assignment on system thinking

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• Unit 1: Introduction to Systems Thinking – What is a System?

Lisa Gilbert (Williams College), Deborah Gross (Carleton College), and Karl Kreutz (University of Maine)

This activity was selected for the On the Cutting Edge Exemplary Teaching Collection

Resources in this top level collection a) must have scored Exemplary or Very Good in all five review categories, and must also rate as "Exemplary" in at least three of the five categories. The five categories included in the peer review process are

For more information about the peer review process itself, please see https://serc.carleton.edu/teachearth/activity_review.html .

• First Publication: October 24, 2016
• Reviewed: July 12, 2017 -- Reviewed by the On the Cutting Edge Activity Review Process
• File/Data Set Update: August 1, 2024 -- Updated file: 'Examples of Systems Diagrams - Word' Removed broken links and added alternatives
• File/Data Set Update: August 1, 2024 -- Updated file: 'Examples of Systems Diagrams - pdf' Removed broken links and added alternatives
• Fix Links: August 1, 2024 -- Removed broken links and added some alternatives as examples of systems diagrams

This unit introduces systems and systems thinking. The unit is easily adaptable to any course and includes an introduction of terminology, motivation for using systems thinking, and practice reading, as well as interpreting and evaluating systems diagrams. Note that an Internet connection and speakers are required to play the audio file in Part 3.

Expand for more detail and links to related resources

Activity Classification and Connections to Related Resources Collapse

Grade level.

View Standards Details »

Science and Engineering Practices

Developing and Using Models: Develop and/or use a model to predict and/or describe phenomena. MS-P2.5:

Developing and Using Models: Develop, revise, and/or use a model based on evidence to illustrate and/or predict the relationships between systems or between components of a system HS-P2.3:

Cross Cutting Concepts

Systems and System Models: Models can be used to represent systems and their interactions—such as inputs, processes and outputs—and energy, matter, and information flows within systems. MS-C4.2:

Systems and System Models: When investigating or describing a system, the boundaries and initial conditions of the system need to be defined and their inputs and outputs analyzed and described using models. HS-C4.2:

Systems and System Models: Systems can be designed to do specific tasks. HS-C4.1:

Systems and System Models: Models (e.g., physical, mathematical, computer models) can be used to simulate systems and interactions—including energy, matter, and information flows—within and between systems at different scales. HS-C4.3:

Stability and Change: Systems can be designed for greater or lesser stability. HS-C7.4:

Stability and Change: Much of science deals with constructing explanations of how things change and how they remain stable. HS-C7.1:

Stability and Change: Feedback (negative or positive) can stabilize or destabilize a system. HS-C7.3:

Learning Goals

• Students will be able to define systems terminology (such as open and closed system, reservoir, flux, and feedback loop).
• Students will be able to read and interpret simple systems diagrams.
• Students will be able evaluate a given diagram's appropriateness for a written description of a system.

Context for Use

The unit is intended for use in a course or module for which systems thinking is critical to the goals of the course or module. The examples used are general enough to be used with nearly any course. This unit can stand alone or be used at any point during a course to help promote systems thinking.

Description and Teaching Materials

Materials for this introductory unit are included in the following PowerPoint: Introductory System Slides (PowerPoint 2007 (.pptx) 82kB Oct11 16) (also available as a PDF (Acrobat (PDF) 523kB Oct11 16) ). An Internet connection is needed to access the radio piece in Part 3.

Part 1. Knowledge surveys and introduction to systems thinking (5–10 min)

The instructor begins class with a knowledge survey about systems diagrams. Students will complete the same survey at the start and end of class, which will allow them (and you, the instructor) to reflect on their progress.

Either on slips of paper, in their notes, with this handout (Microsoft Word 2007 (.docx) 60kB Sep10 16) , or using clickers, ask students to answer:

How do you rate your knowledge of systems diagrams right now? I have never heard of systems diagrams. I have heard of systems diagrams, but cannot elaborate. I could explain a little about systems diagrams. If given a systems diagram, I could explain it. I could create a systems diagram and then explain it.

Then, the instructor gives students a short introduction to systems thinking.

b) Slide 4: Prompt students to work individually to describe a bathtub in 2–4 complete sentences.

Part 2. Motivation for studying systems thinking and The Bathtub System (10 min)

Part 3. Example of a system, using systems terminology (20 min)

a) Slide 17: The instructor plays the first two minutes of the Minnesota Public Radio piece linked within the PowerPoint. The instructor asks students to list influences on climate. Then, at slide 18, with a partner, students should sort their list of influences into fluxes, reservoirs, and feedbacks. To access audio file:

• An MP3 file can be downloaded in advance, or
• Audio played on via some browsers at this link: Is climate change fueling more wild fires? .

b) Slide 19: The instructor prompts students to work with a partner to answer the following on the Student Handout for Evaluating a System Diagram Activity (Microsoft Word 2007 (.docx) 97kB Jul15 15) (also available as a PDF (Acrobat (PDF) 69kB Jul5 16) ):

• Does the diagram fully represent the complexity of the system described by the speaker? If not, add to the diagram.

c) Slide 20–21: The instructor leads a discussion about possible answers to prompt.

Part 4. Expanding the simple bathtub (10–15 min)

Slide 22: The instructor prompts students to draw a diagram of their bathtub at home and use systems vocabulary to explain in a paragraph how it works. How is your bathtub different from the simple open system bathtub we imagined in class? Using systems vocabulary, write a paragraph to explain the differences. The instructor leads a class discussion and wrap-up.

End of class assessment

How do you rate your knowledge of systems diagrams now? I have never heard of systems diagrams. I have heard of systems diagrams, but cannot elaborate. I could explain a little about systems diagrams. If given a systems diagram, I could explain it. I could create a systems diagram and then explain it. And , reflect briefly on your learning today: what aspect of class most helped you improve your knowledge of systems? Why?

Teaching Notes and Tips

Terminology.

Many of these terms, including feedback loops, have equivalents in economics, math, and other fields. We have chosen the terms we believe are most common in the natural sciences and concur with Kastens (2010)' Earth and Mind blog post on her choice of reinforcing and balancing feedback loops (in place of positive and negative feedback loops). For instructor reference and to give to students, many systems terms are defined here: Systems Thinking Glossary (Microsoft Word 2007 (.docx) 19kB Dec5 14) ; also available as a PDF (Acrobat (PDF) 93kB Jun21 16) ).

Knowledge Surveys

The start/end of class assessments can be done with any size class in less than a minute. The assessments can be done on paper or with clickers, but it is important for students to reflect on both their final confidence rating and the difference between their initial and final ratings. If students only write their ratings in their notes, ask for a show of hands about how many people went up one level or more.

Video alternative to audio

Should an instructor prefer to use a video in place of the MPR audio, a similar-length video provides a reasonable alternative: How Wildfires Affect Climate YouTube video from Michigan Engineering. The instructor would need to slightly alter the student handout (Microsoft Word 2007 (.docx) 97kB Jul15 15) and PowerPoint file for alignment with the video.

How do you rate your knowledge of systems diagrams right now, before class? I have never heard of systems diagrams. I have heard of systems diagrams, but cannot elaborate. I could explain a little about systems diagrams. If given a systems diagram, I could explain it. I could create a systems diagram and then explain it.

How do you rate your knowledge of systems diagrams right now, after class? I have never heard of systems diagrams. I have heard of systems diagrams, but cannot elaborate. I could explain a little about systems diagrams. If given a systems diagram, I could explain it. I could create a systems diagram and then explain it.

Reflect briefly on your learning today: what aspect of class most helped you improve your knowledge of systems? Why?

From the MPR piece Student Handout for Evaluating a System Diagram Activity (Microsoft Word 2007 (.docx) 97kB Jul15 15) or PDF version (Acrobat (PDF) 69kB Jul5 16) . Write down anything you can identify as a : flux reservoir   feedback   Does the diagram fully represent the complexity of the system described by the speaker? If not, add to the diagram.

References and Resources

Systems Thinking Glossary (Microsoft Word 2007 (.docx) 19kB Dec5 14)

Additional background on Earth Systems Thinking: Complex Earth Systems , from Bringing Research on Learning to the Geosciences

Relevant Images/Concepts within other InTeGrate Modules:

• InTeGrate "Climates of Change" Module, Unit 5 systems @play
• InTeGrate "Exploring Geoscience Methods" Module Unit 2, Activity 2.2 (see Step 7)
• Concept maps in InTeGrate: " Humans' Dependence on Earth's Mineral Resources "

Other Systems Diagrams:

This document Examples of Systems Diagrams (Microsoft Word 2007 (.docx) 15kB Aug1 24) (also available as a PDF (Acrobat (PDF) 18kB Aug1 24) ) includes a non-comprehensive list of freely-available systems diagrams for a variety of geoscience-relevant systems. The diagrams are presented at a variety of levels and are provided in case the instructor wishes to provide students with a diagram for a class assignment, or for other uses on a case-by-case basis.

Dynamic Visualization:

Many freely-available tools for creating systems diagrams, or causal loop diagrams, include the option to animate, such as LOOPY . An example of how to introduce LOOPY is explained in Visualizing Systems .

« Previous Page       Next Page »

• Instructor Materials: Module Overview
• Unit 2: Picturing Complexity
• Unit 3: Modeling a System
• Unit 4: Feedbacks in a System
• Unit 5: Analyzing Complexity
• Unit 6: Systems Thinking Synthesis
• Student Materials

Teaching Themes

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Considering using these materials with your students? Get advice for using GETSI modules in your courses » Get pointers and learn about how it's working for your peers in their classrooms »

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Human-Centered Systems Thinking Course

People are at the heart of every complex human system--but they’re often the most overlooked. Effective problem solvers today know how to visualize the larger dynamics of the system while staying grounded in the needs of people. In this course, you’ll learn to combine the analytical tools of systems thinking with the creative mindsets of human-centered design to make sense of complex systems challenges. Explore mapping tools to identify the right places to focus, surface insights about your stakeholders, and pick the most impactful solutions to experiment with so you can go beyond the obvious and design lasting solutions.

Course Outcomes

• Gain techniques for mapping complex systems and identifying the root causes of a problem.
• Establish a shared view of the system and reframe problems from different perspectives to uncover new solutions.
• Find the right problems to solve and pick the best solutions to experiment with.
• Deepen your understanding of your organizational systems by taking an iterative approach to testing solutions and gaining insights.

Part of Certificate Programs

• Change Leadership Certificate

Skills You’ll Gain

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Go Deeper with Certificate Programs

Human-Centered Systems Thinking is part of a certificate program:

What You'll Learn

Week 1: overview, watch a sneak peek, 1 video lesson, 1 assignment.

Define Your Systems Challenge: Choose a systems challenge from your work to help you practice and apply the mindsets and methods outlined in this course. Define your challenge in the form of a question. If you do not have a systems challenge at work, you can choose one as a model.

1 Discussion:

If you're familiar with systems thinking, what are some ways that you bring this mindset to your work? If you're not, how might your work benefit from a systems view?

Week 2: Visualize the System

3 video lessons.

Uncover the Connections - Make sense of the relationships and interactions between stakeholders.

Make it Visible - Break down a complicated process

Go Beneath the Surface - Focus on solving the root causes of a problem

Create a Systems Map: Choose one type of systems map based on your systems challenge and create the first iteration of it to share with your peers. Reflect on what you learned from the process.

3 Discussions

What are some other types of maps and tools you use to make sense of complexity?

What strategies do you use to align different perspectives and build a shared understanding?

Have you noticed any patterns of behavior in your own work? What might be the underlying structures or mindsets that contribute to these behaviors?

2 Resources

Three Ways to Map a System: Get guidance on how to choose the best map for your systems challenge.

Systems Map Gallery: Get inspired by examples of how others have visualized their systems.

Week 3: Humanize the System

Listen to the System - Uncover the needs, challenges, and motivations of the people in your system

The Power of Perspective - Unlock new ways of seeing and thinking

Look for Leverage - Look beyond the obvious solution

Conduct a Stakeholder Interview: Choose one stakeholder from your systems map and conduct an in-depth interview. Then reframe your systems challenge and identify an opportunity for redesign.

Think about the last system you interacted with. What was your experience and how did it influence your perspective?

What are techniques you like to use to help you get a new perspective on a challenging problem or situation?

Think back to a situation where a small shift, either in your personal or professional life, had an outsized impact. What was the change and how did it affect you and/or others?

Week 4: Redesign the System

4 video lessons.

Activate the Levers of Design - Redesign systems in small but effective ways

Prioritize for Impact - Evaluate the impact and feasibility of different solutions

Experiment with the System - Test your ideas and deepen your understanding of your system

Surface your Learnings - Draw out insights from your prototype

Test Solutions: Pick 1-2 ideas around each design lever and then choose 1 that is potentially high impact and easy to implement. Build a small prototype, test it out, and reflect on the outcome.

4 Discussions

Prototyping helps us explore how a system works, feels, responds to change. Of the three, which resonates the most with you, and why?

Which levers do you have the most control over in your organization? Which have you used to create positive change and improve outcomes?

Think about a time when you or others made a decision or implemented an idea that had unintended consequences. What was the outcome?

What is one small experiment you could try today that would be meaningful to learn from?

Prototyping Primer: Get familiar with the process of prototyping.

Prototyping Gallery: Get inspired by examples of how others have approached prototyping.

Week 5: Looking Ahead

Systems Change by Design - Expanding your sphere of influence.

Envision the Future: Imagine that you learned from your experiment, and kept iterating and experimenting over a period of time. Write a story from the future about how you were able to shift the system toward a better outcome.

1 Discussion

After learning about the mindsets and methods of human-centered systems thinking, are there any big complex challenges that you feel inspired to take on?

Meet Your Instructors

Meet your instructor.

Deirdre Cerminaro

Former executive design director, ideo.

Deirdre was an Executive Design Director and co-lead of the Systems & Strategy practice at IDEO. As a former architectural designer with a background in business and psychology, she has a knack for breaking down complex systems and finding simple levers to drive lasting change. She is passionate about bringing a human-centered lens to intractable systemic challenges, especially in education where much of her work had focused at IDEO.

Deirdre was an Executive Design Director and co-lead of the Systems & Strategy practice at IDEO. As a former architectural designer with a background in business and psychology, she has a knack for breaking down complex systems and finding simple levers to drive lasting change. Passionate about the power of systems design to create a more equitable future, much of her work at IDEO had focused on designing education systems—from reimagining student services at a community college in Ohio to creating programs to deliver quality, affordable education at scale in Peru. Deirdre holds a B.A. in Cognitive Science from Yale University and an MBA from the Yale School of Management. In her spare time, she can usually be found outside with her dog or off on an adventure. She's ridden her bicycle across the U.S. twice and hiked the 211-mile John Muir Trail.

Frequently Asked Questions

How do ideo u cohort courses work does my time zone matter.

We offer three types of courses: self-paced courses, cohort courses, and certificate programs. Cohort courses run on a set calendar, with fixed start and end dates. Course learning is self-paced within those dates and requires approximately 4-5 hours per week over 5 weeks. Courses consist of videos, activities, assignments, access to course teaching teams, and feedback from a global community of learners. There are also optional 1-hour video Community Conversations, held weekly by the teaching team. 

All of our cohort courses are fully online, so you can take them from any time zone, anywhere in the world. With our cohort course experience , while you'll be learning alongside other learners, you'll still have the flexibility to work at the pace that fits your own schedule. There aren’t mandatory live components, so you don't have to worry about having to log in at a specific time. At the same time, you'll have access to a teaching team, which is composed of experts in the field who are there to provide you feedback, and there are also plenty of options to connect with your fellow learners.

What is the role of the instructor and teaching team? Will learners be able to get feedback?

Course instructors have a strong presence in the courses through the course videos, but they're not actively providing feedback or holding direct conversations with our learners. We have a teaching team to ensure that you have the feedback, guidance, and support you need to learn successfully in your course. Our teaching team members are design practitioners that have experience applying course methods and mindsets in a wide variety of contexts around the world.

Our teaching team consists of teaching leads and teaching assistants, who are experts in their fields. Many of them have been with IDEO U for many years, and we have selected those who have direct experience with applying the course methods and mindsets in all sorts of contexts around the world. They all go through multiple training sessions by our instructional designers on not only on the subject matter, but also on how to create safe and collaborative learning experiences and environments.

What are Community Conversations, and how are they related to the course material?

Community Conversations are one-hour live video conversations hosted by the teaching team on Zoom. These happen once per week, with each one having two to three time options to accommodate different time zones. Each week focuses on the lesson that you’ve just gone through, so the output and the content depend on the specific lessons. You'll have the opportunity if you work together with your peers on the tools and mindsets from the course, reflect on what you’ve learned, and also address any challenges that you might be going through.

What will I have access to during and after my course?

All course materials, including videos, activities, and assignments will be available while you are enrolled in a course. During the 5 weeks of the course, you will have full access to our learning platform and can refer back to it any time. You will only have access to the course materials while you are enrolled. 

Assignments must be submitted during the 5-week course duration in order for you to receive a certificate of completion.

Can I take the course with my team?

Absolutely! We have had many teams go through our courses together. For those taking our courses as a team, we provide a number of additional benefits:

1. A Team Learning Guide, developed to provide your team with resources to facilitate offline discussions that complement the in-course experience.

2. A Manage Learners function, which provides visibility into your team's progress within the course.

3. The ability to create a private Learning Circle, which is a closed space for discussion on the learning platform specifically for your team.

For more information, visit our Team Learning page.

Do you offer discounts?

We offer a discount when you enroll in multiple courses at the same time through some of our certificate programs, including Foundations in Design Thinking , Business Innovation , Human-Centered Strategy , and Communicating for Impact . 

You can also enter your email address at the bottom of this page in order to receive updates on future offers or possible discounts. 

Will I get a certificate after completing a course?

After completing a cohort course, you will be able to add it to your “licenses and certifications” on LinkedIn.

We also have certificate programs that consist of multiple courses. After completing a certificate, you will receive a certificate of completion via email as a downloadable PDF within 1-2 weeks of completing the final required course. Certificates are configured for uploading and sharing on LinkedIn.

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You can purchase a course on our website using a credit card, PayPal, or Shop Pay. For US customers, we also offer installment plans at checkout if you use the Shop Pay method of payment.

We typically are not able to accommodate bank transfer or invoicing. However, if your order includes 10 seats or more, please contact [email protected] and our team will be happy to review your request. 

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Work with expert coaches.

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Loved by Learners Across the Globe

“For me, the most exciting application of human-centered design is when it is aimed at reimagining the complex systems of our society—like education or healthcare—that are full of promise but also fraught with inequalities. This is also the space where systems design is needed the most.”

“I've never met a designer who is able to fuse the crafts of systems thinking and human-centered design more effectively. Deirdre effortlessly sensemakes complex systems. And perhaps most importantly, she's a teacher and a leader who is a master at enabling others to embrace the skills and mindsets of systems design”

“Public education, decentralized finance, the energy ecosystem—these are examples of systems too complex and distributed to shift through a top-down solution. Deirdre is a dynamic systems designer who shares her knack for simplifying the complex and uncovering human-centered opportunities for change.”

“Deirdre is both process driven and intuitively insightful when it comes to systems design. She has helped us design complex systems at the service of reimagining a better learning systems for all Peruvians... she just rocks!”

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How to Create the Systems Thinking Diagrams

Complex systems can’t be seen as individual parts. We need a broader perspective to see the whole pattern that causes the problem, as many factors as affecting both the current state and the desired state of the system. The systems thinking theory was first introduced by Jay Forrester and members of the Society for Organizational Learning at MIT in his book, The Fifth Discipline, to help us see a complex system as a framework with interrelationships between different internal and external elements that affect the system.

Related articles:

The Six Systems Thinking Steps to Solve Complex Problems

What Does Systems Thinking Teach us About the Problems of Problem-Solving Practice

Design Schools Should Teach Systems Thinking, and This is Why

What is Systems Thinking?

Systems thinking (Also known as system dynamics) is an approach to address problems by looking into them as a whole rather than small parts and considering the dynamic nature of the problem. Each element affects the other elements in the system. The approach helps us to present the root solution by considering the impact of this solution on different parts of the system. Systems thinking extend to seeing the world around ad complex interested systems that influence each other rather than isolated systems. The below video visualises what systems thinking mean:

Think about reducing the price of a specific product to ncrease sales. This will negatively affect the quality of the product and increase external competitiveness. Therefore, the systems thinking diagram provides us with a visual aid to understand the connection between different factors in the system.

Characteristics of the Systems Thinking

Before building the systems diagrams, we first need to understand the general principles that control the complex systems known as The 11 Laws of the Fifth Discipline (Check What Does the Systems Thinking Teach us About the Problems of Problem-Solving Practice ). These principles were highlighted in the Fifth Discipline theory by Peter Senge in his book, The Fifth Discipline: The Art and Practice of the Learning Organization . These principles are below: 1- Today’s problems come from yesterday’s solutions. So, before adopting any new solutions, it is very important to understand the history of the existing problem. 2- The harder you push, the harder the system pushes back in a phenomenon known as “compensative feedback.” 3- Behavior grows better before it grows worse 4- The easy way out usually leads back in, therefore, the best solution is to understand the problem from a systematic approach to eliminate it. 5- The cure can be worse than the disease 6- Faster is slower. For example, If the solution aims to increase the system productivity beyond its optimal rate, the system may actually slow down to compensate for this change in growth rate. 7- Cause and effect are not closely related in time and space

8- Small changes can produce big results—but the areas of the highest leverage are often the least obvious 9- You can have your cake and eat it too — but not all at once. The systems thinking method teaches us that we need to look at the big picture. We can provide a complete solution that accomplishes all of the required goals if we consider achieving these solutions based on a determined timeline. 10- Dividing an elephant in half does not produce two small elephants. The problems need to be seen as a whole rather than as individual parts. 11- There is no blame. One of the common difficulties when solving problems is to point the finger at someone as the sole guilty person. However, in system thinking, everyone is part of a whole system

Structure of the Systems Thinking Diagrams

In order to build the systems thinking diagram, we need to clearly identify the elements of the system and how it interacts with each other. Building the systems diagrams requires four steps; identify the events, identify the pattern of behaviour, build the system, and determine the mental models.

Step 1: Event

The first step is to identify the problem at hand that we would like to learn about. This may include one or more related problems to be addressed. For example:

• Customers wait for a long time at the reception
• The unsatisfied patients at the hospital reception in the systems thinking in healthcare setup

Step 2: Patterns of Behaviors

The next step is to observe the patterns that show the relationship between different elements involved in the system. These elements represent the potential causes of the problem (effect). The Cause Effect Diagram can help identify the different causes that may involve the problem highlighted in the previous step.

Charts like the one below can show the positive and negative relation between different factors and how they contribute to the main problem that need to be analyzed in the system.

Step 3: System

After identifying the potential causes for the final effect. The relation between every two elements in the system is controlled by the feedback loops. The loops either show positive or negative relations, as shown in the figure below. Sometimes, the relationship is referred to as Same/Opposite instead of Positive(+)/Negative(-).

Based on the above relation, there are two types of loops that are classified based on how they change the system:

Balanced feedback loops

This loop is the natural loop elements that tend to naturalize the impact of the change. For example, talking to each patient in the hospital reception office increases the waiting time, which positively increases the patient’s unsatisfactory. In this example, the feedback “patient unsatisfactory” decreases the impact of the change “talking to the patients.”

Reinforcing Feedback Loops

In contrast to the balanced loop, in the reinforcing loop, the feedback increases the impact of the change. Both are moving in the same positive direction. In our example, reducing the time at the reception office reduces the waiting time and, subsequently, reduces the patient’s unsatisfactory.

Once we build the relationship between different factors, we can add external factors that affect the system, such as the parking lots available for the patients or the medicine and governmental support…etc.

Identifying Gaps and Delays

In some cases, the current state of one of the elements stands as a barrier to achieving the intended goal or contributing to increasing the problem. These states are known as gaps. For example, the limited number of reception personnel halts any initiative to reach higher patient satisfaction. This factor is set as a gap in the system.

Once the gaps are defined, we can clearly see if our initiative may work out or if we need to fix these gaps before moving further to solving the problems in the system.

As highlighted Fifth Element Theory, the cause and effect may be separated by time and place. Therefore, it is crucial to understand the time delay in the feedback loops. For example, training reception employees to handle patients’ problems more efficiently may take time to see its impact on the system. These delays are represented in the systems by double slashes on the loop.

Further details can be added to the systems diagram, such as adding numerical data that show exactly how each element is affected by the other elements in the system.

Step 4: Mental Models

At the end of the process, the model guides us through the next steps required to achieve the intended goal. For example, improving the customer experience at the hospital front desk may involve the following:

– Increase the parking lots in front of the hospital

– Train the personnel to handle a large number of customers

– Wait for the government to provide better medicine prices…etc.

The below workshop from MIT Open Courses provides another practical example of applying the system dynamics using the Fishbone diagram :

The systems thinking diagrams allow us to effectively apply the theory to understand the different elements in the complex systems by visualizing the relation between them and determining the form of this relation. Once the systems diagram is complete, we’ll better understand of how it works, its gaps, the delays in the system, and how to improve the system based on the concluded data.

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Dr Rafiq Elmansy

As an academic and author, I've had the privilege of shaping the design landscape. I teach design at the University of Leeds and am the Programme Leader for the MA Design, focusing on design thinking, design for health, and behavioural design. I've developed and taught several innovative programmes at Wrexham Glyndwr University, Northumbria University, and The American University in Cairo. I'm also a published book author and the proud founder of Designorate.com, a platform that has been instrumental in fostering design innovation. My expertise in design has been recognised by prestigious organizations. I'm a fellow of the Higher Education Academy (HEA), the Design Research Society (FDRS), and an Adobe Education Leader. Over the course of 20 years, I've had the privilege of working with esteemed clients such as the UN, World Bank, Adobe, and Schneider, contributing to their design strategies. For more than 12 years, I collaborated closely with the Adobe team, playing a key role in the development of many Adobe applications.

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• Our Mission

Teaching Students About Systems Thinking

These strategies guide students to explore the interconnected parts of complex systems like the human body, governments, and ecosystems.

Our world is interconnected and complex. As a result, our students need to move beyond fragmented ways of thinking, which look at problems in isolation or focus on short-term solutions. By developing our students to be systems thinkers, we can enable them to see patterns and organize their learning both inside and outside of school.

Let’s break this idea down by first describing what we mean by a system. Generally speaking, a system is a group of interconnected elements that are organized for a function or a purpose. System elements, or parts, may be physical or intangible things.

Importantly, system parts are interdependent. A change in one element can produce change within the entire system. This means systems are nonlinear. When consequences occur, they’re not isolated. They ripple through a system. Systems we encounter daily include the human body, cities, governments, social networks, and the Earth’s climate.

To give a narrative example, in Dr. Seuss’s well-known book The Lorax , the parts of the system are things like the water, air, Truffula Fruits, Brown Bar-ba-loots, and Humming-Fish, as well as the Once-ler’s greed and desire for economic growth above all else. Imagine if the Once-ler had truly understood how his behaviors impacted the Truffula Tree ecosystem, including the sustainability of his own Thneed production. His inability to think holistically led not only to a range of negative environmental consequences, but also to the collapse of his own business. 

In a global issue such as plastic pollution, system parts may include crude oil production, plastic manufacturing, companies, consumers, wastewater, and greenhouse gas emissions.

Systems thinking helps students manage complexity

Systems thinking is a mindset as well as a set of tools that enables students to recognize and understand relationships and interconnectedness. It’s an ability to toggle between the parts and the whole of a system to understand how interactions produce negative or positive behaviors. 

Systems thinking supports our students to understand the complexity of the world and manage its uncertainty, especially in a time of increased globalization; it is an essential component of critical thinking that teachers can apply across the curriculum. For example, using systems thinking, students can do the following:

• Chart character development in a piece of literature with behavior-over-time graphs
• Map nonlinear causes and consequences of historical or political conflicts
• Understand the relationships between parts of a cell, as well as between cells, organs, and body systems
• Analyze and take action on real-world issues, such as global warming, poverty, or overfishing

Teachers, curriculum coordinators, and school leaders can also use systems thinking tools, such as Agency by Design’s Mapping Systems protocol , to better understand the way parts of our educational system connect to produce positive or negative outcomes for students, such as lower attendance, higher referrals to learning interventions, or increased mental health issues.   

Fostering systems thinking as critical thinking

There are a number of ways teachers can facilitate systems thinking in the classroom. By slightly shifting how we interact with students—our questions or thinking prompts—we can promote “thinking in systems.”

Question with intention: Knowing we want to move away from “A leads to B” linear thinking, we can intentionally ask questions that encourage students to reflect on multiple parts of a system and how they connect. Instead of asking, “What caused this?” which communicates that there is a single cause, we can instead ask, “What factors contributed to this?” allowing students to search for multiple causes and nonlinear relationships.

Take a helicopter view: Toggling between the details and the big picture is an important systems thinking skill and one of the habits of a systems thinker . When looking at a situation, event, or particular issue, encourage students to discuss systems as a whole. For example, in the classroom we may create a circle, where each student represents a system part and makes connections with a ball of string. Students name how they connect to another system part as they toss the ball of string to one another, with each student retaining some of the string as they pass the ball around. At the end, students can see the interconnectedness of parts by gently tugging on the yarn and seeing who is affected.

Encourage pattern recognition: We want students to see the web of interconnections within systems and recognize how systems connect to other systems. During the Covid-19 pandemic, for instance, we saw how health systems impacted transportation and the economy, leading to certain goods being unavailable. By asking, “What’s this got to do with that?” we nudge students to go both deep and wide in an investigation.

Strategies for Teaching systems thinking

Many strategies for systems thinking encourage students to visualize and create “system pictures.” Because of the high degree of interaction within systems, many strategies invite students to map connections in nonlinear ways. Here are some concrete strategies we can use in the classroom.

Connected circles: In this strategy, a circle represents a particular system, and the parts of the system are written around the outside. Using a case study such as an article, video, or real-life experience, students chart connections across the parts of the circle, writing the relationship between parts on the connector line. A connected circles template can be modified for any system that students will explore.

Systems models: After researching a system such as a tropical rainforest or coral reef, students create a systems model using divergent physical materials, e.g. Lego, magnetic tiles, wooden blocks, paper, cotton balls, shells, stones, etc. After making representations of the system and its parts, students annotate the model with sticky notes, arrows, etc. to show relationships between them. This may also include inputs and outputs of the system. For example, sunlight and carbon dioxide go into the rainforest (inputs), and oxygen and water vapor come out (outputs).

Games and simulations: Matthew Farber has written extensively about the use of constructionist gaming to promote thinking about complex systems. He shows how making and thinking come together to allow students to play with systems. The Joan Ganz Cooney Center at Sesame Workshop also writes about the role of digital learning to promote understanding of systemic causes in young children. 

By inviting students to play with and explore systems thinking tools, we enable them to see structures and patterns within and across the content areas. Such engagements can empower students to find solutions to local, global, and intercultural issues that may have previously seemed unsolvable.

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• BMJ Open Qual
• v.9(1); 2020

Development and application of ‘systems thinking’ principles for quality improvement

Duncan mcnab.

1 Medical Directorate, NHS Education for Scotland, Glasgow, UK

2 Institute of Health and Wellbeing, University of Glasgow, United Kingdom

Steven Shorrock

3 EUROCONTROL, Brussels, Belgium

4 University of the Sunshine Coast Sippy Downs Campus, Sippy Downs, Queensland, Australia

Associated Data

bmjoq-2019-000714supp001.pdf

bmjoq-2019-000714supp002.pdf

Introduction

‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a ‘Safety-II systems approach’ to promote understanding of how safety may be achieved in complex work systems. We aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting.

The original EUROCONTROL principles were adapted using consensus-building methods with front-line staff and national safety leaders.

Six interrelated principles for healthcare were agreed. The foundation concept acknowledges that ‘most healthcare problems and solutions belong to the system’. Principle 1 outlines the need to seek multiple perspectives to understand system safety. Principle 2 prompts us to consider the influence of prevailing work conditions—demand, capacity, resources and constraints. Principle 3 stresses the importance of analysing interactions and work flow within the system. Principle 4 encourages us to attempt to understand why professional decisions made sense at the time and principle 5 prompts us to explore everyday work including the adjustments made to achieve success in changing system conditions.

A case study is used to demonstrate the application in an analysis of a system and in the subsequent improvement intervention design.

Conclusions

Application of the adapted principles underpins, and is characteristic of, a holistic systems approach and may aid care team and organisational system understanding and improvement.

Adopting a ‘systems thinking’ approach to improvement in healthcare has been recommended as it may improve the ability to understand current work processes, predict system behaviour and design modifications to improve related functioning. 1–3 ‘Systems thinking’ involves exploring the characteristics of components within a system (eg, work tasks and technology) and how they interconnect to improve understanding of how outcomes emerge from these interactions. It has been proposed that this approach is necessary when investigating incidents where harm has, or could have, occurred and when designing improvement interventions. While acknowledged as necessary, ‘systems thinking’ is often misunderstood and there does not appear to be a shared understanding and application of related principles and approaches. 4–6 There is a need, therefore, for an accessible exposition of systems thinking.

Systems in healthcare are described as complex. In such systems it can be difficult to fully understand how safety is created and maintained. 7 Complex systems consist of many dynamic interactions between people, tasks, technology, environments (physical, social and cultural), organisational structures and external factors. 8–10 Care system components can be closely ‘coupled’ to other system elements and so change in one area can have unpredicted effects elsewhere with non-linear, cause–effect relations. 11 The nature of interactions results in unpredictable changes in system conditions (such as patient demand, staff capacity, available resources and organisational constraints) and goal conflicts (such as the frequent pressure to be efficient and thorough). 12 13 To achieve success, people frequently adapt to these system conditions and goal conflicts. But rather than being planned in advance, these adaptations are often approximate responses to the situations faced at the time. 14 Therefore, to understand safety (and other emergent outcomes such as workforce well-being) we need to look beyond the individual components of care systems to consider how outcomes (wanted and unwanted) emerge from interactions in, and adaptations to, everyday working conditions. 14

Despite the complexity of healthcare systems, we often appear to treat problems and issues in simple, linear terms. 15–17 In simple systems (eg, setting your alarm clock to wake you up) and many complicated systems (eg, a car assembly production line) ‘cause and effect’ are often linked in a predictable or linear manner. This contrasts sharply with the complexity, dynamism and uncertainty associated with much of healthcare practice. 1 7 18 For example, in a study to evaluate the impact of a comprehensive pharmacist review of patients’ medication after hospital discharge, the linear perspective suggested that this specific intervention would improve the safety and quality of medication regimens and so reduce healthcare utilisation. 19 Unexpectedly the opposite result was observed. The authors suggested that this emergent outcome may have been due to the increased number of interactions with different healthcare professionals increasing the complexity of care resulting in greater anxiety, confusion and dependence on healthcare workers.

Analyses of safety issues in healthcare routinely examine how safety is destroyed or degraded but have surprisingly little to say about how it is created and maintained. In the UK, like many parts of the world, root cause analysis is the recommended method for analysing events with an adverse outcome. 20 At its best, this should take a ‘systems approach’ to identify latent system conditions that interacted and contributed to the event and recommend evidence-based change to reduce the risk of recurrence. 20 However, we find that the results of such analyses are commonly based on linear ‘cause and effect’ assumptions and thinking. 15 16 21 22 Despite allusions to ‘root causes’, investigation approaches have a tendency to focus on single system elements such as people and/or items of equipment, rather than attempting to understand the interacting relationships and dependencies between people and other elements of the sociotechnical system from which safety performance and other outcomes in complex systems emerge. 21 By focusing on components in isolation, proposed improvement interventions risk unintended consequences in other parts of the systems and enhanced performance of the targeted component rather than the overall system. The validity of focusing on relatively infrequent, unwanted events has been questioned as it does not always reveal how wanted outcomes usually occur and may limit our learning on how to improve care. 22

Despite much related activity internationally, the impact of current safety improvement efforts in healthcare is limited. 23–25 Similar to other safety-critical industrial sectors, such as nuclear power or air traffic control, there is a growing realisation in healthcare that exploring how safety is created in complex systems may add value to existing learning and improvement efforts. The European Organisation for the Safety of Air Navigation (EUROCONTROL), a pan-European intergovernmental air navigation organisation, published a white paper, Systems Thinking for Safety: Ten Principles . 26 This sets out a way of thinking about safety in organisations that aligns with systems thinking and applies ‘Safety-II’ principles, for which there is also growing interest in healthcare. 27 This latter approach attempts to explain and potentially resolve some of the ‘intractable problems’ associated with complex systems such as those found in healthcare, which traditional safety management thinking and responses (termed Safety-I) have struggled to adequately understand and improve on. 28 The Safety-II approach aims to increase the number of events with a positive outcome by exploring and understanding how everyday work is done under different conditions and contexts. This can lead to a more informed appreciation of system functioning and complexity that may facilitate a deeper understanding of safety within systems. 29 30

In this paper, we describe principles for systems thinking in healthcare that have been adapted and contextualised from the themes within the EUROCONTROL ‘Systems Thinking for Safety’ white paper. Our goal was to provide an accessible framework to explore how work is done under different conditions to facilitate a deeper understanding of safety within systems. A case report applying these principles to healthcare systems is described to illustrate systems thinking in everyday clinical practice and how this may inform quality improvement (QI) work.

Adaptation of EUROCONTROL Systems Thinking Principles

A participatory codesign approach 31 was employed with informed stakeholders. 32 33 First, in March 2016, a 1-day systems thinking workshop was held for participants who held a variety of roles in front-line primary care (general practitioners (GP), practice nurses, practice managers and community pharmacists) and National Health Service (NHS) Scotland patient safety leaders ( table 1 ). The relevance and applicability of the EUROCONTROL white paper system principles were explored through presentations and discussion led by two experts in the field (including the original lead author of this document—SS). This was followed by a facilitated small group simulation exercise to apply the 10 principles to a range of clinical and administrative healthcare case studies ( online supplementary appendix 1 ) ( figure 1 ).

Systems Thinking for Everyday Work model.

Characteristics of attendees at Stage 1—‘Systems thinking’ workshop

Supplementary data

Second, two rounds of consensus building using the Questback online survey tool were undertaken with workshop participants in April and July 2016. 34

Finally, in May 2017, two 90 min workshops were held to test and refine the adapted principles with primary and secondary care medical appraisers (experienced medical practitioners with responsibility for the critical review of improvement and safety work performed by front-line peers).

At each stage, feedback was collected and analysed to identify themes related to applicability including wording, merging and missing principles. These themes directed the modification of the original principles and descriptors, which were then used at the next stage of development.

Throughout the process, external guidance and ‘sense-checking’ were provided by a EUROCONTROL human factors expert and lead author of the original systems thinking for safety white paper. While we believe the outputs from this work are generically applicable to all healthcare contexts, we have focused on the primary care setting for pragmatic purposes. The agreed principles are illustrated graphically in the Systems Thinking for Everyday Work (STEW) conceptual model ( figure 1 ), and detailed descriptions are provided in online supplementary appendix 2 .

Patient and public involvement

Patients and the public were not involved in the design of the study or the adaptation of the principles. The presented case study included a patient in the application of the principles to analyse the system. A service user read and commented on the manuscript and their feedback was incorporated into the final paper.

Systems Thinking for Everyday Work

The STEW principles consist of six inter-related principles ( figure 1 , tables 2 and 3 , online supplementary appendix 2 ). A fundamental, overarching conclusion is that the principles should not be viewed as isolated ideas, but instead as inter-related and interdependent concepts that can aid our understanding of complex work processes to better inform safety and improvement work by healthcare teams and organisations.

Adaptation of Systems Thinking Principles

EUROCONTROL, European Organisation for the Safety of Air Navigation.

Analysis of GP-based pharmacist work system

GP, general practitioner; STEW, Systems Thinking for Everyday Work.

Foundation concept

The foundation concept acknowledges that ‘ most healthcare problems and solutions belong to the system ’. This emphasises that the aim of applying a systems approach is to improve overall system functioning and not the functioning of one individual component within a system. For example, improving clinical assessments will not improve overall system performance unless patients can access assessments appropriately.

All systems interact with other systems, but out of necessity those analysing the system need to agree boundaries for the analysis. This may mean the GP practice building, a single hospital ward, the emergency department, a pharmacy or nursing home. Despite this, it is important to remember that external factors will influence the system under study and changes may have effects in parts of the system outside the boundary.

Multiple perspectives

Appreciate that people, at all organisational levels and regardless of responsibilities and hierarchical status, are the local experts in the work they do. Exploring the different perspectives held by these people, especially in relation to the other principles, is crucial when analysing incidents and designing and implementing change.

System conditions

Obtaining multiple perspectives allows an exploration of variability in demand and capacity, availability of resources (such as information or physical resources) and constraints (such as guidance that directs work to be performed in a particular way). These considerations can help identify leading indicators of impending trouble by identifying where demand may exceed capacity or where resources may not be available. Multiple perspectives can also help explore how work conditions affect staff well-being (eg, health, safety, motivation, job satisfaction, comfort, joy at work) and performance (eg, care quality, safety, productivity, effectiveness, efficiency).

Interactions and flow

System outputs are dependent on the constantly changing interactions between people, tasks, equipment and the wider environment. Multiple perspectives on system functioning help explore interactions to better understand the effects of actions and proposed changes on other parts of the system. Examining flow of work can help identify how these interactions and the conditions of work contribute to bottlenecks and blockages.

Understand why decisions made sense at the time

This principle directs us that, when looking back on individual, team or organisational decision-making, we should appreciate that people do what makes sense to them based on the system conditions experienced at the time (demand, capacity, resources and constraints), interactions and flow of work. It is easy (and common) to look back with hindsight to blame or judge individual components (usually humans) and recommend change such as refresher training and punitive actions. This must consider why such decisions were made, or change is unlikely to be effective. The same conditions may occur again, and the same decision may need to be made to continue successful system functioning. By exploring why decisions were made, we move beyond blaming ‘human error’ which can help promote a ‘Just Culture’—where staff are not punished for actions that are in keeping with their experience and training and which were made to cope with the work conditions faced at the time. 35

Performance variability

As work conditions and interactions change rapidly and often in an unpredicted manner, people adapt what they do to achieve successful outcomes. They make trade-offs, such as efficiency thoroughness trade-offs, and use workarounds to cope with the conditions they face. In retrospect these could be seen as ‘errors’, but are often adaptations used to cope with unplanned or unexpected system conditions. They result in a difference between work-as-done and work-as-imagined and define everyday work from which outcomes, both good and bad, emerge.

Case report

The included case report describes the practical application of these principles to understand work within a system and the subsequent design of organisational change ( table 3 ). The presented details are a small part of a larger project in which the authors (DM, PB and SL) were involved. The new appointment of a health board employed pharmacist to a general practice had not had the anticipated impact and there had been unexpected effects. The GPs had hoped for a greater reduction in workload quantity, the health board had hoped for increased formulary compliance and there had been increased workload in secondary care.

Traditional ways of exploring this problem may include working backwards from the problem to identify an area for improvement. In this case, further training of the pharmacist may have been suggested and targets may have been introduced in relation to workload or formulary compliance. However, without understanding why the pharmacist worked this way, it is likely any retraining or change would be ineffective. The STEW principles provided a framework to analyse the problem from a systems perspective, understand what influenced the pharmacist’s decisions and explore the effects of these decisions elsewhere in the system. Obtaining multiple perspectives identified that the pharmacist had to trade off between competing goals (productivity vs thoroughness including safety and formulary compliance). The application of the principles identified how pharmacists varied their approach to increase productivity while remaining safe. Learning from this everyday work helped bring work-as-done and work-as-imagined closer and several changes to improve system performance were identified and implemented.

Access to hospital electronic prescribing information

This ensured pharmacists had the information needed to complete the task ( System condition—resources ). It also reduced work in other sectors ( Interactions ) and increased the efficiency of task completion and so reduced delays for patients ( Flow ).

Work scheduling

The timetable for the week was changed to prioritise other prescribing tasks at the start of the week and complete medication reconciliation later in the week ( System condition—capacity/demand ). Through discussion of system conditions, the pharmacist identified that certain discharges took longer to complete, resulted in further contact with the practice (with a resultant increased GP workload) or had an increased risk of patient harm. Discharges that included these factors were prioritised and completed early in the week in attempt to mitigate these problems.

Protocols were changed to have minimum specification to allow local adaptation by pharmacists ( System conditions—constraints ). This supported the pharmacists to employ a variety of responses dependent on the context ( Performance Variability ) which reduced pharmacists’ concerns of blame if they did not follow the protocol ( Understand why decision made sense ). For example, after a short admission where it was unlikely medication was changed, pharmacists did not need to contact secondary care regarding medication not recorded on the discharge letter ( Understand why decision made sense ). If they felt they did have to check, the option of contacting the patient was included. Similarly, the need to contact all patients after discharge was removed. Pharmacists could use other options such as contacting the community pharmacy if more appropriate ( Performance Variability ).

Pharmacist mentoring

Regular GP mentoring sessions were included as pharmacists’ found discussing cases with GPs allowed them to consider the benefits and potential problems of their actions in other parts of the system (Interactions and Performance Variability ). For example, not limiting the number of times certain medication can be issued but instead ensuring practice systems for monitoring are used. This also allowed them to consider when they needed to be more thorough at the expense of efficiency ( Performance Variability ), for example, when there were leading indicators of problems such as high-risk medication.

This paper describes the adaptation and redesign of previously developed system principles for generic application in healthcare settings. The STEW principles underpin and are characteristic of a holistic systems approach. The case report demonstrates application of the principles to analyse a care system and to subsequently design change through understanding current work processes, predicting system behaviour and designing modifications to improve system performance.

We propose that the STEW principles can be used as a framework for teams to analyse, learn and improve from unintended outcomes, reports of excellent care and routine everyday work ‘hassles’. 36 37 The overall focus is on team and organisational learning by, for example, small group discussion to promote a deep understanding of ‘how everyday work is actually done’ (rather than just fixating on things that go wrong). This allows an exploration of the system conditions that result in the need for people to vary how they work; the identification and sharing of successful adaptations and an understanding of the effect of adaptations elsewhere in the system (mindful adaptation). From this, we can decide if variation is useful (and thus support staff in doing this effectively) or unwanted (and system conditions can then be considered to try to damp variation). These discussions can help reconcile work-as-done and work-as-imagined . Although, as conditions change unpredictably, new ways of working will continue to evolve and so we must continue to explore and share learning from everyday work, not just when something goes wrong.

The focus of safety efforts, in incident investigation and other QI activity, is often on identifying things that have gone wrong and implementing change to prevent ‘error’ recurring. 20 The focus is often on the ‘root causes’ of adverse events or categorising events most likely to cause systems to fail (eg, using Pareto charts). 20 38 This linear ‘cause and effect’ thinking can lead to single components, deemed to be the ‘cause’ of the unwanted event or care problem, being prioritised for improvement. Although this may improve the performance of that component it may not improve overall system functioning and, due to the complex interactions in healthcare systems, may generate unwanted unintended consequences. The principles promote examining and treating the relevant system as a whole which may strengthen the way we conduct incident investigation and how we design QI projects.

To successfully align corrective actions or improvement interventions with contributing factors, and therefore ensure actions have the desired effect, a deep understanding of everyday work is essential. 39 Methods such as process mapping are often promoted to explore how systems work which, when used properly, can be a useful method to aid healthcare improvers. To more closely model and understand work-as-done , the STEW principles could be considered to show the influences on components that affect performance such as feedback loops, coupling to other components and internal and external influences.

The STEW principles may also support another commonly used QI method: Plan, Do, Study, Act cycles. 40 It has been suggested that more in-depth work is often required in the planning and study stages of improvement activity, especially when dealing with complex problems. 40 The application of the principles may help explore factors that will influence change (such as resources, interactions with other parts of the systems and personal and organisational goals). Similarly, during the study phase, the principles can help explore how system properties prompted people to act the way they did. This level of understanding can then inform further iterative cycles.

Patient care is often delivered by teams across interfaces of care which further increases complexity. 41 It is estimated that only around half to three-quarters of actions recommended after incident analysis are implemented. 21 Although this is often due to a lack of shared learning and local action plans and involvement of key stakeholders, 21 those investigating such cases may feel unable to influence change in such a complex environment. This may result on a focus on what is perceived as manageable or feasible changes to single processes. Obtaining multiple perspective on work and improvement encourages a team-based approach to learning and change but systems are still required to ensure learning and action plans are shared. Although the principles have been used in incident investigation and to influence organisational change across care interfaces, simply introducing a set of principles alone will not improve the likelihood of the implementation of effective system-level change. 42 43 Training on, and evaluation of, the application of the principles is required.

Understanding how safety is created and maintained must involve more than examining when it fails. Improvement interventions often aim to standardise and simplify current processes. Although these approaches are important, in a resource-limited environment, it will never be possible to implement organisational change to fix all system problems. Even if this was possible, as systems evolve with new treatments and technology, conditions will emerge that have not been considered. To optimise success in complex systems, the contribution of humans to creating safety needs to be explored, understood and enhanced. 44 Human adaptation is always required to ensure safe working and needs to be understood, appreciated and supported. Studying systems using the principles may support workers who make such adaptations to be more mindful of wider system effects.

There is growing interest in healthcare in how we can learn more from how people create safety. The Learning from Excellence movement promotes learning and improvement from the analysis of peer-reported episodes of excellent care and positive deviancy aims to identify how some people excel despite facing the same constraints as others. 36 45 The Safety-II systems approach that influenced these principles is similar in that it focuses on how people help to create safety by adapting to unplanned system factors and interactions.

By understanding why decisions are made, the application of the principles supports the development of a ‘Just Culture’—indeed this was one of EUROCONTROL’s original principles and was incorporated into the principle, ‘Understand why decisions make sense at the time’. A ‘Just Culture’ has been described as ‘a culture of trust, learning and accountability’, where people are willing to report incidents where something has gone wrong, as they know it will inform learning to improve care and not be used to assign blame inappropriately. 35 Our approach aims to avoid unwarranted blame and increase healthcare staff support and learning when something has gone wrong. 46 47 Furthermore, application of the principles may empower staff and patients to not just report incidents but contribute to analysis and become integral parts of the improvement process through coproduction of safer systems. Obtaining the perspective of the patient when applying the principles is critical to understanding and improving systems as they are often the only constant when care crosses interfaces. This type of approach to improvement is strongly promoted and may avoid short-sighted responses to patient safety incidents (eg, refresher training or new protocols) and result in the design of better, and more cost-effective care systems. 48

Alternative methods exist for modelling and understanding complex systems, such as the Functional Resonance Analysis Method, 49 and a complex systems approach is used in accident models such as the Systems Theoretic Accident Modelling and Processes 50 and AcciMAPs. 51 These robust methods for system analysis are difficult for front-line teams to implement without specialised training. 29 The principles, on the other hand, were designed with front-line healthcare workers in order to allow non-experts to be able to adopt this type of thinking to understand and improve systems. The influence of conditions of work, including organisational and external factors, on safety has been appreciated for some time and is included in other models used in healthcare to explore safety in complex systems. 52–54 The Systems Engineering Initiative for Patient Safety (SEIPS) model is arguably one of the best known systems-based frameworks in healthcare. 53 While this model promotes seeking multiple perspectives to describe the interactions between components, the STEW principles focus on how these interactions influence the way work is done and thus may complement the use of the SEIPS model.

Strength and limitations

Any consensus method can produce an agreed outcome, but that does not mean these are wholly adequate in terms of validity, feasibility or transferability. Only 15 participants were involved in the initial development with 32 more in workshops; however, a wide range of professions with significant patient safety and QI experience were recruited. The appraiser workshop was attended by both primary and secondary care doctors, and other staff groups. Their comments were used to further refine the principles, but no attempt was made to assess their agreement on the importance and applicability of principles. The principles have not been shown in practice to improve performance, and further research and evaluation of their application in various sectors of healthcare is needed.

Systems thinking is essential for examining and improving healthcare safety and performance, but a shared understanding and application of the concept is not well developed among front-line staff, healthcare improvers, leaders, policymakers, the media and the general public. It is a complicated topic and requires an understandable framework for practical application by the care workforce. The developed principles may aid a deeper exploration of system safety in healthcare as part of learning from problematic situations, everyday work and excellent practices. They may also inform more effective design of local improvement interventions. Ultimately, the principles help define what a ‘systems approach’ actually entails in a practical sense within the healthcare context. ​

Research ethics

Under UK ‘Governance Arrangements for Research Ethics Committees’, ethical research committee review is not required for service evaluation or research which, for example, seeks to elicit the views, experiences and knowledge of healthcare professionals on a given subject area. 55 Similarly ‘service evaluation’ that involves NHS staff recruited as research participants by virtue of their professional roles also does not require ethical review from an established NHS research ethics committee.

Acknowledgments

The authors thank all those who contributed to the adaptation of the principles and Michael Cannon for his comments from a service user’s perspective.

Twitter: @duncansmcnab, @pbnes

Contributors: DM, JM and PB conceived the project. SS developed the original principles and led the consensus building workshop. DM and SL collected the data. DM, SL, SS, JM and PB analysed the feedback to adapt the principles. DM drafted the original report and SL, SS and JM revised and agreed on the final manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: Data are available upon reasonable request. Data are available upon request relating to the stages of the consensus building process.