introduction to the systems approach · training overview • three components 1. introduction to...
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Introduction to the Systems Approach
Thomas Jun & Patrick WatersonHuman Factors and Complex Systems Research Group
Loughborough University
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Introductions
• Dr Gyuchan Thomas Jun ([email protected])
• System Engineer, Human Factors Specialist, Design
Researcher and Animation/film producer
• Applying systems thinking and design thinking to the
complex socio-technical system research
• Healthcare, shipping, nuclear, etc
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Introductions
• Dr Patrick Waterson ([email protected])
• Psychologist, Human Factors Researcher
• Applying the systems approach to accident investigation
• Healthcare and patient safety
• Other domains – rail, construction, nuclear, …
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Training overview
• Three components
1. Introduction to the systems approach
2. Tools for systems analysis: influence diagrams
3. Tools for systems analysis: Systems Theoretic Accident
Modelling and Processes method (STAMP)
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Training overview
• Three components
1. Introduction to the systems approach
2. Tools for systems analysis: influence diagrams
3. Tools for systems analysis: Systems Theoretic Accident
Modelling and Processes method (STAMP)
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1. Introduction to the systems approach
• Why is the systems approach necessary?
• What is the systems approach?
• How to apply the systems approach?
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Why is systems approach necessary?
• Public Health
• Healthcare Improvement
• Patient Safety Incident Analysis
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Major Public Health Issues
• Smoking and mental health
• Air pollution
• Alcohol
• Antimicrobial resistance
• Dementia
• Preventing Sexually Transmitted Infections
• Nutrition, physical activity and obesity
• Prescription drug overdose
• Teen pregnancy
(Public Health England, https://www.gov.uk/government/collections/health-matters-public-health-issues)
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Obesity
(Swinburn, B., et al, 2011, Lancet)
Food supply
Economic systems
Transport
Employment
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Linear model Look at isolated interventions
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Systems Approach to Public Health Problems
• Approaches to research that aim to
evaluate a single component using
randomisation and control, are of
limited use
• There is growing recognition that we
need a new evidence model that looks
at public health problems, and our
potential responses in terms of a
complex systems approach
(Rutter, H., et al, 2017, Lancet)
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Why is systems approach necessary?
• Public Health
• Healthcare improvement
• Patient Safety Incident Analysis
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Checklists for Intensive Care Unit
• Saved 1500 lives and $100 million in
the State of Michigan during an 18-
month period (New England Journal
of Medicine, 2006)
• Triumph of the “Simple Checklist” as
a Solution to Patient Safety Problems
(Popular Media)
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The Problem with Checklists
• Simple intervention vs Complex socio-
technical intervention:
• Right checklist in the right place with right
design and implementation by right people
with the right skills
(Catchpole. K,. et al, 2015, BMJ Q&S)
• Widespread deployment of checklists
without an appreciation of how or why they
work is a potential threat to patients' safety
and to high-quality care
(Pronovost, P,. et al, 2009, Lancet)
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2008: The Science of Improvement
Clinical Evidence
• a powerful research design to explore the
efficacy of conceptually neat components
of clinical practice, e.g. drugs
• WHETHER it works or not?
Evidence for Process of Care
• Quality and safety improvement usually
requires Complex, Multicomponent
interventions - a process of Social Change,
e.g. rapid response systems
• WHY it works or not?
(Berwick, D. JAMA, March 12, 2008—Vol 299, No. 10)
Randomised Control Trial Context & Mechanism (Mixed methods)
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Why is systems approach necessary?
• Public Health
• Healthcare Improvement
• Patient Safety Incident Analysis
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Root Cause Analysis (RCA)
RCA’s fishbone diagram
Why? • Wristband not checked
Why? • Wristband missing
Why? • Wristband printer on the unit was broken
Why? • Label jam
Why?• Poor
product design Root
Cause!
Five whys
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The Problem with RCA1. Promotes a flawed reductionist
view
2. Fail to explore deep system
problems
3. Recommend staff retraining
(behaviour-based) as action plans
4. Similar incidents tend to repeat
again and again
5. Create blame culture
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Systemic Accident Analysis
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Systems approach to healthcare improvement
doi: 10.1136/bmj.k2014 | BMJ 2018;361:k2014 | the bmj
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Contents
• Why is systems approach necessary?
• What is systems approach?
• How to apply systems approach?
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• “A problem clearly stated is halfway to solution”
(Robert Graves)
Linear thinking Systems thinking
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Linear thinking
• Big picture (forest) thinking
Context of relationships
• Dynamic thinking
Behaviour over time
• Interaction (loop) thinking
Feedback relationships
• Tree by tree thinking
Focusing on the details
• Static thinking
Focusing on events
• Factors thinking
Listing factors and ignoring
interdependence
(WHO, 2009, Systems Thinking for Health Systems Strengthening)
Systems thinking
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Contents
• Why is systems approach necessary?
• What is systems approach?
• How to apply systems approach?
![Page 28: Introduction to the Systems Approach · Training overview • Three components 1. Introduction to the systems approach 2. Tools for systems analysis: influence diagrams 3. Tools for](https://reader034.vdocuments.net/reader034/viewer/2022052023/60388e3f65fbee3e644e8477/html5/thumbnails/28.jpg)
Contents
• Why is systems approach necessary?
• What is systems approach?
• How to apply systems approach?
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How to apply the systems approach?
• We often use models, tools and methods
• There is a huge range of models we could use
• ‘All models are wrong, but some are useful’ (George
Box)
• We will focus on a few models in the training
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System Building Blocks
• SHELL Model
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System Building Blocks
• Systems Engineering Initiative for Patient Safety
(Carayon, P., et al, BMJ Q&S, 2006)
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System Building Blocks
• Micro/Meso/Macro
− Macro-level (regional/national)
− Meso-level (organisation and delivery of health care)
− Micro-level (patient and practitioners)
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System Building Blocks
(Rasmussen, 1997)
• System Theory-based
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System Building Blocks - WHO
(WHO, 2009, Systems Thinking for Health Systems Strengthening)
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Interconnectedness of blocks - WHO
(WHO, 2009, Systems Thinking for Health Systems Strengthening)
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Implications of systems approach
• Multidisciplinary and multi-stakeholder involvement
• Multiple interventions (care bundles)
• Intervening at high leverage points
• Comprehensive assessment of the main effects and
the contextual factors that may help explain the
success or failure of the intervention (mixed methods)
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Recap and summary• Applying the systems approach to public health helps to identify the
multitude of interdependent elements (all within a connected whole – the
NHS, the Kenyan Health Service) which exist within the overall system
• The systems approach uses a variety of methods to design, implement and
evaluate public health interventions
• Helps to put together ‘helicopter views’ and ‘microscope views’ (and avoid
focusing on single components in isolation)
• The systems approach can be used to identify barriers (blockages,
bottlenecks), but also ways forward (e.g., parts of the system which require
improvements) and strategies for improvement (potential solutions)
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Some questions for you to think about – homework • How does what we have described differ (or is similar)
to what you normally would consider ‘Healthcare Systems Research’?
• How could you apply the systems approach to interventions such as the Baby Friendly Community Initiative?
• What might be some of the components? Who might be the stakeholders? etc
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Thanks for Listening!
Thomas and Patrick