A bad system will beat a good person every time


Remember the broken telephone game where one person whispers something into the next person’s ear and the message is passed through a line of people with the last person announcing the message received. The message has typically changed as words and information is lost (or added) each time the message is passed on.

We play this game in acute care and we call it transitions in patient care whenever a patient is transported from one specialty to another; for instance from an accident scene to an emergency center or emergency center to a critical care unit. The transition is risky, important patient information including baseline presentation and initial management is exchanged in a very short period of time, intuitive assumptions are made about the patient, the transition itself is frequently interrupted and the arrival of the patient in any busy facility will interrupt other tasks, thus the practitioner receiving the handover are distracted by patient load and tasks.

The flow of information during this transition time links the various parts of the greater system involved in time-critical patient care. It is obvious that missing information flows is a common cause of patient error and system malfunction.

There are various variations of the added poster and they all imply segregation of the acute care team. It is a symptom of a culture that needs a shift so that we can improve transitions of care.

Culture is the way that things are done and it is the result of all the daily conversations, negotiations, habits, traditions and stories told to each other while at work. These shared assumptions are considered valid and are continuously reinforced through behavior and attitude.

The culture of an industry, organization or unit is an important leverage point within a system and is a strong indicator of the strength of linkages and flows between subsystems. A poster like this implies a certain mind set about team approach, team dynamics and views on the role of other functions in this case paramedics. It makes a statement about the openness within the unit to learn through cross pollination from other functions.

Am I reading too much in a mere poster? I think not, with years of diverse experience across the acute care system this is just one example of the consistent messages within the system.

I could’ve easily reversed this example to implicate other members of the acute care team as the culprits of poor cultural behavior. However it is not about which example is used, it is about what these examples signify about the health of our industry’s sociocultural behavior, the unwritten rules within the system and how it harms the core function of what we are trying to achieve.

We are often so blinded by our function that we completely miss the bigger picture and how care transcends from one area to the next. None of us function in isolation, we are all linked and if we complicate another team member’s function it boomerangs and complicates our own function.

This poster is merely a conduit demonstrating the culture, how we do things and treat each other. These examples represent a culture that discourages adequate care and that is damaging to the linkages between subsystems.

The problem with this behavior
– It creates silos or barriers resulting in providers that should be working towards the same goal (rendering emergency care to the best of our ability) to work against each other.
– Segregating the functions may result in providers attributing vital patient information as unnecessary and providers may be ignorant of the value of the information exchanged. There is a saying that we don’t know what we don’t know. An example of such behavior is when emergency center providers tell paramedics that they are not interested in information including structural damage to a vehicle, why the patient is immobilized or why certain decisions in management was made etc.
– This poster is the result of the parts (or functions) in a system not understanding the binding context for working together. This poster and behavior basically obstructs members in the same team from performing their tasks. Without understanding the context there is no direction and we harm patients.
– It prevents knowledge generation. Healthcare facilities are organized around functions with numerous transitions in care and a variety of tasks occurring simultaneously. One of our biggest challenges is the lack of reliable feedback mechanisms and knowledge to integrate all these functions into a coherent whole. We need to improve relations with our actions, not make it worse.
– The acute care system is a complex system facing an unpredictable demand within a time critical frame. Such a system can easily be overwhelmed leading to chaos without adding stress to the system, to the team dynamics, and additional stress on transitions or risky situations. The outcome of not working together is degradation of overall performance, patient error or harm and a negative impact on system effectiveness.

What can we do to improve the transitions of care?
– Be more systematic and intentional about improving team work. Remove the posters and refrain from destructive comments. Try to understand other team member’s functions and how it impacts on your function.
– Go back to basics, what is the core function of an ambulance service? What is the core function of the emergency center? When our behavior hampers the ability of another link within the acute care services to meet their core function we decrease our effectiveness and ability of our entire system.
– Do not disregard the emotions evoked by exposure to these posters and messages. It impacts the lines of communication of persons working within the unit and those entering the unit.
– Understand that the entire health sector is overstretched and understaffed. Within the health sector, the acute care system functions within unpredictable demand and time critical intervention. It is only by having insight and working together that we can improve patient outcomes and our work conditions.
– Communicate and share stories with members of the other parts of the system, discover the shared purpose, create a collective intelligence and craft effective coping strategies for all.
– Create a culture that embraces the concept of psychological safety enabling everyone within the system a voice and ability to perform their function. Interaction is the key to successful transitions in care.
– Accept that some tensions across the boundaries are ok and used it to improve the collective performance and thus patient care.
– Look at the bigger picture whatever the facility policy; it has an impact on patient care in a wider context. Example, by banning the ambulance from being calling free at your facility because they have to drive to another facility to discard medical waste and clean their equipment, prohibits them from responding to priority calls which negatively access to care

It is mind boggling to even consider the complexity added together when the broken, injured human organism with interconnected body, mind and spirit enters the complex, multifunctional acute care system. I don’t think we need to add a broken acute care system to aggravate chaos.

The parts of the acute care system should not be blinded by a single minded linear function. We need to share knowledge, insights and stories to create overlaps and a culture of collaboration as survival skill in the ever changing landscape that we work in. By creating overlaps we create the ability to gain knowledge and to survive.

Inadequate information flows and missed feedback is common causes of system malfunction. So let’s remove the posters and behaviors that highlight dysfunctional relationships.

Note on the terminology acute care as opposed to emergency care. According the World Health Organization definition of Acute Care it includes emergency medical care, trauma care, pre hospital care, acute care surgery, critical care, urgent care and short term inpatient stabilization.