Page 7 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

Introduction

“A bad system will beat a good person every time.”
- w. edwards deming

Dr. Deming is often quoted to encourage physicians and other

professionals to recognize that even the most well-intentioned action
can fail due to an ineffective system. It is an attempt to get people to
understand the importance of the system and the futility of trying to

focus on blaming people for failures. Deming also said, “We are being

destroyed by best efforts. Trying harder to do what you understand as
your job, when a system is broken, often results in more damage.”
1

For physicians and other clinicians, it can be devastating to learn that
a patient suffered harm from a preventable systems failure. Clinical risk

management is a top concern among healthcare providers, hospital
systems, and other health organizations. The risk environment is

continually evolving, requiring an ever-shifting focus and anticipation of
new risk. One component of successful risk management tends to remain

the same – designing and maintaining effective systems, such as tracking
test results, tracking patient notification, reducing patients lost to follow-

up, preventive screening, therapeutic monitoring, and managing missed
appointments and referrals. These systems reduce the likelihood of risk

issues associated with delayed or missed diagnosis which may result in
devastating consequences. Everyone who works in a hospital or clinic

encounters these risk issues, and often, the challenge is to recognize
ineffective (or nonexistent) systems and be able to respond accordingly

to minimize the impact of an unsafe situation or environment. Sounds

1 https://deming.org/a-bad-system-will-beat-a-good-person-every-time/

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