System Thinking in Perioperative Medicine

Complexity in Medicine

When a frail 80-year-old patient attends for an elective hip replacement, her perioperative care pathway may include interactions with the primary care physician, physiotherapist, occupational therapist, pharmacist, the anesthesiologist and preoperative clinic staff, and eventually the surgeon. She may be brought into hospital by a transport service, be reviewed by geriatricians, pass through the operating department and postanesthesia care unit, and interact with hundreds of staff throughout this journey. Multiple procurement systems, financial systems, information technology (IT) systems, and human resource systems will interact around her care pathway for a successful outcome. The care she receives will be shaped by the culture and context of the organization.

Because of the complexity of the healthcare system, any attempt to improve part of this process in isolation may not result in a predictable improvement in her outcome overall. The usual input-output-result relationship no longer functions. Approaching the complexity in perioperative medicine requires us to apply a system-thinking approach.

What Is a System?

A system is a series of interconnecting components that interact for a common purpose. Health care is very much a system, and an increasingly complex one.

In health care, we can consider care at micro , meso, or macro system levels. We refer to microsystems as the environment where the patient directly experiences clinical care. At the level of the microsystem, care includes the patient, the clinical team, and their interactions in a defined environment, such as an operating room (OR). Mesosystems are collections of interrelated microsystems that interact across a care pathway; for example, breast cancer care is delivered in the outpatient clinic, radiology department, OR, and oncology clinic, among other places. Achieving improvements in patient experience and outcome requires an understanding of how the system is integrating and functioning at this mesosystem level. At the macrosystem level, we understand that the hospital is operating with interactions into primary and community services, shaped by economic, political, and wider organizational drivers, and that these interactions need to be mapped and understood to facilitate improvement. System thinking can be applied to each level of these healthcare interactions ( Fig. 9.1 ).

What Is System Thinking?

System thinking has diverse multidiscipline origins, which have resulted in a plethora of terms and methods, the definitions of which can be unclear and daunting to clinicians. After a review of these multiple definitions, Arnold and Wade proposed the following in 2015:

Systems thinking is a set of synergistic analytic skills used to improve the capability of identifying and understanding systems, predicting their behaviors, and devising modifications to them in order to produce desired effects. These skills work together as a system.

Barry Richmond, the originator of the term system thinking, stated simply that by system thinking “people see both the forest and the trees; one eye on each.” By understanding the complexity, we begin to appreciate that there are no longer any simple solutions, and our mindset must shift, and we must adopt new skills to system think ( Fig. 9.2 ).

System thinking requires a different skill set and approach to thinking about problems ( Box 9.1 ).

Additional information about system thinking approaches can be found in the “Habits of a System Thinker” courses at https://thinkingtoolsstudio.waterscenterst.org/courses/habits , which list 14 considerations, including recognizing the impact of time delays when exploring cause-and-effect relationships and considering the short-term, long-term, and unintended consequences of making changes to a system.

How to Do It: Key Concepts

Williams and Hummelbrunner examined the wide range of system thinking approaches to explore what they had in common. They suggested that there are three core concepts underpinning all system methodologies that are vital for novice system thinkers to consider at the beginning of systems work : interrelationships, perspectives, and boundaries.