Systems Thinking Perspectives on CQI and Public Health

Mapping the system
Mapping the system

Systems thinking involves taking account of where you stand, what you’re doing, and where the bounds of your influence and influences are. By learning how to think about systems, we are better able to design strategies to ensure that our engagements are producing the most beneficial results for our efforts and when combined with design thinking we gain further opportunities to shape the systems closer to what we aspire them to be.

I recently was invited to speak to the first meeting to advance CQI (Continuous Quality Improvement) in public health in Ontario (Canada) on the topic of systems thinking. The one day workshop was aimed at bringing together members from nearly every public health unit in the province to meet and discuss issues related to quality improvement and public health.

In twenty minutes we did a whirlwind through some of the key features of systems that are relevant to quality improvement by looking at the nature of systems (chaotic, complex and ordered) and steps that can be taken to understand them in terms of setting the appropriate targets, methods and tools for defining and assessing quality within such systems.

Understanding systems

By understanding the nature of systems we can avoid the trap of using linear metrics for non-linear problems. Much of the literature on quality improvement has its roots in manufacturing, which are largely linear systems that seek to predict, control and emphasize efficiencies and the elimination of waste. Yet, public health is largely about complexity. In a complex system, what might be considered inefficiencies could be natural byproducts of the system itself and cannot be necessarily avoided. Further, such ‘noise’ could be sources of innovation or weak signals that indicate something significant is to come.

Public health operates in a tricky space because it deals with highly complex problems and systems and linear, straightforward ones simultaneously.

Below is a summary set of slides used to highlight the talk (the original slides were more visual, but those don’t help you out if you hadn’t been in the room).

(For those who read this blog through subscription, you may not see the above presentation in your feed so here is the link)

Building Quality Into Systems Design

One of the central points I made was that systems can be (partly) designed and that developmental design is a process that integral to optimal functioning in a complex system. By paying attention to what is going on and the relationships that form within the system the feedback is set to allow for intentional development of the system itself. This does not assure control, but it allows for positive influence rather than being solely reactive to whatever the system produces. This is necessary if one is to promote quality and ensure quality not just measure it as if it was a static object.

Whether one uses linear, quantitative measures or more non-linear, multi-method approaches to assessing the quality of a public health product or service, the key is knowing what kind of system you are operating in.

My takeaway points were:

•CQI depends on seeing quality as embedded in and a product of systems;
•Systems are defined by where you stand in relation to them and how variation operates within the system;
•Where you stand determines your metrics for quality;
•Your metrics feed your improvement and (re)define quality by influencing where you stand.
The process then repeats iteratively and in an ongoing manner just as one repeats the use of the strategies below:
•Pay attention / pay intention;
•Map your system to intentions, people, settings, contexts based on what you see;
•Collect relevant, timely, useful data based on the context of your operations and strategy (build on what you map);
•Engage in collective sense-making of the data;
•Design & redesign your programs.
By setting up the appropriate processes and structures to monitor, assess, sense-make, and design programs in congruence with the type of systems programs and services are operating in, not only with public health professionals be better equipped to assess quality, they will be producing it along the way (and creating a learning organization in the process).

2 thoughts on “Systems Thinking Perspectives on CQI and Public Health”

  1. Thanks. I agree, we see things from where we stand. My challenge is to balance that with the underlying principles that could help us all move further.

  2. Thanks. The challenge is to strike the balance between acknowledging that people’s systems are based on where they stand and not siloing ourselves since the same principles apply.

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