When Systems Collide

February 28, 2019


You know how weather people on the news often talk about systems colliding?


You’ll hear them talk about a hot or dry weather system coming from one direction which will cause one set of potentially uncomfortable conditions or a cold or wet system coming form a different direction which will cause a different set of potentially uncomfortable conditions. It’s usually not a big problem….until those systems collide! That’s when we have major storms of one sort of another that cause life to stop temporarily.


Anybody who runs or works in a business or organization has come into contact with systems.


Systems help us keep order when it comes to repetitive actions that are necessary to keeping things going. Systems can keep our daily functions running smoothly or can become an albatross around the necks of our employees, coworkers, and customers/stakeholders. And the devil is in the details. Sometimes we create systems that appear to solve a problem for us that unintentionally create problems for others. Sometimes our systems work just fine on their own but when they collide with the systems of other organizations, huge problems arise for those stuck in the middle.


Here’s an example:


My child attends public elementary school in an enormous school system. 


We routinely take my child to see a local pediatrician in one of the ever-growing practices that employ many doctors and have several locations. This allows for more flexibility in scheduling and the ability to be seen by a doctor urgently even when “our” doctor is not working or has a packed schedule.


At the last well check, it was discovered that my child had an underlying infection of which we were completely unaware. He had not displayed any of the usual symptoms. Much to our surprise, we walked out of our well-check waiting to be notified by the pharmacy that the antibiotic prescription was ready to be picked up. When it was finally ready to be picked up, we got it just in time to crash after what had been a long, unexpectedly busy day. So we administered the medicine, started our medicine journal and figured out when the next dose was needed. I set an alarm and gave him the medicine in the middle of the night.


The next morning, it became clear that he now would need to take the medicine for his 3rd dose right in the middle of the school day. So, when it was just before time to give it to him, I packed all of the stuff up and went to the school fully intending to be able to hand the stuff over to the nurse and have her administer it daily for the next 10 days.


What I found was that although the school has a nurse, the nurse is out for an extended period of time. There is a nurse from a neighboring school that is covering for her who comes once per day (coincidentally at the perfect time to give my child the medicine) to administer prescriptions to the students who have chronic illnesses. However, I cannot simply leave the medicine (which is fully documented with my child’s name, the medicine’s name, the dosage and the prescribing doctor’s information) for her with a note asking her to give the dose at a particular time every day until a certain day. No. There is a form. ( read system)


OK. No problem. I’ll fill out the form.




The form must be filled out by a doctor or a nurse. transition music


So now I call the pediatrician’s office asking them for an email address to which I can have the form sent so that someone in their office can fill it out and email it back to the school. No problem. I leave the school thinking that it’s all taken care of.


Fast forward a few hours. I get a call from the school telling me that the doctor’s office has informed them that they cannot fill out the form until I fill out the top of the form. (Another system) So now the school registrar is going to print the form and include it in my child’s take-home papers so that I can take care of it.


I pick up my child and take him and the forms to the doctor’s office directly. Upon looking at the form to figure out what information they need me to fill out in order to properly fill out their part, I discover that the information consists of 1. the school year, 2. the name of the school (which was in the signature of the email sending the form to them), 3. child’s name, and today’s date. I proceed to fill it out only to be told that I also need to fill out as much of the bottom ( the part labelled “FOR COMPLETION BY PRESCRIBER”) as well…. and it’s going to cost me $10 to have it filled out at all….and if I would like to guarantee that it is filled out within 24 hours it will cost me another $20. 


The form that I actually filled out.


So now I wait for the doctor’s office to get around to “filling out” this form and notifying me so I can go back and pick it up and deliver it to the school- all so that a qualified medical personnel can administer an antibiotic during the school day for the next week or so. 


You might wonder: why don’t you just go yourself like you have been?


I have done so in the past but I have classes scheduled on some days that do not allow me to take the time at the right time of day.


You might also wonder: why don’t you just wait and give it after school?


Because having grown up with a nurse for a grandmother and a father who worked in pharmaceutical research and development for 30 years, I know that timing of doses is particularly important when it comes to antibiotics. If you separate the doses by hours more or less than than the prescribed interval, you risk it not being effective and having to endure another round. This is one of the things that contributes to bugs that become antibiotic resistant. Ever heard the saying “what doesn’t kill you makes you stronger?” Well, it applies to more than human psychology. When a bug survives a round of antibiotics, it makes it stronger and able to resist that kind of drug in the future. So it’s important. The way the timing worked out this time, my child needs a third dose in the middle of the school day and honestly, it shouldn’t be that complicated. 


What made it unnecessarily complicated is not even each system but the intersection of two systems created by unrelated organizations.


You might be thinking…so what am I supposed to do about that?


Often times customers or other stakeholders in our organization get frustrated with our system. At those times, many of us double down and defend the system, assuming they just don’t want to comply. But more often than you might realize, the frustration is coming from how our system is colliding with someone else’s system. It is worth it to investigate and see what we can do to alleviate the stress of that collision that our stakeholder is caught in. After all, it’s not their fault our systems collided.


So the next time you have a frustrated person in front of you questioning why they have to use your system, you might want to look into what the real problem is. If you can tweak your system for them, you will gain relationship rewards that could just lead to increased patronage, referrals and other such benefits.


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