“Every system is perfectly designed to get the results it gets. If we want better outcomes, we must change something in the system. To do this we need to understand our systems”
Don Berwick, President and CEO, Institute for Healthcare Improvement (IHI) USA
The way systems are designed determines what we are able to achieve and the majority of problems are the system, rather than the people.
Understanding that healthcare organisations are made up of complex systems and processes is very important to improving the quality of the care we deliver. ‘Systems thinking’ draws on a number of disciplines and enables us to see that improvements are achieved by systematic approaches to change that take account of this complexity.
As someone working in health or social care, you know that how you and your team works depends upon lots of other things besides your personal skill, such as demand or organisational processes, culture and leadership, technology, human resource strategies and the ways in which funds are organised in your organisation. Increasing interdependencies between working teams, departments and organisations means that local solutions to problems are often not sufficient. What we do impacts upon others and what others do impacts upon us.
These are the challenges and the opportunities of systems.
Systems thinking provides a framework for looking at relationships between parts of the system and how they connect, rather than separate activities as disconnected, individual parts. It helps us to see and understand patterns over time rather than just snapshots in time.
Processes and systems
Processes are the components of a system. A process is a series of connected steps or actions to achieve an outcome. They have purposes and functions of their own but cannot work entirely by themselves.
A system is a collection of parts and processes organised around a purpose and each system is embedded in other systems.
A useful example to consider is the cardiovascular system. In the cardiovascular system, the process is the way blood passes through the heart: from the vena cava into the right atrium then into the right ventricle and off to the lungs via the pulmonary artery. It returns to the heart by the pulmonary veins into the left atrium and into the left ventricle before leaving the heart in the aorta. You could map this process. However the heart is only one part of the cardiovascular system. The process of blood going through the heart is affected by all sorts of other things such as exercise, hormones, disease, blood volume, etc. Each of these needs to be understood when thinking about how the heart works
Complex adaptive systems
Very little in health and social care is simple – we know that. In fact many of our systems can be considered to be complex! Health and social care organisations are complex adaptive systems:
- Systems in the sense that there is coordinated action towards some purpose.
- Complex in the sense that there are many and varied relationships among parts of the systems, making detailed behaviour hard to predict.
- Adaptive in the sense that people who make up the systems can change and evolve in response to new conditions in the environment
Elements of a system
If we want fundamental and transformational change in a complex adaptive system, we must consider interactions and changes in each of these three elements: structure processes and patterns.
- Organisational boundaries
- Layout of equipment, facilities and departments
- Roles, responsibilities
- Teams, committees and working groups
- Targets and goals.
We are very familiar with structure in the NHS. Time and time again, when improvement is required, the first action is to restructure – often with very little effect!
- Patient journeys and care pathways
- Supporting processes, such as requesting, ordering, delivering and dispensing
- Funding flows, recruitment of staff and procurement of equipment.
We have gained a lot of knowledge about how to understand and improve processes, bottlenecks and so on.
- Thinking and behaviours
- Relationships, trust and values
- Conversations, communication and learning
- Decision making
- Conflict and power.
Patterns are often ignored and remain unchanged and unchallenged within systems, despite changes to structures and processes.
The use of clinical microsystems as a framework for service improvement was developed at Dartmouth Hitchcock Medical School in the US who defined a clinical microsystem as “the small, functional, front-line units that provide most healthcare’s to most people. They are the place where patients and the care teams meet.”
Microsystems are the essential building blocks of the health system. They are the place where patients and healthcare staff meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed.
A microsystem includes not only the multidisciplinary team who work together to deliver that care, but the supporting staff (clerical, ancillary, etc.) who help them, the patients, and the families who benefit from that care. The context is important, and the environment and information that teams use are also part of the microsystem.
Supporting microsystems also exist, such as Pharmacy, Estates and IT. They are microsystems in their own right but also stakeholders in many other microsystems.
The quality and value of care produced by a large health system can be no better than the services generated by the small systems (microsystems) of which it is composed.
Microsystems already exist. Microsystem improvement involves engaging the microsystem team members (the multi-disciplinary members of staff that work in that microsystem) in a structured process to improve the quality of care for patients and the staff who work there.
Sheffield Microsystems Coaching Academy are taking a unique approach, established and developed since 2011/2, to improve defined microsystems within the health community.
The diagram below is taken from Sheffield Microsystems Coaching Academy website and shows the three key elements involved in their approach. For more information please see links below.
Quality improvement is not easy, and having a coach to help the team through the work is very helpful. Evidence from research shows that having a coach to help and support improvement work greatly increases the chance of success. The Sheffield Microsystem Coaching Academy trains coaches to help microsystems work on improvement.
There are a number of tools and techniques that are essential for improvement work. The Sheffield Microsystem Coaching Academy trains the coaches to use tools such as process mapping, time series measurement, and making small tests of change (Plan-Do-Study-Act cycles, or PDSA) to help the microsystem. The microsystem then learns with the coach how to apply these tools to deliver measurable improvements. The coach builds with the team the capability to understand and use improvement science so that the process is sustained and everyone has two jobs when they come to work: to do their work and to improve it.
This approach requires the active involvement of the microsystem team and regular weekly meetings are required to work on improvement. Representatives from the stakeholders who play a part in that care are needed – doctor, nurse, therapist, clerical, ancillary, and manager, as well as any key supporting microsystems. Patients are at the heart of microsystem improvement, and involving a patient in these microsystem improvement meetings is essential.