Systems Theory And Quality Patient Care

Systems theory and quality patient care

Understanding Quality through Systems Thinking

Basis of this presentation: Paper by Dr Peter Cusins entitled:

Understanding Quality through Systems Thinking

Published in The TQM Magazine, 1994

What is a system?

A way of thinking about any dynamic process.

Five key statements about systems:1. Arbitrary boundary2. Inputs cross boundary from environment3. Within system inputs interact in

transformation process4. Transformed inputs leave system as outputs5. Direction of flow indicates flow of energy,

materials, information, etc.

What is systems theory and how is it relevant to the health sector? – a simple model

Input Process Output

The “natural law” of systems

“If the outputs of a system do not satisfy the environment, the inputs will cease” Decisions around satisfactoriness

governed by the environment The environment is everything not within

the artificial boundary of the system

Complexity of Systems

Input Process Output

Input Process Output Input Process Output

Input Process Output

Input Process Output

Input Process Output

Input Process Output

•All systems are sub-systems of larger systems•Environment is complex collection of other systems•“Focus” system is that part on which we are focussing•All inputs to any system are outputs from some other system, all outputs are inputs to another system

First two principles of systems thinking

1. Any system is always a part of a complex set of systems

2. All systems function as both source and user systems

Systems in health care

Human body is a set of systems:• Skeletal system• Endocrine system• Muscular system• Nervous system• Bronchial system• Alveolar system• Blood system

Which all work together to maintain bodily healthSo what are the systems in the health care “body”?

Third principle of systems thinking

3. Whether we zoom in or out, we always find more systems

The concepts of product and waste

Product = satisfactory output (the user system is able to use it)

Waste = unsatisfactory output (the user system is unable to use it)

Because it is an output, “waste” will always enter another system (nature, very often)

Waste which is damaging the system it enters is “toxic” waste

Applicable to service systems also

The concepts “output” and “outcome”

Output produced within focus system – cross boundary into environment

Outcome/s the effect of outputs on the environment

Four more principles of systems thinking

4. Outputs can be seen from within the system while outcomes can only be seen outside the system

5. Beneficial or adverse outcomes might only be observable at some remove from focus system

6. Might take some time to manifest7. External feedback loops impact on

effectiveness; internal ones on efficiency

Feedback and open systems

Closed system has no feedback loops

Open system has effective feedback loops

Hard system – purpose of internal feedback loops is to maintain consistency

Soft system – effective external feedback loops allow flexible outputs in response to changing needs of users

The relevance of the concept of quality to patient care – a systems view.

What is quality? A judgement made at the boundary

between producer and user systems Judgement made against referent/s▪ Especially standards agreed between

producer and user systems Quality can only start when the supplier

knows exactly what the user wants

Quality judgements involve:

Observing actual output Comparing output with standards Judging whether or not actual

outcomes fulfil expectations of user As Covey said – “is the ladder against

the right wall?”

What constitutes quality in terms of patient care?

While actual outputs might be defined in terms of agreed standards judgement of outcomes introduces a value question

Values are core beliefs about what is good or bad, right or wrong.

To judge quality in terms of patient care we have to go outside the system to see the effect of the system on the environment

Quality patient care

Patient system (and its sub-systems) is the user system – efficiency will be judged at boundary between patient system and health care provider Primarily – are the sub-systems of the

patient improved? Effectiveness will be judged outside

of the user and provider systems Is the environment improved?

Stakeholders from patient perspective

PatientPatient’s familySociety

Stakeholders from provider perspective

Nurse/doctorManagementOrganisation

Who cares? – some implications for management

All systems are operated by people Managing quality or systems is a

myth Management is about people Most important principle in

managing people – always treat your people exactly as you would want them to treat your most valued customer (Covey)

Who is the “most valued” customer of the health care system?

Essentially it is the person most directly affected by any sub-system within the environment

The patient who enters the system with the expectation of getting “better”, whatever that might mean to her or him

Without a patient there is no purpose for the health care system

Frontline systems interacting with patient

Patient

NursingMedical

Administrative

References

Cusins, Peter J.: Understanding Quality through Systems Thinking. The TQM Magazine, Volume 6 Number 5, pp 19 – 27

Covey, Stephen R: The Seven Habits of Highly Effective People. Simon & Schuster, 1992.

My contact details

Tony McGregor Email: [email protected] Cellphone: 072 163 2463