QUERI – Quality Enhancement Research Initiative

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Quality Improvement Methods

48. Systems Approach

a. Definition: Considering problems and improvements while including the various relevant components affecting the outcome is a systems approach. A system is defined as a set of interacting parts to achieve a common purpose. Certainly, healthcare is a system involving many elements and related factors but ignoring the interrelationships would miss opportunities for improvement. The science developed to manage and improve systems is useful in QI work. Errors in healthcare delivery are often the result of numerous factors and improvements cannot be successful unless the broad elements and relationships are considered.

The so-called systems approach involves problem solving by understanding the components of a system in order to avoid unintended consequences of too narrow a view. Often the system is understood to operate in a cyclic nature rather than a linear one. Important elements include interaction with components outside the system being studied. A systems view of healthcare can be shown as below.4

4 From Ozcan, Yasar A. Quantitative methods in health care management: techniques and applications. Vol. 4. John Wiley & Sons, 2005.

A number of the methods described in this handbook are often cited as so-called systems engineering tools, such as Failure Mode Analysis, Queuing Theory and Discrete Event Simulation.

b. Literature:

  • Padula, William V., et al. "Integrating systems engineering practice with health-care delivery." Health Systems 3.3 (2014): 159-164.
  • Bergeson, Steven C., and John D. Dean. "A systems approach to patient-centered care." Jama 296.23 (2006): 2848-2851.
  • Boon, Heather, et al. "Evaluating complex healthcare systems: a critique of four approaches." Evidence-Based Complementary and Alternative Medicine 4.3 (2007): 279-285.
  • Fanjiang, Gary, et al., eds. Building a Better Delivery System:: A New Engineering/Health Care Partnership. National Academies Press, 2005.

c. Example

When developing a new diagnostic test, a researcher should consider more than the reliability of the test itself. The research could include relationships with various elements such as financial aspects, regulatory constraints, environmental factors, risks, and related therapies. Perhaps all, or nearly all, healthcare research based improvements should consider the larger system of which they are a part.

d. Steps:

A good first step is to determine the scope of the system being studied, in other words what is included and what is not included in the system being studied. Still another early step could be to create a model or description of the system components and their interrelationships. The areas that a systems approach might address are so broad that it is difficult to define a single set of steps to be followed. Much of the systems literature focuses on information systems which often follow the sequence of planning the new system, analysis of requirements, do the design, carry out the implementation, and ongoing maintenance.