Development and application of ‘systems thinking’ principles for quality improvement

Introduction ‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a ‘Safety-II systems approach’ to promote understanding of how safety may be achieved in complex work systems. We aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting. Methods The original EUROCONTROL principles were adapted using consensus-building methods with front-line staff and national safety leaders. Results Six interrelated principles for healthcare were agreed. The foundation concept acknowledges that ‘most healthcare problems and solutions belong to the system’. Principle 1 outlines the need to seek multiple perspectives to understand system safety. Principle 2 prompts us to consider the influence of prevailing work conditions—demand, capacity, resources and constraints. Principle 3 stresses the importance of analysing interactions and work flow within the system. Principle 4 encourages us to attempt to understand why professional decisions made sense at the time and principle 5 prompts us to explore everyday work including the adjustments made to achieve success in changing system conditions. A case study is used to demonstrate the application in an analysis of a system and in the subsequent improvement intervention design. Conclusions Application of the adapted principles underpins, and is characteristic of, a holistic systems approach and may aid care team and organisational system understanding and improvement.

[1]  C. Powell.  The Delphi technique: myths and realities. , 2003, Journal of advanced nursing.

[2]  C. Landrigan,et al.  Temporal trends in rates of patient harm resulting from medical care. , 2010, The New England journal of medicine.

[3]  K. Shojania,et al.  Root-cause analysis: swatting at mosquitoes versus draining the swamp , 2017, BMJ Quality & Safety.

[4]  P. Carayon,et al.  SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients , 2013, Ergonomics.

[5]  S. Hignett,et al.  Finding ergonomic solutions--participatory approaches. , 2005, Occupational medicine.

[6]  J. Elliott.  Safety I and safety II: the past and future of safety management , 2016, Ergonomics.

[7]  E. Hollnagel.  The Etto Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong , 2009 .

[8]  M. Dixon-Woods,et al.  The problem with root cause analysis , 2016, BMJ Quality & Safety.

[9]  Kathryn M. Kellogg,et al.  Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? , 2016, BMJ Quality & Safety.

[10]  P. Bowie,et al.  Enhancing the Effectiveness of Significant Event Analysis: Exploring Personal Impact and Applying Systems Thinking in Primary Care , 2016, The Journal of continuing education in the health professions.

[11]  G. McCarthy.  FRAM: the functional resonance analysis method, modelling complex socio-technical systems , 2013 .

[12]  K. Moorthy,et al.  Is health care getting safer? , 2008, BMJ : British Medical Journal.

[13]  A. Esmail.  Measuring and monitoring safety: a primary care perspective , 2013 .

[14]  M. Marshall,et al.  What we know about designing an effective improvement intervention (but too often fail to put into practice) , 2016, BMJ Quality & Safety.

[15]  Erik Hollnagel,et al.  Resilience Engineering: A New Understanding of Safety , 2016 .

[16]  Ashok Sarkar,et al.  Issues in Pareto analysis and their resolution , 2013 .

[17]  K. Wiesner,et al.  What is a complex system? , 2012, European Journal for Philosophy of Science.

[18]  P. Bowie,et al.  Understanding patient safety performance and educational needs using the ‘Safety-II’ approach for complex systems , 2016, Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors.

[19]  O. Sibony,et al.  Using and Reporting the Delphi Method for Selecting Healthcare Quality Indicators: A Systematic Review , 2011, PloS one.

[20]  Nancy G. Leveson,et al.  A new accident model for engineering safer systems , 2004 .

[21]  B. Sckell,et al.  Just Culture: Balancing Safety and Accountability , 2009 .

[22]  David H Peters,et al.  The application of systems thinking in health: why use systems thinking? , 2014, Health Research Policy and Systems.

[23]  Ella-Mae Hubbard,et al.  Second victim: error, guilt, trauma, and resilience , 2014 .

[24]  Luci K. Leykum,et al.  Interventions to reduce readmissions: can complex adaptive system theory explain the heterogeneity in effectiveness? A systematic review , 2018, BMC Health Services Research.

[25]  Anita L. Tucker,et al.  Operational failures and interruptions in hospital nursing. , 2006, Health services research.

[26]  Vincenzo Liberatore,et al.  Using complexity theory to build interventions that improve health care delivery in primary care , 2006, Journal of General Internal Medicine.

[27]  Donald M. Berwick,et al.  Era 3 for Medicine and Health Care. , 2016, JAMA.

[28]  Alan J Card,et al.  The problem with ‘5 whys’ , 2016, BMJ Quality & Safety.

[29]  P. Bowie,et al.  Participatory design of an improvement intervention for the primary care management of possible sepsis using the Functional Resonance Analysis Method , 2018, BMC Medicine.

[30]  Taghreed Adam,et al.  Systems thinking for health systems strengthening. , 2009 .

[31]  E. Hollnagel,et al.  From Safety-I to Safety-II: A White Paper , 2014 .

[32]  Jeffrey Braithwaite,et al.  Resilient health care: turning patient safety on its head. , 2015, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[33]  J. Carroll,et al.  Moving Beyond Normal Accidents and High Reliability Organizations: A Systems Approach to Safety in Complex Systems , 2009 .

[34]  Steve Cross,et al.  Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions , 2011, Quality and Safety in Health Care.

[35]  Guideline developers are not the only experts: Utilising the FRAM method in sepsis pathways , 2018, BMC Medicine.

[36]  I. Svedung,et al.  Proactive Risk Management in a Dynamic Society , 2000 .

[37]  Jon Wade,et al.  A definition of systems thinking: A systems approach , 2015 .

[38]  Julie E. Reed,et al.  The problem with Plan-Do-Study-Act cycles , 2015, BMJ Quality & Safety.

[39]  P. Byass.  Systems thinking for health systems strengthening , 2011 .

[40]  Richard J. Holden,et al.  The Challenges of Measuring, Improving, and Reporting Quality in Primary Care , 2017, The Annals of Family Medicine.

[41]  Charles Vincent,et al.  Patient Safety: Vincent/Patient Safety , 2010 .

[42]  J. Braithwaite,et al.  False Dawns and New Horizons in Patient Safety Research and Practice , 2017, International journal of health policy and management.

[43]  L. Shepstone,et al.  Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial , 2005, BMJ : British Medical Journal.

[44]  Jeffrey Braithwaite,et al.  Positive deviance: a different approach to achieving patient safety , 2014, BMJ quality & safety.

[45]  P. Plsek,et al.  The challenge of complexity in health care , 2001, BMJ : British Medical Journal.

[46]  A. Plunkett,et al.  Learning from excellence in healthcare: a new approach to incident reporting , 2016, Archives of Disease in Childhood.