The importance of systems

I was reminded of the importance of systems today while reading The Premonition by Michael Lewis.

The book tells the story of two VA nurses who bathed an old veteran. The veteran suffered from mental illness and subsequently would start to scream randomly throughout the day. They bathe him every morning to soothe the old man and make it easier for the nurses on the next shift.

The VA hospital where this took place had a system for bathtubs that controlled water temperature. Hospitals want the water hot enough to kill bacteria but cool enough not to scold the person bathing. The system had been broken for months, producing water at colder temperatures than it was set to. To compensate, the nurses increased the setting and carried on.

The plumbing department fixed the temperature control system one day without telling anybody. The next morning, the two nurses bathed the veteran, and as usual, the old man started to scream. Only after an hour, as his skin began to peel off his body, did they notice something was wrong. By then, the old vet was being boiled alive.

Who was at fault? The plumbers? The nurses? No. It was the system that allowed all of it to happen. Multiple safety layers should have been in place to prevent this horrible accident.

Naturally, the nurses were mortified, but it wasn’t their fault—the system they were encouraged to trust had failed them. Most things go wrong not due to bad people but rather bad systems.

When the systems depend on human vigilance, they will fail.

It should not have been possible for the nurses to make this mistake. Human error should be accounted for. We cannot depend on the absence of human error – especially when lives are on the line.

The quality of a leader is evidenced by their ability to discern between human and system error.

How many leaders continue to blame people for the failures of the organization? People that they put in place. People work under the conditions that they construct. People are bound by the resources that they provide. Ultimately, it’s not bad people at the root of the problem, it’s bad systems.

Organizational leaders may not be to blame for the environment they find themselves in, but they are obligated to take responsibility for it.