WEBVTT 1 00:00:00.000 --> 00:00:07.240 Well, good afternoon. Welcome. My name's Brenton Caffin. I'm the CEO of the Australian Centre for Social Innovation. 2 00:00:07.680 --> 00:00:11.340 I'd like to welcome you to today's session, Drift Into Failure with Sydney Decker. 3 00:00:11.920 --> 00:00:19.400 And it's fantastic to see yet another full house and so many people coming out to check out ideas on this lovely day. 4 00:00:19.580 --> 00:00:27.600 A little bit of housekeeping before we start. If you have mobile phones, could you please turn them off or set them to silent during the presentation? 5 00:00:29.000 --> 00:00:32.540 You are most welcome to tweet, which means you probably need to keep your phones on. 6 00:00:33.280 --> 00:00:41.140 And the address for those who are tweeting is at Ideas Adelaide and our hashtag is hash AFOI. 7 00:00:42.480 --> 00:00:49.540 Today's presenter is Sydney Decker, who is the Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University. 8 00:00:50.000 --> 00:00:55.520 And the former Director of the Leonardo da Vinci Laboratory for Complexity and Systems Thinking at Lund University, Sweden. 9 00:00:56.400 --> 00:00:57.480 Sydney Decker. 10 00:00:57.600 --> 00:01:01.700 He's a PhD, has also lived and worked in the Netherlands, New Zealand, the US, the UK and Singapore. 11 00:01:02.340 --> 00:01:04.880 Recently active as a part-time airline pilot. 12 00:01:05.720 --> 00:01:06.600 Jumbos, Sydney? 13 00:01:08.440 --> 00:01:08.880 737s. 14 00:01:09.480 --> 00:01:10.700 He's also a prolific author. 15 00:01:11.080 --> 00:01:17.540 One of his latest books is titled Drift Into Failure, From Hunting Broken Components to Understanding Complex Systems. 16 00:01:17.760 --> 00:01:21.800 And it's on the basis of this book that we were delighted to invite him to Adelaide to speak. 17 00:01:22.020 --> 00:01:23.720 And I'd ask you to welcome him to the stage. 18 00:01:28.760 --> 00:01:30.640 Good afternoon Adelaide. 19 00:01:31.820 --> 00:01:33.900 It is good to see so many people. 20 00:01:34.000 --> 00:01:42.180 I am not going to talk about complexity theory as a set of master equations, which we won't find anyway, by the way, because it's not so enticing. 21 00:01:42.400 --> 00:01:51.940 I want to do this by telling you some stories that perhaps illustrate the need to think in terms of complexity. 22 00:01:52.220 --> 00:01:53.740 Let me give you one such story. 23 00:01:54.880 --> 00:01:57.580 It is actually from a case. 24 00:01:57.600 --> 00:02:02.300 It's a case that shows up in another book of mine about a child protection case gone awry. 25 00:02:03.440 --> 00:02:07.800 There's a one-year-old girl in a country very much like Australia. 26 00:02:08.900 --> 00:02:15.700 And the one-year-old girl shows some signs of neglect and abuse and the state decides to intervene. 27 00:02:16.240 --> 00:02:19.020 The state takes the child out of family care. 28 00:02:19.520 --> 00:02:27.580 But then the child is returned to the family after a while without the necessary paperwork for that having been logged in. 29 00:02:27.600 --> 00:02:32.120 And without notification of what's called child protection council. 30 00:02:32.500 --> 00:02:41.500 Now, a social worker then shows up a couple of times, visits the family, checks in with the mother and finds nothing to report. 31 00:02:43.000 --> 00:02:45.300 So the child stays with the family. 32 00:02:46.780 --> 00:02:52.060 After a while, as they do, the social worker goes on sick leave. 33 00:02:54.100 --> 00:02:56.360 It takes months for a replacement to be found. 34 00:02:58.500 --> 00:03:10.680 The replacement social worker, who comes in after a few months, sees the family, finds a child that is in need of some serious TLC, tender love and care. 35 00:03:11.240 --> 00:03:13.400 And she tries to draw up a plan for the mother. 36 00:03:13.580 --> 00:03:16.800 As in, don't feed her chips, you know, for breakfast. 37 00:03:16.920 --> 00:03:18.680 That might not be an entirely wise idea. 38 00:03:18.880 --> 00:03:21.060 Do bathe her once a week, you know, that might... 39 00:03:21.060 --> 00:03:23.560 A plan, basically, for how to manage a young child. 40 00:03:24.080 --> 00:03:26.180 The mother never manages. 41 00:03:26.180 --> 00:03:29.600 The child starts to fall behind in language. 42 00:03:29.940 --> 00:03:32.420 And she starts looking a little blue in the face. 43 00:03:32.740 --> 00:03:36.040 By this time, she is almost three years old. 44 00:03:37.680 --> 00:03:43.440 Then one day, the police stops a car on another trigger. 45 00:03:44.360 --> 00:03:50.720 In the car, which is driven by a gentleman, they find the body of the little girl. 46 00:03:51.560 --> 00:03:53.460 It is wrapped in a shower curtain. 47 00:03:54.440 --> 00:03:56.160 And her stepfather was driving the car. 48 00:03:56.180 --> 00:03:59.800 He was on his way to dump the body in a wood just outside of town. 49 00:04:00.960 --> 00:04:04.620 The little girl had a rag stuffed down her throat. 50 00:04:06.280 --> 00:04:08.540 Her mother put it there to stop her from crying. 51 00:04:08.780 --> 00:04:11.660 She'd be shoved under a bed and left there to perish. 52 00:04:14.880 --> 00:04:16.900 How do you respond as a country? 53 00:04:17.460 --> 00:04:26.160 How do you respond when one of the systems that we set up, that we give the confidence to deal with, 54 00:04:26.160 --> 00:04:29.320 deals with these things well and not end up with dead children, 55 00:04:30.320 --> 00:04:32.880 when a system like that delivers failure? 56 00:04:33.400 --> 00:04:34.460 How do you respond? 57 00:04:34.740 --> 00:04:36.360 What is the right thing to do? 58 00:04:37.520 --> 00:04:39.140 Well, this country had the solution. 59 00:04:39.320 --> 00:04:40.260 You know what they did? 60 00:04:42.700 --> 00:04:43.820 Ah, you're good. 61 00:04:44.560 --> 00:04:45.980 Oh, they do that here too. 62 00:04:46.020 --> 00:04:46.800 Are you a social worker? 63 00:04:47.060 --> 00:04:47.180 No. 64 00:04:49.560 --> 00:04:52.200 Not only did they blame the social... 65 00:04:52.200 --> 00:04:52.620 Well, which one? 66 00:04:52.640 --> 00:04:53.520 Because there were two involved. 67 00:04:53.820 --> 00:04:54.780 Which one would it be? 68 00:04:56.160 --> 00:04:58.920 The second one, the replacement social worker. 69 00:04:59.180 --> 00:05:00.440 Would you like to do my talk? 70 00:05:02.560 --> 00:05:08.260 The replacement social worker was charged with second degree manslaughter. 71 00:05:09.860 --> 00:05:15.780 Second degree manslaughter because she would have neglected obvious signs of abuse. 72 00:05:16.360 --> 00:05:21.720 Now, the obviousness of these signs, as we all know, are only there to see in hindsight. 73 00:05:21.860 --> 00:05:26.140 You got a dead girl, well, obviously, you know, all of a sudden, all the signs become quite palpable. 74 00:05:26.160 --> 00:05:29.660 You know, you're a path dependent and we're very able to draw the line from A to B then. 75 00:05:30.420 --> 00:05:33.840 But when you're visiting, what, 26 families, right? 76 00:05:33.920 --> 00:05:34.940 That's your caseload. 77 00:05:35.020 --> 00:05:37.300 This becomes a completely different issue. 78 00:05:37.520 --> 00:05:49.480 Now, the claim I want to make is not only that such judicial responses in the wake of system failure are deeply unfair and very counterproductive. 79 00:05:49.760 --> 00:05:53.140 And let me just elaborate on that for a little sidebar. 80 00:05:53.940 --> 00:06:00.740 Counterproductive in the literal sense that what do you think the response of all the other social workers is at that point? 81 00:06:01.400 --> 00:06:02.180 What do they do? 82 00:06:03.820 --> 00:06:05.560 Well, some resign, obviously. 83 00:06:05.820 --> 00:06:07.880 They say, well, to hell with this, right? 84 00:06:07.940 --> 00:06:13.840 If this is the reward that I get for doing this job, which, by the way, in the West is significantly underfunded. 85 00:06:13.900 --> 00:06:15.660 It is very low status work. 86 00:06:15.820 --> 00:06:18.980 And we have the highest expectations, right? 87 00:06:19.060 --> 00:06:20.520 But we're not willing to pay for them. 88 00:06:21.320 --> 00:06:22.420 So some resign. 89 00:06:23.140 --> 00:06:28.540 But the others who stay at work, what do they do as soon as a kid, as much as burps? 90 00:06:28.900 --> 00:06:30.220 Ooh, a burp. 91 00:06:30.240 --> 00:06:39.540 Better take you out of care because you need to be put in care of the state because we need to intervene early because if I don't and the kid ends up dead, I end up in jail. 92 00:06:40.280 --> 00:06:40.800 Right? 93 00:06:40.860 --> 00:06:45.020 So the criterion for intervening shifts forward dramatically. 94 00:06:45.700 --> 00:06:48.240 Now, you know what happened in this country the year after? 95 00:06:49.520 --> 00:06:53.120 100% increase in kids taken out. 96 00:06:53.120 --> 00:06:54.160 100% increase in kids taken out of family care. 97 00:06:55.780 --> 00:06:56.940 It wasn't Texas. 98 00:06:57.120 --> 00:06:58.940 It was a much more developed place than that. 99 00:07:02.060 --> 00:07:04.360 A place without the death penalty. 100 00:07:04.660 --> 00:07:07.280 It was actually my own country, the Netherlands. 101 00:07:07.580 --> 00:07:08.480 I'm Dutch. 102 00:07:08.580 --> 00:07:09.200 I'm from Amsterdam. 103 00:07:09.460 --> 00:07:10.700 And this was in my own country. 104 00:07:10.840 --> 00:07:14.320 Which, you know, perhaps puts a different twist on it. 105 00:07:14.520 --> 00:07:22.620 And comparing me with Texas, by the way, I talk like a Yank because that's because if I talk like an Australian, it sounds like I'm making fun of all of you people. 106 00:07:23.620 --> 00:07:24.200 You know? 107 00:07:25.200 --> 00:07:25.600 So... 108 00:07:28.600 --> 00:07:29.000 Right. 109 00:07:31.800 --> 00:07:34.620 When you're from Queensland, I learned this yesterday, you can't win. 110 00:07:34.820 --> 00:07:35.760 Is that correct? 111 00:07:37.180 --> 00:07:38.900 And you're always laughing somehow. 112 00:07:40.720 --> 00:07:44.700 But I've only been from Queensland for the last eight months so I can still fudge that one a little bit. 113 00:07:44.780 --> 00:07:45.340 I'm still a guest. 114 00:07:46.020 --> 00:07:46.420 Okay. 115 00:07:46.460 --> 00:07:47.980 My storyline is completely screwed up. 116 00:07:48.100 --> 00:07:48.580 Where was I? 117 00:07:49.240 --> 00:07:52.520 100% increase in the kids taken out of family care. 118 00:07:52.520 --> 00:07:56.780 And of course these kids end up in all kinds of other types of care. 119 00:07:57.180 --> 00:07:58.980 Institutional, foster families. 120 00:07:59.280 --> 00:08:02.380 And this may be very good for children. 121 00:08:02.520 --> 00:08:10.720 But we also know that foster families in state care can be the sites of troubled childhoods, of sexual abuse, of various other ills and problems. 122 00:08:11.040 --> 00:08:16.880 And of course if you have that much pressure to get foster families, what happens to the standard of them? 123 00:08:17.020 --> 00:08:19.700 I mean getting foster families to show up in the first place is hard. 124 00:08:19.840 --> 00:08:20.020 Right? 125 00:08:20.140 --> 00:08:20.580 So... 126 00:08:20.580 --> 00:08:23.200 The standard may go down there as well. 127 00:08:23.660 --> 00:08:28.300 Now, so if you look at this case from a consequence ethic point of view, it's not very smart. 128 00:08:29.020 --> 00:08:29.460 Right? 129 00:08:29.520 --> 00:08:33.940 Because you create consequences later on that you as a society will have to deal with again. 130 00:08:34.980 --> 00:08:46.380 Now, what I want to claim here is that these sorts of responses and that these are natural, in fact so natural that they spontaneously emerge from the audience. 131 00:08:46.480 --> 00:08:48.220 Oh, they probably blame the social worker. 132 00:08:49.940 --> 00:08:58.360 We seem to replicate a very Newtonian, what I call in this book, a very Newtonian idea of how our complex systems fail. 133 00:08:59.500 --> 00:09:01.280 Newtonian in various senses. 134 00:09:01.600 --> 00:09:08.740 First of all, of course Newton proposed that we can understand systems by understanding the parts that they're made up of. 135 00:09:08.920 --> 00:09:09.160 Right? 136 00:09:09.200 --> 00:09:12.160 If you understand the behavior of the part, you can understand the behavior of the system. 137 00:09:12.600 --> 00:09:16.360 Failure of the system reduces to failure of the part. 138 00:09:16.580 --> 00:09:18.100 That's social services. 139 00:09:18.100 --> 00:09:20.600 Eventually ended up killing this child. 140 00:09:21.120 --> 00:09:27.080 Is merely and entirely reducible to one social worker who didn't stare hard enough. 141 00:09:27.440 --> 00:09:29.620 Should have looked a little more carefully. 142 00:09:30.100 --> 00:09:30.740 Oh, is that blue? 143 00:09:31.040 --> 00:09:31.240 Hmm. 144 00:09:31.500 --> 00:09:31.900 Right? 145 00:09:31.980 --> 00:09:34.660 If only this social worker had done this or that. 146 00:09:34.900 --> 00:09:36.280 Zigged versus zagged. 147 00:09:36.320 --> 00:09:38.360 Then this child would still be alive today. 148 00:09:39.100 --> 00:09:42.580 Failure of the system reduces to the failure of the part. 149 00:09:42.760 --> 00:09:44.480 And that is the end of the story. 150 00:09:45.240 --> 00:09:46.860 I've called this in another book. 151 00:09:46.860 --> 00:09:51.020 A lullaby that we sing to ourselves at night. 152 00:09:51.280 --> 00:09:57.540 You know, we are still safe because we've now nailed this one person to the cross. 153 00:09:57.740 --> 00:09:58.000 Right? 154 00:09:58.080 --> 00:09:59.180 So now we're all safe. 155 00:09:59.260 --> 00:10:00.440 We can go to sleep at night. 156 00:10:00.620 --> 00:10:01.220 All right? 157 00:10:01.240 --> 00:10:06.080 On the other hand, though, you could easily argue that this is scapegoating to the highest degree. 158 00:10:06.580 --> 00:10:09.360 Gutzé puts it beautifully in the novel Disgrace. 159 00:10:09.400 --> 00:10:10.140 Have you read it? 160 00:10:10.240 --> 00:10:10.760 Disgrace. 161 00:10:11.820 --> 00:10:16.560 Where he says, of course, this is described in Leviticus quite nicely. 162 00:10:16.560 --> 00:10:21.200 But you loaded the sins of the city on the back of the goat and you drove it out. 163 00:10:21.280 --> 00:10:23.580 And the city was cleansed. 164 00:10:24.100 --> 00:10:28.620 Everybody understood this because everybody knew how to read the ritual. 165 00:10:29.200 --> 00:10:30.820 The city is cleansed. 166 00:10:30.820 --> 00:10:31.660 The goat is gone. 167 00:10:32.140 --> 00:10:35.340 But what are the sins of the city in this regard? 168 00:10:38.520 --> 00:10:46.480 Expecting that an underfunded, overworked body of people can take care of the weakest among us? 169 00:10:46.480 --> 00:10:47.220 The most vulnerable? 170 00:10:47.940 --> 00:10:49.460 The most defenseless? 171 00:10:51.560 --> 00:10:52.440 Back to Newton. 172 00:10:53.980 --> 00:10:54.820 Reductionism is one. 173 00:10:55.000 --> 00:11:02.660 The second way in which I think Newton shows up in our responses to failure is the cause-consequence symmetry. 174 00:11:03.080 --> 00:11:05.040 Second law of motion. 175 00:11:05.940 --> 00:11:06.320 Thank you. 176 00:11:06.660 --> 00:11:07.320 Which reads? 177 00:11:09.240 --> 00:11:10.020 Oh, man. 178 00:11:10.120 --> 00:11:10.980 So where were you educated? 179 00:11:12.300 --> 00:11:13.100 Not in Queensland? 180 00:11:13.860 --> 00:11:14.540 Oh, okay. 181 00:11:14.800 --> 00:11:15.260 Okay. 182 00:11:15.300 --> 00:11:15.800 This is not good. 183 00:11:16.480 --> 00:11:17.180 I was in school in Queensland. 184 00:11:17.400 --> 00:11:17.540 All right. 185 00:11:18.640 --> 00:11:22.520 But the symmetry between cause and effect, right? 186 00:11:22.560 --> 00:11:24.920 For every cause, there's an equal and opposite effect. 187 00:11:24.980 --> 00:11:27.180 Or for every effect, there's an equal and opposite cause. 188 00:11:27.420 --> 00:11:32.260 So if the effect is very bad, then the cause must have been very bad as well. 189 00:11:32.360 --> 00:11:38.620 A dead child must have been the result of a monumental failure on part of this social worker. 190 00:11:38.840 --> 00:11:42.320 If the child had only been sick or something, then the failure would not have been as bad. 191 00:11:42.540 --> 00:11:45.880 And you see this cause-consequence symmetry or equivalence. 192 00:11:45.880 --> 00:11:50.100 And acted in courts and the aftermath of failure in all kinds of ways. 193 00:11:50.280 --> 00:11:57.040 The result is worse than the consequences we append to the people who helped lead up to that result are often quite much worse. 194 00:11:59.380 --> 00:12:12.320 Now, what I would want to suggest in sharp contrast to this Newtonian belief about the simplicity of failure, that failure emerges from somebody who didn't watch out carefully enough, failure reduces to the part. 195 00:12:12.480 --> 00:12:15.860 What I want to claim instead is this. 196 00:12:15.860 --> 00:12:29.960 That failure in a system like this, bruise non-randomly, opportunistically, at the very core of the processes and structures that we set up to prevent it. 197 00:12:31.300 --> 00:12:32.400 Let me say that again. 198 00:12:32.680 --> 00:12:34.980 Because this is, I mean, if any, then you can go away. 199 00:12:35.180 --> 00:12:36.460 I mean, that's basically the point, right? 200 00:12:36.540 --> 00:12:45.500 The point is failure in these large complex social systems that we build to protect ourselves from bad things. 201 00:12:45.860 --> 00:12:52.500 Failure in them isn't introduced from the outside by a social worker who doesn't do the work. 202 00:12:52.700 --> 00:12:52.960 No. 203 00:12:53.240 --> 00:13:03.820 The potential for that failure bruise non-randomly, opportunistically, among the very processes and structures that we set up to prevent it. 204 00:13:04.860 --> 00:13:06.700 Let me try to illustrate that. 205 00:13:08.700 --> 00:13:14.560 At the broadest level, you could make the argument, of course, we can't do this experimentally or empirically. 206 00:13:14.560 --> 00:13:18.500 Because that would be both unethical and really hard to verify. 207 00:13:19.840 --> 00:13:22.700 But as a gedanken experiment, right? 208 00:13:22.720 --> 00:13:23.320 Gedanken experiment. 209 00:13:23.600 --> 00:13:24.940 As a thought experiment. 210 00:13:25.340 --> 00:13:29.280 Just imagine a more primitive social organization of society. 211 00:13:29.620 --> 00:13:36.180 In which we do not give responsibility for these sorts of functions over to a government faceless bureaucratic apparatus. 212 00:13:36.620 --> 00:13:41.080 But rather, as a community, take care of the most vulnerable people among us. 213 00:13:42.060 --> 00:13:44.540 In a village that would have looked after itself. 214 00:13:44.540 --> 00:13:47.520 With its own people in a more, what, three, four hundred years ago. 215 00:13:47.720 --> 00:13:49.060 Would this girl have died? 216 00:13:50.800 --> 00:13:52.180 Would this girl have died? 217 00:13:53.100 --> 00:13:53.980 Of neglect. 218 00:13:54.180 --> 00:13:56.500 Because children died of all kinds of things at that time, obviously. 219 00:13:56.800 --> 00:13:58.600 But of the same sorts of causes. 220 00:13:59.160 --> 00:14:06.040 You see, the very fact that we've built this structure to prevent this girl from dying accelerates her trajectory to death. 221 00:14:06.860 --> 00:14:07.300 Right? 222 00:14:07.380 --> 00:14:08.240 That's the irony. 223 00:14:08.460 --> 00:14:10.060 That's the irony of the West. 224 00:14:11.860 --> 00:14:14.480 And let me boil this down to a very simple example. 225 00:14:14.480 --> 00:14:15.820 You got the case worker. 226 00:14:16.020 --> 00:14:19.260 Now, we assign families to case workers in this country. 227 00:14:19.420 --> 00:14:19.620 Right? 228 00:14:19.660 --> 00:14:21.400 And there's various ways of organizing this, obviously. 229 00:14:21.700 --> 00:14:25.480 But one case worker may have, as I said, 26 families. 230 00:14:25.700 --> 00:14:27.760 Now, that has a great advantage. 231 00:14:28.800 --> 00:14:30.140 Because there's continuity. 232 00:14:30.720 --> 00:14:31.160 Right? 233 00:14:31.240 --> 00:14:31.980 You visit once. 234 00:14:32.120 --> 00:14:34.140 You visit again three weeks later, five months later. 235 00:14:34.300 --> 00:14:35.720 You see things change over time. 236 00:14:35.860 --> 00:14:36.980 You see trends build up. 237 00:14:37.100 --> 00:14:38.700 And you can intervene appropriately. 238 00:14:38.960 --> 00:14:39.780 Has a great advantage. 239 00:14:40.600 --> 00:14:42.800 But at the heart of that very structure. 240 00:14:42.960 --> 00:14:43.960 That very process. 241 00:14:44.020 --> 00:14:44.460 That we set up. 242 00:14:44.480 --> 00:14:48.540 To prevent things from not getting our attention. 243 00:14:49.100 --> 00:14:50.160 Lies its failure. 244 00:14:50.500 --> 00:14:56.100 And that is that there is no opportunity for informed second opinion. 245 00:14:56.320 --> 00:14:57.580 In that type of structure. 246 00:14:58.200 --> 00:15:00.560 Because when does somebody else show up and go, 247 00:15:00.680 --> 00:15:02.280 Have you seen this kid lately? 248 00:15:02.500 --> 00:15:03.300 Oh my God. 249 00:15:03.520 --> 00:15:05.100 It really is not looking good. 250 00:15:05.220 --> 00:15:07.620 No, because we're always sending the same social worker to this family. 251 00:15:07.980 --> 00:15:08.140 Right? 252 00:15:08.360 --> 00:15:13.160 So, a recipe for success is at the same time a recipe for failure. 253 00:15:14.000 --> 00:15:20.300 Failure breeds non-randomly, opportunistically at the heart of the processes that we set up to prevent it. 254 00:15:20.840 --> 00:15:22.280 I work with healthcare a lot. 255 00:15:22.400 --> 00:15:23.260 Just one more example. 256 00:15:23.360 --> 00:15:25.140 So, try to drive home this point. 257 00:15:25.820 --> 00:15:34.120 And one of the big problems in bureaucratic care is that fluids go into bodies and fluids come out of bodies. 258 00:15:34.880 --> 00:15:37.580 When fluids go into bodies, it's typically all kinds of medicines. 259 00:15:37.880 --> 00:15:38.000 Right? 260 00:15:38.760 --> 00:15:41.560 When fluids come out, it's blood or other fluids that need testing. 261 00:15:41.700 --> 00:15:43.080 On the basis of which you then. 262 00:15:43.080 --> 00:15:44.880 Decide to put more fluids in or less. 263 00:15:45.380 --> 00:15:45.540 Right? 264 00:15:45.660 --> 00:15:48.600 So, this is a rather mechanistic way. 265 00:15:48.740 --> 00:15:51.900 But, you know, this is not entirely inappropriate. 266 00:15:53.100 --> 00:16:02.820 Now, in order to do that well, however, you need to make sure that the body that you think you're drawing fluids out of or putting fluids into is the one that you were aiming to actually administer. 267 00:16:03.120 --> 00:16:03.300 Right? 268 00:16:04.140 --> 00:16:06.740 We call this the patient identification problem. 269 00:16:08.220 --> 00:16:10.200 Now, which is non-trivial actually. 270 00:16:10.740 --> 00:16:13.060 In fact, it is so non-trivial that we can't. 271 00:16:13.080 --> 00:16:16.420 We keep putting wrong stuff in the right patients or right stuff in the wrong patients. 272 00:16:16.640 --> 00:16:18.620 Wrong stuff in the wrong patients for that matter. 273 00:16:19.320 --> 00:16:22.420 Or taking blood out and thinking it's somebody else's. 274 00:16:22.600 --> 00:16:34.720 But, in order to prevent that from happening, hospitals that I've worked with, in fact in this country, have devised a very rational, Weberian procedure. 275 00:16:35.420 --> 00:16:37.340 Be very rational about this. 276 00:16:37.480 --> 00:16:39.680 Walk up to the patient and don't say, 277 00:16:39.820 --> 00:16:41.860 G'day John, how you doing today? 278 00:16:41.860 --> 00:16:42.420 Right? 279 00:16:42.680 --> 00:16:42.920 No. 280 00:16:43.120 --> 00:16:45.900 Because that already assumes that you know that this is John. 281 00:16:46.040 --> 00:16:49.900 And John may be out in La La Land because of all the stuff you're pumping in his body. 282 00:16:50.000 --> 00:16:50.180 Right? 283 00:16:50.340 --> 00:16:52.120 Which means John doesn't know he's John. 284 00:16:52.240 --> 00:16:52.920 John, eugh. 285 00:16:53.240 --> 00:16:53.660 Right? 286 00:16:53.820 --> 00:16:56.400 So, that's a very brittle procedure. 287 00:16:56.720 --> 00:16:57.040 Right? 288 00:16:57.420 --> 00:17:06.700 So, the rational hospital administration, who by the way worked on the ward like for the last time 30 years ago, probably couldn't see a ward, couldn't recognize a ward if they saw one. 289 00:17:06.760 --> 00:17:07.540 Ooh, is this a ward? 290 00:17:08.160 --> 00:17:09.360 A patient, really. 291 00:17:10.520 --> 00:17:10.940 Right? 292 00:17:10.940 --> 00:17:14.860 So, the rational procedure that is then introduced is to say, 293 00:17:15.940 --> 00:17:16.960 What is your name? 294 00:17:18.080 --> 00:17:19.760 And John is supposed to say, 295 00:17:19.860 --> 00:17:21.000 My name is John. 296 00:17:21.660 --> 00:17:22.200 John who? 297 00:17:22.420 --> 00:17:22.800 Right? 298 00:17:22.820 --> 00:17:24.560 And then John is supposed to produce even more. 299 00:17:24.700 --> 00:17:24.940 Right? 300 00:17:25.020 --> 00:17:27.060 And that then is checked against another source. 301 00:17:27.200 --> 00:17:30.980 And if they check up, then you're allowed to put either fluids in or take fluids out. 302 00:17:31.440 --> 00:17:32.260 Positive identification. 303 00:17:34.040 --> 00:17:36.760 But why do people come to the nursing profession? 304 00:17:39.800 --> 00:17:40.520 Because they're... 305 00:17:40.520 --> 00:17:40.920 No, no, no, no. 306 00:17:40.920 --> 00:17:41.520 People... 307 00:17:41.520 --> 00:17:44.200 Oh, yes, the patients come to the nursing profession because they're sick. 308 00:17:44.700 --> 00:17:45.420 Well, there's... 309 00:17:49.640 --> 00:17:54.160 In that case, coming to a hospital is not necessarily the healthiest thing to do, by the way. 310 00:17:54.600 --> 00:17:55.040 It's... 311 00:17:56.840 --> 00:17:57.280 Wow. 312 00:17:57.900 --> 00:17:58.340 The... 313 00:17:59.960 --> 00:18:01.500 But that's for another talk. 314 00:18:03.020 --> 00:18:08.260 And so, and if you're a patient, I don't want to make you too concerned right now. 315 00:18:08.600 --> 00:18:09.840 We'll do that after the talk. 316 00:18:11.340 --> 00:18:12.980 But it's safer to fly my jet. 317 00:18:13.100 --> 00:18:13.820 I'm telling you that. 318 00:18:13.960 --> 00:18:14.260 All right? 319 00:18:14.620 --> 00:18:15.060 So... 320 00:18:17.120 --> 00:18:19.880 Why are people attracted to the nursing professions? 321 00:18:20.360 --> 00:18:24.660 Because it has something of caring for people. 322 00:18:24.840 --> 00:18:25.420 All right? 323 00:18:25.480 --> 00:18:29.620 That is one of the major attractions, which is why people want to fly jets, is to fly 324 00:18:29.620 --> 00:18:33.700 them, which most pilots don't do anymore, which is why it gets really boring, very boring 325 00:18:33.700 --> 00:18:34.240 very quickly. 326 00:18:35.040 --> 00:18:39.820 And why many nurses actually, after 20, 30 years of slaving away at the war, they're 327 00:18:39.820 --> 00:18:44.820 either burned out or a bit cynical about some of the work that they're supposed to perform. 328 00:18:45.720 --> 00:18:53.540 Now, we have this procedure that asks nurses to be completely dehumanized, to be a machine. 329 00:18:53.900 --> 00:18:54.760 What's your name? 330 00:18:55.020 --> 00:18:58.500 You know, you didn't go to nursing school to say that to your patients. 331 00:18:59.100 --> 00:19:01.420 You say, John, how are you doing today? 332 00:19:01.620 --> 00:19:01.780 Right? 333 00:19:01.860 --> 00:19:04.720 And in some sense, we want that because doctors only come in to visit. 334 00:19:04.840 --> 00:19:05.460 They have no idea. 335 00:19:05.540 --> 00:19:08.260 John is just a hunk of meat in the bed with a problem in it. 336 00:19:08.360 --> 00:19:08.620 Right? 337 00:19:08.620 --> 00:19:10.760 I mean, to the nurse, John is a person. 338 00:19:11.060 --> 00:19:11.680 All right? 339 00:19:11.700 --> 00:19:14.840 Now, speaking in hyperboles is necessary if you've got 35 minutes. 340 00:19:14.980 --> 00:19:17.800 So I'm sorry if my categories are a little strict here. 341 00:19:17.900 --> 00:19:20.620 But I'm sure there are caring docs as well. 342 00:19:20.740 --> 00:19:25.320 But any volunteers? 343 00:19:26.540 --> 00:19:27.620 You know of any? 344 00:19:29.560 --> 00:19:30.900 Oh, this is this. 345 00:19:31.900 --> 00:19:33.800 And a caring one, I'm sure. 346 00:19:35.800 --> 00:19:38.100 Would it still be possible in today's system, though? 347 00:19:38.160 --> 00:19:38.600 No. 348 00:19:39.620 --> 00:19:40.580 I'm not sure. 349 00:19:40.880 --> 00:19:42.240 See, that's an interesting answer. 350 00:19:42.460 --> 00:19:44.820 Well, some say yes, and you say, I'm not sure. 351 00:19:45.000 --> 00:19:45.460 I'm not sure. 352 00:19:45.620 --> 00:19:49.300 In general practice, there's lots of proceduralization. 353 00:19:49.420 --> 00:19:51.920 You stare at the computer screen more often than at the patient. 354 00:19:51.980 --> 00:19:53.660 You know, the mouse, click, click, click. 355 00:19:53.700 --> 00:19:54.520 Oh, there's a patient. 356 00:19:54.760 --> 00:19:56.240 That's not even part of your talk. 357 00:19:56.580 --> 00:19:57.380 It's really not. 358 00:19:57.440 --> 00:19:58.800 But I'm having fun, so that's all right. 359 00:19:59.020 --> 00:20:01.920 So God knows if I know what my talk is, really. 360 00:20:02.060 --> 00:20:03.000 But no, I do. 361 00:20:03.040 --> 00:20:03.880 I did write it down. 362 00:20:03.980 --> 00:20:05.260 So I haven't looked at it yet, though. 363 00:20:05.320 --> 00:20:06.100 Shall I look at it? 364 00:20:07.380 --> 00:20:08.060 But, yeah. 365 00:20:08.280 --> 00:20:08.600 I'm not sure. 366 00:20:08.600 --> 00:20:14.300 But again, I think the example of the nursing, and perhaps in making general practice work, 367 00:20:14.420 --> 00:20:18.300 I think the example does work, right, that we want to deliver, in a very utilitarian 368 00:20:18.300 --> 00:20:22.660 sense, more care to more people, and streamline it, and standardize it, and there's standardized 369 00:20:22.660 --> 00:20:24.100 protocols, and the computer helps. 370 00:20:24.220 --> 00:20:27.640 But precisely by doing that, we will miss stuff, right? 371 00:20:27.720 --> 00:20:31.500 And not only miss the humanity, but we might miss some symptoms that the computer won't 372 00:20:31.500 --> 00:20:32.560 tell us about, right? 373 00:20:32.660 --> 00:20:36.260 So by making it more successful, we make it fail, right? 374 00:20:36.360 --> 00:20:38.580 And I think that's the obvious conclusion for me. 375 00:20:38.600 --> 00:20:41.900 And from that claim that I've put forward, which may be completely wrong, and I'm happy 376 00:20:41.900 --> 00:20:47.240 for you to say that it's wrong, or misguided, or misconstrued, or oversimplified, but it's 377 00:20:47.240 --> 00:20:50.760 that these systems fail precisely because they are successful. 378 00:20:52.360 --> 00:20:54.940 They fail precisely because they are successful. 379 00:20:55.320 --> 00:20:58.260 But the question is, how do we measure their success? 380 00:20:59.120 --> 00:20:59.940 Patient throughput? 381 00:21:01.040 --> 00:21:02.740 Amount of people seen in a day? 382 00:21:03.140 --> 00:21:03.500 Right? 383 00:21:03.540 --> 00:21:08.580 If that's the measure of success, then they will create failure as a normal, non-random 384 00:21:08.580 --> 00:21:10.840 byproduct of their pursuit of success. 385 00:21:11.260 --> 00:21:11.860 All right? 386 00:21:12.340 --> 00:21:19.060 Now, what that book is about is the idea that even if this were the case, then there is 387 00:21:19.060 --> 00:21:22.740 a regularity that we can read into how these systems fail. 388 00:21:22.940 --> 00:21:30.660 Because I run a research center up in Brisbane since January, which studies, essentially, 389 00:21:30.840 --> 00:21:32.080 why things go wrong. 390 00:21:32.460 --> 00:21:36.220 We really, I mean, the key set of ethics, law, justice, and governance is a mouthful 391 00:21:36.220 --> 00:21:37.420 that I have had to learn. 392 00:21:37.420 --> 00:21:41.480 And I'm changing the name as a result because it really is unpronounceable. 393 00:21:41.560 --> 00:21:45.220 But it should be called the Center for Understanding Why Things Go Wrong. 394 00:21:46.120 --> 00:21:49.320 Because this is what most of my researchers do. 395 00:21:49.660 --> 00:21:55.420 All the way from youth sexual violence, intimate partner homicide, indigenous overrepresentation 396 00:21:56.020 --> 00:22:00.600 in the criminal justice system, peacekeeping operations going awry, deliberative democracy 397 00:22:00.600 --> 00:22:07.000 not working out of particular countries, throughout all of these problems, there seems to be a 398 00:22:07.000 --> 00:22:07.660 regularity. 399 00:22:07.720 --> 00:22:13.920 And that is that things that go fail in these large, complex systems are really quite wicked. 400 00:22:14.040 --> 00:22:15.900 Wicked literally in the analytic sense. 401 00:22:17.000 --> 00:22:22.760