systems theory and quality patient care
DESCRIPTION
A presentation I made to a conference on quality patient care in JulyTRANSCRIPT
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Systems theory and quality patient care
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Understanding Quality through Systems Thinking
Basis of this presentation: Paper by Dr Peter Cusins entitled:
Understanding Quality through Systems Thinking
Published in The TQM Magazine, 1994
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What is a system?
A way of thinking about any dynamic process.
Five key statements about systems:1. Arbitrary boundary2. Inputs cross boundary from environment3. Within system inputs interact in
transformation process4. Transformed inputs leave system as outputs5. Direction of flow indicates flow of energy,
materials, information, etc.
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What is systems theory and how is it relevant to the health sector? – a simple model
Input Process Output
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The “natural law” of systems
“If the outputs of a system do not satisfy the environment, the inputs will cease” Decisions around satisfactoriness
governed by the environment The environment is everything not within
the artificial boundary of the system
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Complexity of Systems
Input Process Output
Input Process Output Input Process Output
Input Process Output
Input Process Output
Input Process Output
Input Process Output
•All systems are sub-systems of larger systems•Environment is complex collection of other systems•“Focus” system is that part on which we are focussing•All inputs to any system are outputs from some other system, all outputs are inputs to another system
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First two principles of systems thinking
1. Any system is always a part of a complex set of systems
2. All systems function as both source and user systems
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Systems in health care
Human body is a set of systems:• Skeletal system• Endocrine system• Muscular system• Nervous system• Bronchial system• Alveolar system• Blood system
Which all work together to maintain bodily healthSo what are the systems in the health care “body”?
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Third principle of systems thinking
3. Whether we zoom in or out, we always find more systems
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The concepts of product and waste
Product = satisfactory output (the user system is able to use it)
Waste = unsatisfactory output (the user system is unable to use it)
Because it is an output, “waste” will always enter another system (nature, very often)
Waste which is damaging the system it enters is “toxic” waste
Applicable to service systems also
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The concepts “output” and “outcome”
Output produced within focus system – cross boundary into environment
Outcome/s the effect of outputs on the environment
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Four more principles of systems thinking
4. Outputs can be seen from within the system while outcomes can only be seen outside the system
5. Beneficial or adverse outcomes might only be observable at some remove from focus system
6. Might take some time to manifest7. External feedback loops impact on
effectiveness; internal ones on efficiency
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Feedback and open systems
Closed system has no feedback loops
Open system has effective feedback loops
Hard system – purpose of internal feedback loops is to maintain consistency
Soft system – effective external feedback loops allow flexible outputs in response to changing needs of users
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The relevance of the concept of quality to patient care – a systems view.
What is quality? A judgement made at the boundary
between producer and user systems Judgement made against referent/s▪ Especially standards agreed between
producer and user systems Quality can only start when the supplier
knows exactly what the user wants
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Quality judgements involve:
Observing actual output Comparing output with standards Judging whether or not actual
outcomes fulfil expectations of user As Covey said – “is the ladder against
the right wall?”
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What constitutes quality in terms of patient care?
While actual outputs might be defined in terms of agreed standards judgement of outcomes introduces a value question
Values are core beliefs about what is good or bad, right or wrong.
To judge quality in terms of patient care we have to go outside the system to see the effect of the system on the environment
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Quality patient care
Patient system (and its sub-systems) is the user system – efficiency will be judged at boundary between patient system and health care provider Primarily – are the sub-systems of the
patient improved? Effectiveness will be judged outside
of the user and provider systems Is the environment improved?
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Stakeholders from patient perspective
PatientPatient’s familySociety
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Stakeholders from provider perspective
Nurse/doctorManagementOrganisation
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Who cares? – some implications for management
All systems are operated by people Managing quality or systems is a
myth Management is about people Most important principle in
managing people – always treat your people exactly as you would want them to treat your most valued customer (Covey)
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Who is the “most valued” customer of the health care system?
Essentially it is the person most directly affected by any sub-system within the environment
The patient who enters the system with the expectation of getting “better”, whatever that might mean to her or him
Without a patient there is no purpose for the health care system
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Frontline systems interacting with patient
Patient
NursingMedical
Administrative
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References
Cusins, Peter J.: Understanding Quality through Systems Thinking. The TQM Magazine, Volume 6 Number 5, pp 19 – 27
Covey, Stephen R: The Seven Habits of Highly Effective People. Simon & Schuster, 1992.