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Development and application of ‘systems thinking’ principles for quality improvement
  1. Duncan McNab1,2,
  2. John McKay1,
  3. Steven Shorrock3,4,
  4. Sarah Luty1,
  5. Paul Bowie1,2
  1. 1Medical Directorate, NHS Education for Scotland, Glasgow, UK
  2. 2Institute of Health and Wellbeing, University of Glasgow, United Kingdom
  3. 3EUROCONTROL, Brussels, Belgium
  4. 4University of the Sunshine Coast Sippy Downs Campus, Sippy Downs, Queensland, Australia
  1. Correspondence to Prof Paul Bowie; paul.bowie{at}


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.

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

Results 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.

  • quality improvement
  • human factors
  • complexity

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  • 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.

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