As public servants and advocates, it is our duty to acknowledge and mitigate errors within the municipal management systems in which we operate. An insightful video titled "How Can You Apply Clinical Skills to Q.I" (2014) by Spear provides a conceptual framework for understanding errors within a system. According to Spear, only a finite number of things can go wrong within a system. He categorizes these errors into four categories:
Being off target: This refers to a lack or misunderstanding of the goal/object or incorrect actions taken to achieve the desired results.
Wrong person, wrong thing, wrong time: This category refers to errors stemming from inappropriate allocation of tasks or resources.
Dropped batons: These are issues related to content, format, timing, or location.
Misfiring: This category refers to an inappropriate approach when executing assigned responsibilities.
These categories of errors are deeply embedded in the systems that we work within. The Innovations Associates Iceberg, as described by Kim in "Introduction to Systems Thinking" (1999), visually represents this reality. It portrays a system as more than a superficial awareness of seemingly isolated, unrelated events. It calls attention to a system as “any group of interacting, interrelated, or interdependent parts that form a complex and unified whole that has a specific purpose.” This complexity requires adopting a systems thinking approach, which is described as “a way of seeing and talking about reality that helps us to better understand and work with systems to influence the quality of our lives” (Kim, 1999).
Humans, as Kim points out, tend to focus on single moments in time (events) that are not jarringly unusual. We are drawn to superficial stability, which can sometimes lead us to overlook more subtle signs of instability. This tendency can have serious consequences in a municipal management setting. For example, in a busy emergency department, a firehouse, or a police station, it can be easy to dismiss minor irregularities or to stay within the confines of one's own responsibilities. However, this approach can prevent us from identifying and addressing systemic issues.
Adopting a systems thinking approach requires challenging the status quo and questioning standard operating procedures and acceptable behaviors. This can be uncomfortable and even threatening. However, it is essential for developing highly reliable, fluid, safe, and effective systems. Without a deep understanding of the system's structure, mental models, and vision, we act upon systems without knowing their purpose or design. This lack of understanding can lead to errors and unanticipated consequences.
As servants of the public, we must strive to understand the systems in which we operate at a deeper level. This will allow us to identify and correct errors, and to create more effective and efficient systems. Embracing a systems thinking approach is not just beneficial, but necessary for the future of municipal management.
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IHI Open School. (2014, May 9). How Can You Apply Clinical Skills to QI? [VIDEO]. YouTube. https:www.youtube.com/watch?V=Kmh_hVwGo-Q&t=2s.
Kim, D.H. (1999). Introduction to Systems Thinking. Pegasus Communications, Inc. www.pegasuscom.com.