In this post we will revisit some of the basic systems principles that underlie the functioning of the health care system today. To make effective change in any portion of this very complex system, the interactions of its parts must be understood.
There are five basic principles of an effectively operating system:
1. A system is greater than the sum of its parts and requires investigation of the whole situation rather than individual parts of the system.
2. Though each sub-system is a self-contained unit, it is part of a wider entity.
3. Every system is an information system and must be analyzed in terms of how suitable information is transmitted between units.
4. Open systems means high interaction with and between the system and its environment.
5. The purpose of the sub-systems must be aligned with the purpose of the system as a whole.
General Systems Theory
A primary developer of the concepts for general systems thinking is Russell Ackoff. His criteria for working with a system:
1. Systems are democratic organizations in which all voices should be heard and authority is collective.
2. Systems have an internal market economy where there are continued trade-offs among sub-sets of the system.
3. Systems are multidimensional structures designed by the allocation of resources.
4. Systems-based planning has to be interactive. Ends have to be clear before means are discussed.
5. Systems-based planning must have control systems in place to make the process manageable.
The Clinical System
The general systems thinking concept can be extended to health care. To improve health care operations, it is important to understand the systems that influence the delivery of care. Clinical care delivery is embedded in a series of interconnected systems (see figure).
The patient care microsystem is where the health care professional provides hands-on care. Elements of the clinical microsystem include:
• The team of health professionals who provide clinical care to the patient;
• The tools the team has to diagnose and treat the patient (e.g., imaging capabilities, lab tests, drugs); and
• The logic for determining the appropriate treatments and the processes to deliver this care.
Because common conditions (e.g., hypertension) affect a large number of patients, clinical research has determined the most effective way to treat these patients. Therefore, in many cases, the organization and functioning of the microsystem can be optimized.
The organizational infrastructure also influences the effective delivery of care to the patient. Ensuring that providers have the correct tools and skills is an important element of infrastructure. For example, the electronic health record is one of the most important advances in the clinical microsystem for both process improvement and the wider use of Evidence-based Medicine. Another key component of infrastructure is the leadership displayed by senior staff. Without leadership, effective progress or change will not occur.
Finally, the environment strongly influences the delivery of care. Key environmental factors include competition, government regulation, demographics and payer policies. An organization’s strategy is frequently influenced by such factors (e.g., a new regulation from Medicare, a new competitor).
Significant improvements in health care can be achieved when the change leaders base their strategy on both general and health care specific systems thinking.
(Additional information in this post provided by Dan McLaughlin)
1. On Purposeful Systems: An Interdisciplinary Analysis of Individual and Social Behavior as a System of Purposeful Events (Paperback) by Russell Ackoff and Fred Emery, Aldine Transaction (2005).
2. Figure Source: Ransom 2005. Based on Ferlie, E., and S. M. Shortell. 2001. “Improving the Quality of Healthcare in the United Kingdom and the United States: A Framework for Change.” The Milbank Quarterly 79(2): 281–316.
3. McLaughlin and Hays, Healthcare Operations Management, Health Administration Press, 2008