The Quality Academy Tutorial 18 Systems Thinking The Quality Academy Tutorial 18 The National Quality Center is pleased to bring you the Quality Academy, an online learning opportunity on key quality management concepts.  The NQC provides no-cost, state-of the-art technical assistance for all Ryan White Program grantees to improve the quality of HIV care nationwide.  The Center is funded through a cooperative agreement with the HRSA HIV/AIDS Bureau and managed by the New York State Department of Health AIDS Institute.   This Tutorial is titled: Systems Thinking

Learning Objectives: You Will Learn About… What a system is Importance of system change in HIV care Transforming systems with the help of quality improvement tools Hello and welcome to the National Quality Center’s Quality Academy. Throughout the Tutorials in this Quality Academy we have referred to “system change” and the importance of thinking about systems. In Tutorial 17, on leadership, we described system thinking as one of the key skills an organization and its leaders needs for a commitment to quality. In this Tutorial we look more closely at this notion of a system. We begin with the definition of a system and then explore the topic of system change: what it involves and why it is our goal. System change is complex, so finally in this Tutorial we present a tool, the “system diagram,” that your organization can use to begin to grapple with the concept and practicalities of system change. We at the National Quality Center applaud your interest in this topic and hope you find this Tutorial helpful to your work. Learning Objectives

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Key Question How do I account for the complexity of my organization in my program’s quality improvement work? If all we need to do is improve a process here and there, why do systems matter? As we will explore in this Tutorial, improvement may actually be a lot more complex than just “improving a process here and there.” We care about systems because they help us begin to answer the key question, “How do I account for the complexity of my organization in my program’s quality improvement work?” Key question

A System is…. “…an interdependent group of items, people or processes with a common purpose.” Langley et. al., The Improvement Guide Here is the formal definition of a system, “an interdependent group of items, people or processes with a common purpose.” The key word in this definition is “interdependent.” All the components of an organization: its people, departments, processes, procedures, buildings, equipment, etc. have to work together. As we described in Tutorial 17, part of a leader’s job is to make sure that all the parts of the system do work together: the success of the organization depends on it. Without the unifying factor of the common purpose, there is no system. An organization requires interdependence to function efficiently. System Definition

Lack of a System Can Show Up As… Lost lab results Delays in specialty appointments More cases of HIV infection Not having an understanding of systems, or of the importance of the interdependence of parts of a system, can manifest itself in a number of ways in any health care organization, including an HIV program. For example, suppose your health insurance plan requires a certain procedure for processing reimbursement requests for clinical lab work. Imagine that an HIV program’s patients belong to 8 or 9 different insurance plans and each plan has its own procedures. Picture how hard it would be to keep track of requesting reimbursement in a timely fashion. Or another situation, where all specialty referral needs approval before the appointment can be scheduled. Not uncommon, but imagine the delays that result. The whole question of the spread of HIV infection is affected by system issues as well. There are many players in the HIV prevention “system,” with different roles and ideas about the messages that should be sent. When the messages are not coordinated, the prevention system’s efficacy is compromised, and farther spread of the virus results. One common thread runs through all these examples. In each, one part of the system seeks to maximize its own return, at the expense of (a) another part of the system and (b) the common goal which is supposed to pull them together. In this case, an insurance company wants its own reimbursement procedures. Whoever manages the specialty care wants to control how that resource is allocated. One agenda is more important, or more powerful, than another in determining the HIV prevention message. Why Systems Matter for HIV Care

A Few Important Principles for Improving Systems A system needs a purpose to aid people in managing their interdependencies The structure of a system significantly determines the performance of the system Thomas W. Nolan, Ph.D. In a useful article on the role of systems in medical care, Tom Nolan presents a number of important principles about the nature of systems. His first principle is, “a system needs a purpose to aid people in managing their interdependencies.” At times people are not good at understanding where their own particular piece of work fits into the overall purpose of the organization. When the leadership of the organization clearly articulates this purpose, however, and manages the organization based on this purpose, then the workers in the system have the tool they need to, as Nolan says, “manage their interdependencies.” Nolan’s second principle states that “the structure of a system significantly determines the performance of the system.” Therefore, if you want to change the performance, you need to change the structure of the system. Nolan says, “Learning to move beyond events to see the structure in the system that underlies the problems is a start.” So let’s explore what we mean by “the structure of the system.” Why Systems Matter for HIV Care

To function, a system must: Test Question To function, a system must: A) Have a common purpose B) Make a profit C) Meet regulatory requirements D) Keep patients happy E) Employ lots of staff The core components of a system are important for understanding the rest of this Tutorial, so let’s take a minute to make sure you understand them. Take a minute and choose the best answer to this question. F) All of the above G) None of the above Why Systems Matter for HIV Care

Traditional pictures of organizations (for example, tables of organization) do not show the inter-relationships of the parts of a system. How can we do this if we don’t know what they are? Deming developed a diagram of "The Organization as a System" that helps to clarify these interrelationships. This diagram shows three aspects of a system: Production: How we produce what we produce. This aspect flows along the bottom of the diagram, as suppliers provide inputs that move through key processes and are turned into outputs that go to customers. Purpose: Why we produce what we produce. See the upper right-hand corner of the diagram. The organization exists to meet some sort of community need. Whatever this need is, it drives our vision and also the determination of who our customers are; and the needs of our customers and vision of our organization drive the characteristics our products or services must have. Improvement: How we improve what we produce. Our performance, measured against the key performance characteristics, drives our plans to improve, and through these plans the design or redesign of inputs and, especially, key and support processes. When this diagram is filled out for a specific organization, it becomes a powerful tool for “communicating the interdependency,” for describing to people in an organization how their work relates to the work of others. System Diagram Tool

Questions to Understand Your System What product(s) do we make? What service(s) do we provide? Who uses or receives these products or services? What is the underlying, core need that those customers have for what you make? What measures or characteristics do customers use when they assess and judge the goodness or quality of what you make? Paul Batalden developed a series of questions for health care providers to use to define their organizations "as a system." Batalden's questions include: ● What products do we make? What services do we provide? ● Who uses or receives these products or services? ● What is the underlying, core need that those customers have for what you make? ● What measures or characteristics do customers use when they assess and judge the goodness or quality of what you make? Batalden recommends working in a team to answer these questions for your specific organization. Let’s think for a minute about a generic HIV program. How would we answer these questions for a primary care clinic that serves people with HIV and AIDS? System Diagram Tool

What Products and Services? Primary health care services for people with HIV and AIDS A physical environment in which care can take place Information about HIV and its effective treatment Referrals to other providers, social services What products and services does a primary care HIV program provide? First, obviously, it provides health services for people with HIV and AIDS. But there’s more. It produces a physical environment in which care can take place. Think how many people’s jobs relate to keeping this physical environment together and clean. Through the care provided and the results seen, the program produces information about the nature of HIV disease and about its effective treatment. And finally, it makes referrals to other providers for the HIV care it does not offer. What else? Have we forgotten something? System Diagram Tool

Who Uses or Receives Them? People with HIV and AIDS Their families, partners and friends Employees Provider staff-in-training (e.g., medical residents, students in other disciplines) Governmental funding agencies Advocacy groups Specialty care services and social services The next questions to focus on are: who are our HIV program’s customers? Who uses, or relies on, the products and services we produce? This list is a long one! People with HIV/AIDS The people who care about them Our employees Those whom we train, if we’re a teaching program Governmental funding agencies Advocacy groups And don’t forget the specialty and other care services who receive our referrals. System Diagram Tool

The Underlying, Core Need Is? “Reduction of the impact of HIV and AIDS on the lives of individuals with the diagnoses and on society as a whole” Next, let’s look at the underlying, core need that drives our system. There are many ways to think about it, but a group of HIV programs working on the system diagram came up with this description: “Improvement of quality of life of people with HIV and AIDS and on society as a whole” What do you think? Similar statements are probably used in your organization’s mission statement. System Diagram Tool

Characteristics to Assess the Goodness or Quality? People with HIV and AIDS: Effectiveness of care Respect and compassion from caregivers Clarity and relevance of information given Ease of use of facility (friendliness of support staff, waiting time, cleanliness of facility, etc.) Confidentiality Families, partners and friends Confidence that loved one is satisfied with care Information targeted to specific needs of this group Now let’s get to characteristics. In short, what do our customers need? How will they evaluate whether we are meeting this core need we have expressed? This can be a very interesting question to answer, and we urge you to work on this with others from your organization. One important tip: be aware that different customers may be using very different characteristics. Let’s see what our group came up with: For people with HIV and AIDS: Effectiveness of care Respect and compassion from caregivers Clarity and relevance of information given Ease of use of facility (friendliness of support staff, waiting time, cleanliness of facility, etc.) Confidentiality of care For their families, partners and friends Same as above Information targeted to specific needs of this group System Diagram Tool

Characteristics to Assess the Goodness or Quality? Employees Adequate resources to provide effective, respectful, compassionate care Safe environment Respect for their contribution Opportunities to grow and advance Provider staff-in-training Accurate information Good teaching Opportunity to practice skills State-of-the-art models to follow Additional customers, including employees and provider staff-in-training, involve additional needs. Employees use other characteristics to assess goodness or quality, such as: Adequate resources to provide effective, respectful, compassionate care Safe environment Respect for their contribution Opportunities to grow and advance Provider staff-in-training have still different requirements: Accurate information Good teaching Opportunity to practice skills State-of-the-art models to follow System Diagram Tool

Characteristics to Assess the Goodness or Quality? Governmental funding agencies Health care services that meet governmental standards Non-wasteful use of government funds Advocacy groups Confidence that patients are satisfied with their care Responsiveness to their requests for information and action Specialty care services and social services Complete information on any patients referred Finally, we have a set of “outside” customers who have distinct needs of their own: Governmental funding agencies can be concerned about: Health care services that meet governmental standards Efficient use of government funds Advocacy groups require: Same as patients Responsiveness to their requests for information and action Specialty care services and social services need: Complete information on any patients referred System Diagram Tool

What Do I Have Now? Right-hand section of the system diagram Clarity of purpose Understanding of complex needs This exercise, however you want to adapt it for your own organization, gives you roughly the right-hand side of the system diagram, including the answer to the key “why you make what you make” question. As we have said before, answering this question clarifies the common purpose that makes your system a system. Looking at quality characteristics by customer group also helps to display the complexity of the needs your organization tries to fulfill – needs that, when taken individually, can break down your system but that when widely understood as deriving from a common purpose can actually serve to strengthen your organization’s functioning as a system. System Diagram Tool

Test Question Which of these is an example of a product or service a health care organization could provide? A) Drawing blood for testing purposes B) Individualized "When to Take Your Medications" calendars C) Neither Paul Batalden describes the question, “what do you make?” as “the hardest place to start.” Let’s make sure you understand how to answer it. Take a minute to consider the options and choose the one you think best answers the question. D) Both System Diagram Tool

What Can I Do Next? Turn your quality characteristics into measures Clarify key and support processes Having gone this far to create a system diagram, you can now move on to explore your organization further. First, the quality characteristics form a great basis for organizational measures. Only by measuring can you determine whether you are providing products and services with the quality characteristics your customers seek. Assessing the range of your customers’ needs helps you to make sure that your choice of measures (and therefore the focus of your organization) is appropriate and well-balanced. Also, you can work to flesh out the “how do we make what we make” aspect of the system diagram. Define the key and support processes that take place in your organization. When you have a full picture of these processes, you will have a tool to help everyone in the organization begin to understand how their work supports the organization’s overall purpose. System Diagram Tool

We’ve Only Scratched the Surface Changes in the structure of a system have the potential for generating unintended consequences Another reason for PDSA Systems must be managed An effective quality program helps in this Nolan’s article on systems contains more information about systems thinking and why it is important. While the whole article will be very useful for you, and we encourage you to get the resource's link at the end of the Tutorial, we would like to highlight just two more of his “principles for the improvement of systems:” “Changes in the structure of a system have the potential for generating unintended consequences.” PDSA cycles provide huge benefit as they allow you to test for these changes on a small scale. “Systems must be managed.” Measurement, tracking, evaluation – all the parts of a quality management program – help in the management of systems. Topics for Future Study

Key Points A system is a an interdependent group of items, people or processes with a common purpose Your long-term goal is to improve the operations of your system, because system changes have the greatest impact Understanding how the parts of your system support its purpose strengthens your ability to improve your system To review: A system is a set of processes with a common purpose. Without the common purpose, there is no system. Your long-term goal is to improve the operations of your system because system changes have the greatest impact. Health care systems have many different customers and the operations of these systems can be sub-optimized when the needs of different customers aren’t aligned with the system’s common purpose. And finally, Understanding how the parts of your system support its purpose strengthens your ability to improve your system. Drawing the system diagram can help. Key Points

Resources For more information on principles for improving systems in health care, see: Nolan, Thomas W., “Understanding Medical Systems,” Ann Intern Med 1998;128:293-298. For more information on how to change systems by identifying key leverage points, see Senge, Peter, The Fifth Discipline. New York: Doubleday, 1990. The Deming System Diagram and an exercise to support its use in your HIV program is available in the HIVQUAL Group Learning Guide, which can be downloaded by going to: http://www.nationalqualitycenter.org/index.cfm/5659 Many sources were used in the creation of this Tutorial. If you would like to learn more, you can review these valuable resources on your own or you can also contact the National Quality Center for more help, at www.NationalQualityCenter.org. Resources

Related Tutorials To learn more about leadership, study Tutorial 17 If you found this Tutorial helpful then you may wish to view these other related trainings. You can navigate to these Tutorials by simply clicking one of the images on your screen. Related Tutorials

The Quality Academy In Closing For further information, contact: National Quality Center New York State Dept. of Health 90 Church Street, 13th floor New York, NY 10007-2919 Work: 212.417.4730 Fax: 212.417.4684 Email: Info@NationalQualityCenter.org Or visit us online at NationalQualityCenter.org This concludes our training session for now. As you can see, there is a lot to learn about improving quality. If you have not done so yet, please check out the other training resources we have available for you. Each module is just a piece of a larger puzzle. You will need all of the information to truly understand how your organization can create a successful quality management plan. You can also contact us here, email us here or visit us online here. Thank you for your time today and we look forward to hearing from you soon. In Closing