WE HAVE A FAILURE OF OUR SYSTEM

Fixes are necessary to help our democracy, which is on life support with gridlock in D.C.

In my four-decade career as a practicing physician and hospital leader, I have witnessed a remarkable transformation in American hospitals, an advancement of standards in health care quality and safety that continues unabated. Our use of evidence to make decisions, the way we handle mistakes to promote safety, and our systematic approach to performance improvement all have contributed to this impressive achievement. Although we still have a long way to go, our progress continues on an upward slope.

Is the same true of our nation? Have our standards of national leadership similarly advanced in recent years? Do we employ evidence to make decisions, handle mistakes in a just way, or use a systematic approach to do anything? Most Americans would say no. In survey after survey of leadership performance, our elected officials in Washington score lower than just about anyone else.

Our COVID-19 pandemic response is a case in point. While American hospitals stood up to an unprecedented challenge, while hospital leaders rapidly transformed their institutions under great duress and while health workers bravely risked their lives to carry out their mission, our nation’s leaders faltered in the most fundamental way. Their poor performance is captured by sobering statistics.

Our total number of COVID-related deaths (more than 600,000) leads the world. Our COVID death rate per capita is 50 times that of South Korea. Astonishingly, more Americans died in one year from COVID than died of all causes in World War II.

I believe that if our political apparatus had absorbed important lessons from the health care industry, we could have done much better. Let me explain with a story about hospital culture.

A number of years ago, a patient in one of our intensive care units (ICUs) was maintained on a ventilator that malfunctioned. As expected, an alarm went off in the central station. The patient’s nurse, Natalie (not her real name), heard the alarm but did not respond. Instead, she ignored it and just continued with her work. A few minutes later, the alarm sounded again. This time she went to check on the patient but it was too late; the patient died. Natalie’s delayed response was a fatal error.

At first glance, this was definitely a case of dereliction of duty. By failing to respond to the alarm, Natalie harmed her patient. She was solely responsible for the outcome. Our executive leadership team realized that we would have to punish her, perhaps even fire her, to set an example for all the other employees. But that was at first glance. Before we finalized our conclusions, we conducted a formal investigation, as we always do after a serious incident like this. A team of investigators interviewed Natalie and then went to the ICU to test the equipment and talk to the other staff there. Natalie’s fellow nurses were eager to talk about the alarms. It seemed that they went off constantly for no good reason — false alarms all day long. The nurses understandably had learned to ignore the alarms so they could get their important work done. It wasn’t just Natalie; it was everyone .If we were going to fire Natalie, we might as well just fire them all.

In light of these findings, we came to an important new conclusion. This wasn’t a people problem. This was a system problem. Even more important, the accountability for this system defect was in the hands of the executive leadership team (namely us), who had failed to recognize the faulty alarm settings or to monitor staff performance.

So, we repaired the defect. We reset the alarms, retrained the nurses, and began monitoring response times on a monthly basis. All the nurses began responding to the alarms and the problem was solved.

In my medical career, I have learned this lesson over and over again. Hospitals are very complicated places with much at risk and with very high expectations of our dedicated staff. Whenever an employee goes astray, there is usually a good reason: a system shortfall that either leads them off course or fails to protect them from making that error.

And whenever a group of employees behaves badly, it is always a system problem. You have to fix the system to change the behavior. The goal of leadership, then, is not to blame and shame, but to find that defect and repair it. Everybody wins. This systems approach creates alignment and is largely responsible for the steady improvement in quality and safety we have seen in American hospitals.

So, where is the lesson here for our political world? Do we see any patterns of bad behavior among our elected leaders? Do we ever!

Gridlock in Washington has become such a staple of our democracy that voters are stunned whenever the two parties agree on anything.

Indeed, the most striking aspect of our failed COVID response was our lack of alignment. Not only did states directly compete with each other for staff and supplies, but the call for national sacrifice in social distancing, mask-wearing and vaccinations was fractured along party lines, and this division was largely fomented by elected officials.

Is this universal pattern of bad behavior the telltale sign of a system defect? It most certainly is.

While many political factors contribute to increasing political polarization, one of the most glaring system defects contributing to divisions in our democracy is gerrymandering, the redrawing of district lines for political advantage. As most people know, reshaping a district “purifies” the electorate by excluding voters from the opposite party. Those who remain are a concentrated bloc of party loyalists who will be true to the cause. The main purpose of gerrymandering, after all, is to create safe seats in solidly blue or solidly red districts. Once a candidate wins the primary, they are guaranteed to win the general election. Of course, both parties do this for the purpose of gaining an electoral advantage.

While gerrymandering creates unfair advantages for the party in power and dilutes the impact of the individual voter, its effect on national governance is absolutely devastating. Anyone who holds a safe seat has zero incentive to collaborate with the opposing party to achieve meaningful progress addressing issues of national importance. Indeed, representatives from gerrymandered districts will face the wrath of their solidly red or blue constituents if they show any hint of compromise in their legislative roles.

Nowadays, the vast majority of House seats are won by a margin that exceeds 10% of the vote. In 2016, for example, 92% of House races exceeded that margin of victory. As a result, the occupant of that seat has little motivation to collaborate and every incentive to posture, draw lines in the sand, and do battle with the opposing party. Meanwhile, we, the electorate, gnash our teeth in frustration at the lack of progress.

Thus, the system defect, gerrymandering, elicits the undesirable behavior, obstructionism, which leads to the performance failure: extreme partisanship and gridlock. You can draw a straight line from system defect to system failure. Replacing the representative from a gerrymandered district will have no impact on system performance because the replacement will behave just as one would expect given the system they work in, and this defect is no more a people problem than the faulty alarms in our ICU. To truly drain the swamp, you must drain the water.

Would eliminating gerrymandering cure the polarization problem? Sadly not. The political extremism of voting districts is largely driven by the geographic distribution of voters, who increasingly settle in politically homogenous patterns, a sign of these divisive times. But this specific defect is easily repaired, and the electoral reform bill passed this year by the House, H.R. 1 (the For the People Act of 2021), would slay the gerrymander by requiring all district lines to be drawn by independent, nonpartisan commissions — in every state.

The elimination of gerrymandering is just a start. Private campaign financing is an equally egregious example of a system defect that subverts the will of the people and could easily be addressed by generous public financing of campaigns for all our leaders in Washington — in the presidency, House and Senate. We could literally buy our government back! H.R. 1 takes a small step in that direction. Once you start fixing system defects, you find it hard to stop. But we have to walk before we can run.

So, who is responsible for fixing our broken democracy? I said earlier that system defects are the responsibility of the executive leadership team. When it comes to our nation, that leadership team is the electorate.

Namely, we the voters are the ones accountable for the system as we have maximum leverage over our elected officials and ultimate control over our fate. Until we insist on system change, we can fully expect obstructionist behavior to rule the day in the corridors of power. We can start by pressing our elected officials to support H.R. 1.

Link is chief medical officer of Bellevue Hospital. He is author of “The Ailing Nation: Lessons from the Bedside for America’s Leaders.”