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Improvement teams in health and care already have a range of theories of change and improvement approaches available: the NHS change model, IHI model for improvement, leading large scale change, human factors in healthcare, lean in healthcare, experience-based co-design, root cause analysis, to name a few.

While a number of these approaches already include tools, such as Failure Modes and Effect Analysis (FMEA) and mapping techniques, that may be found in engineering methods the systems approach proposed in this report has the potential to add further value to the improvement agenda in two distinct forms. The provision of new tools and ways of thinking can supplement existing approaches; and the adoption of a systems approach as a method in its own right can guide a design from a set of complex needs through to validated, effective operational systems (Figure 1).

Figure 1: A systems approach to health and care improvement

Improvement tools, such as the IHI model for improvement, the NHS house of quality and driver diagrams can complement the activities of a systems approach that in turn can add new tools and ways of thinking to existing improvement approaches.

New ways of thinking include designing for ease of access. As we live longer, we are more commonly living with cognitive and/or physical conditions that restrict our access to services. Consider the arthritis sufferer struggling with a child-proof cap, or the dementia sufferer regarded as a ‘Did Not Attend’ because she forgot her appointment. Inclusive design, the design of mainstream products and/or services that are accessible to and usable by people with the widest range of abilities within the widest range of situations, is embedded within the systems approach. It uses a suite of tools to help answer two important questions: what proportion of our service users can easily access the service we offer; and how do we systematically design for maximum user accessibility? While other approaches proceed with the user in mind – for example, human-centered design immerses the patient or service user in the design process – none systematically ensure that we design with the whole population in mind, both as patients and providers.

There are other key areas in which new ways of thinking, derived from a systems approach, can supplement existing methods. This includes, measuring and designing system interfaces to alleviate service integration issues and using systems safety assessment to proactively design risk out of systems and avoid incidents rather than merely reactively preventing a recurrence. In such cases, existing improvement approaches may be enhanced by using techniques from a systems approach.

The systems approach is also a method in its own right that applies tools to answer a series of questions (Section 5: A framework for action) in an iterative and systematic way in order to guide a design from a set of complex needs through to validated, effective operational systems. During this process, experienced improvers can use their own tools, frameworks and experiences of change to supplement those drawn from the systems community. Whether it is in enhancing existing approaches through additional tools and techniques, or encouraging improvements to be guided by a series of critical questions, a systems approach can greatly enhance the capability and potency of professionals delivering change.

There are a number of approaches from the health and care improvement and engineering communities that have the potential to help teams understand people, deliver systems, facilitate design and manage risk (Annex 4: Compilation of approaches). Most excel with one of these perspectives while some attempt to support a more holistic integrated systems approach. Table 2 maps their strengths in delivering a systems approach.

We can summarise our shared learning as:

1 Systems are centred on people

– an effective systems approach is centred on people, their needs, their capabilities and ultimately their role in understanding, designing, delivering and maintaining success.

2 Iteration before implementation

– the behaviour of complex systems is not easily understood and improvement is most often the result of successive iterations targeted at maximising the chance of success prior to implementation.

3 Design is an exploratory process

– improvement results from a creative process that seeks not only to explore the real need, but also to evaluate a range of possible solutions in order to select the best option.

4 Risk management is a proactive process

– the identification of possible opportunities for and threats to a system before they arise is more likely to lead to the delivery of robust and adaptable systems.

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Foreword

Executive summary

Introduction

Section 1

Healthcare as a ‘system of systems’

Section 2

Approaches to improvement

Section 3

Defining a systems approach

Section 4

A framework for thinking

Section 5

A framework for action

Annex 1

Applications of the approach

Annex 2

Case studies

Annex 3

Elements of a systems approach

Annex 4

Compilation of approaches

Bibliography

About the project