The health care system can be defined as a set of interrelated parts or agents, which include caregivers and patients, bound by a common purpose and acting on their knowledge. This great number of interconnections within and among makes the healthcare organisation complex (IOM, 2009). Such complexity brings problems and opportunities and requires organisations to adjust to the changes. The ability to understand and respond to both the external and internal environments might require a holistic thinking approach of the system (Lebcir, 2006).
Systems consist of interrelated, interacting and interdependent parts configured in a manner that produces a unified whole. System thinking studies these components parts, their interrelationship and the way they function as a whole. According to Senge (1993), system thinking is a conceptual framework, a body of knowledge and tools that has been developed to make the full patterns of systems clearer, and to help see how they can be changed effectively.
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There are various system thinking approaches and the essay will review some methodologies that were used in managing the case study of Ashford hospital.
1.1 Case Study- Ashford Hospital
Earlier in the year, Ashford hospital which serves quite a large population experienced severe pressure on service. The hospital had 67 ward beds. Patients had to wait for long in chairs or trolleys at accident and emergency unit (A & E) before they could be admitted into the wards. This led to overcrowding of A&E unit. Patients were asked to stay away from the hospital's A&E unless absolutely necessary. The healthcare providers were put under pressure and resulted in trading of blames amongst them. Patients were no longer satisfied with the quality of care. The management of the hospital was disturbed and wanted a way out of the messy situation.
2 Soft Systems Methodology (SSM)
SSM is an action oriented approach for tackling perceived real world problematic (social) situations ( Checkland and Poulter, 2006). Appendix A shows the SSM process steps that were followed in the course of investigation.
2.1 Finding out
An investigation team was invited by Chief Executive (CE) and introduced to some health workers. Using the SSM the first stage was to identify and provide a brief description of the situation. Due to the workload the clinicians were encountering, getting them round a discussion table wasn't easy. However, the investigation team moved around asking questions and observing proceedings. A rich picture was developed to help capture the main entities, structures and view points in the problem situation of Ashton hospital (Figure1, Appendix B).
As part of the finding out, the team had to identify key roles that were affected in this situation (Analysis 1). The team already knew who the client was because it was the CE who requested for intervention. The nurses and doctors (some with specialisation) in A& E provided treatment to patients with various illnesses and injuries.. Where necessary, patients were moved to the ward. The bed manger allocated beds to patient, while the ward manager supervised the ward. Table1 shows the outcome of Analysis 1 while table 2 shows the worldviews of the issue owners.
Having known the key issue owners, the social texture (Analysis 2) of the issue owners in term of their role in the hospital, the norms (expected behaviour associated with such role) and the values (standard by which behaviours are judged) were identified. This is illustrated in table 1 of Appendix B.
A political analysis (analysis 3) which enriched the cultural appreciation previously obtained through Analyses 1and II was done. The essence was to find out the disposition of power associated with the roles within the hospital thereby buttressing our cultural understanding of the situation. The CE, being the head of the hospital, had positioned power over other roles while the doctors enjoyed expert power across the hospital. The details of the analysis 3 are shown in figure 2 of Appendix B. The culture analysis provided a basic for identifying the relevant issues, actors and conflict in the hospital.
The Client- person(s) who
caused the intervention to
The Chief Executive of Ashford hospital
The Practitioner- people performing
The Investigation team (Us)
The issue owners-people who are
Always on Time
Marked to Standard
concerned about or
affected by the
Doctors, Bed managers, nurses, patients, ward managers, Chief Executive
Table 1: Analysis 1 (the Intervention Itself) in Ashford hospital case study
''Targets must be met with the available
''Patients need to be given effective
treatment before they are discharged''
''Doctors do not discharge patients on
time and are always bed blocking''
''We need better healthcare service''; "we
Need to get well before we are
''High standards must be maintained in
''To many patients to cope with''
Table 2: Worldviews of the issue owners in Ashford hospital case study.
2.2 Making Purposeful Activity Models.
According to Checkland and Poulter (2006), every human situation reveals people trying to act purposefully. The models of purposeful activity system viewed through the world view of the doctors and the bed manager were considered very relevant. This was because the doctors made decisions on patients that needed admission while the bed manager was involved in allocation of beds.
In order to model the purposeful activities, root definitions describing the primary activity processes and functions were developed using a mnemonic 'CATWOE' analysis. Appropriate root definitions for the primary functions performed by doctors and bed manager were formulated as follows:
A doctor system to provide quality and effective treatment care, through the use of appropriate acquired knowledge and hospital resources in, order to improve patient's condition.
A bed manager system that provides timely placement of patients in wards, by optimizing the use of available hospital beds, in order to contribute to quality and effective patient care.
Tables 3 and 4 show the purposeful activity models for the Bed Manager and Doctor respectively. The conceptual purposeful activity models are illustrated in figure 2 and 3 of Appendix B.
Purposeful Activity model 1
A bed manager system that provides timely placement of patients in wards, by optimizing the use of available hospital beds, in order to contribute to quality and effective of patient care.
Admission of patients
Patients are admitted in hospital ward beds
Doctors do not discharge patients on time and they contribute to bed blocking
Bed managers, doctors, ward managers, nurses
Number of beds, bed management and ward policies
Are beds available for patients? Are beds data correct?
How long do patient wait before being admitted? Do patients over stay on ward bed? Optimal bed usage, waiting time
Have all patients been admitted on time?
Table 3: Purposeful Activity model of Bed Manager.
Purposeful Activity Model 2
A doctor system to provide quality and effective treatment care, through the use of appropriate acquired knowledge and hospital resources in order to improve patient's condition.
Treatment and admission of patients
Patients are admitted and treated in the hospital
Patients need to be given effective treatment before they are discharged
Nurses, doctors, bed managers, ward managers
Bed management and ward policies, availability of beds
Have patients been treated and admitted
Are patients getting better?, cost of drugs, time
Have all patients been treated and admitted on time?
Table 4: Purposeful Activity model of Doctors
2.3 Discussion and Outcomes.
Activities in conceptual models developed were used for the discussion. The most significant finding that resulted from the investigation was in the area of discharge. The actual problem which was assumed to be limited to the A&E was actually as a result of failure to adequately plan discharge in the wards. When the rate of patients needing admission increased, there was a need to change discharge plans.
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However, it was realised that the doctors did not change discharge behaviour and created waiting lists for patients that needed admission. Facilitated brainstorming sessions resulted in identifying number of contributing causes of delayed discharge. Discharge was done after ward round which took place in morning during week days alone. Insignificant numbers of discharge were done over the weekend because there was no major ward round. This meant that most patients needing admission in A & E over weekend had to wait till following week before beds could be arranged for them. This also compounded the bed crises.
A discharge project team was immediately set up. The main function of the discharge team was to carry out additional ward rounds in the evenings and on weekends so as to discharge patients and free up more beds. They were able to indentify other causes of delayed discharge and resolved them. This ensured timely discharge fashion which then freed up beds for patients in A&E.
2.4 Strength and weakness of SSM
The methodology provided guidelines that were flexible to apply. The use of models provoked debate and learning among the issue owners. Through discussion and debates, the hospital was able to realise that there was a need to amend patient discharge policy.
However, this methodology could not satisfy everybody. Some of the discharge decisions were not favourable to the ward patients. Also members of the discharge team had extra work to do and ways of compensating them were not discussed. This could be seen from Jackson (2000) arguments that SSM tends to favour the more powerful people in the system while genuine participative debate could be severely constrained.
3.0 Thinking Differently
Most of the inventions in our society today, such as electricity, telephone, automated teller machine and many more, are the results of some people who decided to think differently. Thinking differently involves using innovative and creative approaches to transform healthcare delivery service (NHS, 2007)
The first stage was to stop and think of the whole situation and identify areas where creative thinking could improve matters. It was observed that there was poor co-ordination of patients and beds management while poor communication existed between the bed manager and other clinicians, in the wards and A & E, about bed availability.
A tool called Others' Point of View (OPV) was then selected to describe the issue from others peoples' perspective. The aim was to generate some alternative ways of framing the problem and to think about what other people might say about bed management of the hospital.
Hotel manager - "Despite their poor hospitality, they still have more
clients....poor service in hotel industry will make you to be
out of business"
Service Consultant - "Poor customer service in the hospital...no regards for
patients...customers are kings ..so are the patients"
Journalist - "Taking the sick to a sick hospital".
Patient -''This is disgusting...where else do they want us to go
The second phase allowed clinicians to brainstorm and come up with ideas. At this stage no idea was good or bad. It allowed for people to speaking out their imaginations. The Fresh eyes tool was picked to see how similar issues were managed in other industries and the possibility of adopting the solutions into the hospital.
Hotels- Hotels manage rooms, checks customers in and out using software
systems designed to help administrator to track all rooms availability.
University- students can book their accommodation online while a system
assists in organising and allocating rooms to students
Airline - Airline Reservations Systems that manages airline schedules, fare
tariffs, passenger reservations and ticket records.
This gave us insight to how clients and resources were being managed in other industries. The stake holders then agreed to try out a bed management information system.
The hospital implemented bed management information system on a small scale and some of the benefits were highlighted (Table 5).
Real time online monitoring of bed position, bed manager did not have to go round wards again
It improved communication between units for patient admissions
Saved time searching for available beds in the hospital
It provided an overview of bed occupancy rate in hospital
It was user friendly and easy to use.
Enabled more accurate allocation of beds for emergency patients
Table 5: Realised benefits of Bed management information system after implementation.
3.1 Strength and weakness
The thinking differently methodology was a powerful tool in stimulating thinking and lots of ideas were suggested. However, this took time and caused arguments as feasibility, advantages disadvantages and risk of each idea were all argued out. Also, traces of people trying to impose their ideas on others were noticed while others brought up ideas that would satisfy their own interest.
4 System dynamics
System dynamics is an approach and simulation technique for studying and managing complex feedback systems, that are seen in business and other social systems (SDS, 2009). According to Jun el at (1999), there has been increased use of simulation in healthcare. This could be attributed to numerous success reports of using simulation to address health care system problems and availability of simulation software packages.
The methodology was used to estimate and manage the aggregate flow of patient through the hospital and its environment. As the number of people visiting A&E increased, it in turn increased the number of people who needed hospital admission. Also, as patients waiting for bed increased, it caused an increase in number of patients that were discharged home early. This is illustrated in Figure 1.
There was the need to control the number of patients coming through A& E. The availability and use of other healthcare facilities such as GP practice, community care and nearby hospitals would have a negative feedback on the inflow of patients into a&E. This would directly affect the number of patients needing admission. Most of the patients that were discharged home might not have to return to A&E as community care could assist carter.
This methodology helped the hospital to forecast inflow of patients and ways that could be adopted to control it. Community care services around were informed about the situation of things in the hospital. In addition, ambulance bringing patients were informed ahead to make use of other hospitals or GP practices if condition of patient was not too severe.
Figure 1: A model to show the flow of patients through the hospital
The complex nature of healthcare system makes system thinking well-suited to tackle problems in this sector. The various methodology approaches used assisted in better understanding of the relationship between the various units in Ashford hospital and its environment. This showed that like any other system, no unit in the hospital is an island. The different methodologies applied in Ashford hospital situation yielded various positive outcomes that helped improved the problematic situation.
While some of the methodologies used have their roots in action research, further participatory research will be carried out to investigate occupational work stress among the clinicians. This may help identify majors causes of stress associated with their workflow, how it affects their relationships with others and with the patients in particular.
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