This is the century of the system and the network. The term ‘system’ is widely used but often when people refer to a ‘system of care’, for example in the United States or in England, they are in fact referring not to a single system but to a set of structures.
There are, it is true, a number of microsystems, such as payment systems or systems for procuring equipment openly and fairly, and certain clinical microsystems, like the microsystem for increasing safety in operating theatres. However, although they make a limited contribution to increasing value, these microsystems are not what is needed to transform a health service into one that increases value for both individuals and populations.
A system is a set of activities with a common set of objectives and it may be expressed diagrammatically and we need to move from an archipelago of autonomous services like this:
To an integrated system, like this:
Or perhaps like this to illustrate the relative size of the contributions:
What is needed is a system for every sub-segment of the population. For example, within the segment of people with respiratory disease we need a system for the sub-segment of people with asthma and a system for the sub-segment of people with COPD.
There are about 80 such sub-segments focusing not only on conditions like asthma or type 2 diabetes but also on symptoms such as pelvic pain or a characteristic such as a system for people in the last year of life.
The key elements in system performance measurement can be expressed in a simple table:
The principles of system design for OVSP are that in designing a system it is necessary to:
- Define the scope of the system.
- Define the population to be served.
- Reach agreement on the aim and objectives of the service
- For each objective to find one or more outcome criteria
- For each of the criteria identify levels of performance that can be used as quality standards
- Identify all the resources used in the system, thus creating a system budget
- Define all the partners so that they need to be engaged in a Clinical Network
- Agree the principal pathways that need to be made explicit
- Produce a system specification
- Prioritise the different activities within the system using the STAR tool
- Prepare a plan to build the system and issue a contract
A network is a set of individuals and organisations which deliver the system’s objectives to a defined population. The system sets out what is to be achieved, the network being left to determine how the objectives can be achieved taking into account local history, geography and politics. A network is a new type of organisation which does not replace the existing bureaucratic organisations but, as described by Nonaka and Takeuchi, floats beside them and is accountable to the population served.
“A business organisation should have a nonhierarchical, self-organizing structure working in tandem with its hierarchical formal structure…..As business organisations grow in scale and complexity they should simultaneously maximise both corporate level efficiency and local flexibility…the most appropriate name is the ‘hypertext’ organization.
Ikujiro Nonaka and Hirotaka Takeuchi, The knowledge creating company, OUP 1995
The OVSP Learning Programme
This is the third of the five modules in our online learning opportunity to help you develop the understanding and skill to:
- Improve healthcare systems by increasing value and reducing waste (Module 1)
- Shift the focus from bureaucracies to populations (Module 2)
- Design population based systems and deliver care through networks (Module 3)
- Create a culture of stewardship (Module 4)
- Optimise personal value (Module 5)
As a result of learning from this module, and from other people learning with you, you will be able:
- To define what is meant by a system and how systems relate to programmes and programme budgets
- To show how the concept of systems relates to those of integrated care, accountable care organisations and accountable care systems
- To design a well scoped system specification with an aim, objectives and criteria
- To outline the different types of criteria or measures that can be used to monitor progress towards meeting system objectives
- To explain how systems can increase the technical value of a health service
- To describe how networks relate to bureaucracies and deliver the objectives set out in the system’s specification
- To define the term ‘action learning’ and the role of a community of practice