“You are saying,” Luke started, “that if I see friction in the system, I should look at the system, rather than trying to fix the people?”

I nodded affirmative. “You can have intelligently designed systems, if you create them. But, most systems emerge as a set of outcomes created by random behavior. Worse. Those random behaviors get repeated and become the norm.”

“But, we have standards,” Luke protested. “This is a hospital. We have to inspect and comply with those standards.

“Tell me,” I prodded. “A few years back, you made a change at your hospital. You had a not-so-intelligent system in your operating theatre that created a problem. Mortality rates in your surgical area were statistically above the norm. Even your doctors scratched their heads trying to figure this out. So, you asked your nursing staff what could be the problem. They recommended that you change your system, to make it more intelligent.”

“I remember,” Luke nodded. “We had to change our system of authority. Often, our surgeons were not washing their hands sufficiently prior to surgery. Of course, in the hospital, the surgeon has the authority for most all decisions. We changed our system to give the nursing staff the authority to question a surgeon related to hand-washing. We brought all the nurses and all the surgeons in the same room to discuss and create this new authority for nurses.”

“What happened?” I asked, already knowing the answer.

“Mortality statistically came back in line within seven days,” Luke replied.

I nodded. “You didn’t change the people, you changed the system.”