Only YOU Can Prevent PX Wildfires

Systems Thinking and the Patient Experience

This is a summary of the presentation given at the 2019 Beryl Institute Annual Conference in Dallas, TX on April 3, 2019. The presenters were Tiffany Fortin, Senior Coordinator for Patient Experience, Munson Healthcare; Sheila Moroney, Director, Patient Experience for Hennepin Healthcare; and Mark VanderKlipp, Founding Partner, Connect_CX.

In 2017, the US Forest Service spent over $2.5 billion fighting fires. As a nation, we tend to focus on what the flames destroy: property, habitat and communities. But research suggests that proactive steps can mitigate the damage caused by naturally occurring wildfires: focusing on the fuel, rather than the fire, is key. The fires that PX professionals fight every day are the outcome of decades of cultural undergrowth, providing ample fuel: siloed organizations, disconnected communication systems, unclear lines of authority, disagreement on shared measurements. Cost constraints and compliance requirements only add to the tinder-dry conditions.

The victims? Staff, patients, families. The answer: Systems Thinking.

Using examples from frontline experiences, the presenters shared stories of patient experience in flames, their underlying causes and the systems that have been designed to prevent them.

US Forest Service Beginnings

Gifford Pinchot, first Chief of the  United States Forest Service  from 1905 until 1910

Gifford Pinchot, first Chief of the United States Forest Service from 1905 until 1910

When Theodore Roosevelt ascended into the presidency in 1901, he brought a forester and politician named Gifford Pinchot into his Cabinet. Together, they were determined to seize the mantle of conservation and radically re-think how the nation managed its estate, the vast woodlands that provided rich resources to a growing nation.

Their vision was to create a system of National Forests, controlled by an enlightened corps of rangers overseeing timber, water, minerals and wildlife. They saw this as a “utilized landscape”: it served a purpose, and needed to be managed. 

Pinchot oversaw 200 million acres of forest range, at that time a land mass larger than most European countries. But fire threatened the timber, the resources his rangers had sworn to protect. It had to be stopped at all costs. What made their jobs difficult were the people in these towns: the roustabouts, workers in the mines, railroads, etc. The Forest rangers, many of them educated at elite East Coast universities, were considered outsiders, standing between the frontier mentality and profitable resources. Both sides would be humbled by one implacable foe: nature itself.

“The question of forest fires, like the question of slavery, may be shelved for a time at enormous cost in the end - but sooner or later, it must be faced.”

— Gifford Pinchot

Years of conservation theory and fire suppression laid the foundation for “The Big Burn,” the largest wildfire in the history of the United States which happened only five years after the Forest Service was established. A great number of problems contributed to the destruction caused by the Great Fire of 1910. The wildfire season started early that year because the spring and summer were extremely dry. The drought resulted in forests that were teeming with fuel, which had previously grown up on abundant autumn and winter moisture. Hundreds of fires were ignited by hot cinders flung from locomotives, sparks, lightning and other human activity. By mid-August, there were 1,000 to 3,000 fires burning in Idaho, Montana, and Washington.

The fire burned over two days on the weekend of August 20–21, after strong winds caused numerous smaller fires to consolidate into a firestorm of unprecedented size. It killed 87 people, mostly firefighters, destroyed numerous manmade structures, including several entire towns, and more than three million acres of forest with an estimated billion dollars worth of timber lost. It is believed to be the largest, although not the deadliest, forest fire in U.S. history. The extensive burned area was approximately the size of the state of Connecticut.

System Visualizations

We all know that fires are problematic. But how does the Forest Service work to “see” the system of elements and connections that influence the frequency and duration of wildfires?

With Systems Thinking.

We found a System Map that the Forest Service uses to model management practices:

  • Physical and political dynamics affect suppression and prevention policies

  • Too much suppression reinforces further suppression and crowds out prevention

  • A balanced approach minimizes the feedback cycle and long-term damages


This map, comprised of elements and links, shows the relationship of physical and political factors that influence wildfire suppression and prevention. Note that the elements consist of three types:

  • Structural: can be measured or quantified

  • Attitudinal: mindsets that influence the system

  • Transactional: catalysts that cause transition

Note that the single attitudinal element - the pressure to control fires - influences the map in very real ways. In fact, it’s the reason we chose the wildfire metaphor in the first place: focusing on the outcome, rather than the root causes, results in short-term thinking and an imbalance of resources.

“Forest Service spending on fire suppression in recent years has gone from 15 percent of the budget to 55 percent … which means we have to keep borrowing from funds that are intended for forest management”

— Sonny Perdue, U.S. Secretary of Agriculture

Great. So how does this relate to healthcare?

Healthcare providers continually battle two tensions: a necessarily short term view of priorities and a culture organized around crises, acute care, emergency response. We are collectively reactive, faced every day with unplanned, unexpected crises. Since we’re geared up to do that, responding in the moment is a learned behavior that becomes ingrained in our DNA. And we become addicted to the adrenaline rush.

The goal of our presentation was to show the over 70 session attendees what typical PX problems “look like” from the viewpoint of systems thinking and practice: by investing time and energy in visualizing the context of the problem, we can better approach the underlying conditions that cause them.

For each of the following stories, we drew system visualizations in real time - showing the attendees the value of thinking beyond the typical approach: apologize to the family, discipline the staff, and try to train other staff to assure the problem doesn’t occur again.


Tiffany Fortin: Peace Lamp

After his wife’s heart attack, a husband had to make the difficult decision to discontinue treatment and let nature take its course, ending his wife’s life. As the equipment was being removed, the husband was overwhelmed and walked to the family waiting room for respite and reflection. As he walked back down the hallway to his wife’s room – knowing that he would be saying good-bye for the last time – he passed the nursing station. Here, nurses were laughing and talking about non-work related things.

Clearly, they did not intend to cause harm, but they were oblivious to the husband’s state of mind. In a post-procedure interview, the husband mentioned this to his wife’s care team. After apologizing profusely, they resolved that this situation not happen again on this or any other unit. They looked at the entire journey that the husband had experienced, and designed a simple solution: a light on each end of the unit hallway that represented an end of life issue on the unit. Inexpensively purchased from Hobby Lobby, staff were notified that when it appears and is lit, they need to be aware and respectful.

On hearing this, the husband offered to purchase multiple “Peace Lamps” to honor his wife and to assure that this not happen to other families at Munson Medical Center.

A visualization showing how the Peace Lamp ultimately addressed a number of factors that contributed to a lack of situational awareness on the part of Cardiac unit staff.

A visualization showing how the Peace Lamp ultimately addressed a number of factors that contributed to a lack of situational awareness on the part of Cardiac unit staff.

“People think the solution has to be a new drug or a new laser or something really high tech to be powerful. They have a hard time believing that these simple choices that we make in our lives every day can make a powerful difference.”

— Dr. Dean Ornish, Founder and President of the Preventive Medicine Research Institute, quoted in the documentary “Escape Fire.”

Sheila Moroney: “I Wasn’t Present”

A patient presented at a clinic for allergy shots. He had a common name—John, which will be important to the story. As a “frequent flyer,” he was known to staff and familiar with the process. As per usual, the attending staff member did what’s called a “Check 2” for safety: asking the patient’s name and date of birth. John answered. He then questioned the contents of the shot tray: “usually I only have 2 vials, you have 3 on the tray.“ The staffer replied “the doctor must have changed your order.” John questioned the content and duration of the injection he was about to receive, then asked to see the orders. Immediately he said “this is not me. You have the wrong John.”

In the event review, the staff member quickly admitted “I wasn’t present. I was moving too quickly and didn’t hear his answer to the Check 2, except John.”  The other patient’s name was John as well.

Human-centered design helped prevent future occurrences by engaging both staff and patients to envision a safe process. We asked, in the midst of a busy clinic, how do we help staff with their emotional wellbeing — to ensure presence? How do we engage patients in their own safe care? What steps in the process could be designed in to prevent this from happening again? Using the energy generated by their resolve, the staffer, the patient and fellow staff members hypothesized and tested a quick fix: as part of the standard Check 2 process, physically show the patient the vials and have them confirm that this is their name.


To the uninitiated, these may seem like simple drawings, or a confusing exercise. But the point of a system map isn’t necessarily the creation of the artifact itself; rather, it’s the value in the conversation that occurs between multiple people, from multiple points of view, that helps to visualize, then test, then act upon potential solutions to better address the core issues of the problem as its defined.


The 110-year history of the US Forest Service is a cautionary tale of incorrect assumptions, well-meaning mismanagement, hard lessons learned, technological advances and extraordinary heroism in the face of existential challenges. Sound familiar?

In their various roles, Patient Experience professionals have seen the impacts of these same factors. We’ve used the Forest Service as a metaphor to illustrate how Systems Thinking can reveal previously unforeseen solutions to seemingly intractable problems - and how individual and collective reflection can prevent disaster. Using stories from our own experiences, both as patients and practitioners, we’ve illustrated the factors that contributed to negative outcomes and have shown, using systems mapping, how proactive, consistent steps have been engaged to resolve these issues.

For more visualizations of Systems Practice in action, check out Wicked Problems on our website. And please comment below or contact us with questions!