“Every system is perfectly designed to get the results it gets. If we want better outcomes, we must change something in the system. To do this we need to understand our systems”
Don Berwick, President and CEO, Institute for Healthcare Improvement (IHI) USA

The way systems are designed determines what we are able to achieve and the majority of problems are because of the system, rather than the people.

Understanding that healthcare organisations are made up of complex systems and processes is very important to improving the quality of the care we deliver. ‘Systems thinking’ draws on a number of disciplines and enables us to see that improvements are achieved by systematic approaches to change that take account of this complexity.

Understanding your local context, systems and culture

Improvement happens within a complex system, context and culture. There are likely to be things in your system, context or culture that
can either support your improvement work or make it harder.

• What does your benchmarking information tell you about
your local context?
• What patterns can you see from your service data?

You might want to look at your team. Do you have a clear aim you all work towards? What are your patterns of working, how do you best communicate with each other and with your service users?

Do people feel safe? Listened to? Do people feel empowered to make changes? Is it a good place to be in? Does the building and technology you use support or hinder your work? Is there good access?

A good place to start in understanding your local system is to undertake a 5Ps assessment, a key tool from microsystem theory derived from Dartmouth Institute. It looks at your system with regard to it’s:

• Purpose: ‘our system exists to….?’

• Patients:

o Who do we care for? Are there any sub-populations
we could care for differently?
o What support do we need?
o How satisfied are our patients/carers?

• Professionals:

o Who provides care and who supports them?
o What skills and talents are required?
o What is the role of IT?
o How is staff morale?

• Processes:

o How is care delivered? (core/supporting processes)
o Do our operating hours match our customer’s needs?
o How does technology support us?
o How do we learn from our mistakes?

• Patterns:

o Health outcomes
o Cost of care
o Interaction with other systems
o Common work activities
o What’s it like to work in the team?
o Leadership
o How often is quality and safety discussed?
o Team traditions and rituals