The next topic I'd like to talk about is Reductionistic Thinking versus Holistic Thinking. Both are important, and it's important to think about how these things work together to really understand systems thinking. Reductionistic thinking, it focuses on an error itself. It focuses on a very narrow aspect of a larger whole. The question regarding the apparent immediate cause or it answers questions regarding the apparent immediate cause of how an error occurred. So let me give you an example. A nurse gave an incorrect medication of a dose to a patient because she didn't read the medication label. In reductionistic thinking, we might narrowly focus on that very last step and will likely come up with a fix, telling the nurse, "Be more careful and make sure you read the label next time." That might be the fix. Let's consider that same example and use holistic thinking. As an aside, it is important for the nurse to read that label but she could have been distracted as you'll see in a second. In holistic thinking, what we do is we will review an error or a system component by considering that step at which an error occurred as part of a larger hole. We'd consider how other central parts of the system contributed to that error or problem. And in holistic thinking, we answer the question why an error occurred not just how. So going back to that same example, a nurse gave an incorrect dose of a medicine to a patient. In holistic thinking what we might do is approach the issue of staffing patterns. Was the nurse on a triple shift? Is there adequate staffing for the demand.? How about the order entry system, is that useful to the prescriber, the nurse, the pharmacist and everyone else? It may be that that added some confusion leading to that error. Maybe the medication label was very very small. Maybe staff wasn't trained properly. Maybe drug procurement. Maybe we had an opportunity to purchase two drugs that don't look the same, and yet we purchased two drugs that looked very very similar increasing the chance of an error. I'd now like to turn and tell you a little bit about Russell Ackoff. As an aside, I had the wonderful privilege of working with Russell, Dr. Ackoff, about 16 years ago. He had come to Johns Hopkins Hospital to help us redesign our medication use system and his teachings were wonderful. He gives fantastic lectures on systems and systems thinking. So if you can, not required for this program, but if you can go to YouTube, look up Russell Ackoff and the lecture that he performed or provided at Hopkins as he's provided many many different places and they've often separated it into three or four parts, it's about an hour long. Your time would be very well spent listening to Russell Ackoff's lecture on systems thinking. Very very important. He has a number of really important teachings. The first one is here on the screen, and what he says is over 90 percent of problems that arise in a corporation are better solved somewhere other than where the problem appears. And why is that? Because the central system parts interact with one another, so it may be that we have to fix something distal or away from where the error actually occurred. Here's of other some important points. Complex systems have many essential parts. So in a hospital setting and on your screen here is just a very, very partial list: information technology, nurses, environmental services, pharmacists, physicians. Boy, that list goes on and on. And, it's important to also realize that essential parts aren't static. We might upgrade our information technology system or maybe we've changed the pattern within one of our professional groups. Well, any of those changes will have impact on other essential parts that we have to keep in mind. Also focusing on the output of the whole. Again, in our situation the whole is our healthcare system or our hospital, and it's important remember that no one part can independently provide the output of the whole. So we may have a world renown neurosurgeon that does phenomenal procedures but that output isn't going to be very good if that person isn't supported by environmental staffing, by nursing, by pharmacists making sure that the medicines are there when they need them, by anesthesiology, and by the technology supporting that surgeon. So, no one in central parts can create that whole and in our case, the output of our whole is excellent patient care and teaching and research. So no one part can provide that output. Output is not the summation of the outputs of each part, but rather the output of the whole is determined by the interaction of its central parts. The last point here is consequences of holistic thinking. I've alluded to some of these before but I want to reemphasize it, and that is the performance of a system is not necessarily improved when the performance of each individual part is improved, if the performance of each department of an organization is improved, the organization may not be improved. Consider the "BEST CAR" example I gave previously.