Section 5

A framework for action

An integrated approach to design and improvement

The systems approach can also be considered as a method in its own right that applies tools to answer the key questions in an iterative and systematic way to guide a design from a set of complex needs through to validated and effective operational systems.

In this context, the questions have been rationalised where the four perspectives overlap and improvement programme questions, relating to the problem, team and success, have been added:

What is the problem?

— leads to a common and clearly articulated view of a better system based on an understanding of the current system (problem).

Who should be involved?

— leads to a common and clearly articulated understanding of who should deliver the improved system (team).

What does ‘good’ look like?

— leads to a common and clearly articulated understanding of success and how it would be measured (success).

Reordering then provides a natural sequence for all the questions (Figure 6):

Design Bugs Out

A collaborative programmeto identify opportunities to help combat infections by making hospital furniture and equipment easier and quicker to clean

Figure 6: A systems approach as an ordered series of questions

A systems approach can be thought of as an ordered and iterative set of activities targeted to answer questions relating to people, systems, design and risk, and the general process of improvement.

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The spiral model shows the natural order of the steps. It also highlights that a systems approach is not a simple linear process, but an iterative process of continuous improvement. It suggests that the first question to be asked concerns the problem to be addressed by the system. This would be followed by questions based on people to understand the background and context to the new system. The questions on systems, design and risk are then interwoven to provide an opportunity to specify, design and evaluate the system and its constituent elements, with a question on what a good outcome would look like early in this sequence.

The idea would be that in the first ‘pass’ of the questions, preliminary answers would be provided. Further ‘passes’ would offer an opportunity to provide more detailed answers or again to ‘skip’ and use the previous answer for that iteration. This process affords the opportunity to progressively increase knowledge of the problem, reduce uncertainty regarding the solution, and manage the implementation risk to an acceptable level. Ultimately, the answers would form a description of the improved system.

It is expected that the methods used to answer the questions would increase in complexity as each question is revisited, until further effort brings limited benefit to other questions in the cycle. For example, initial answers might be based on estimates or knowledge of previous solutions, while later answers could be determined by extensive investigation, advanced modelling and simulation, or evaluation of prototypes.

The spiral model allows the questions to be overlaid on an existing improvement process, at sufficient intervals and to the level of precision required, while ensuring that they are asked in an appropriate order. A number of existing approaches already exist that may assist in answering the questions (Section 2: Approaches to improvement and Annex 4: Compilation of approaches). The spiral model is also adaptable to all levels of scale, from the service level, through the organisation level to the cross-organisational level, and is sufficiently versatile to apply across all areas of health and care.


— leading to a description of the current system (now), a common understanding of the problem, a consensus view of what the future system might look like (better) and a clearly articulated case for changing the system.


— leading to a clear description of the future system, based on the iterative design of the system architecture with its elements and interfaces, the evaluation through successive prototyping of its likely behaviour, and a plan for its delivery.


— leading to the successful deployment of the new system with the levels of measurement necessary to evidence its success, and acceptance that it achieves appropriate value for its stakeholders.


— leading to the continued operational success of the new system along with consideration of further improvement potential or wider deployment.

This approach is common to all improvement processes where the focus on moving a system from its current performance to a future, measurably better state. Such processes typically include a number of key phases to ensure success (Figure 7):

End of life care

Services needed by terminally ill patients and their carers are coordinated across Airedale General Hospital by a 24/7 telehealth and phone line service

Figure 7: A generic improvement process

A generic improvement process transforms a system’s current performance into a measurably better state through phases intended to understand, design, deliver and sustain the future system.

The purpose of the phased approach is to progressively increase the clarity of definition of the revised system while reducing the operational risk. Each of these phases can be inspired by the adoption of the individual people, systems, design and risk perspectives. Alternatively, the spiral model, which may be thought of as progressing through time and spanning all phases, can be adopted and adapted to complement the generic improvement approach (Figure 8).

Figure 8: A systems-spiral improvement process

A systems-spiral improvement process transforms a system’s current performance into a measurably better state through the application of an ordered and iterative set of activities based on a systems approach.

The early iterations of the spiral would focus on increasing understanding of the problem and, if a case for change is agreed, later iterations would provide more focus on the design and delivery of the system and its sustainability. The model also lends itself to the development of systems of systems, where early iterations of the spiral would focus on architecting the overall system, leading to parallel iterations to develop and deliver individual systems, and further iterations to ensure their integration and subsequent evaluation of the overall system.

The ultimate success of the systems approach would depend on keeping all of the relevant questions in mind on each iteration. In practice, a degree of concurrency across the phases is required. The understand phase requires adequate consideration of the design, delivery and sustain phases to create a clear view of the future system, while the sustain phase depends on consideration of sustainability issues throughout the previous phases. Such concurrency, or involvement of key stakeholders throughout the improvement process, is essential if new performance targets are to be realised in a safe, timely and cost-effective manner.

The sequence of questions in the spiral model not only provides an excellent starting point for delivering a successful improvement process, but also assists in addressing a number of other factors that should be considered when designing systems:


— when integrating people, processes, technology and the built environment, it is hard to predict all the behaviours that will subsequently emerge. It is important to design for intended behaviours and outcomes, observe the resultant system behaviours, identify unintended consequences and predict possible variations over time (problem, identify, locate, organise, evaluate, assess, integrate).


— systems behave in a variety of predictable and less predictable ways in response to internal and external data and events. It is important to understand the need for measurement of a system’s performance, implement the means to facilitate such measurement and determine the way in which the resulting data will be used (success, organise, explore, create, evaluate, integrate).


— dysfunctional teams are unlikely to deliver good systems; functional teams are more likely to do so. It is important that the team talks to one another, develops clear plans and instructions, ensures there is a common understanding of the system and engages with all the stakeholders, particularly the users, in the delivery of the system (identify, locate, understand, organise, integrate, plan, team).


— the ability of individuals and organisations to learn enhances their chances of delivering and sustaining effective systems. It is important to develop a culture of continued learning for all stakeholders, build capacity within organisations to deliver effective systems and share stories of success to inspire future systems-based change (identify, locate, situate, team).


— systems are only as good as their interfaces. Between every element of a system there are interfaces to other elements or systems. It is important to organise the elements of a system, define and maintain the necessary interfaces between them, and define and manage the interfaces between the system and its environment (problem, identify, locate, organise, success, integrate).

A true systems approach then combines consideration of people, systems, design and risk in an ordered and well-executed manner to ensure that improvement is driven by clear and agreed goals, is systematic, holistic and inclusive, is supported by trustworthy evidence and is sustainable.

The adoption of a systems approach to design and improvement will transform health and care. Transformation teams and individuals charged with improving care are encouraged to ask the questions posed in this preliminary report as a first step towards changing the way they think and act.

Further assistance may be sought from members of the working group and project team listed in About the project, or by reference to reading material and tools listed in the Bibliography.

Sustainability and care

Lighting levels in a new neonatal intensive care unit provide a calm environment for parents and staff leading to better care and lower energy consumption

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