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Abstract
Introduction Healthcare is a highly complex adaptive system, requiring a systems approach to understand its behaviour better. We adapt the Systems Thinking for Everyday Work (STEW) cue cards, initially introduced as a systems approach tool in the UK, in a US healthcare system as part of a study investigating the feasibility of a systems thinking approach for front-line workers.
Methods The original STEW cards were adapted using consensus-building methods with front-line staff and safety leaders.
Results Each card was examined for relevance, applicability, language and aesthetics (colour, style, visual cues and size). Two sets of cards were created due to the recognition that systems thinking was relatively new in healthcare and that the successful use of the principles on the cards would need initial facilitation to ensure their effective application. Six principles were agreed on and are presented in the cards: Your System outlines the need to agree that problems belong to a system and that the system must be defined. Viewpoints ensure that multiple voices are heard within the discussion. Work Condition highlights the resources, constraints and barriers that exist in the system and contribute to the system’s functions. Interactions ask participants to understand how parts of the system interact to perform the work. Performance guides users to understand how work can be performed daily. Finally, Understanding seeks to promote a just cultural environment of appreciating that people do what makes sense to them. The two final sets of cards were scored using a content validity survey, with a final score of 1.
Conclusions The cards provide an easy-to-use guide to help users understand the system being studied, learn from problems encountered and understand the everyday work involved in providing excellent care. The cards offer a practical ‘systems approach’ for use within complex healthcare systems.
- Human factors
- Quality improvement
- Quality improvement methodologies
- Healthcare quality improvement
- Complexity
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Human factors
- Quality improvement
- Quality improvement methodologies
- Healthcare quality improvement
- Complexity
WHAT IS ALREADY KNOWN ON THIS TOPIC
There is a growing knowledge base regarding using a systems approach when developing quality and safety interventions in healthcare, though there are relatively few tools available for use by front-line healthcare workers.
WHAT THIS STUDY ADDS
The present study developed and validated an easy-to-use, robust set of systems thinking cards for use in developing healthcare interventions.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study fills a gap by providing practical tools that promote a deeper understanding of systems thinking within the healthcare context.
Introduction
Numerous studies explore methods for enhancing performance, yet no universally effective solution has emerged for all healthcare scenarios.1–3 Much of this may be attributed to a lack of knowledge or acceptance that healthcare is a more highly complex adaptive system4 than a complicated one. As a complex adaptive system, healthcare presents an environment that is not as amenable to the linear, reductive thinking represented in many accepted quality and safety approaches.5 6 A systems approach1 can arguably better characterise the system’s behaviour and inform improvement efforts. It has been posited that Systems Thinking can create a better understanding of the system story, allowing quality and safety improvement professionals to develop more meaningful and sustainable interventions.2 3
However, while the term ‘Systems Thinking’ is commonly employed in healthcare, its meaning is frequently misconstrued and a shared understanding of the underlying principles and methodologies seems lacking.4 7 8 McNab et al4 created a series of principles to help users apply systems thinking to their everyday work. These principles originated from a white paper for EUROCONTROL, which manages pan-European air traffic control.9 The principles were co-designed with front-line primary healthcare professionals and safety experts in the UK.4 The framework consists of six interlinking concepts that guide healthcare team discussions on characterising the system under investigation. This process facilitates the exploration of everyday work, individuals’ work dynamics, prevailing work conditions, factors impacting their work and adaptive strategies in response to those conditions to allow for the development of safe, high-quality care. These principles are presented in six cue cards, known as the Systems Thinking for Everyday Work (STEW) cards, and are detailed in table 1.
Systems Thinking for Everyday Work card principles
The cards incorporate concepts from General Systems Theory,10 Complex Systems Theory,11 Socio-technical Systems Theory12 and Resilience Engineering (RE).13 General Systems Theory, developed by Ludwig von Bertalanffy, proposes that systems can only be appropriately studied and understood by looking at them in their entirety, understanding the internal interactions between components and interactions between the system and the external environment. These interactions define the properties of the system, making them greater than the sum of its parts.10 The Complex Systems Theory was developed in the 1970s and 1980s to study systems that are far from equilibrium and unpredictable.14 This theory suggests that a complex system’s ongoing evolution and adaptation arise from its ever-changing environment and interactions, leading to emergent outcomes such as safety incidents and patient experiences that are greater than the sum of its individual components. Therefore, studying the performance of an individual component to improve a system’s performance (eg, the reliable delivery of a specific care process) will not produce predictable results, as seen in less complex linear systems, such as car manufacturing production lines. Healthcare also involves social and technical aspects. As a socio-technical system, it is vital to understand the interactions among people, tasks, technology, environments (physical and social), organisational structures and external factors.12 Socio-technical systems theory suggests that no system can be understood or improved without studying and understanding the interactions between work’s social and technical aspects.15 RE studies a system’s adaptability, aiming to enhance or maintain resiliency by analysing responses. It is particularly interested in comparing work-as-done with work-as-imagined.13 Acknowledging that these theories are complex, the STEW cards integrate these approaches into user-friendly conversation cues for front-line staff.
This study is the first to introduce STEW cue cards into the US healthcare environment. Developed for the National Health System in the UK, these cards were initially used to investigate why introducing a pharmacist into a primary care setting did not produce the expected results. Through a focus group and three consensus-building sessions, this study aims to detail how front-line staff in the US reviewed and adapted the cards for use.
Methods
Theoretical underpinnings
This study adopted a pragmatic perspective and employed a participatory co-design approach.16 When selecting a paradigm, the researcher considers their contributions to the process.17 The lead researcher was located within the healthcare system in which the study was conducted. It was felt that a pragmatic approach would allow the study to adjust as needed, given the experience and potential bias the researcher may bring. Additionally, this study took place during the COVID-19 pandemic, resulting in several adaptations throughout the research process. A participatory co-design approach was selected to ensure that those closest to the work provided a deep understanding of the need to adapt STEW cards to the US healthcare system.16 18
Setting
The study occurred in a not-for-profit, community-owned US healthcare system in Southwest Michigan, Corewell Health South (formerly Spectrum Health Lakeland). This health system comprises 3 regional hospitals, 49 ambulatory sites, over 500 primary and specialty providers and 4000 staff. Participant recruitment for the study included hospital advertising and quality improvement meetings held at inpatient and ambulatory healthcare sites. Eight volunteers who willingly participated were selected.
Focus group sessions
The focus group17 met four times from November 2021 to December 2021. The sessions varied in length from 30 to 90 min. Due to the COVID-19 pandemic, the sessions were a mix of in-person and Microsoft Teams meetings. All sessions were recorded using Microsoft Teams19 and Otter.ai.20 Transcription was conducted for all sessions, and all were led by the primary researcher (SEF). Concurrent notes were maintained on comments and recommendations, including annotations directly on the card printouts at all stages. Comments and suggestions were reviewed and consolidated to identify themes related to usability, language and clarity of each card’s principles. Comments were elicited by presenting and reviewing each card, and an example case study was used for reflection on how the cards might be applied. Thematic analysis was used for holistic theme development.21 22 After each session, the recordings and transcripts were reviewed to identify recurring themes. These themes prompted the revision of original principles and descriptors in preparation for subsequent sessions. The initial themes were reassessed and refined until a final set was developed.
Patient and public involvement
The cards were intended for staff; hence, patient and public involvement was not included.
Results
All participants were women (n=8) between the ages of 25 and 60 years, with work experience ranging from 5 to over 25 years. Half of the participants had extensive clinical care experience, the remaining half had operational backgrounds and the majority (7/8) had engaged in quality improvement facilitation. Table 2 provides the demographic details.
Focus group demographics
Education session
This phase began with an educational session, during which a presentation on systems thinking, detailed healthcare complexity and STEW cards was delivered. This session was conducted through Teams. All were present except for one participant who viewed the meeting recording before the start of the working sessions. Before starting, each participant received an electronic copy of the original cards, the original paper by McNab et al,4 a video on systems thinking, a glossary of terms and a presentation for review.
Session one
The first 1-hour session comprised a brief overview of systems thinking, a session agenda and a quality improvement example for card reflection. This session was conducted in person. Only one participant could not attend and sent feedback on the cards after watching the recorded introductory session. All the participants agreed that they understood the concept of systems thinking and the session’s objectives. The level of engagement in this session was high, with each participant expressing their ideas and opinions on the cards. Each card was examined for relevance, applicability, language and aesthetics (colour, style, visual cues and size). There is general agreement that healthcare needs a systems thinking approach to quality and safety. Table 3 highlights some comments for each card. Session analysis revealed usability, language and aesthetics as the most prevalent themes. The group often discussed the cards’ practical application in daily tasks, and usability was identified as the dominant theme.
Session one comment overview for each principle
Specific terms or words did not resonate due to their lack of familiarity in the US context. Particular graphics were also singled out as not user-friendly, and changes were recommended. Finally, it was often mentioned that the cards would not be easy for front-line staff to use as standalone conversation cues. During this session, the idea of employing two sets of cards was proposed due to the evolving nature of the concept and the potential use of tools unfamiliar to front-line workers. The first set would be for an experienced quality improvement (QI) facilitator. These cards should contain more details to guide the facilitator in using concepts and tools. The second set would be for the front-line staff, using questions to prompt a discussion of the principle. Another suggestion was to present the cards in a dual-sided format: a succinct principle introduction on one side and prompts with visual cues on the other. An introductory card was recommended to guide their use. Minor adjustments to the aesthetics of the cards (including colours) were also recommended.
Session two
Session two was held 1-week later. Ahead of each meeting, the researcher supplied an updated set of cards that integrated the modifications recommended during the prior session. Figure 1 shows examples of the two sets of cards. The session was conducted through Teams. Due to the COVID-19 pandemic, several group members came in and out of the meetings as their schedule allowed. The participants remained actively engaged, articulating their thoughts and viewpoints on the cards. Table 4 highlights some of the comments provided for each card. Analysis of the sessions revealed that usability, language and aesthetics were the most prevalent themes. Generally, the single-colour scheme was less user-friendly than the previous concept-specific colour scheme. The ‘Work Condition’ card also prompted discussions on its graphics and layout. The Systems Engineering Initiative for Patient Safety12 framework graphic was present on several cards as an example of a ‘system’. This diagram, used in ‘Your System and Interactions’ and the other cue cards, was unanimously rejected. It was felt that the framework was confusing to the users and should be removed. The facilitator and user cards were presented side by side, sparking many conversations on usability and elevating it as the next prominent theme. As the group reached a consensus, usability was extensively discussed, particularly concerning the ‘Interactions, Performance, and Understanding’ cards.
Example of viewpoints principle—STEW cards V.1.0. Facilitator and user cards.
Overview of session two comments for each principle
Throughout the sessions, consensus was reached through group discussions and approval. All participants agreed that changing the original language of the cards made them easier to understand and more functional. There was a general agreement that dividing the cards into two sets enhanced user-friendliness and facilitated the acceptance of a new concept. The group also concluded that further updates were required to help guide the facilitator using these cards. Using QR codes on each card to provide easy access to tools would make them even more straightforward. It was also suggested that questions instead of lengthy statements be employed to enhance the accessibility of the user cards to the audience.
Session three
Following session two, a concluding meeting was held to review the cards after implementing the suggested changes, aiming to reach a final consensus. A brief 30 min meeting was convened with the entire team, including all study participants. An updated version of the facilitator and user version of the STEW cards was again presented. Coding based on previous thematic analyses of aesthetics, language, principles and usability revealed a focus on language, resulting in minor changes in vocabulary. Overall, the cards were considered professional, and the consensus was that they were ready for use during the pilot phase of the study. Table 5 highlights some of the comments in this section. Online supplemental file A highlights the changes made to the cards during each session.
Supplemental material
Session three comments overview for each principle
Content validity survey
Validating any changes to a tool is crucial to ensure that these modifications maintain their accuracy in measuring or describing concepts.23 Content validity refers to the degree to which an instrument covers the material it is supposed to represent.24 A content validity survey measures the extent to which a new instrument performs.25 A content validity survey was undertaken to establish consensus regarding the purpose and utilisation of these cards. The survey asked focus group participants to rate the relevance, clarity, simplicity and ambiguity of each principle for both the facilitator and user cards on a scale of 1–4. The survey is available on request. Each participant received a final revised copy of the facilitator and user cards before completing the survey. For practical reasons, it was determined that a Content Validity Index (CVI) of 75% or higher would indicate that the card fulfilled its intended purpose. None of the participants rated any principle below three on the scale, achieving a CVI of one for all categories in each of the principles in both sets of cards.
Discussion
This study describes adapting and reshaping a set of previously developed STEW cards for use in a US healthcare system. The six STEW principles present a holistic approach to understanding and developing quality and safety interventions. The focus groups produced several findings. An evaluation of the principles and concepts conveyed in the cards highlighted that these would be novel and unfamiliar to front-line staff within the US healthcare system. Therefore, it was deemed necessary to tailor the cards with this consideration. This alignment echoes existing literature on systems thinking, human factors, ergonomics and RE in healthcare.26–28 In a comprehensive assessment, the group concluded that the optimal approach to introducing systems thinking to the front line required two sets of cards: one for facilitators and another for users. A review of the literature supports this approach as a majority of the application of the principles presented in the STEW cards have been carried out by researchers and those experienced in the concepts and techniques required and not front-line staff.29–34 Facilitation is recommended for other tools that seek a systemic approach.35 36 Facilitator cards were then designed for seasoned professionals who could be trained and coached in these concepts. Everyday, user cards were developed for front-line staff. The facilitator set contained detailed descriptions of the principles to help guide conversations, whereas the user cards provided questions to inspire thoughts on the concept.
Each card was reviewed to develop four significant themes regarding the card’s usability, aesthetics, language and clarity of principles. A robust discussion was held about using colours and graphics to help better convey ideas on the cards and to change some words and phrases to make them more approachable. Each principle is renamed using a single term to provide a more specific cue to the user. The Understanding principle produced a great deal of discussion, with concerns about how it might be interpreted by front-line staff. As identified in other research,37–39 this principle, which embraces a Just Culture approach, struggles with its application. The same reflections were observed on the Performance card. This card reflects the concepts of RE, particularly the concepts of work as done, regarding the study of an event and how work is done daily. RE is relatively new to healthcare, and its principles and concepts are expected to be unfamiliar, although the research base is growing.40–42 Throughout the discussions, the focus group consistently evaluated the cards’ usability, leading to conclusive suggestions such as producing smaller cards for users and larger ones for facilitators.
The last set of cards was sent for content validation, and the results were overwhelmingly favourable, with agreement on relevance, clarity, simplicity and lack of ambiguity. The fundamental changes to STEW principles are described in online supplemental box 2. This participatory co-designed approach ensured that the adaptation of cards was ‘grounded’ and relevant to developing quality and safety interventions in the healthcare system. This approach has been successfully used to develop other healthcare tools and interventions.35 43 44 The sessions provided an in-depth review of the tool and a more informed understanding of the context in which the cards were to be used, increasing the chance of success in the pilot phase.
Supplemental material
The original STEW cards were produced by adapting previously developed principles.9 Its purpose was to introduce the concept of systems thinking to a healthcare setting in the UK.4 Compared with the previous work conducted by McNab et al,4 this study used a group of improvement practitioners and clinical staff to examine STEW card functionality within the confines of the US healthcare system. This focus group provided valuable insights into how the cards would be used, ultimately creating two sets of cards. The resultant cards reflected their experiences, deep knowledge and understanding of their fields. Finally, the study met its objectives and the adapted cards are now ready for use in real-time scenarios in the US (online supplemental file B).
Supplemental material
Implications
The concept of systems thinking and its use in healthcare are fundamental to the mission of providing safe and high-quality care.28 45 46 Throughout this phase, the focus group paid particular attention to the usability of the STEW cards, reflecting on potential use cases to ensure that each principle was appropriately represented and the desired outcomes were listed. This novel approach to their work generated energy and excitement about the insights they could bring to front-line teams. STEW cards provide accessible systems thinking tool to help explore, investigate and learn not only from unintended outcomes but also how excellence is achieved in everyday circumstances.47 48 The cards can now promote a deeper understanding of the system under investigation, providing insight into the interactions and adaptations made by system components to ensure that things go right.41 These principles also promote examining the entire system rather than attempting to isolate elements to root out a single cause.37 Recognising that single causation is unlikely, using STEW cards promotes a Just Culture, which is also necessary for today’s healthcare, where burnout and disengagement of clinical staff are rampant.38 42 The cards also reflect excellent conversation cues to discuss how changes can impact the system, potentially as part of the plan, do, study, act cycle or standard QI tool.49
The successful implementation of these adapted STEW cards will support systems thinking in any healthcare system. It is hoped that this study and its next phase will prime the healthcare system to accept the use of systems thinking in developing quality and safety interventions.
Further development of the STEW cards and embracing their concepts and benefits will require education on complex systems, human factors and RE to help frame conversations. Embedding these concepts into healthcare systems’ quality and safety curriculum, professional health education and quality and safety certification programmes will require more than local acceptance. These concepts must also be taught at all leadership levels. This teaching will ensure that the value provided by this approach is understood and supported across the entire organisation. It will also be incumbent for state and national agencies to aid in the broader acceptance of systems thinking in healthcare. The Health and Human Services, Joint Commission and Center for Medicare and Medicaid Services (CMS) must integrate these approaches into their programme requirements. The CMS and Joint Commission have recently used this method for health equity and created new accreditation and performance requirements to acknowledge the importance of health equity in improving national health. This technique has had its intended effect, with local and national healthcare systems creating system-wide equity agendas to ensure they meet these requirements.50–52
Further validation is required as these cards have been adapted for use in a US healthcare system. This validation should determine the practicality and usability for which they have been designed and engage different groups within the healthcare system to understand their level of acceptance and the potential need to adapt them further. Testing should also determine the impact of cards on users, groups and even the system. The next phase should determine whether these cards impact the well-being of those using them (Just Culture) and whether they provide better learning opportunities for understanding the system under study. This phase should also explore whether the developed interventions improve patient quality and safety and lead to a better patient experience. The answers to these questions will be explored in future studies.
Strengths and limitations
There is a potential for selection bias in this study. Although the initial recruitment was advertised in various formats throughout the health system, most participants were QI leads and specialists. The participants also had potential strengths. These participants were engaged and motivated in this work and had years of experience. As a leader within this health system, there was also the potential for bias, although the level of participation and discussion was robust. The work occurred during the third wave of the COVID-19 pandemic, causing in-person sessions to be converted into team sessions and competing demands interfered with participation to some extent. One of the strengths of this study is the group’s focus on card accessibility. A potential limitation of the initial creation of the cards was that this group paid particular attention to how they would appear to the intended users. If further adaptation is required once this study is completed, it is recommended that other end users be engaged. Finally, multiple methods, including in-person sessions, team sessions, PowerPoint presentations and surveys, provided a well-designed study to conclude that the final cards were wholly adequate for the US healthcare system.
Conclusion
Healthcare is highly complex, and systems thinking is essential for exploring and improving the quality and safety of healthcare systems. Developing a shared understanding of how to use systems thinking in healthcare using straightforward, practical tools is a gap that must be filled. The cards’ original development and adaptation for use in the US healthcare system may help address this gap. These adaptations have addressed card accessibility, aesthetics, usability and practicality in front-line care teams. These cards provide easy-to-use guidance for developing a deeper understanding of the studied system, learning from these problems and everyday work on their journey to provide excellent care. Ultimately, these cards offer a practical ‘systems approach’ that can be used within today’s complex healthcare systems.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Queen’s University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board (TRAQ#: 6032925) and Spectrum Health Lakeland Research Ethics Board. Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @pbnes
Contributors PB is the corresponding author and guarantor of this work. SEF, PB and JM are credited with the study’s conception and design. SEF conducted the research. All authors edited and approved this version of the manuscript for publication.
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 not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.