Systems Are More Than The Sum Of Their Parts

Yesterday I was reacting to the way a health agency minimized a terrible problem by presenting data in a misleading way, and I framed it as predictable behavior by a bureaucratic system.  While I may find the charts fascinating, this is a terrible way of introducing people to the healthcare challenges of people living in Northern Ontario.

I made things worse by characterizing systems as “assemblies of interdependent parts,” which is true, but far less interesting than when reminded that the most important parts are people.  One of my mentors, Rod Smith, would never say that he was going to talk to a company or agency by name.  He would always connect with an individual person, insisting that companies are nothing, but groups of people bound by a purpose and rules about how they work together. 

Kenichi Ohmae reduces corporations to assemblies of people, money, and things.  They are nothing more.  And of those three elements, only the people have feelings, motives, talents, and strategies, and only people make decisions.

In our practice, working with organizations in all three sectors, with different governance and management styles, we tend to think of corporations as people, money, and things, that are combined through defined structures, systems, policies, and programs, to become more than the sum of their parts.  In-fact that’s the prime benefit of organizing these human, financial, and material elements into, what we aptly call an “organization.”  It is how humans make the parts work to better effect together than they would if used separately.

Before boring you further with apologies for my boringness, I’d like to share three stories that made this data vivid for me.  Rather than talk about structures, systems, policies, and programs, we should talk about the human consequence of system failure.  When something is not working, like the healthcare system outside our major cities, data doesn’t tell the whole story.

First, an old friend was working as a subcontractor on network infrastructure for the disastrously implemented EHealth project nearly a decade ago.  EHealth was an overdue idea that would have been well worth the billion-dollar price tag if haste and waste hadn’t turned it into a symbol of corruption and incompetence. 

In this friend’s story, he and his team were dispatched to a small Ontario town, just an hour’s drive from a big city, to deal with problems found in the new EHealth software and high capacity data infrastructure.  To his astonishment he discovered that, in addition to the reported issues they’d been sent to fix, local doctors and clinicians had never connected to the fibre-optic data cabling that had been installed for them.  They were instead trying to navigate the massive, centralized data storage and sharing system using their old commercial ISP’s like Rogers and Bell.  Anytime the required volume or speed of transmission exceeded the capacity of these services, the system failed, while at the installed node of the fibre optic network, the necessary speed and capacity was available but unused.  This story, like most consulting war-stories, evoked some laughter and head scratching.

Year’s after the EHealth implementation, a dear friend and his wife told the painful story of how he became paralyzed by a C4 neck injury because of an inability to transmit his MRI pictures from the northern city where he’d been injured in a bike accident, to the northern city where they could have performed the surgery to save him.  The MRI files were copied onto a compact disk (remember those?) in the city where his accident occurred, which should have been packed with him onto the helicopter that flew him to the surgical hospital.  It wasn’t.  The team at the surgical hospital wouldn’t operate without reviewing the MRI, so in the hours and hours that they waited for the CD to be transported from the other city, swelling increased at the point of his neck injury until the spinal cord, which was intact until then, ruptured under pressure. 

It’s easy to see how the second story adds relevance to the first story.  It raises questions about whether or not those big image files could have been sent online from one hospital to the other over the internet or uploaded to the cloud for download by the other hospital.  If that capacity didn’t exist, it’s impossible not to wonder why not, and if it did exist, why it wasn’t used.  Furthermore, what policy prevented repeating the MRI at the second hospital rather than waiting hours for a return trip by air or ground ambulance?  If I was trapped in a wheelchair for the rest of my life, I couldn’t think about much else.

The third story is from yet another close friend and colleague who lost her mother-in-law to a stroke during a family vacation in northwestern Ontario.  It was during the annual visit to their family’s island camp.  When it became apparent the woman was in difficulty, the family called the Telemedicine service to ask for direction.  They were told that she would need to go to the emergency ward of the nearest hospital, hundreds of kilometres away.  So with assistance, she boarded the family boat and was taken to the mainland where they waited for an ambulance.  The total time elapsed between the call and the pronouncement of her death after arrival at the ER, was more than 12 hours spent, most of it spent either in an ambulance or waiting for an ambulance. 

This story adds a dimension to the other two in that it demonstrates the limits and defects of the adaptations our medical systems have made for care outside major population centres.  In cities, we all live within minutes of a staffed and equipped emergency ward, usually attached to a full-service hospital or within easy reach of the specialized diagnostics and treatments we need.  But when you move that model into smaller centres, in thinly populated areas, with vast service catchment areas, the system can’t deliver the service for which it’s been designed.

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