynamism of systems sufficiently for me.

I like even less…….  ‘A condition of harmonious, orderly action’.   Really!? Harmonious and orderly?  Some maybe.

So, I have decided to craft my own definition……….. ‘A collection of stable and dynamic elements, and tools, coordinated and managed by a process, seeking to achieve a predetermined outcome’.

So what might be a ‘health system’? That is how do we APPLY HEALTH? How do we make health happen?

Donabedien talked about ‘structure, process, outcome’.

But you and I have seen the breakdown of systems often enough to recognise their complexity. Elements act independently of the system and the system impinges on the elements within it and those bombarding it from without so the whole thing gets thrown out of whack.
‘Every intervention from the simplest to the most complex has an effect on the overall system and the overall system has an effect on every intervention.’  (de Savigny and Adam eds 2009)

This is where Systems Thinking might play a role.

‘Systems thinking works to reveal the underlying characteristics and relationships of systems’  (idem)          

But sometimes you need a miracle if you are to succeed.

Systems thinking can ‘…accelerate the strengthening of systems’  (idem) but only if it is applied with liberal doses of leadership, conviction and commitment. When used properly it can find where the blockages are and give us ideas on how to clear those blockages.

Is systems failure all down to human error at the coalface? In some cases it clearly is. The workers at the Bhopal chemical plant pumped Methyl-isocyanate into a leaking tank; the officers and crew of the Herald of Free Enterprise set to sea with their bow doors open; the Costa Concordia was deliberately diverted from her planned course at the Isola del Giglio; Night Nurse Marie misread the medication chart on the ward because she had left her reading glasses at the nurses’ station. In other cases, not so much and systems failure can be more down to managerial or organisational factors that create the pre-conditions for things to go wrong. But then I ask myself, are not deficient managerial and organisational factors man made problems?

Chris Johnson talks about management’s role as organising and managing work practices; and managerial failure being when they do this badly. He identifies another culprit though, which I think is important, and which is often overlooked; this is regulatory failure. Regulatory failure refers to the ways in which governments and other statutory bodies govern and monitor the work practices of companies and industry.

Johnson argues that the role of managerial and regulatory practices as preconditions for human error has been particularly neglected. He says most human factors and systems engineering has focussed on the immediate causes of human error and systems failure and has not looked at the organisational and regulatory context of that error, in other words, step back look at the forest as well as the trees.

‘Given the complexity of healthcare work systems and processes’……there is a need to…. ‘emphasise the need for increasing partnerships between health sciences and human factors and systems engineering to improve patient safety’ (Carayon 2010).

Transitions of care are increasing – this is a high risk process. A transition may occur within a ‘system’ or between ‘systems’. Either way they are plagued by poor communication and inconsistency in care and adverse events are a common outcome (Beach et al 2003).

Returning to Lord Darzi’s Global Leader Lecture; I was interested to hear him talk about the high correlation between one factor, being patient satisfaction/feedback, and most if not all other commonly used measures of patient safety/quality. He suggested a quick and accurate way of determining if you are doing it right is to ask the patient if you are doing it well in her or his eyes.
This is patient centered care, and it’s good because not only is it safer care but it is ‘…. care that is respectful of and responsive to individual and patient preferences, needs, values …’   and ensures ‘…patient values guide all clinical decisions’. (Institute of Medicine Committee on Quality of Health Care in America 2001).

Donabedian may have characterised health systems as structure – process – outcomes but he also referred to another important, and for him the most important ingredient. So I will let Donabedien have the last word:

“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love.”

Peter Carter
Chief Executive Officer
October 2014

Professor the Lord Darzi of Denham
http://www.isqua.org/education/resource-centre/lord-darzi's-global-leader-lecture

Don de Savigny; Taghreed Adam eds: Systems Think in for Health Systems Strengthening. WHO, Alliance for Health Policy and Systems Research: 2009.

C.W. Johnson, Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting, University of Glasgow Press, Glasgow, Scotland, October 2003.


Pascale Carayon et al:  Patient Safety: The Role of Human Factors and Systems Engineering. Stud Health Technol Inform. 2010 153: 23 – 46. 

Beach C.  et al: Profiles in Patient Safety: emergency care transitions. Academic Emergency medicine. 2003; 10(4): 364-367.