Presentation by Juliette Kumar, Associate Director of Education and Improvement, Innovation Agency: Seeing systems at the Maternity and Neonatal Learning System: Patient Safety Culture event on Tuesday 11 December at Haydock Park Racecourse.

1. Understanding
Systems
Juliette Kumar

2. W.E. Deming – Theory of Profound Knowledge

4. •See the whole
•See the bigger picture
•Look for connections
•Pay attention to boundaries

5. What is a system?
‘A system is a set of related components
that work together in a particular
environment to perform whatever
functions are required to achieve the
systems objective’
Donella Meadows

6. ‘Systems thinking embodies the idea that the
inter-relationships among parts, relative to a
common purpose of a system, are what is
important’
Systems Thinking Tools (2000)

7. What do you get if you cut a cow in half?

8. Systems have their own culture
For systems to work effectively it is important to see them
Language
Uniform
Rules – explicit and implicit
Access – open/closed
Feeling – warm/cold
Rules
Rewards
Power
Position

9. Understanding systems
Activity
In small groups describe the system you work in
1. What is the aim of the system?
2. Do you have a special language you use?
3. Are you an open system or closed system?
4. What are your rules? How do others find out
about them?
5. What other parts of the system do you need to
interact with in order to meet your objective?
6. How easy is it for people to ask you for what
they need?

11. These are conditions, not positions

12. Think of a time when you are as a Top/Middle/Bottom
Consider:
When you are a Top
What are you seeing/feeling/doing when things are going well?
What are you seeing/feeling/doing when things are not going well?
When you are a Middle
What are you seeing/feeling/doing when things are going well?
What are you seeing/feeling/doing when things are not going well?
When you are a Bottom
What are you seeing/feeling/doing when things are going well?
What are you seeing/feeling/doing when things are not going well?

13. •See their space as complex
•Feel the heavy weight of responsibility and accountability
•Feel isolated
•Tend to take suggestions as criticisms
•Too much to do and not enough time to do it.
•Feel they don’t get the support they need from middles.
•Feel unfairly judged by their customers/shareholders.
-Their challenge is to share their responsibility with others

14. • They tend to specialise in one area (due to complexity), and become concerned for what’s good for
their area. This leads to:
• Status differentials between Tops
• Resentment
• Turf warfare
• Relationship breakdown
• Conflicting messages sent to the organisation.

15. • Feel torn between competing interests and agendas of bottoms and tops.
• Feel weak and powerless, unsupported
• Seen by others as “wishy-washy”, indecisive
• Tend to “solve” their isolation by aligning to bottoms (become militant), or tops (coerce bottoms to
behave as tops demand).
• Burnout is common
• They see themselves as unique with little in common with others.
-Their challenge is to get tops and bottoms to engage and talk to one another.

16. • Become isolated from the other middles
• Competition with other middles for Tops’ favour, and become judgemental.
• No collective power
• Lack of co-ordination

17. • Feel invisible, powerless, oppressed.
• Things happen to bottoms
• Voices ignored.
• Don’t understand how they fit into the whole.
• Regard the tops like “Greek Gods”: fickle, capricious, decision-making bizarre at times
-Their challenge is to share/take responsibility.

18. • Unified by a dislike of Tops and Middles, they tend to behave and think as a group: “Groupthink”.
• Pressure for individuals to conform.
• Diversity and creativity is lost
• Distrust and eviction form the group of those with contrary/alternative views, or labelling them as the
“village idiot”.
• Splintering of groups can occur.

19. • Feel neglected and “done to”.
• Surprised that the system treats them as the problem.
• Receive excuses for poor service
• See system as self serving rather than being there for them

20. •The emotions we experience are clues that this “dance”
is going on.
•Our experiences are not only personal but also a
systemic phenomenon
•To change the system you must first be aware of it.