Systemic Problems

Hello my Zebras and Spoonies! Thank you for coming and hanging out with me today. I am glad that you are here. Today I am going to talk about the complexity of systemic problems.

For those that don’t know, I worked several years as a nurse manager. I hated it, but there is one thing that I learned while working in that capacity: Systemic problems need systemic solutions. This means that you will never solve problems within a system by addressing individuals. It doesn’t work. Let’s break it down and then discuss some of the implications of the concept.

Systemic problems are flaws, imperfections or issues that are ingrained or essential characteristics of an overall system. In other words, such problems are not due to specific, individual or isolated causes. Rather, they are the result of general background conditions of the system itself. They’re a feature, not a bug. Systemic problems require changes to the structure, organization or policies that govern the system. It’s no use trying to reduce user error when the software has been coded in such a way to crash under routine operating conditions. In the quality improvement world, we call such conditions common causes.

There are many things going on in our world today that are example of systemic problems. Police violence is a systemic problem. Medication errors are a systemic problem. Students being bullied in public schools is a systemic problem. There is no way to fix these large, complex problems by focusing on a single person or a single incident within the system. That being said, that doesn’t mean that I don’t think that we shouldn’t be looking at individual cases of police violence and holding violent police accountable. I also believe that every medication error needs to be reviewed and assessed regardless if it caused harm. And yeah, we absolutely need to do our best to help out the student that is being bullied. But we cannot fall into the trap of believing that addressing individual cases is going to solve larger systemic problems.

Instead, we need to be looking at the root causes. What is going on in these systems that is leading to the negative and unwanted outcomes that we are seeing? Once we find the causes within the system, we need to work to change the system to address the causes. Systemic problems persist not due to a lack of effort or concern but often due to misdirected efforts. Actions such as more training, additional oversight, or reallocation of funds to and from programs are rarely enough to address systemic problems. We’ve seen this over and over again in the medical field where they will add in another in-service as the answer. But the increased educational offerings hasn’t helped. Adding more regulation has not helped. And shuffling the funding around has not helped. So, how do we address this bigger, systemic problems?

Even when we recognize a problem as systemic, it’s easy to fall into the trap of addressing its superficial aspects. We may add technology safeguards, punish the bad apples, update policies or associated penalties, or audit adherence to the rules more carefully for a time. We want to find the bug in the system and fix it. This works up to a point. Sometimes we need to upgrade the whole system.

When problem solving, we use a fishbone diagram to identify the man, machine, material, method, and measurement factors. These are what are known as special causes. They are inputs to the process that fail unpredictably and intermittently. While they shouldn’t be ignored, when we focus problem-solving efforts on special causes, we leave common cause unexamined, systemic roots unaddressed.

So what is a fishbone diagram and why am I bringing it up? Well, I’m bringing it up because it is one of the seven most commonly use tools for quality control. It is considered a basic tool for quality assessment. Let’s look at a fishbone diagram and how that’s set up.

Common cause factors lead to failures even when the inputs of people, equipment and methods are perfectly adequate. There is random variation inherent in the performance of any system due to common cause factors. Because common causes are those factors that result from policies, norms, culture, and the broader environment, change requires action at the leadership level. This means that system needs to be changed rather then an individual within that system.

How much of the problem with a systemic issue are due to common cause variation and how much due to special cause variation? The rule of thumb is the 80/20 principle. In other words, for one special cause failure there are four common cause failures. For every police officer who commits a malicious act of violence against a civilian there may be four who hold no hate in their hearts but who stand by and allow it, simply going along with the norms of their system. And until the norms within the system are addressed, these four police officers are likely to continue to contribute to the problem through inaction.

Common cause variation is a measure of a process’ potential to perform properly when special cause variation is removed. In other words, even if every violent racist was removed from the police force, it is not enough. The common cause conditions that generate these behaviors in otherwise well-intentioned people must also be removed. If the culture that violence is acceptable remains in place, then people will continue to choose that option even when they normally wouldn’t. This is because in other situations they do not feel that violence is an option allowed to them. When they can make a different choice, a portion of them will make a different choice. That is the nature of system issues.

In any type of problem solving it’s tempting to zero in on solutions and get to work right away. When facing systemic problems, it’s more important than ever to grasp the overall scope. This is hard because it requires looking at the big picture, the detailed parts, and also their interactions. It may also require broadening our examining to include interactions with adjacent systems. When grappling with complexity, we have to resist our urge to settle on simple answers. The simplest solutions often fail to address an issue’s complexity.

Consider charging nurses criminally for making medications errors. This is a recent trend that has risen out of the idea of holding individuals accountable for the medication errors that they make. However, this is a simple solution to a very complex problem and fails to address the complexity of the issue. The first problem with this solution is the very real fact that it is only a matter of time before a nurse makes a medication error. Every nurse does their best to be accurate and correct with their medication passes, but the reality is that all of us make mistakes. This means that following through with holding us accountable for our errors would result in every nurse facing criminal charges and going to jail. This country would be left with no one to work. This simple solution does nothing to actually reduce the number of medication errors because nurses are already doing everything that we can to be accurate. So, there is also no value in punishing a handful of nurses to serve as an example to get the rest of us to perform better. Superficial and simple solutions will never fully address the greater complexity of a systemic problem.

When creating a map to visualize the system it’s useful to physically walk through the processes in question. For a healthcare problem, walk through it as if we were the patient. For delivery of goods, as if we were the product. If the process is justice, we may need to do this not only from the viewpoint of the police officer and the civilian but also the victim. Walking the process in these shoes helps us develop empathy for each person who experiences the process. This helps us to see the system as it is, rather than as we believe it to be. It helps us see where the system is failing to properly support the various people with in the system rather then looking at how those people are failing their system.

A good rule of thumb for managing a business is that ideal processes deliver what the customer wants, when they want it, one at a time, at a low cost, right the first time, safely and so forth. These things are hard to argue with. They are not immediately achievable. But they provide a sort of True North reference point on the journey. This is nearly impossible to do if we are addressing it at the detail level of specific countermeasures to specific complaints. To avoid argument over details, we need to start with a high-level agreement on the outputs an ideal system would provide so that we can compare it to where we are and see the gaps. This is true when dealing with any systemic problem. There needs to first be an expectation that we are working towards achieving so that we can compare where we are to where we desire to be. Then we can begin the process of considering how the system needs to change in order to get to the goal.

Piecemeal solutions very rarely fix systemic problems. But neither are all-at-once transformations likely to succeed. Time, attention, resources and support for improvements are all in limited supply. It’s best to concentrate resources, attention and efforts on building one or more small but shining examples of success. The model embodies as many of the “ideal state” notions as possible. These model areas become laboratories for rapid experimentation and learning. This allows us to correct failed ideas without too much expense and to copy successes rapidly. Once you have a working model, this can then be scaled up and applied to larger areas. You keep doing this until you have converted the entire system to the new model.

The people closest to the work often know best how to improve it. Those who have never done a job are less likely to be aware of the processes in place that direct the work flow. Even the managers who create these work flows don’t have a true understanding of the way that they impact the work being done. We need people to own the solutions, rather than feel owned by them. There is no room for blame when correcting systemic problems. All the people effected by the systemic problem need to come together to problem solve on how to make the system work better. Pushing big, top-down change is inherently slow. With changes at the top, policies may be reversed. Pulling small, local change is more likely to survive leadership changes. People are more likely to maintain and protect what they had a hand in building.

Try out simple, low-cost solutions immediately, even if they are only partial improvements. When demanding drastic changes to address systemic problems, we sometimes fall into the trap of waiting for the 100% solution. Such a thing rarely exists, and when it does, it comes late and with a big price tag. If we can make a 60% improvement and make it stick, we can build on that. Remember that any improvement is better then things remaining in the broken and dysfunctional state that they currently standing in. And because these are human run systems, it is unlikely that we will ever achieve anything close to perfection. Accepting better goes a long way to reaching goals towards systemic change.

Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!