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    The System

    The System has far-reaching aims.

    It is a resource to facilitate paradigm change. It addresses issues that are widely recognized, where there is a gap between rhetoric and aspiration on the one hand and practical action on the other.


    The System address  issues of long-term change in working practices, culture and communication with:

    a) Medical Students, about to graduate.

    b) Junior Doctors, beginning their clinical careers.

    c) Clinical Team Leaders whose values form a role model for others.

    d) Nurses and Support Staff who hold systems together.

    e) Managers responsible for systems performance and resources of time and money

    Inescapable Progression
    Among successful organizations engaged in other kinds of high hazard endeavors:
    Values drive Behaviors >> Behaviors drive > > Performance > > Performance drives Outcomes.

    Why Some Initiatives Stall
    Many well-intentioned initiatives stall because they are introduced at the level of performance without first addressing issues of values and behaviours.

    Aspiration to Implementation
    The System addresses these issues - from aspiration to implementation.

    Self-Drive Package
    The System is a self-drive package readily usable by anyone: clinicians, managers and facilitators in support specialties.

    The System comprises two powerful drama-documentaries and an observational documentary of a real-life case history where the principles of paradigm change have transformed the culture and outcomes in a major hospital.

    In both dramas, the characters are portrayed by actors, but the events are drawn from actual events.

    Part 1 The Facts of Life?

    Engage the Attention
    Part One
    engages the attention of the audience with familiar failures: individually unremarkable , but in combination potentially lethal. The story is set among these realities of culture, clinical practice, communications and working relationships: beginning w ith the initial GP consultation; the interface with the hospital, consenting, communications, clinical procedures and post-operative care.

    A key objective is to ensure the right questions are asked. Not least: "Could this happen to us? If it couldn 't, why are we so special? If it could, what are we doing about it?"

    Alternative  Future
    Part Two
    captures the imagination with an alternative future. As the team recovers from disaster, they see that: "current defects are neither acceptable or inevitable." With flashbacks to the past and changed insights into what can be achieved, they begin the process of change: "We could do that here."

    Part Three tells the remarkable real-life story of a district general hospital that has been profoundly changed by the people working in it.

    The series is accompanied by support materials CD on covering key issues, from BSIR and Health Foundation, together with a 70-point list of starting points for discussion.

    Contents - in multi-pack format -DVD Programs:

    • 1 Hour approx l running time
    • 2 X Drama-Documentaries
    • 1 X Case History
    • 1 X CD with support materials

    The System is receiving very powerful responses . For example, when show at the IHI International Symposium, where it formed the keynote and detailed agenda for a day-long workshop , it received a spontaneous ovation.

    Click here to download a testimonial by Dr Nikki Maran, Scottish National Patient Safety Initiative

    Professor James Reason
    Here is an exerpt of a letter from Professor James Reason, one of the world's most widely respected experts in safety science and communication of the issues involved.

    "As perhaps the closest observer of your work, I can say without fear of contradiction, that this is the best thing you've ever done in this area. The events your film describe are the best representations  of  systemic  flaws  I've  come  across. It's so subtle and so realistic. For each of the healthcare players in your drama, the systemic issues seem remote, familiar and unchangeable. That's brilliant. And so is the remedy. Practical, doable and recognizable. I'm so pleased  to have taken part."
    Professor James Reason CBE




    Country of production: Australia  
    Duration: 3 part series  
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      The System