Sidney Dekker is a world recognized researcher, successful author, speaker and consultant on safety, error, and complex systems. He is currently at Griffith University and most recently was Professor of Community Health Science at the University of Manitoba. He founded the Leonardo DaVinci Laboratory for Complexity and Systems at Lund University. HHis framework for understanding errors, safety and why things go wrong in complex systems is very applicable to managing for excellence (quality and safety) in the health care environment.

A complex system like a health care organization is a network of interconnected and interdependent smaller systems which function and optimize locally. Because of resource limitations, communication barriers and collaboration failure, internal competition, and interdependence, local optimization guarantees unpredictable problems elsewhere in the organization. The usual response is to focus on errors, perceiving them as violations of protocol and policy by individuals. Further systems are put in place to monitor and track problems, and more policies and protocols are devised to control individual behavior.  These approaches work, but only locally, and they borrow against quality and safety elsewhere in the organization. This short sighted and misdirected focus on local events prevents the recognition that the majority of errors are systems failures (80% or greater in most research) rather than individual human error. Even while local and narrow optimization causes the collected and addressed metrics to improve, bigger and more significant systemic issues remain unrecognized.  As Dekker says, we feel safer and safer until we blow something up.

He makes some very specific recommendations:

  • Remember that individuals are not a problem we need to control. They are a resource we need to support and harness.
  • Complex systems are inherently unpredictable and therefore unsafe, and can only be made safer and more predictable by empowered individuals and a supportive culture.
  • To reduce errors and improve quality, do not focus on errors and poor quality. Focus on what you do best, on your best outcomes. Study them to learn why the work and apply those lessons elsewhere.
  • Remember that human error is not the cause of error and poor quality. It is a symptom of deeper systemic issues. This will lead you to understand the value in errors: they are the chance to find the systemic barriers to quality and success. They should be studied to understand their context, not to penalize or reward individuals.
  • In complex systems with multiple and variable inputs and products (in contrast to manufacturing) excess focus on standardization and elimination of variability decreases quality, adaptability and resilience. The more complex the process (or organization) the fewer and narrower in scope the things that can be automated without paying a high price. (The approach to processing a blood specimen for chemical analysis is the poster child for something that benefits from standardization. Taking a patient history or collaborative goal setting with patients require tremendous creativity, and variability is a mark of quality.)
  • Standardized systems (protocols, algorithms, prescribed workflows)  are superb for mindless, predictable, repetitive tasks, but are inherently narrowly focused and short sighted. They are the engine for local optimization. They can never see how their activity impacts the organization or its product overall. That is a job for properly trained people with autonomy.
  • It is essential to avoid the trap of consensus and group-think (which are often praised as team player, easy to work with, employee loyalty) in the organization. Instead, seek people with diverse viewpoints, in all projects involve people with divergent expertise, look for people who are willing to challenge the status quo and question everything. These are the people who will see the larger systems errors resulting from local optimization or narrow problem solving. These are the people who will find new approaches. These are the people who will tell the emperor to get dressed. Without these people 9and a culture that values and empowers them), a large and complex organization will consistently undercut its own efforts at quality and safety.
  • To keep and empower this essential diversity of approach, create a culture that values them and makes it safe for them to challenge and question. Otherwise they will either leave, be marginalized and become apathetic, or become alienated and adversarial.



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