What the COVID-19 pandemic has taught us about system change

One of the many unique aspects of the COVID-19 pandemic is that it is hitting the entire country at the same time. In contrast, most floods, hurricanes, disease outbreaks, and other disasters are local or regional in impact. Given COVID-19’s universal reach, it is not surprising that we look for national-level response systems.

When issues seem bigger than any individual organization, we look for systems. While many of us looked to systems we thought could guide us through COVID-19, we discovered that there were no systems where we expected to find them. What we are calling “system failure” is really system “expectation” failure.

Advocates often work to shift systems to have the greatest impact on the most people, but we must consider whether there is a system to change in the first place and whether a system can create the change we’re seeking. Here are three questions to consider:

1. Does the system have the necessary reach?

Are there limits to the area or people (jurisdiction) the system operates in and is the system taken seriously (credibility) within their jurisdiction?

While the Polk County Health Department may be credible on some issues, their jurisdiction is limited to Polk County.

When the Centers for Disease Control and Prevention (CDC) proposed the initial test kits for the COVID-19 virus, their recommendations were accepted as coming from a credible national organization. States turned to the Strategic National Stockpile, housed within the U.S. Department of Health and Human Services (HHS), for needed personal protection equipment (PPE) and supplies, because they thought it was a national, credible organization. While we saw both national systems as credible in responding to COVID-19, we discovered other problems in the systems.

2. Is the system competent?

Had the test kits proposed by CDC been effective, they would have been used because they worked, not because they were required. But, since they were not effective, questions were raised about CDC’s competence for the given task.

Multiple requests to the Strategic National Stockpile in previous disasters had been managed effectively by the HHS indicating their competence, but then a new challenge arose.

3. Does the system have the capacity to deliver?

While CDC can recommend which test kits states and communities could/should use, they do not have the formal authority to require anyone to use those kits. As such, when the CDC kits were not effective, communities chose other kits, creating a confusing and disjointed response.

Because the requests for resources from the SNS exceeded the inventory, HHS did not have the capacity to effectively respond, causing hospitals and organizations to scramble to find their own PPE.

Opportunities for system change:

When the system can effectively reach (jurisdiction and credibility) the desired population, is competent to provide what is needed, and has the capacity (authority and resources) to make it happen, the essentials of a system are in place.

These elements were not in place to expect a systemic response for testing or to address the PPE shortage during the COVID-19 pandemic.  These were not system failures. There were no systems to fail.

In these cases, communities have a couple of options to create a “system-like” response where a system doesn’t exist.

1. Provide a missing piece in the system.

Polk County Emergency Management is positioning itself as the clearinghouse for PPE in Polk County. Organizations submit their needs. Donors submit their resources and Polk County Emergency Management gets the latter to the former. They provide a missing piece.

2. Leverage power to create consistency.

In an attempt to end a lot of the confusion around testing, the State of Iowa signed a large contract for an external partner to operate the Test Iowa program. Their intent was to establish a program big enough to discourage other communities from choosing other products or competitors, using their leverage to create consistency in testing.

3. Build new capacity.

Polk County established a Medical Coordination Committee (comprised of the hospitals, federally qualified health centers, the local health department and other providers) to ensure coordination and collaboration that doesn’t happen (and often cannot happen due to anti-trust restrictions) on a day-to-day basis. They built new capacity.

System-level change can be an effective and efficient way to create positive change or minimize negative change in our communities. But, only, if the system really exists.