Systems in healthcare are described as complex. In such systems it can be difficult to fully understand how safety is created and maintained.
Complex systems consist of many dynamic interactions between people, tasks, technology, environments (physical and social), organisational structures and arrangement, and external factors, such as the influence of national policy or regulation.
The nature of these interactions often results in unpredictable changes in system conditions (such as patient demand, staff capacity, available resources and organisational constraints) and goal conflicts (such as the frequent pressure to be efficient and thorough).
To achieve success, people frequently adapt to these system conditions and goal conflicts. But rather than being planned in advance, these adaptations are often approximate responses to the situations faced at the time.
Therefore, to understand patient safety or staff wellbeing (and other emergent outcomes) we need to look beyond the individual components of care systems to consider how outcomes (wanted and unwanted) emerge from interactions in, and adaptations to, everyday working conditions.
This short video developed by ST4CHealth briefly explains Systems Thinking and Complexity.
Systems Thinking is often recommended in healthcare to support quality and safety activities, but a shared understanding of this concept and guidance on application of related thinking and tools are limited.
Adopting this approach to healthcare issues is recommended as it may improve the ability to understand current work processes, predict system behaviour and design modifications to improve related functioning.
Systems Thinking involves exploring the characteristics of components within a system (e.g. work tasks, technology, physical environment, culture) and how they interconnect to improve understanding of how outcomes emerge from these interactions.
This approach is necessary when trying to:
We have included details of three models that can be used to frame team discussions to encourage a systems approach to exploring and improving safety in healthcare.
1.Systems Engineering Initiative for Patient Safety (SEIPS) model
The Safety Engineering Initiative for Patient Safety (SEIPS) is arguably the best known and most published systems-based Human Factors framework in healthcare worldwide.
Developed by Professor Pascale Carayon and colleagues in the University of Wisconsin, the SEIPS framework is partly based on Donabedian’s well-known Structure-Process-Outcome model of healthcare quality.
SEIPS is strongly grounded in a Human Factors based systems approach.
As we can see from the diagram to the right, key characteristics of the model include:
A description of the interacting clinical work system elements – this could refer to any clinical setting,
incorporation of the well-known quality of care model developed by Donabedian, as mentioned care processes being influenced by the work system and contributing to system outcomes, integration of patient outcomes and organizational/employee outcomes – it is important to note that both of these outcomes relate to the joint improvement of system performance and human wellbeing which are well-established, fundamental Human Factors principles and goals.
And, finally, feedback loops between the process and outcomes, and the actual work system
Overall the model is, from a Human Factors perspective, quite simple and elegant in its attempts to convey a highly complex interacting environment and its related system outcomes
A blank worksheet can be downloaded below.
An elearning module explaining its use is under development.
2. PAcE (People, Activity, Environment) analysis
Enhanced SEA is a NES innovation (funded by the Health Foundation 2012 SHINE programme) which aims to guide health care teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved.
Taking this approach will help individual clinicians and care teams to openly, honestly and objectively analyse patient safety incidents, particularly more difficult or sensitive safety cases, by ‘depersonalising’ the incident and searching for deeper, systems-based reasons for why the significant event happened.It prompts teams to consider the interactions between the people involved in incidents, the activities they were undertaking and the influence of environment within which they were working.
In this way, a more constructive approach to learning can take place and more meaningful improvement can be implemented to minimise the risks of the event happening again.
This method is used within Enhanced Significant Event Analysis and an elearning module can be found here.
3. System Thinking for Everyday Work (STEW)
The STEW principles help teams to explore why people work the way they do. In complex systems people often have to adapt how they work based on demand/ capacity issues, availability of resources, interactions with other components and competing goals (such as efficiency thoroughness). Consideration of these factors can help explore work-as-done and therefore, why decisions were made and whether variation is helpful or not.
A blank worksheet that can be used by teams to consider a system using these principles can be download below.
An elearning module to explain the use of the principles is under development.