Section 3

Defining a systems approach

Critical questions that deliver a systems approach

A system (or system of systems) is a set of elements: people, processes, information, organisations and services, as well as software, hardware and other systems that, when combined, have qualities that are not present in any of the elements themselves.

A system is delineated by its spatial and temporal boundaries, surrounded and influenced by its environment, described by its structure and purpose, and expressed in its functioning. In other words, the whole is very likely to be greater than the sum of the parts.

For example, the human body is a system of systems where each has its own purpose and function. When combined, the systems produce for the body qualities not present in any of the individual elements. Conversely, if any individual system is compromised or a part of the body is damaged, the overall function may be significantly or terminally impaired (Figure 2).

Figure 2: A system of systems — different perspectives on the human body

The human body is a system of systems, comprising amongst others the circulatory, digestive, nervous, integumentary, muscular, skeletal and respiratory systems. Each has its own purpose and function and yet when combined, they produce for the body qualities not present in any of the individual elements.

A systems approach uses a range of techniques to determine requirements for the system, organise its structure, create and evaluate alternative designs, produce quantitative analyses and predictions where appropriate, assess possible threats to and opportunities for people and other systems, integrate all the individual elements and deliver a system that is shown to be fit for its intended purpose. A true systems approach does not deliver solely technical solutions; rather it ensures the appropriate alignment of technology, processes, interactions and policy to deliver innovative responses to today’s most complex and pressing challenges.

A systems approach can be applied to the design and improvement of systems across many areas of health and care. This is illustrated by the inclusion of references to case studies throughout the report.

A systems approach can be applied to the design and improvement of systems at all extremes of scale, with service level improvement taking place within a wider context that may subsequently require changes at the organisation level and cross-organisational level. Within the delivery of health and care, many systems are distinct and can be operated independently, yet are also connected to or integrated with other systems, either in layers or as part of a network. The strength of a systems approach is its ability to overcome the complexity associated with such systems of systems and deliver solutions at all levels of scale regardless of the form of the system. Its value has been recognised in health and care and increasingly referred to in national policies and used in improvement methods.

A systems approach aims to determine the system design and implementation that delivers the best service. It has the potential to drive greater efficiency and a better understanding of threats and opportunities present when shaping the delivery of health and care services. A systems approach brings together four key and complementary perspectives (Figure 3):

Empowering patients

Clinical support services in imaging, physiotherapy, occupational therapy, dietetics and speech and language therapy are coordinated through inpatient schedules

Figure 3: Perspectives of a systems approach

A systems approach as the sum of people, systems, design and risk perspectives.


understanding of interactions among people, at the personal, group and organisational levels, and other elements of a system in order to improve overall system performance (identify, locate, situate)


addressing complex and uncertain real world problems, involving highly interconnected technical and social elements that typically produce emergent properties and behaviour (understand, organise, integrate)


creating a range of possible solutions and refining the best of these to deliver appropriate outcomes (explore, create, evaluate)


managing risk, based on the timely identification of threats and opportunities in the system, assessment of their associated risks and management of necessary change (examine, assess, improve).

A holistic approach

Seeing a visit to the Emirates stadium as one part of a wider ‘system of systems’ helps create a successful match day experience for Arsenal fans

All these perspectives are inextricably linked and uniquely contribute to a systems approach. It is only when all four are robustly understood (Annex 3: Elements of a systems approach) that a systems approach will have the greatest success. Their scope, purpose and operation can be summarised through the answers to a number of high-level questions (Table 3) that were developed and agreed during the project workshops (About the project). These are listed according to their particular perspective and with reference to a number of case studies (Annex 2: Case studies) that highlight their application in practice.

The challenge is to convert these questions into a useful, versatile and systematic process that repeatedly delivers results. Each of the four perspectives of people, systems, design and risk can be seen as individual components within an improvement process and there is merit in emphasising their particular individual characteristics when striving for improvement.

Strategies for implementing a systems approach range from the adoption of individual people, systems, design and risk perspectives within existing improvement processes, to the design of new processes that provide an appropriate frameworkfor combining all the perspectives.

Table 3: Key questions that summarise an effective systems approach


Who are the stakeholders?

— leads to an understanding of the diversity of people involved and their needs and capabilities (identify).

Where is the system?

— leads to an understanding of the physical, organisational and cultural context of the system (locate).

What affects the system?

— leads to an understanding of the political and policy landscape within which the system is situated (situate).


Who are the stakeholders?

— leads to a common view of the stakeholders and their individual interests, needs, values and perspectives (understand).

What are the elements?

— leads to an agreed system boundary, architecture and details of the interfaces between all the system elements (organise).

How does the system perform?

— leads to a complete, operational system that is proven to meet the stakeholder requirements (integrate).


What are the needs?

— leads to a common understanding of the needs for a system, taking account of the full range of stakeholders (explore).

How can the needs be met?

— leads to a range of possible solutions that would help meet the needs identified by the explore phase (create).

How well are the needs met?

— leads to an evaluation of possible concepts that could meet the needs identified by the explore phase (evaluate).


What is going on?

— leads to an understanding of the system architecture and details of the interfaces between the elements (examine).

What could go wrong?

— leads to a systematic assessment of the likelihood and potential impact of threats and opportunities in the system (assess).

How can we make it better?

— leads to a range of possible solutions that would help mitigate the threats or exploit the opportunities (improve).

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Improvement initiatives involve people and systems that, in turn, are inevitably part of other systems. Consequently, they would all stand to benefit from using a systems approach that delivers coordinated improvement to all the systems.

All improvement initiatives should start with the question: why are we doing this? This leads to a documented rationale for improving an existing system or developing a new one (trigger).

Triggers to start an improvement initiative

Strategic development:

where risk reduction and improvement is part of an ongoing strategic initiative

An incident:

where an event has resulted in actual or potential harm to patients or clinicians

Local concerns:

where the potential for incidents has been identified through general observation or evidenced by data trends

Routine service review:

where a team or individual wishes to check the integrity of their service

Service improvement:

where national, regional or local changes are planned to an existing service or system

New service:

where a new service is to be introduced into practice or an existing one decommissioned

Technology introduction:

where new equipment or technology is to be introduced to an existing service

Building or estate changes:

where estates or buildings are being built, refurbished or maintained

Staff changes:

where new staff are to be introduced to an existing service or exiting staff levels are changed

External directive:

where specific strategic changes or checks are requested

national initiatives:

where teams are encouraged to propose and deliver service improvements

A clear understanding of the trigger helps to identify the initial scope of the improvement and ensures that an appropriate team is assembled to initiate any subsequent improvement process. Whether the trigger relates to people, systems, design or risk, a systems approach will consider all of these perspectives in a seamless and integrated way. This leads onto a final ongoing challenge: what should we do next?

System failure

How limited understanding of whole system performance and emergent behaviours led to the collapse of a computerised command and control system

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