By Janice Molloy
At our 2008 conference in Boston, keynote speaker Dr. Atul Gawande kept us on the edge of our seats as he spoke about a tool shown to significantly reduce surgical complications: the checklist. Like many other participants, I had tears in my eyes as he recounted the story of a three-year-old Austrian girl who was 
brought back from the brink of death after being submerged in an icy fishpond--all because the rescue team followed a checklist to guide and streamline their response.
Not surprising, Dr. Gawande garnered stellar reviews from participants. But in the feedback on his talk, while praising the presentation, a handful of people commented that the checklist concept seemed simplistic or not applicable to their industry. Anyone who runs events learns not to take isolated comments too much to heart, but I did wonder, had we been off base in thinking that Atul's work would be relevant to the complex challenges of our cross-sectoral audience?
Gawande's recently released book, The Checklist Manifesto: How to Get Things Right, puts to rest any concerns I might have had about the general applicability of this approach. In the book, he shows how people in occupations as diverse and complex as building skyscrapers to flying jumbo jets to evaluating multi-million dollar investments use checklists to make "the reliable management of complexity a routine." As he states, "Even the most expert among us [in virtually any endeavor] can gain from searching out the patterns of mistakes and failures and putting a few checks in place."
How often do we identify "patterns of mistakes," come up with fixes, and then fail to change our behavior? According to Gawande, the checklist provides both a discipline and a structure for capturing those learnings, embedding new routines, and continually evaluating their effectiveness. Far beyond a static collection of "to dos," at its best, this kind of resource reflects ongoing, systemic learning.
It also, interestingly, supports open communication and collaboration. Through examples from many different industries, Gawande shows how, rather than being a set of instructions dictated from above, a well-constructed checklist "pushes power out of the center" and gives professionals room to adapt and respond, based on their experience and expertise. Through trial and error in his own operating room, he found that having the circulating nurse, not the surgeon, kick off the checklist sends the message that every member of the team is responsible for the success of the surgery and has the power--and the obligation--to question the process at any point.
It's easy to see the checklist as something "other people" should use--people in other professions or with other job requirements. But Atul argues that, by using checklists, we can improve our outcomes without improving our skill, without "working harder and harder to catch the problems and clean up after them." He observes, "The checklist gets the dumb stuff out of the way, the routines your brain shouldn't have to occupy itself with . . . and lets it rise above to focus on the hard stuff."
Obviously, a checklist isn't a silver bullet--it can't solve deep-seated structural issues in an organization or an industry. Unless users regard it as a living, evolving tool, it runs the risk of becoming just another task. But taken as a way to identify and potentially eliminate failures before they happen, the checklist shows a lot of untapped promise. We're working on ours here at Pegasus; what about you?
Janice Molloy is content director of Pegasus Communications, managing editor of The Systems Thinker newsletter, and program director of the annual Systems Thinking in Action conference.
photo of Atul Gawande by Sarah Viera
by Vicky Schubert
We huddle together in the tiny, darkened room, waiting with breathless anticipation for the characters we've created to appear on the giant screen at the front of the theater. How grand they'll be!
First, we'll see the Noble One. With his classic good looks, intelligence, and eloquence, he'll embody all our hopes. He'll movingly remind us that we've emerged from our emotional adolescence to embrace a post-racial society. Cool as a cucumber, he'll take on the enormous challenges of our time, healing our differences and single-handedly delivering better education, better healthcare, a stable climate, and a world at peace.
As soon as he falters and we begin to feel like he's selling us out to the Wall Street moguls and special interests (forgetting that it was we who created him), we will send in the Righteous Gunslinger. Affable and sincere, he'll take no prisoners. He'll embody our outrage at being underestimated and he'll single-handedly return the People to power. We can see that he's flawed--not too flawed, mind you, just flawed enough to be one of us. He drives a truck. Yeah, that's a nice touch.
The projector whirrs into action, and we smile expectantly as the feature starts to roll. But what's this? In the chaotic barrage of images that fills the screen, we strain to follow the plot. Through bone-crushing Dolby sound we can barely discern our original heroes.
We're taken at breakneck speed from one scene to another. The camera manically pans urban streets and wild landscapes. We see utility grids, manufacturing plants, the blur of a stock market trading floor, and a crater-pocked battlefield. We hear undecipherable deals being hashed out in boardrooms and back rooms. Buildings are tumbling, bodies of the sick and dying lie in piles around us. Shouts of panic ring out in hundreds of different languages. Children run toward us with outstretched hands, and angry mobs point fingers of blame.
There's too much going on here! Who are the good guys? Who are the bad guys? What happened to our heroes?! Rewrite!
We turn off the projector. Someone hits the lights and, dumbstruck, we look around at our fellow projectionists. After a long silence one of us speaks up. "We need to create better heroes, folks. Things have gotten way too complicated for these guys to fix." Another long silence. "Maybe it's not about heroes," one small voice offers. "Let's just talk for a few minutes about what really matters to us. Maybe that's where we start."
Vicky Schubert is marketing director at Pegasus Communications.
By Vicky Schubert
As you read the many "decade in review" lists that have popped up like mushrooms across the media, do you see what I see? The theme that jumps out from story after story is that complexity and interdependence have rightly come to dominate our understanding of life on earth.
From the tsunami in Southeast Asia to Hurricane Katrina; from extremist aggression and war in Iraq and Afghanistan to internecine conflict in Rwanda, Darfur, Burma, Georgia, and beyond; from global climate change to the spread of the H1N1 virus; from financial meltdown to the reshaping of world markets--we are growing more adept at recognizing the extensive systems that link our actions and experiences with those of others, both near and far. There is no denying that complexity is here to stay all around our shrinking planet and in the problems we encounter at work every day.
Here's a little perspective on complex challenges from three great systems thinkers, lost over the past 10 years, whose wisdom will be with us forever. They encourage us to increase our potential for effective action by broadening the ways in which we see and learn.
From Barry Richmond
"The easiest problems to solve are 'local' both in space and time. If you tip over a glass of milk, there really is no need to cry. The spill will confine itself to a relatively small area. And, spilled milk doesn't stain. So, you simply fetch something absorbent, plop it down, soak up and then discard the errant booty. No traces. No remorse. No problem.
Now consider spilling either radioactive waste, 'the beans,' or 'your heart out.' Each of these 'spills' will have far broader and long-lasting consequences than spilled milk. And, in each case, the consequences ramify far from their point of origin in both space and time. They affect not just the 'spiller' and the immediate area. The impact no longer is 'local.' Indeed, applying local solutions to far-reaching spills usually only serves to make things worse both locally and distally.
As our personal relationships, technologies, jobs, institutions and communities continue to grow increasingly complex and interdependent, the occurrence of 'spills' will increase. At the same time, the chances of any spill remaining 'local' diminish. Almost any 'fix' that we implement reverberates through a web of interconnections, producing a wave of counter-reactions that are widely distributed in both space and time. Only by increasing our appreciation for the growing 'systemicness' of our reality, can we begin to function as responsible web-mates, and can our social institutions (from families, to corporations, to governments) achieve some modicum of effectiveness and stability. As interdependency increases, we must learn to learn in a new way."
From Russ Ackoff
"The only problems that have simple solutions are simple problems. The only managers that have simple problems have simple minds. Problems that arise in organizations are almost always the product of interactions of parts, never the action of a single part. Complex problems do not have simple solutions."
And . . .
"All of our problems arise out of doing the wrong thing righter. The more efficient you are at doing the wrong thing, the wronger you become. It is much better to do the right thing wronger than the wrong thing righter. If you do the right thing wrong and correct it, you get better."
From Donella Meadows
"For those who stake their identity on the role of omniscient conqueror, the uncertainty exposed by systems thinking is hard to take. If you can't understand, predict, and control, what is there to do? Systems thinking leads to a conclusion [that becomes] obvious as soon as we stop being blinded by the illusion of control. It says that there is plenty to do, of a different sort of 'doing.' The future can't be predicted, but it can be envisioned and brought lovingly into being. Systems can't be controlled, but they can be designed and redesigned. We can't surge forward with certainty into a world of no surprises, but we can expect surprises and learn from them and even profit from them. We can't impose our will upon a system. We can listen to what the system tells us, and discover how its properties and our values can work together to bring forth something much better than could ever be produced by our will alone. We can't control systems or figure them out. But we can dance with them."
Learning to learn in new ways, doing the right thing, dancing with systems--aren't these bracing ideas to reach for when we find ourselves wishing things were simpler and knowing that they can't be?
Vicky Schubert is marketing director at Pegasus Communications.
by David W. Packer
Dear President Obama, Senators, Congressional Representatives, and Interested Citizens:
In these momentous times, the debate in the United States on the financial stimulus and other economic policies continues to heat up as weeks pass and frustration grows. Actions have been taken but results to date are largely underwhelming. In an earlier post, I talked about the importance of time delays in systems. Once a policy (like "stimulus") has been put in place, clear and visible results almost always take much longer to appear than we expect. The current heat and frustration is, I think, largely a direct result of unrealistically short time expectations.
The period when delays are active is particularly hazardous, because there is little or no visible feedback to reveal the growing impact of our actions. Not recognizing the lag times in complex system structures, many are likely to draw erroneous conclusions. They say things like, "See, nothing is happening, so we must do something else/or more/or give up entirely." Valuable programs are abandoned prematurely, and new ones formed that will likely suffer the same fate. Even worse, most likely to survive are quick fixes that undermine any progress that has been made and produce no enduring advances.
The period we are in now, as we wait for compelling evidence of success or failure of different initiatives, is one of those times when the hazard is huge and uncertainty prevails. This is a perfect storm for error, for stopping good actions or for pulling high-leverage levers but in exactly the wrong direction (as Jay Forrester warned about long ago).
So, with opportunity rife and risk ever present, let's take out our systems lens, look at patterns, think realistically about time delays and system structure, resist jumping to conclusions, and improve our ability to know when enough feedback has emerged from the delay "pipeline" to guide us toward the future we want to create.
I know this is hard to do in a highly charged political environment, as it is for us in everyday life. But the results will benefit us all, and the learnings will endure, I guarantee.
Sincerely,
David W. Packer
David W. Packer is founding partner of the Systems Thinking Collaborative, veteran of the MIT System Dynamics Group and of Digital Equipment Corporation, grandparent of eleven, Ginny Wiley's spouse, and a Red Sox fan, among other things.
by Janice Molloy
On September 18, the University of Alabama board of trustees approved a new research center at its Huntsville campus to study systems thinking in government and industry. In a statement, UAH said that the Center for Systems Studies will conduct research into "the many complex ways that technology, nature, people and society interact so that the workings of an engineered solution are more predictable and more desirable." Former NASA Administrator Mike Griffin will head up the center, which UAH says is the first of its kind in the U.S.
According to The Huntsville Times, Griffin, who is UAH King-McDonald Eminent Scholar and a professor of mechanical and aerospace engineering, stated that "Small system failures might create inefficiencies and frustration for us in our daily
lives. Large system failures, however, imprint on our collective memory stories of personal tragedies and our vulnerability as a nation." Some of the examples of major system failures cited in the UAH statement include the Three Mile Island nuclear accident and the space shuttle Challenger and Columbia disasters.
UAH President David Williams indicated that, through the center's work, "UAHuntsville will offer both solutions and 'systems-smart graduates.'" The center will be funded through contracts and grants from government and corporate clients. Its staff will include current UAH faculty, adjunct staff from local institutions, and graduate students.
Janice Molloy is content director of Pegasus Communications and managing editor of The Systems Thinker.
photo of Three Mile Island, courtesy U.S. Department of Energy
By Janice Molloy
As in most places, summer in New England means an extravagance of local produce. Even my veggie-phobic son can't turn down a farm-fresh ear of corn, carrot, or handful of green beans. It was against this backdrop of abundance that I recently read Michael 
Pollan's lastest book, In Defense of Food: An Eater's Manifesto--a systemic look at the evolution of the "Western diet" and its devastating effect on the health of people and planet alike. Pollan's sobering analysis is a stark illustration of the dangers of reductionist thinking as well as a call for a more holistic approach to diet and health.
No one denies that obesity and diabetes have skyrocketed in the U.S over the past several decades. Some might argue that this trend reflects a failure of individual self-control. But Pollan points to several larger factors, including U.S. dietary guidelines from the late 1970s that promoted "healthy" carbohydrates over "unhealthy" fats; a rise in the consumption of processed foods; and an emphasis on the nutrients in foods to the exclusion of foods as a whole.
This last item stems from what Pollan calls "nutritionism," a belief that "food is not a system but the sum of its nutrient parts." The implications of this paradigm are huge. When nutrition scientists break food down into its constituent parts, study them one by one, and deem an element to be vital for my health, it doesn't matter whether I get it from a crisp green salad or a bag of highly processed, fortified corn chips. As Pollan states, "a notorious junk food [can] pass through the needle eye of nutritionist logic and come out the other side looking like a health food."
Pollan quotes New York University nutritionist Marion Nestle: "The problem with nutrient-by-nutrient nutrition science . . . is that it takes the nutrient out of the context of the food, the food out of the context of the diet, and the diet out of the context of the lifestyle." So, for instance, for many years, health experts have been perplexed by the "French paradox": the fact that French people suffer a relatively low incidence of coronary heart disease while consuming a diet that is rich in saturated fat. Scientists have searched for the magic bullet--Is it the red wine? The fish? The foie gras?
Holism, the opposite of reductionism, recognizes that a thing can have properties as a whole that are not explainable from the sum of its parts. The French--and Italian and Greek and Japanese and Indian and Mexican--paradox may result from a synergy of factors, including the ingredients used, portion sizes, savoring of meals with friends and family, amount and type of exercise people get, and other, less obvious variables. Unfortunately, as much as we might like to package healthfulness in an energy bar or vitamin pill, it doesn't seem to be that easy.
Pollan concludes the book with a set of general guidelines for escaping the harmful effects of the Western diet. Most of them are common sense, such as shopping the peripheries of the supermarket and avoiding the processed crackers, cookies, and chips that fill the middle. Some demand more effort, like doing all of your eating at a table--a discipline that can be challenging in today's go-go world.
None of these behavioral shifts rise to the level of large-scale systemic change--something I'd love to see Pollan tackle in a future book. By making smart individual choices, we may not make much headway against the rising tide of obesity, diabetes, heart disease, and cancer in our culture. But we can improve our personal health and well being--and eat some fabulous meals in the process.
Janice Molloy is content director of Pegasus Communications and managing editor of The Systems Thinker.
Cabbage photo by Nancy Daugherty
By Jon Bergstrom
We sometimes find ourselves in situations where we recognize that things are not going the way we want them to go. This can be a work situation or a personal/family relationship. Our recognition leads us to look for ways to make changes.
Gaining Understanding
There are often numerous and complex reasons that things are not going well. Systems thinking principles and concepts help us gain understanding. They also offer some hope for a way out. Here are a few things to consider:
1. The system is perfectly designed to deliver what we are getting. We may not understand why, but unless we change something, we will continue to get about the same results. High-leverage strategies are needed for change. We can seldom find these on our own.
2. We are often confused about what changes to make or suggest because of the complexities of the situation. For example:
- There are often long time spans between cause and effect.
- People in the system have significantly different mental models about how things work or should work.
- There are commonly very different levels and kinds of emotions present in the system.
We need to consider if these complexities are present.
3. We often attempt to apply simple solutions that do not work or work for only a short time. Be cautious if the solution looks easy.
4. One simple solution we often employ is to attempt to talk people into thinking or acting in a new way (our suggested way). This often fails for lack of enthusiasm or agreement. People can also feel bullied. Recognize that our own patterns of behavior can sometimes prevent the system from adopting the very suggestions we have for "improvements."
Reflecting on Our Role in the System
One way to begin our understanding of the system is to consider our own role in maintaining it as it currently exists. While everyone plays an important role, when we reflect on our part in the system, we begin to recognize our leverage for creating change. We may or may not be able to shift our patterns of behavior, but we will have a different (and likely a better) view of the situation.
The following is a suggested process for reflecting on our patterns of behavior and the impact that these have in maintaining the system:
1. Write a story in the third person about yourself as you operate in the system.
2. Write your reflections on the following:
- What familiar patterns do you recognize (what are you likely to do the next time given the same circumstances)?
- What is the payoff for you for using these patterns (what is positive for you in using these patterns)?
- What is the cost to you and others for continuing to use these behaviors?
3. Consider how you might revise these patterns of behavior to increase the payoff and decrease the cost. This step recognizes that it is often difficult to change or get rid of patterns of behavior that are entrenched. However, we may be able to recognize better ways to use these patterns to get different (and presumably better) results.
photo: Nancy Daugherty