Systems thinking

I'm continually surprised by how much of our safety culture in health care is one-dimensional. How can we expand our minds to incorporate systems thinking?

Freshman year in high school math, we read Flatland, an 1884 novella about Victorian culture and geometry. The narrator lived in a two dimensional world. The story revolved around his experiences meeting people from the one dimensional world of Lineland and the three dimensional world of Spaceland. The memory that sticks with me almost twenty years later is the perspective of the characters when confronted with evidence of the other dimensions. Just as the inhabitants of Lineland struggled to comprehend how something could move in two dimensions, the inhabitants of Flatland had trouble understanding how a third dimension worked. 

 The two dimensional square looks down upon Lineland.   

The two dimensional square looks down upon Lineland.

 

After reading this story, the idea of a fourth dimension made more sense to my teenage brain. By putting myself in the perspective of the square, I could imagine more clearly the limits of my awareness and ponder what else could be out there.

 The three dimensional sphere moving through space: a mind blowing concept for the inhabitants of a two dimensional world.

The three dimensional sphere moving through space: a mind blowing concept for the inhabitants of a two dimensional world.

In medicine,  systems thinking is our fourth dimension. In medical school we learn to do a history and physical exam with one patient. As residents, we learn to manage a team of patients. We start to realize the limits of our individual abilities - medicine happens in a complex system with many factors outside our immediate control. As attendings, we learn how to see the systems behind our care and work to improve them.

Yet when something goes wrong, we fall back to the one dimensional patient-provider interaction. Mortality and morbidity conferences or malpractice cases usually focus on the actions of individuals instead of on the complex interworkings of the systems of care. The Root Cause Analysis process often falls short of finding systematic root causes. Ultimately, this approach limits our ability to improve care. Until we recognize and analyze the strengths and weaknesses of our systems, we can't improve them to provide better and safer care.  

Watch this 3 min Animation on Systems Thinking in health care incident investigation from the Systems Thinking Lab for an overview.

 Systems Thinking: the fourth dimension of health care. 

Systems Thinking: the fourth dimension of health care. 

Many folks in medical education and patient safety are expanding on our mindset to incorporate systems thinking. Bon Ku runs the Health Design Lab at Jefferson University. Martin Bromiley runs the Clinical Human Factors Group, a charity inspired after his wife died from a medical error. Steven Shorrock blogs at Humanistic Systems about "views on human factors, systems and safety from the perspectives of humanistic thinking, systems thinking and design thinking."

It is imperative that we push the limits of our awareness to incorporate systems thinking. Once we do, we can create meaningful improvements that cause lasting change, bringing joy to our work and justice to our patients. 

Onward.