"The definition of insanity is continuing to do the same thing over and over again and expecting a different result."
—Albert Einstein
“We must accept human error as inevitable — and design around that fact.”
—Donald Berwick, MD, MPP, President and CEO, IHI
Systems thinking is not easy. It’s an unnatural act. We see the parts, not the whole; the trees, not the forest. Yet, mastering the art of improvement requires a deep and fundamental understanding that parts are connected — inexorably — in a system.
A system is a set of interdependent elements interacting to achieve a common aim — a set of things that work together to get to a goal. A system takes inputs and transforms them into outputs through a process or series of processes.
The essential theoretical foundation for improvement lies in the notion that performance is a foreseeable property of a system. If the system is stable, the performance is predictable. In other words, the performance is embedded into the design of the system, and all systems are perfectly designed to achieve the results they get.
An automobile that is designed to achieve a maximum speed of 100 miles per hour will not fare well in a NASCAR race. This system — the car — is designed for a performance level that is inadequate for this purpose. Its top speed is a predictable property of the system, and no matter how hard we push this system, it cannot possibly achieve the desired performance given its current design. Going faster requires a different system.
Similarly, if a hospital’s pneumococcal immunization rate is 50 percent, it is because the system is designed to achieve a 50 percent immunization rate. If the wait for a new patient appointment in an outpatient clinic is two months, it is because that is what the system is designed to provide. If 5 percent of a hospital’s patients experience an adverse drug event, this is a predictable outcome given the design of the hospital’s medication system. If we are unhappy with these results, the remedy lies in changing work processes. Improve the design to change the result.
When we come to see that performance features are system properties, we come to realize that most problems in organizations do not come from individual workers. They come from the structure of the systems themselves, and people are only parts of those systems. Changing the people, or pushing them to “try harder” or “do better” will not result in improved performance. If we want a new level of performance, we must get a new system.
