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Systems Thinking & The Building Blocks of Health Systems, CMMU MGMG 548, Wk#2 2014.6.1
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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
Pix source: Amazon.com
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
Pix source: online.wsj.com
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
