Only YOU Can Prevent PX Wildfires

US Forest Service Beginnings

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

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?

  • 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
  • Structural: can be measured or quantified
  • Attitudinal: mindsets that influence the system
  • Transactional: catalysts that cause transition

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.

Tiffany Fortin: Peace Lamp

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.

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.”


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?



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Mark VanderKlipp

Mark VanderKlipp

Partner at Connect_CX, The Adjacency; speaker, facilitator, systems thinker, healthcare experience designer: