How to use system theory in healthcare change

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Healthcare is the product of a complex adaptive system of people, equipment, processes, and institutions working together. Problems can arise with either deficiencies in individual system elements, or in their relationship with each other, and improving the overall function of such a system can be challenging. A striking example of this is the case of Dr Hadiza Bawa-Garba, 2,3 a paediatrician convicted of gross negligence and manslaughter in , temporarily suspended from practising medicine by a medical practitioners tribunal, and later struck off by the General Medical Council GMC.

The case has raised many questions both about how we allocate blame when systems fail and how we improve them in the future to avoid catastrophe. But no one is served when one doctor is blamed for the failings of an overstretched and understaffed system. The Bawa-Garba case highlights the complexity of direct healthcare, where the actions of an individual doctor can be contextualised within a team, a ward, and a hospital all facing deficiencies. However, it also throws into relief the wider system in play — of regulatory bodies, the legal framework within which medicine is practised, the media, and prevailing cultural attitudes toward the NHS.

Engineers have long understood that well designed systems can prompt individuals toward desired behaviours, and act to restrain them from undesirable ones. This understanding is reflected in much of the medical literature around improvement from fields such as quality improvement, implementation science, and operational research.

However, a consolidated systems approach to healthcare improvement has been elusive. Critics of a systems approach to healthcare might argue that it is simply a mechanism to absolve individuals where they have made mistakes or acted inappropriately, or that it is an excuse to paint improvement as too difficult to attempt. We argue instead that a systems approach should seek to answer fundamental questions about the people involved in a given situation, the wider system in which they operate, the opportunities for risk, and what can be designed to mitigate these.

There will be occasions where individuals are culpable, where machines fail, or where processes are weak; the system should be designed to reduce the possible harm which results. More optimistically perhaps, robust systems offer the opportunity for increased quality and efficiency without a commensurate increase in material resources — an increasing priority for an NHS under pressure. The idea of a systems approach is not new.

The first half of the 20th century saw a growing interest in systems and their inherent complexities in several disciplines including engineering and biology. The World Health Report had a primary focus on health systems. In the following few years, high profile reports were published both in the USA and the UK that were to significantly challenge the status quo and justify the need for a better approach to improving the quality of the healthcare delivery systems in these countries.

In the USA, the publication of two key reports by the Institute of Medicine IOM — To err is human 8 and Crossing the Quality Chasm 9 — demonstrated a disparity in the state of patient safety and the concerning discrepancy between the care that was possible and that which many patients were receiving.

The revelation of these challenges within the American healthcare system were enough to raise quality of healthcare to centre stage. Similar challenges were being described in the UK over the same period. In response to these findings the Department of Health DoH made far-reaching changes to the health system with a focus on standards, performance monitoring, patient-centeredness, patient and public involvement. This led to the first review of design and systems practice within the NHS. Several other high profile reports have consistently alluded to the need for a systems approach, although often lacking guidance on how to realise this at any level of the NHS or in the USA.

In , in response to the calls to adopt a systems approach to designing and delivering high-quality services in the UK, the Royal Academy of Engineering RAEng , in collaboration with the Royal College of Physicians RCP and the Academy of Medical Sciences AMS , established a cross-disciplinary Working Group to work with the health and care professions to explore how engineers can add to current understanding and practice of systems engineering in quality improvement and healthcare design.

To an engineer, the world is full of systems. From the simple water heater to the fully integrated international airport, all systems share one key feature: their elements together produce results not obtainable by the same elements alone.

A systems approach involves integrating the necessary disciplines into a team who then use a structured process to deliver a system, working from needs to requirements and from design to delivery. However, to those unfamiliar with the language of systems engineering, the nuances and value of the V-model may be difficult to appreciate. These perspectives provided the framework for a series of workshops with engineers and health and care professionals to explore the relevance of each perspective to health and care improvement and to express them as a series of open questions.

The spiral illustrates that the questions are revisted at each stage of design and delivery in an iterative manner. A spiral model of the questions that define an iterative approach to health and care improvement. This representation, of an idealised view of a systems approach, does little to guide how it might be used in practice. This resonated with health and care improvement specialists, going some way toward translating the description of a systems approach into a practical implementation guide.

To help further, case studies from published work were used to illustrate the potential of a systems approach in practice, reviews of improvement approaches eg the Model for Improvement, Lean etc, and key literature were undertaken. Further background to the core concepts were provided. The final report, Engineering Better Care: a systems approach to health and care design and continuous improvement, 37 provides an accessible description of a systems approach, and how it can build on current approaches to improvement in healthcare, nearly 20 years after the first call to adopt such an approach.

A systems-spiral improvement process. An ordered and iterative set of activities drawn from people , systems , design and risk perspectives and linked to the spiral questions, applied at each stage of the improvement process.

The practice of healthcare can be conceived as two objectives: to provide care, and to avoid causing harm. Similarly, engineering can be considered as the practice of solving problems, while managing the risk inherent in those solutions. A shared understanding between engineering and healthcare might then be — what can we do better, and what could possibly go wrong?

In England the New Care Models programme 38 and similar work, are showing promise in a redesigning and delivering health and care systems to meet population and system needs. These have had varying approaches to design and improvement, with varying outcomes. The value of the systems approach put forward in Engineering Better Care is that it provides a simple framework for those trying to improve care to reflect on their efforts with a new perspective.

Seeking to answer the questions posed prompts reflection on both the methodologies used, and the desired outcomes. This does not need to supplant existing methods, but instead might suggest where alternative techniques could add value. The ongoing challenge is to bring this framework to bear on real problems, in partnership with those already striving to make things better. The focus here is on the definition of a range of simple but effective interventions to identify a real need, define a problem and a business case for change, develop viable solutions and deliver the preferred solution into practice.

An Engineering Better Care toolkit, facilitating a systems approach to health and care improvement. Future Healthc J. Find articles by Tom Bashford. Author information Copyright and License information Disclaimer. Email: ku. All rights reserved. Introduction Healthcare is the product of a complex adaptive system of people, equipment, processes, and institutions working together. Background to the need for a systems approach The idea of a systems approach is not new. Realising a systems approach in practice In , in response to the calls to adopt a systems approach to designing and delivering high-quality services in the UK, the Royal Academy of Engineering RAEng , in collaboration with the Royal College of Physicians RCP and the Academy of Medical Sciences AMS , established a cross-disciplinary Working Group to work with the health and care professions to explore how engineers can add to current understanding and practice of systems engineering in quality improvement and healthcare design.

Open in a separate window. Fig 1. Table 1. The elements of a systems approach. Perspective Description People The understanding of interaction among humans and other elements of a system in order to optimise human wellbeing and overall system performance Systems The means to address complex and uncertain problems, involving highly interconnected technical and social entities that produce emergent behaviour Design The identification of the right problem to solve, creation of solution options and refinement of the best of these to deliver an appropriate solution to the problem Risk The management of what can go wrong and right , based on the identification, assessment and management of hazards and opportunities present within the system.

Fig 2. Fig 3. A linear improvement process transforming current performance into a measurably better state. Table 2. The critical stages of an improvement approach. Stage Description Understand Leads to a description of the current system now , a common understanding of the problem, a consensus view of what the future system might look like better and a clearly articulated case for changing the system Design Leads to a clear description of the future system, based on the iterative design of the system architecture with its elements and interfaces, the evaluation through successive prototyping of its likely behaviour, and a plan for its delivery Deliver Leads to the successful deployment of the new system with the levels of measurement necessary to evidence its success, and acceptance that it achieves appropriate value for its stakeholders Sustain Leads to the continued operational success of the new system along with consideration of further improvement potential or wider deployment.

Fig 4. In an outbreak response, the sooner investigators identify how and why the germ got into the food, the sooner they can make recommendations on how to stop it from happening interventions. Looking at the restaurant as a system helps to identify how the outbreak happened contributing factors and the root causes of why it happened environmental antecedent. For example, a norovirus outbreak might have happened because a food worker was sick contributing factor.

The investigator would try to determine why environmental antecedents the worker was working while sick with norovirus. Those reasons could include the following:. After determining how and why the outbreak happened, the investigator can make informed recommendations to the restaurant for preventing another outbreak.

The investigator might recommend that the restaurant. Identifying contributing factors and environmental antecedents to outbreaks often focuses on inputs, processes, and internal system variables. Read about how the systems approach has been used to investigate foodborne and waterborne outbreaks:. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site.

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If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Skip directly to site content Skip directly to page options Skip directly to A-Z link. System Theory. Minus Related Pages. The farm-to-fork continuum is the path food takes from source to final service.

Where the food item originates, including A farm where produce is grown, A body of water where fish are harvested, and A dairy farm or beef cattle operation. Point of final service. Looking at a restaurant as a system can show how each step influences the outcome. Using system theory can help investigators understand how and why a foodborne illness outbreak happened. His manager said she could not find anyone to work his shift.

The investigator might recommend that the restaurant Provide opportunities for those who miss work because they were sick to make up their hours.

Train workers on the importance of not working while sick. Schedule an on-call worker to be available in case another worker is sick.

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