Systems Thinking & The Building Blocks of Health Systems

Systems Thinking & The Building Blocks of Health Systems

Borwornsom Leerapan, MD PhD

MGMG 548: Health Service Systems and Health Systems

CMMU, Mahidol University June 1, 2014

Pix source: ra.mahidol.ac.th

Format

Pix source: online.wsj.com 

F/U

Mini-lecture

DiscussionQ&A

Wrapup

To-do list

1.  Review of course objectives 2.  What is “Systems Thinking”? 3.  The “Building Blocks” of health systems 4.  Systems dynamics of health systems 5.  Discussions

Outline for Today

Pix source: online.wsj.com

Why Should We Care about Health Systems

& Health Services Systems?

Pix source: online.wsj.com

Pix  source:  h"p://hbr.org/2008/01/the-­‐five-­‐compe66ve-­‐forces-­‐that-­‐shape-­‐strategy/ar/1  

Strategic  Analysis  

Force  Field  Analysis  

Stakeholder  Analysis  

Pix  source:  Start  and  Hovland  (2004)  Tools  for  Policy  Impact:  A  Handbook  for  Researchers    

Gap  Analysis  

Pix  source:  www2.ifm.eng.cam.ac.uk/  

Strengths Advantages

Financial reserves, likely returns Qualifications, certifications Competitive advantages

Capabilities Location and geography Innovative aspects

Resources, Assets, People Processes, systems, IT, communications Culture, attitudes, behaviours Management cover, succession Experience, knowledge, data Strong brand names

Marketing - reach, distribution, awareness Unique selling points “USP” Price, value, quality

Weaknesses Lack of competitive strength

Gaps in capabilities Disadvantages of proposition Weak brand name

Financials Cash flow, start-up cash-drain High cost structure

Our vulnerabilities Timescales, deadlines and pressures

Reliability of data, plan predictability Continuity, supply chain robustness Processes and systems, etc

Management cover, succession Morale, commitment, leadership

Opportunities Market developments

Competitors vulnerabilities Niche target markets New USP's New markets, vertical, horizontal Partnerships, agencies, distribution Geographical, export, import Unfulfilled customer need New technologies Loosening of regulations Changing of International trade barriers

Business and product development Seasonal influences Technology development and innovation

Threats Environmental effects

Seasonal, weather effects Economy - home, abroad Political effects Legislative effects

Market demand New technologies, services, ideas IT developments Shifts in consumer preferences

Obstacles Sustainable financial backing Insurmountable weaknesses Competitor intentions New policies or regulations Emergence of substitute products

Posi,ve   Nega,ve  

Inte

rnal

Ex

tern

al

SWOT  Analysis  

Figure  source:  Adapted  from  conceptdraw.com  

 Exploit  

 (Rapidly  pursue  opportuni6es)  

 Search  

 (Overcome  weaknesses    with  strengths  in  order  to  pursue  opportuni6es)    

Confront    

(Pursue  the  opportuni6es  once  the  gaps  are  bridged)  

Avoid    

(Create  a  defense)  

Strategy  forma,on  

Strength-­‐Opportunity   Strength-­‐Threat  

Weakness-­‐Opportunity   Weakness-­‐Threat  

SWOT/TOWS  Matrix  

The Six Building Blocks of Health Systems

Pix source: online.wsj.com

“System”

Source: Scheerens and Bosker 1997; Pix source: system humanrevod.wordpress.com

“CIPO” Model 

“Health System”

Pix source: WHO’s framework for action. (2007)

•  “The Six Building Blocks” and their interconnections 

“Health System”

Source: who’s World Health Report (2000)

A  Simple  Logic  Model

Source: W.K. Kellogg Foundation (2004)

Health Systems & System Thinking

Pix source: online.wsj.com

Simple, Complicated, Complex Problems

Source: Glouberman and Zimmerman (2002)

Source: Patricia Roger (2008)

“Complicated Systems”

Source: Patricia Roger (2008)

“Complex Systems”

“Health System”

Pix source: WHO’s framework for action. (2007)

Pix source: Don de Savigny and Taghreed Adam (2009).

Pix source: Don de Savigny and Taghreed Adam (2009).

Systems Dynamics: Why many systems interventions failed?

Pix source: online.wsj.com

Counterintuitive Behavior of Social Systems & Policy Resistance

•  People seeking to solve a problem often make the problem worse.

•  Examples: – Road building programs designed to reduce

congestion – Low tar and nicotine cigarette – Antibiotic resistance

Causes of Failed Interventions

•  Tendency to interpret experience as a series of events

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Limitations of Simple Systems

•  Simple model often fail to include the critical feedbacks determining the dynamics of systems.

•  All system dynamics arise from the interaction of just two types of feedback loops – Positive (reinforcing) – Negative (balancing)

“Causal Loop Diagrams”

•  Quickly capturing the hypotheses about the causes of the dynamics.

•  Eliciting and capturing the mental models of individuals or teams.

•  Communicating the important feedbacks believed to be responsible for a problem.

Causal link!

Variable!

Link polarity! Reinforcing Loop !

Balancing Loop !

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Causation vs. Correlation

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Loop Polarity

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Loop Polarity

Complex Adaptive Systems

Positive (Reinforcing) Feedback Loop

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Negative (Balancing) Feedback Loop

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Negative Feedback Loop with Delay

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Combination of Positive and Negative Feedback Loops

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

System Archetypes #1 “Limit to Success”

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

System Archetypes #2 “Fixes that Fail”

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

System Archetypes #3 “Shifting the Burden”

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

System Archetypes #4 “Drifting Goal”

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

System Archetypes #5 “Success to the Successful”

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

System Archetypes #6 “Escalation”

Figure source: Courtesy of Prof. Boonsong Ongphiphadhanakul

Ø “System thinking” is popularized by Peter Senge as the the “fifth” discipline of learning organizations.

“Learning Organization”: 1.  Building shared vision 2.  Mental models 3.  Team learning 4.  Personal mastery 5.  System thinking

Resources for Further Study

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Resources for Further Study

•  System dynamics approach to organizational problem solving

•  Emphasizing simulation models to understand issues such as fluctuating sales, market growth and stagnation, the reliability of forecasts and the rationality of business decision-making.

•  Using modeling software from Vensim, ithink, and PowerSim.

Pix source: Amazon.com

Tools: System Dynamics Software

Source: www.vensim.com

Tools: System Dynamics Software

Source: www.iseesystems.com

System Dynamics Software

Source: www.powersim.com

Q& A Discussions

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Up and Down the Ladder of Abstraction

Abstract:  •  Concepts 

•  Theories •  Principles 

•  Strategies 

Concrete:  •  Case studies •  Data, Evidence 

•  Analysis, Synthesis 

•  Presentations 

Systems Thinking for Health Systems Strengthening: •  What is systems thinking? •  How can researchers and policy-makers

apply it? •  How can we use this perspective to better

understand and exploit the synergies among interventions to strengthen health systems?

•  How can systems thinking contribute to better evaluations of these system-level interventions?

Systems Thinking

Source: nap.edu 

Systems Thinking for Health Systems Strengthening: •  How can healthcare mangers apply systems

thinking? •  How can we use system thinking to better

understand and exploit the synergies among interventions to strengthen health systems?

•  How can systems thinking contribute to better evaluations of our organizational interventions?

Implications for Healthcare Managers

Source: nap.edu 

Better understanding of: •  Current demands for health services •  Current supplies of healthcare services •  Stakeholders in local healthcare markets •  Incentives and disincentives in healthcare markets •  Values of stakeholders in health systems Applications: •  Strategic management of healthcare organization •  Framework for “start-up” •  Evaluation of healthcare organizational performance

Implications for HCM Practices

MGMG 548 •  Major issues in the organization of a health services system •  The role of values in the development of health care policy •  Methods for assessing the health status of populations •  Analysis of need for, access to and use of services; current supply

and distribution of health resources •  Analysis of health care costs and expenditures •  Sociopolitical, economic, and moral/ethical issues confronting the

public health and medical care system •  Trends in service provision, human resources, financing and health

services organization, and implications for the public’s health.

Course Description

Source Prattana Punnakitikashem. PhD; Pix source: online.wsj.com

Course Website

Course Calendar

Week Date Topic 1 May 18, 2014 Overview of health & health services

Systems 2 May 25, 2014 Systems thinking & the building blocks of

health systems 3 June 1, 2014 Healthcare quality 4 June 8, 2014 Healthcare efficiency 5 June 15, 2014 Health equity 6 June 22, 2014 Social determinants of health 7 June 29, 2014 Mid-term exam

Course Calendar

Week Date Topic 8 July 6, 2014 Ambulatory care and primary healthcare 9 July 13, 2014 Chronic care 10 July 20, 2014 Long-term care 11 July 27, 2014 Emergency care 12 August 3, 2014 Palliative care 13 August 10, 2014 Care for certain diseases and populations:

travel clinic 14 August 17, 2014 Student presentations of final papers