"A large system produced by expanding the dimensions of a smaller system does not behave like the smaller system." *This profound truth has implications all around us every day, as we violate it time and again and smash our heads into the same pipe, while instantly denying that a pipe should be "there" or even could be "there" so maybe it was just a bad imagination and we should forget it immediately. No learning takes place during the debrief. We will make exactly the same mistake again tomorrow.
(Aside- This self-sustaining, "error" correcting mechanism of a myth is fully predictable if we take it as a living entity or system simply doing what it needs to in order to survive, happily doing mental housekeeping and removing the "not me" so that the "me" remains unblemished.)
Gall continues (page 23) with a description of "Climax Design"
that is, in the construction of the largest and most complex examples of man-made Systems, whether buildings, ships and planes, or organizations. The ultimate model (the largest, fastest, tallest, etc. ) often , if not invariably, exhibits behavior so unexpected as to verge on the uncanny. The behavior is often an unsuspected way of failing...He gives as examples:
The largest building, the Space Vehicle Preparation Shed at Cape Kennedy, which is so large that it creates its own weather and rains on the ships it was built to protect.
The largest [then] telescope, a 230-inch reflector, which takes so long to reach thermal equilibrium at night that the night is over before it can focus on a star image.
More recent examples would be:
The worlds largest airliners (Airbus A380 and Boeing 787) with huge engines that tend to burn and explode when used.
US Electronic Intelligence apparatus, so large that so much energy is spent collecting "intel" that there is no staff or budget left to actually analyze it. Despite that, new budget goes to collecting even more intel from the web, while focusing management's attention on meeting meetings -- ie, meetings about why there are so many meetings, and hiring new staff whose job it is, not to process intel, but to analyze why other people are not processing intel.
On finding a "shipbuilder" any more
One of the problems with Climax Systems not doing what their name says they should be doing, is that the parts, also, are no longer doing what the parts say they are doing, or what they are named, or even what they think they are doing. Everything is caught up, as it always will be, in a system delusion, which acts as a living being and reinforces and enforces its own dominance. ( In that sense Frankenstein and Young Frankenstein should move over, because, in creating Climax Systems we have already succeeded in creating new life, we just have yet to spring to the fact that that's what we just did.)
One aspect of the system delusion is what Gall refers to as Manager's Mirage -- "The System takes credit for any favorable outcome". Along with this I'd add the CEO's mirage -- the CEO of an organization will always take credit for anything that goes right (and demand extraordinary pay for this "accomplishment") while denying any responsibility for anything that goes wrong (and not accepting any cut in pay for this anti-accomplishment.) The primary skill of a "manager" or "executive" such systems produce, then, of course, is taking credit and spreading blame. As with the "Royal we", the CEO of a huge company will show up on the cover of Fortune or Forbes, speaking in the first person of "How I tamed the oil feeds", etc. fully convincing and even convinced that what he did was the cause of the observed outcome.
Another aspect of system delusion is what Gall calls "Orwell's Inversion" -- the confusion of Input and Output. (page 55)
"A giant program to Conquer Cancer is begun. At the end of five years, cancer has not been conquered, but one thousand research papers have been published. In addition, one million copies of a pamphlet entitled "You and the War Against Cancer" have been distributed. These publications will absolutely be regarded as Output rather than Input. The cancerous multiplication of paperwork will not be regarded as a malignancy."Let us return now to our original thrust, the startling and important realization and insight that nothing in a system is doing what the name would imply it should be doing.
This gets (Chapter 7) to what Gall refers to as The Grand Illusion. His example is excellent.
Three is a man in our neighborhood who is building a boat in his back yard. He knows very little of boat-building and still less of sailing or navigation. He works from plans drawn up by himself. Nevertheless, he is demonstrably building a boat and can be called, in some real sense, a boat-builder.In my words, we have, in fact, created a synthetic life form, a "system", which behaves AS IF IT WERE ALIVE, and carries out observations, actions, planning, responses, consuming energy, growing, having diseases and infirmities, possibly dying, etc. The system is what I call MAWBA -- "Might as well be alive" -- for legacy religious and psychological reasons, even though we are willing to grant the moniker of "life" to a lowly virus, we are strangely unwilling to accept even the mental model that the system has become "living".
Now, if you go down to Hampton Roads or any other great shipyard and look around for a ship-builder, you will be disappointed. You will find in abundance welders, carpenters, foremen, engineers, and many other specialists, but no ship-builders. True, the company executives may call themselves ship-builders, but if you observe their work, you will see that it really consists of writing contracts, planning budgets, and other administrative activities. Clearly, they are not in any concrete sense building ships.
In cold fact, a SYSTEM is building ships, and the SYSTEM is the shipbuilder.
Application of all this to Hospitals and Health Care
Now, I want to bring this frame of mind around to bear on the question of what the nature of a large hospital and even larger "health care SYSTEM" might be, and how an "Electronic Health Record" might play out in such a beast. Similar issues arise in the nature of a "Military intelligence system", of course, and any other suitable large system, such as "government intelligence" -- which we already have the social wisdom of tagging as an oxymoron. We know, on a very deep level and by experience, that "government" and "intelligence" don't really go together.
What Gall is trying to say, and so am I, is that the REASON they do not go together is precisely this discrepancy between what a system is / does and the size or scale of the system. Similarly, if we wish to address or intervene or "fix" such a system's output, we had best start by fully grasping the subtle and surprising nature of the malfunction.First, the realization that "the system" does things, not the persons in the system, is one of those concepts that is in the very awkward position of being PARTLY CHEWED and less digested at this time in our society.
If you go to any large teaching hospital you will find that they are "in the process of implementing" a patient safety "system", based around the poorly grasped concept that "the system does things, not people" and, when bad things happen "it is usually the systems fault, not a bad person's fault".
These are truly profound insights, which, sadly, are mostly only partially grasped, if that, by everyone involved in implementing them. I myself, for the first 5 years of exposure to such words coming "from above", thought that this was really some new clever scheme to avoid having the finger of blame ever come around to point at bad people, surely doctors or managers, who when confronted with something they had done wrong would pull out their "Dont blame me -- the SYSTEM did it!" card and cloak of protection, and thereby be spared being held to account. Having slotted this activity into a cynical slot in my mind, I gave no further thought to the possibility that I might have totally misunderstood what was going on.
Still, here's a snippet of news from a researcher at Johns Hopkins, who has done extensive study of commerical airline accidents, and has probably spent more time in aircraft cockpits than any non-pilot person, Bryan Sexton.
According to his data, 74% of commercial airline accidents occur on the very first day that a set of professionals who had never worked before as a team was assigned to work together as the cockpit crew.These are all seasoned professionals. Any one of them, alone, could "pass a test" with flying colors, so to speak, and DID in fact recently do just that.
What has just come into being, however, is "the team". The "team" is a kind of SYSTEM, subject to all the rules SYSTEMS follow. The team, on its very first day of existence, is still a type of infant, not yet mature, and certainly not very good at flying airplanes. So, it should come as no surprise that it often does a very bad job of flying the airplane,and crashes it instead.
This is a fact. This is observed, over and over. Yet, we, the upright ape with the spear as Gall would have us, are unwilling to accept the fact that a synthetic life form, a "team" is flying the plane, not the attractive pilot in the left hand seat. We are still, in the prior metaphor, looking for "ship-builders". We are still looking for "pilots" and when something goes wrong, we are looking for "the person" to "blame" or to "fix".
But, pilots do not fly planes any more than ship-builders build ships any more than doctors provide "health care". SYSTEMS have been created to do these tasks, SYSTEMS do them albeit generally poorly, and if we wish to intervene, we had best get that straight in our heads from the start.
Hospital as very large doctor
OK, we know from Gall's work and our own observations that
"A large system produced by expanding the dimensions of a smaller system does not behave like the smaller system." *
Now we simply need to take that frame of mind, and, within it, reflect a few moments on what we are trying to do with hospitals, and why it is failing, and what would make it work better.
Without getting tangled in the nuances and politics of doctors versus nurses versus "care-givers" versus "providers" -- let's just call the person who, if there was just one of them doing this, a "doctor".
What we, as patients are looking for is precisely "a doctor" -- a person who is kind, caring, loving and at the same time very wise and experienced and competent. Preferably, this person is our life-partner or someone equally attuned to our nuances and willing to devote 110% of their attention, for as long as it takes, (bathroom breaks excluded), purely onto us and our needs and researching all that is known about our kind of situation and doing it and monitoring it like a hawk and tweaking and adjusting it, etc. If there was just one of these person, again, I will use the term "doctor" -- although as I'll get to in a second, of course, there is no such entity so let's not fight over words or an implicit putting down of nurses.
With me so far? On a single-human basis, we can grasp and point to and nod our heads yes, that, if given the choice and it were free of cost, we would all want such a "doctor" person caring for us when we were not well.
Now comes the "system" part.
For many reasons, society proceeded to increase the desired size, scale, specialization, whatever of this "doctor" being, and, frankly, ran out of the limits of what any one person could do alone. So, we went to larger and larger and larger SYSTEMS, each of which was supposed to replicate the concept of "doctor" except on ever larger scales -- just like the "ship-builder" company instead of ship-builder person.
(Or, in the military, we subdivided the concept "Warrior" into a zillion pieces and sub-roles, and then put them all in the same place and told them "now act as one single coherent system doing what a warrior does except BIGGER" .. .and have been, because we failed to study systems behavior, surprised at the lack of success of this task.)
We took the idea "carter" or cart-builder, expanded it to the scale of General Motors, and then were surprised that the meta-being couldn't even seem to grasp the concept that, if gas cost more, people would drive less, and if gas cost a lot more, people would buy way less expensive cars. This was a SYSTEMS ERROR we made, not a failing of the CEO or various vice-presidents of GM, who all called each other "auto builders" or some equivalent to ship-buliders, despite, as with ships, the fact that they actually if observed pushed paper and went to meetings, and probably didn't even drive their own cars any more.
OK, so, this meta-being the META-DOCTOR SYSTEM, doesn't work very well. This is not news for composite system beings -- none of them EVER work very well. In the occasions on which patients "get better" the system proudly takes credit; on the occasions on which the patients get worse or die, the system of course blames some external agency or "bad person" or even the "bad patient" for this outcome. Again, this is predictable behavior of all SYSTEMS.
Now, however, let's go back to pondering how well we, our society, has done at REPLICATING, on a GRAND SCALE, the functions of "doctor" that we had originally intended it to do (had we planned any of this explicitly, which of course we didn't, but that's another story.)
HOW DID WE DO?
If you, as a patient go to a "hospital", can you expect that some loving, caring, competent person will be at your bedside every moment, watching over you?
Well, frankly, no.
The persons with "MD" after their names are way too expensive and busy to be "at your side" -- so they will see you briefly "on rounds" and occasionally "on demand", but otherwise seem to a patient to have gone away entirely. So, no, THEY are not at your bed-side at every moment.
For a while in the evolution of hospital meta-beings, a new group of people called "Nurses" took this role, and THEY would be at your bedside paying attention to you and your needs. Again, that got kind of expensive (due to "system costs"), so THESE people were multitasked away, and are visible only briefly in short bursts, and callable with a nurse-call-button that seems often to have a one to two hour lag time.
So, no, THESE people are not at your bed-side every moment, serving the "doctor" role.
In fact, nurses (due to "systems costs" ) have become too expensive so a new group of people "Nurses aids" (or various other names) instead are the ones who spend more time near you, but they don't really know that much advanced medical theory. Even THEY are getting too expensive ("to cover all the SYSTEM costs"),so finally there are machines, in some places, monitors, computers that look at a few "vital signs" and ring alarm bells if those go out of specs.
These computers do not look at the whole person with wise and loving eyes, nor can they see very much at all, except for the few "vital signs" they are programmed to scan. They, in fact, don't track downhill progression, only able, for the most part, to sound an alarm AFTER something has gone seriously wrong. They are not, as the original bedside loving doctor person could have done, able to see that the plan of action is "not working" much earlier in the process, being totally sensitive to your normal state and slight variations.
These of course are the kind of variations that, oh, your spouse or partner or parent might recognize.
So, in the ultimate slough-off of responsiblity, the latest word in hospital "health care systems" is a recommendation that you bring along an unpaid family member to "be with you" and "notify the hospital" if something looks wrong.
In other words -- the system has become so self-absorbed by its own functioning needs that it has all but abandoned the role that you originally might have wanted it for.
All aspects of the original role have now fallen through "the cracks". You cannot identify or locate the "person" who is "responsible, overall ,for your outcomes" -- there is no such person. There is no "ship-builder". There is a pain-specialist, a cardiologist, a nurse, an aid, an anesthesiologist, but every one of them has limits on their field of practice, and none of them is, overall, responsible for YOU or YOUR CARE. By expanding the "doctor" concept and attempting to create a META_DOCTOR at a much larger scale, we have created a zillion cracks in the system into which parts of the original "doctor job" have fallen.
Finally, if you truly wish good care, and you can afford it, you could hire a private doctor to come sit by your bedside all day in the hospital.
The birth of the new-living entity, the hospital-system, is thereby complete. It has escaped from the womb, cut the umbilical cord, and now exists in a self-absorbed state focusing entirely on its own system needs, to the point where the original purpose has been totally and explicitly abandoned and rejected.
From a point of view of "new species of life on earth" this is cool. From a point of view of you, a patient, getting better, this sucks. You are back where you started. No, you are way worse than when you started, because when you started, you only needed to pay for the doctor person. NOW, you are billed, often out of sight, for the existence of a whole army of "hospitals" and "health care systems" none of which are really interested in taking care of you, and consider you an annoyance to their even-keeled operation.
Don't blame hospitals. Large banks, similarly, which once loaned money to people , as they kept on growing and kept the same moniker and sense of entitlement, legitimacy, and reputation for fiduciary responsibility, first decided they were too big to be troubled with loaning money to individuals, then it was too much trouble to loan it to small businesses, then it became too much trouble to loan it to large businesses, then it was too much trouble to loan it to entire countries -- so now they simply take in funds and keep them.
The original function of "bank" has been entirely lost, and a new life form "large banks" has evolved, which has divorced itself entirely from the original concept.
If we or policy makers or politicians are surprised by this, they didn't real John Gall's book and understand it. This is EXACTLY what systems do. This is what systems ALWAYS do.
Gall gives many more examples. After centuries to learn that products can be made more cheaply in specialized factories by specialized equipment and mass production, we now have a system that asks consumers to "assemble it yourself" because it is "too expensive" for the system we set up to do it to, well, do it.
Or, of course, the ultimate meta-beings, state and federal government bureaucracies, have taken exactly the same life-course of evolution. Once upon a time, they were set up to serve roles related to getting things done that needed to get done. Over time, they grew, encroached, took on more and more "credit" when things went right (and increased their pay and size), took on less and less "blame" when things went wrong (and increased their pay and size to deal with that), and finally got to the state today, where the proudest members of Congress are not embarrassed to state in public that their aim is to prevent anything from getting done.
This of course leaves all the tasks government was set up to handle no longer handed, because THE SYSTEM doesn't really care about those tasks, now that it can survive on its own without them.
BACK TO HOSPITALS and EHR's
So, hospitals already would have failed to work if they simply expanded and tried to recreate tasks of "doctors" but spread out over many people, if they dealt with patients ONE AT A TIME.
But, one of the reasons (perceived by humans) for expanding is that there were a LOT of patients. So hospitals ALSO transitioned to wanting to deal with many people AT THE VERY SAME TIME.
It is as if we asked pilots, because much of the time they are not that busy, to multitask and actually fly 8 planes at once from the same cockpit -- something I'm quite sure is creeping into the minds of the management of the dudes who fly the drone unmanned aircraft over Iraq and Afghanistan.
So, we ask the "hospital" meta-doctor being to see, oh, say, 500 "patients" SIMULTANEOUSLY. Any school child can see that, if there are 500 children, the parents are going to NOT be spending all their time with any one child. In other words, there is NO WAY that a 500-patient living entity could conceivably SIMULTANEOUSLY focus its full attention and care on one particular patient.
So, again without formal planning, just stumbing into it, we come up with "multitasking". if we had 500 people, and each of them kept changing which patient they were paying attention to, couldn't we effectively SYNTHESIZE the same thing as 500 doctors all paying full attention to EACH patient?
Well, back to the cockpit example and airplane crashes. Yes, if the SAME 500 people learned how to work together and got their act together, ultimately, yes, this might happen. However, that is not in the cards. The 500 (or more likely 5000) staff members that are the cell-equivalents of this meta-body keep on CHANGING.
There is never an opportunity to get past the "First day in the cockpit together" situation, the one that causes accidents.
Next post -- the role of the Electronic Health Record in tying things together -- and making the total result worse.
==== references
* (Chapter 3 in Systemantics - The Underground Text of Systems Lore: How Systems Really Work and How they Fail")
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