When the failure involves many or significant items within the system, then it is a system failure.

The system itself may be absent, or facets of an existing system may not be working. Even minor problems may be indicative of a systemic problem.

For example, if services were not initiated within the timeframes established by the agency's policy for one out of seven clients, it could be a systemic problem if the coordination of information exchange within the agency was so disorganized that staff responsible for scheduling visits did not know when a client was admitted.

A systemic problem requires a PoC that:

• describes what changes in the system will occur to fix the problem; or
• plans for the development and implementation of a new system