System overload

Under stress, including conditions of overload, systems degrade in a predictable manner.  


What does this look like?

Let’s follow the diagram starting at the left.

  • At very low stress (minimal load with excess capacity) performance is often sub par. There is an absence of urgency and little incentive to get to work.  This may be accompanied by a sense that nothing can go wrong.
  • As demand increases, output steadily increases without problems with quality or safety. This increase continues as long as the demand and system resources remain in balance.
  • At optimal demand, output is at or near the best possible quality, and is consistent.  It is important to remember that when resources are being fully used at optimal load or demand, there is no surge capacity. In this setting, any increase in demand will predictably overload the resources and problems of quality or safety will occur.
  • As load or demand begins to exceed the capacity of the system, output increases briefly.  This comes at a cost, usually in the form of errors, slipping quality, burnout, and poor morale.
  • If load or demand continues to outpace the capacity of the system, both the quality and quantity of output starts to decrease.  The decrease in quality is easy to understand: haste makes waste. People take short cuts and skip steps. Equipment malfunctions or breaks. Quality control takes second place after quantity targets. As performance degrades, quantity suffers as well: time and energy are spent fixing (or hiding) mistakes. Mildly defective output remains acceptable, but the system increasing produces output that is so defective that it is discarded, wasting the time and resources involved in its creation. Haste definitely makes waste.  People lose respect for the process, the product and themselves.

The general shape of this curve is quite predictable, but the specifics of timing are not.  System overload is often characterized by prolonged periods of considerable decay that flies under the radar - especially in industries where the workers are highly motivated and able to compensate. Measuring just the output without assessing the health of the process itself (the standard approach in management) means that problems only come to light after a tipping point is reached. Decay and collapse are like walking on thin ice: the danger is there but nothing happens until it gives way. When it gives way, it gives way spectacularly, often with catastrophic results.

Many areas of medicine, and definitely primary care, are operating in the realm of chronic systems overload, focused excessively on the volume of output or fairly meaningless faux-quality metrics, with clinicians and office staffs struggling to patch their sinking ships. The antidote would be to add slack to the system: more resources, slower pace, replacing prescriptive rigid rules with adaptable guiding principles, encouraging flexibility, and fostering innovation and creativity at the margin instead of centrally driven standardization.  I don’t see that happening.


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