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Module 2 – Systems Thinking in Learning from Events

Module 2 – Systems Thinking in Learning from Events

by Professor Paul Bowie

While basic “systems thinking” can be thought of as a simple philosophy, we can apply this by taking a systems approach to understanding how and why things go wrong in complex healthcare systems. This approach is highly flexible and can be applied practically by clinicians.


To raise awareness of

  • the systems approach to learning from events that you can apply to your everyday practice
  • complex risk and safety issues
  • other clinical and organisational problems.

Further principles in systems thinking

In Module 1, we discussed the concept of safety in highly complex work systems such as healthcare.

This second module in the series, introduces a number of important systems thinking principles, which are vital when considering patient safety issues, ie:

  1. Seeking multiple perspectives
  2. “Work-as-Imagined” and “Work-as-Done”
  3. “Efficiency-Thoroughness-Trade-Offs”
  4. “Local Rationality”
  5. Context and situation
  6. Consider work conditions.

These principles will be useful for Mortality and Morbidity reviews and similar team learning processes, eg, learning from complaints, managing your own clinical and organisational risks and problem solving in your everyday clinical work.

1. Seek multiple perspectives
We need to appreciate that people, at all levels, regardless of their job role, responsibilities or status, are the local experts in the work they do.

It is important to recognise that people, in diverse roles, with different information and goals, will have different perspectives on a given situation. Tapping into this experience can be extremely helpful. By exploring the experiences and views of all those who work within the care system of interest (eg, clinical, administrative, ancillary, managerial staff, patients and carers), we can get a fuller understanding of the how they see the care system in action, what risks they experience and what their ideas for change might be. In this way, we can capture potential improvements and re-design ideas that are helpful when we are, for example:

  • analysing incidents or everyday problems
  • designing and implementing change
  • monitoring and evaluating change.

By involving people of relevance at the outset, it also makes it easier to implement and sustain any changes to local practices.

2. “Work-as-Imagined” and “Work-as-Done”
It is assumed that the work people undertake in complex systems can be fully understood and mapped out. This is known as “Work-as-Imagined” (WAI), ie, what designers, managers, regulators and authorities believe should happen. This ‘ideal’ is often enshrined in standards, clinical guidelines and policies but these are often incomplete in their reflection of the reality of those carrying them out.

On the other hand, “Work-as-Done” (WAD) refers to what actually happens in everyday work. People generally perform very well in a complex healthcare system because they are well-trained, flexible, adaptive and innovative. Not because the care system has been well thought out and designed, or because people do exactly what it says in the rules, policies and guidance.

“Sharp-end” clinicians appreciate the fine details of how work is achieved, but often see this as mismatched with policies, guidelines and targets over which they may have little control or influence.

A practical way of reconciling the worlds of WAI and WAD is in the local development of care policies, guidance and checklists. In this way they can be much more useful as they more accurately reflect how clinicians actually do their work in different contexts.

3. “Efficiency-Thoroughness-Trade-Offs”
In complex care systems, with changing conditions, people continually vary their performance, eg, by using workarounds to get the job done successfully.

“Efficiency-Thoroughness-Trade-Offs” (ETTO) are common work-arounds. In resource-pressured situations, thoroughness, eg, the safest care or ‘best practice’ for one patient, is partially sacrificed for efficiency, to achieve the best possible outcome for a number of patients.

Therefore the ETTO principle suggests that “when we face demands to be more productive then our ability to be as thorough, or as safe as possible, is reduced. Whereas when the demand is for us to be as safe as possible, then our ability to be as efficient as possible is reduced.” In healthcare, making these sorts of trade-offs is normal practice. When looking back at safety events we need to identify, explore and learn from these.

Of course, the ETTO fallacy is that clinicians are required to be both efficient and thorough at the same time. It is only in hindsight, after something goes wrong, that someone determines what should have been more thorough and less efficient in the circumstances!

4. “Local Rationality”
When investigating events, we know the outcome and have access to other information that wasn’t available to those involved in the incident. We know that “people do things that made sense to them, given their goals, understanding of the situation and the focus of their attention at the time.” This is known as “Local Rationality”.

When analysing safety incidents and other events retrospectively it is tempting to make presumptions as to what people should have done, or not done based upon what we know now.

However, healthcare work needs to be understood from the local perspective of those who undertake the tasks, while trying to keep in check hindsight bias. (The latter refers to overestimating our ability to predict an outcome that could not reasonably have been predicted.)

Understanding “Local Rationality” is important for a Just Culture, in which people will not be punished when decisions are made in keeping with their training and experience, but where ‘gross negligence, wilful violations and destructive acts are not tolerated’.

5. Context and situation
When we look back at an event, it is important to identify and understand the situational and contextual factors involved:

Situational factors are the circumstances particular to the specific time and place in which the event occurred. These are generally factual and discoverable as evidence of the situation faced by those involved at the time, eg,

  • condition of patient
  • job task demands
  • state of equipment
  • time pressure
  • staffing levels
  • roles and responsibilities
  • design and usability of procedures etc.

Contextual factors refer to the meaning given to a situation by those involved and the beliefs they hold about it, eg, what people believe was expected of them and what they believe to be true about the event in question. By its nature, defining context can involve speculation and trying to attribute meaning to people’s intentions and behaviours, without factual evidence.

6. Consider work conditions
When looking back at a safety incident or considering any system problem, we need to appreciate that the interacting combination of demand, capacity, resource availability and constraints influences the way people undertake work at any given time.

Work conditions include:

  • Demand – includes patients’ need for information, appointments, treatment and the staff need to complete work in a certain time.
  • Capacity – the care system’s ability to meet demand
  • Resources – everything needed to perform a work function
  • Constraints – guidelines, protocols and limits on capacity that restrict decisions and actions either positively or negatively.
    • Explore and understand how demand varies over time and how this is matched by changes in capacity.
    • Where feasible ensure essential resources are available. Identify leading indicators of impending trouble by anticipating changes in conditions, eg, have extra staff after public holidays to increase capacity to meet the expected rise in demand.
  • Staff wellbeing – examine how work conditions affect staff wellbeing, eg, health, safety, motivation, job satisfaction, joy at work and performance (care quality, safety, productivity, effectiveness).

Taking a “Systems Approach”

While basic “Systems Thinking” can be thought of as a simple philosophy, we can apply this thinking through taking a systems approach to understanding how and why things go wrong in complex healthcare systems.

One such approach which is proving popular in healthcare is the “Systems Engineering Initiative for Patient Safety (SEIPS) Model”.

Adapted from the Chartered Institute of Ergonomics and Human Factors, SEIPS model

The model depicts a clinical work system and importantly outlines the different elements of this system, between people, job tasks, procedures, policy targets, equipment, physical environment and how clinical work is organised. It is the interactions between these different system elements that give rise to the outcomes, for example, safe care, increased efficiency, improved patient experience or enhanced staff wellbeing.

This approach is highly flexible and can be applied practically by clinicians and others for a whole host of different purposes, for example:

  • To identify the different system-wide hazards, or issues that can cause harm, when you are designing a local protocol, guideline or checklist.
  • To help you identify and control your own risks in specific aspects of your work such as when introducing a new clinical procedure or reviewing an existing one.
  • When reviewing a safety incident with your team or in a “Mortality and Morbidity” meeting.
  • To help you analyse a justifiable complaint and identify and learn about the key system issues that may need improvement.
  • As a means of thinking through a problem to be tackled when planning a quality improvement or audit project.
  • When designing an improvement intervention and thinking through the different system elements that will facilitate or potentially hinder its success.

A related worksheet can be downloaded for use.

Systems Approach Worksheet - Page 1

The use of the worksheet prompts a structured, systems approach to brain storming, rather than having an unstructured free flowing discussion, which is likely to miss consideration of important system issues.

The reverse side of the worksheet shows multiple examples of the different work system elements that can interact and contribute to outcomes, both wanted and unwanted that impact on system performance and human wellbeing. This provides users of the worksheet with a working definition of the types of issues to think about that fall within each system category.

Systems Approach Worksheet - Page 2

To illustrate at a high level the use of the worksheet here are two examples of common safety-related issues in most healthcare settings, hand hygiene and burnout amongst doctors.

1. Hand hygiene
What would need to be considered to improve hand hygiene compliance?

Systems Approach Worksheet - Handwashing Example

The example above shows the many different system elements that on any one day can interact in both predictable and unpredictable ways to influence hand hygiene compliance amongst different groups of healthcare professionals.

Taking this type of human factors systems approach to identifying and understanding these different elements can help us better comprehend how and why things are going wrong. As well as how to better design the care system to effectively support care professionals to undertake this important task.

2. Burnout amongst doctors
What systems issues contribute to rising burnout rates amongst, for example, junior doctors on a busy medical ward?

Systems Approach Worksheet - Burnout Example

The illustration above provides examples of the many daily hassles and irritations faced by doctors and others that over time can build up leading to work related stress and ultimately burnout.

The SEIPS framework allows staff to take a holistic, systemic perspective of the interacting nature of these issues that makes more meaningful improvement interventions more likely.

Promote a “Just Culture”

Finally, at its core, systems thinking is about promoting a “Just Culture”. This means that we should not seek to punish staff for actions that are in keeping with their experience and training. Instead, we should seek to understand what happened, support those involved and improve work systems to reduce the risk of recurrence.

This involves:

  • being respectful in how we engage with those involved
  • being transparent and holding our systems, ourselves and others accountable
  • learning from incidents and near misses to improve safety and performance.

It is also important to realise that in very rare cases individuals should be held appropriately accountable for reckless behaviour, intent to harm, gross negligence and other wilful acts.

PMP hopes that this second module in the series of Systems Thinking in Learning from Events webinar series has provided you with some helpful insights and information.

In the third and final module of this series, we will discuss how systems thinking principles can be embedded in traditional “Mortality and Morbidity” review meetings.

Information correct at time of publication July 2023

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. We recommend that you seek independent legal and/or professional advice in relation to your legal or medical obligations or rights. Premium Medical Protection Limited is the owner of this material and its contents are protected by copyright law © 2023. All such rights are reserved.

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