Healthcare systems, like family relationships, are extraordinarily complex. When things go right it is usually because of the coordinated actions of various individuals, departments and systems interacting to create that result. When things go wrong, it is usually because we don't see how our actions affect the other systems, departments, and individuals. Healthcare, by its very nature, tends to be event-focused. Our patients typically don't seek our services until an event has happened, like a car accident or a sharp pain or a positive result on a routine test.
Structure produces behavior.
Our reactions and explanations surrounding the event tend to be short term, even though, in reality, the event occurred as part of a multi-leveled system involving complex, dynamic interactions among many individuals on each of those levels. Our response to system-wide failure . . . Declining systems, like families under stress, often slip into survival mode. In this mode we realize that our resources are inadequate to cope with present realities, but we continue to do everything as we have in the past. Inevitably, we are less effective and failures occur.