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Practical Tools for SLRs

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Systems Thinking Principles

Introduction to Systems Thinking
  • In highly complex adaptive systems, such as health and social care organisations, Systems Thinking is considered the most meaningful way to understand and learn from how systems function and how outcomes are achieved.
  • We do not have a shared understanding of Systems Thinking and related principles, and how adoption of this mindset or philosophy can radically change for the better the way we respond to and learn from safety occurrences, including how we treat those impacted by events.
  • We aim to work with informed health and care professionals and safety experts to build consensus on a series of useful Systems Thinking principles that can be integrated into related policy, education, research and practice to influence our understanding of how and why ‘success’ and ‘failure’ are achieved from everyday care work, and how we learn holistically from these system outcomes.
  • The guide below provides examples of common Systems Thinking principles that will prove useful for those involved in leading SLRs.  Becoming familiar with and applying these principles over time as part of SLRs is important for ensuring that a more meaningful learning mindset is adopted at all times.

Systems Thinking Principles for Health & Care Safety

Tools to download

Care System Analysis Tool (CSAT)

The Care System Analysis Tool (CSAT) is based on the Systems Engineering Initiative for Patient Safety (SEIPS) framework which is the most applied entry-level Human Factors tool in healthcare settings. The tool can be used by anyone as a general systems analysis and problem solving tool.

The Local Rationality Principle

This set of open ended questions help you to explore why the care system behaved in the way that it did at the time of an event (incident, or complaint). By exploring system-wide influencers we can identify more meaningful learning and actions for improvement.

Walk-Through-Talk-Through-Analysis

WTTT is a tool commonly used by Human Factors and other similar safety and design specialists working in high-risk industries (e.g. the oil and gas, nuclear, military and transport sectors) worldwide. The purpose of applying WTTT is to understand how ‘work is really done’ at the sharp end of care practice.

In Situ System Observation Guide (ISOG)

A systems-based data collection tool to better understand how people perform work in their natural work setting (e.g. clinicians, managers and administrators, safety, risk, improvement, research specialists, educators) – this is the data collection tool tat would accompany a Walk-Through-Talk-Through analysis.

Capturing Organisational Learning (Mindset and Action)

This guidance outlines key concepts and approaches for capturing learning from everyday work success and when things go wrong. It explains the two key areas in achieving effective organisational learning: mindset and action. Templates are provided with this document to help capture this. Please select the link below to access this document.

Other Useful Tools

More detail on SEIPS, Link Analysis, and Hierarchical Task Analysis can be found in the pre-recorded webinar sub section.