“Every System Is Perfectly Designed to Get the Results It Gets”

Abstract

The insight that “Every system is perfectly designed to get the results it gets,” together with its corollary, “If we keep doing what we’ve been doing, we’ll keep getting what we’ve been getting,” provide profound insight for mitigating the problem of unwarranted practice variation. Healthcare leaders too often identify “re-education” as a solution to a multitude of problems. A solution like “re-education” rests on the assumption that the system itself is not the problem. Without changing the causal system, the leaders will likely find that a need for “re-education” keeps recurring. Among the sample of ideas presented for what to do differently to mitigate unwarranted practice variation: In general, design systems so that doing the right thing is the easiest way to do the work; a checklist is one example. Confirm that assumed processes indeed exist and unfold predictably and within desired limits. Augment the capability of the EMR as a cognitive tool. Professional organizations can synthesize high-quality peer-reviewed medical evidence, estimate interventional benefits/harms, and create guidelines. Conduct observational visits among NICU teams, aiming for fine-grained understanding of local processes. Articulate questions important to the full scope of NICU care that we currently do not, or cannot, answer, but are essential to answer. Unwarranted, chaotic, practice variation is a symptom, more than it is a diagnosis. The underlying diagnosis is under-conceptualization of our work: of how we model it, learn from our experience, and of how we confirm that we succeed.