You are the nurse manager of an emergency department at a small community hospital in rural Ontario. You recently helped facilitate the creation of a group of healthcare professionals to focus on improving patient flow within the emergency department, something that your hospital has noted to be a longstanding issue. The team is meeting for the first time tonight to discuss approaches to improving ED flow. You decide to take some time to gather your thoughts in advance of the meeting, but it is starting to feel like a ‘wicked’ problem and you have no idea where to start. What approaches can you take to analyze the situation? How can you help create change?
Quality improvement (QI) and systems thinking are important concepts for changemakers to understand with each paradigm complementing the other. Moreover, having a systems perspective is required for QI approaches. However, classical QI and systems thinking can differ with respect to problem-solving. In QI, we attempt to deconstruct the messiness of a complex situation, in order to find an uncluttered path forward for change. Systems thinking, however, embraces the messiness. In this HiQuiPs post, we compare quality improvement and systems thinking, using the example of ED flow to highlight key features of the two that we hope will be useful when approaching a problem within your organization.
Quality Improvement vs. Systems Thinking: A General Overview
Quality improvement encompasses a broad range of activities used to improve processes and systems through the development, implementation, and assessment of interventions. (1) After a problem is identified, the next step is analysis, which involves breaking the problem down into specific events or linear processes (e.g. using value stream or lean process mapping) and into individual parts or root causes (e.g. using Ishikawa or fishbone diagrams). A thorough understanding of the issue allows for the development of relevant, targeted interventions, which are implemented through rapid Plan-Do-Study-Act (PDSA) cycles. Measurement includes the main outcome, process measures, and any unintended consequences (balancing measures) is undertaken. (2)
In systems thinking, however, the goal of problem-solving is synthesis. Systems thinking focuses on underlying structures and emphasizes dynamic interactions between elements of a system. It encourages the application of a holistic or circular perspective—to view the dynamic structures, patterns, cycles and interactions in a system, rather than seeing only specific events or individual parts (3). This highlights the interconnectedness of the elements within a system and allows understanding of the system as a whole. It has been utilized in a wide variety of fields, including healthcare.
A Practical Example: The Quality Improvement Approach
To further conceptualize these approaches, let’s take a look at the ubiquitous example of emergency department patient flow. First, let’s view the issue from a QI lens.
In QI, when considering the problem of patient flow, we conceptualize it as linear. We start by using tools such as value stream mapping to break down the issue and analyze backlogs to ED patient flow. Once a specific problem has been identified, we use tools such as the 5 Whys or Ishikawa Diagrams to identify root causes for the problem.
Let's imagine that the backlog is mainly due to delays in triage. Perhaps we identify the root cause to be an insufficient number of triage nurses. One change to target this may be to move more ED nursing staff to triage, using the PDSA approach. Regular measurement is undertaken to track the main outcome, process, and balancing measures. An example of a balancing measure in this scenario could be whether transferring limited nursing resources to triage leads to nursing shortages and backlogs in other areas of the ED. Ultimately, this develops into an iterative process of change, and subsequent improvement.
The Systems Thinking Perspective
With systems thinking, we zoom out on a problem, focusing on the elements of a system and their influence on one another. In practice, we can use a variety of systems mapping tools to visually depict this interconnectedness.
Consider again the example of ED flow. Systems thinking can help us consider how flow may be impacted by not only elements within the ED, but also external factors. For example, ED flow depends not only on ED nursing resources, but also on the availability of inpatient beds, which in turn depends on the number of alternate-level-of-care (ALC) patients awaiting long-term care beds. Continuing to think more upstream, all of these factors are impacted by healthcare funding and massive nursing shortages following the COVID-19 pandemic. In other words, the elements in this complex situation are interconnected, and cannot be adequately understood in isolation.
In this example, we could use behavior-over-time graphs as part of our initial analysis to gain a better high-level understanding of the system. Behavior-over-time graphs depict changes in variables over a given time frame and are a useful tool for depicting and appreciating the interconnectedness between variables. (4)
Next, we could apply causal loop diagrams, to illustrate the often varied, numerous, and interrelated factors that lead to a given outcome. (5) We start by identifying all of the variables at play within a system, with the end goal of depicting the various relationships between them to tell a story. (6,7) We use arrows to show the directionality of impact, and label these connections as positive or negative depending on whether the variables impact each other in the same or opposite direction. (6,7) This tool can be used in practice to help with decision-making and understanding the downstream impact a particular change idea may have. With the systems thinking approach, we pay more attention to this causality from the get-go.
Considering our example, you may draw a feedback loop showing that transferring ED nursing resources to triage would reinforce nursing shortages and backlogs in other areas, which may deter you from that particular change idea. Re-allocating nursing resources could also lower the morale of staff who work in the ED, with a further impact on patient flow and care. Alternatively, improving patient flow might nurture the development of an improvement-focused ED culture. With so many interconnected elements, any changes have complex impacts. Outcomes are based on synergistic interactions between multiple factors, making them less linear and less predictable.
The example of ED flow is summarized in Figure 1 (above), which illustrates the approaches of both QI and systems thinking, as previously discussed.
Putting it All Together
Despite these differences in approach, the paradigms of QI and systems thinking are complementary and draw on similar elements. They do not have to be utilized in isolation. Applying a systems thinking mindset to QI may actually allow for a richer understanding of the processes or systems we are trying to improve. Next time you tackle a PDSA cycle, consider synthesizing the problem with a systems thinking mindset in the planning phase and identifying a holistic change idea. Embrace the messiness!
After composing your thoughts using both a systems thinking approach and a quality improvement perspective, you feel you are going into today’s meeting with a much better understanding of factors that may be impacting ED flow. You are looking forward to presenting your thoughts to your colleagues, with an emphasis on both a systems-level view of the case and the application of key quality improvement concepts in order to facilitate the implementation of change ideas, creating a lasting impact.
That’s all for this HiQuiPs post contrasting quality improvement and systems thinking. We hope you are now able to appreciate some of the different tools and approaches each perspective provides when thinking about a problem and creating change. Be sure to check out our other blog posts (linked throughout) that provide more detail on key concepts in QI and systems thinking to learn more, and stay tuned for our next post on design thinking!
*Synthesis brought to you by the inaugural HiQuiPs Incubatees Radha Joseph, Emma McIlveen-Brown, Hilary Weatherby, Rebecca Prince
Senior Editor: Ahmed Taher
Copyedited by: Jocelyn Price
Quality Improvement Guide. Health Quality Ontario, 2012. Accessed from: https://www.hqontario.ca/portals/0/documents/qi/qi-quality-improve-guide-2012-en.pdf"
Institute for Healthcare Improvement. Science of Improvement: Establishing Measures. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
McNab D, McKay J, Shorrock S, Luty S, Bowie P. Development and application of ‘systems thinking’principles for quality improvement. BMJ open quality. 2020 Mar 1;9(1):e000714.
Calancie, L., Anderson, S., Branscomb, J., Apostolico, A. A., & Lich, K. H. (2018). Using Behavior Over Time Graphs to Spur Systems Thinking Among Public Health Practitioners. Preventing Chronic Disease, 15.
Kim, D. Guidelines for Drawing Causal Loop Diagrams. The Systems Thinker. Accessed from: https://thesystemsthinker.com/guidelines-for-drawing-causal-loop-diagrams-2/
Lannon, C. Causal Loop Construction: The Basics. The Systems Thinker. Accessed from: https://thesystemsthinker.com/causal-loop-construction-the-basics/
Bala, B. K., Arshad, F. M., & Noh, K. M. (2017). Causal loop diagrams. System dynamics (pp. 37-51). Springer, Singapore.