Section 2

Approaches to improvement

Comparison of existing improvement tools

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.

Large scale change

Michigan hospitals reduced the rate of catheter-related bloodstream infections to a median of zero infections per 1000 catheter days by proactively controlling risk

Table 2: Comparison of methods

A map of healthcare and engineering improvement approaches showing the working group's assessment of their relative strengths in delivering a systems approach as described in the following sections and Annex 3: Elements of a systems approach.

The approaches range from health and care improvement methods and tools to design-led safety management and human factors methods. It is evident from Table 2 that engineering approaches provide more complete coverage of a systems approach, particularly in terms of design and risk, than current healthcare approaches. Further details of all the methods and tools are given in Annex 4: Compilation of approaches. The interplay between a systems approach and current improvement approaches is explored in more detail in Section 5: A framework for action.

To a certain extent, this report describes what might be thought as common sense. However, common sense is not always as common as might be imagined. What is new is the development of a framework and language suited to health and care processes.

We explored the elements that make up a systems approach and asked health and care professionals who are active in delivering change to identify which of these elements are missing or not strong enough in current health and care practice.

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.

5. Thinking changes practice, process helps

Individual perspectives give rise to changes in thinking that can immediately permeate current practice; a new process is an opportunity to deploy new thinking.

6. Common sense is not common

There is an increasing number of islands of excellence when it comes to using a systems approach; however, the common sense thinking presented here is still far from being common in practice.

Predicting outcomes

Modelling and simulation informed the required patient-flows and resourcing levels in a London trauma centre, reducing waiting times and improving care


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