HEALTHCARE SYSTEM -

COMPLEX
INTERCONNECTED
NETWORK
Dr Sadaf Khalid
 LEARNING OBJECTIVES

1.Define and explain the concept and characteristics of a system.

2.Identify and describe the main components and functions of a health care delivery
system.
3.Analyze the relationships and interactions among the components and functions of
a health care delivery system.
4.Summarize the principles and methods of systems thinking and how they can be
applied to health care.
5.Recognize and classify the different stakeholders and partners involved in patient
safety programs.
6.Define and explain the concept and benefits of teamwork in health care.
7.Demonstrate effective communication and collaboration skills in health care teams.
CONCEPT OF A
SYSTEM
• System: any collection of two or
more interacting parts or “an
interdependent group of items
forming a unified whole
• A complex system is one in
which there are so many
interacting parts that it is
difficult to predict the behavior
of the system based on
knowledge of its component
parts
WHY HEALTH
CARE
DELIVERY IS
COMPLEX
SYSTEM
• the diversity of tasks involved in the delivery of patient
care
• the dependency of health-care providers on one another
• the diversity of patients, clinicians and other staff
• relationships between patients, carers, health-care
providers, support staff, administrators, family and
community members
• the vulnerability of patients
• variations in the physical layout of clinical environments
• variability or lack of regulations
• implementation of new technology
• the diversity of care pathways and organizations involved
• increased specialization of health-care professionals–while
specialization allows a wider range of patient treatments
and services, it also provides more opportunity for things
to go wrong and errors to be made
CHARACTERISTICS OF A HEALTH-CARE
DELIVERY SYSTEM FOR PATIENT
SAFETY
• Complexity and • Continuous quality
interconnectedness improvements
• Patient centered approach • Interprofessional
• Evidence based practice collaboration

• Safety culture • Patient education and

engagement
• Risk reduction strategies
• Regulatory compliance
• Health information
technology
COMPONENTS OF HEALTH CARE DELIVERY
SYSTEM

• Medical Facilities
• Healthcare Professionals
• Health Information Systems
• Regulatory Bodies
• Health Insurance Providers
 FUNCTIONS OF A HEALTHCARE DELIVERY
SYSTEM

• Diagnosis and Treatment

• Preventive Services
• Emergency Care
• Health Promotion
• Coordination of Care
• Patient Safety Measures
RELATIONSHIPS AND INTERACTIONS AMONG
THE COMPONENTS AND FUNCTIONS OF A
HEALTH CARE DELIVERY SYSTEM.
• Provider-Patient Interaction: The core of the system, where
healthcare professionals diagnose, treat, and communicate
with patients.
• Provider-Provider Collaboration: Healthcare providers work
together, referring patients, sharing information, and
coordinating care.
• Facility-Provider Interaction: Facilities host providers and
provide necessary resources.
• Insurance-Provider Relationship: Insurance companies
reimburse providers for services rendered.
• Government-Provider Interaction: Government
agencies regulate providers, fund programs, and set
policies.
• Patient-Insurance Connection: Patients rely on
insurance coverage for access to care.
• Patient-Government Interaction: Government
initiatives impact public health and healthcare
access.
 PRINCIPLES AND METHODS OF
SYSTEMS THINKING AND HOW THEY
CAN BE APPLIED TO HEALTH CARE.
• A systems approach is to look at health care as a
whole system, with all its complexity and
interdependence, shifting the focus from the
individual to the organization.
• It forces to move away from a blame culture toward a
systems approach.
• a systems approach enables:
• to examine organizational factors that underpin dysfunctional
health care and accidents/errors (poor processes, poor designs,
poor teamwork, financial restraints and institutional factors)
• rather than focus on the people who are associated with or
blamed for these events.

• The traditional approach when things go

wrong–blame and shame
Traditional approach after incident or adverse event
• blame the health-care worker most directly involved in caring for the
patient at the time–often a student or other junior staff member
• Most health-care workers involved in an adverse event are very upset
(“second victim” in such circumstances)
• will be hesitant to report incidents if they believe that they will then be
blamed for anything untoward that may have happened.
• If such a culture of blame is allowed to persist, a health-care
organization will have great difficulty in decreasing the chance of
adverse incidents of a similar nature occurring in the future
 ELEMENTS OF THE SYSTEM THAT SHOULD BE
CONSIDERED AS PART OF A “SYSTEMS-
THINKING

• Patient and provider factors

• Task factors
• Technology and tool factors
• Team factors
• Environmental factors
• Organizational factors
of 272

• Swiss cheese model looking at the multifactorial nature of

any patient safety incident
• active failure errors made of workers that have
immediate adverse effect
• Latent conditions are usually poor decision making,
poor design and poor protocols
• Swiss cheese models explain how fault in different layers
of systems leads to adverse event
LAYERS OF DEFENSE
DIFFERENT STAKEHOLDERS
AND PARTNERS INVOLVED IN
PATIENT SAFETY PROGRAMS.
• Patient and Families • Regulatory agencies and
• Healthcare Providers accreditation bodies

• Healthcare administrator • Health information

and managers Technology developers

• Patient safety officer (PSOs) • Researchers and Academia

• Quality improvement team • Patient safety advocacy
groups
 CONCEPT AND BENEFITS OF
TEAMWORK IN HEALTH CARE.
• A team is a group of individuals who collaborate, each
with specific roles, to achieve shared goals or objectives.
• a distinguishable set of two or more people who interact
dynamically, interdependently and adaptively towards a
common and valued goal/objective/mission, who have
been each assigned specific roles or functions to perform
and who have a limited lifespan of membership
• Core teams consist of team leaders and members who are directly
involved in caring for the patient. Core team members include
direct care providers such as nurses, pharmacists, doctors,
dentists, assistants and, of course, the patient or their carer.
• The coordinating team is the group responsible for day-to-day
operational management, coordination functions and resource
management for core teams.
• Contingency teams are formed for emergent or specific events
(e.g. cardiac arrest teams, disaster response teams, obstetric
emergency teams, rapid response teams)
• Ancillary service teams consist of individuals such as
cleaners or domestic staff who provide direct, task-
specific, time-limited care to patients or support
services that facilitate patient care
• Administration includes the executive leadership of a
unit or facility and has 24-hour accountability for the
overall function and management of the organization.
 CHARACTERISTICS OF EFFECTIVE TEAM

• Common purpose skills)

• Measurable goals’ • task motivation
• Effective leadership • flexibility
• Effective communication • the ability to monitor their own
• Good cohesion performance
• effective resolution of and learning from
• Mutual respect
conflict
• individual task proficiency (both in terms
of personal technical skills and teamwork • engagement in situation monitoring.
EFFECTIVE COMMUNICATION
AND COLLABORATION SKILLS
IN HEALTH CARE TEAMS.
• Good communication skills is the core of patiet safety
and effective teamwork.
• The following strategies/tools can assist team members
in accurately sharing information and ensuring that the
focus is on the information being communicated:
• ISBAR
• Call out
• Check back
• Hand over or handoff
 CALL-OUT
• Call-out is a strategy to
communicate important
or critical information to
inform all team
members
simultaneously during
emergent situations
 CHECK BACK
• Sender Initiates Message: The sender conveys information or a message to the
recipient.
• Recipient Accepts Message and Provides Feedback: The recipient acknowledges the
message and provides feedback to confirm understanding. This step ensures that the
recipient has correctly received the information.
• Sender Double-Checks: The sender follows up to verify that the message has been
understood accurately. If there are any doubts or misinterpretations, the sender can
clarify or rephrase the message.
 HAND-OVER OR HAND-OFF

• Hand-over or hand-off is a crucial time for the

accurate exchange of information.
• Errors in communication can result in patients not
being treated correctly and they may suffer an
adverse outcome.
• “I pass the baton” is a strategy to assist timely and
accurate hand-offs.
 RISOLVING
DISAGREEMENT AND
CONFLICT
• Crucial to successful teamwork
• Challenging for junior team member
• Important that all members of the team to feel that
they can comment
• Following protocols can be used:
• Creating psychological safe environment
• Two challenge rule
• CUS
• The DESC script
 PSYCHOLOGICALLY SAFE
WORK ENVIRONMENT
employees feel that their colleagues will not reject
people for being themselves or saying what they
think, respect each other's competence, are
interested in each other as people, have positive
intentions to one another, are able engage in
constructive conflict or confrontation,
 THE TWO-CHALLENGE
RULE

• is a valuable safety practice in healthcare which empowers team members to

address safety breaches effectively.
• Steps:
• Initial Assertion: When a team member senses a safety concern, they express it
as a question or statement
• First Challenge: If the initial assertion is ignored, the team member restates
their concerned
• Acknowledgment: The team member being challenged must acknowledge the
concerns
 THE TWO-CHALLENGE RULE- EXAMPLE

Initial Assertion Nurse: “I am worried about Mrs.

Jones in bed 23. She looks unwell, and her symptoms
differ from her usual presentation. Can you assess
her?”
First Challenge: “I am really worried about Mrs.
Jones. Her symptoms are concerning. I believe she
needs immediate attention.”
 CUS
CUS is shorthand for a three-step process for assisting
people in stopping a problematic activity
 THE DESC SCRIPT
• Describe the Situation: Begin by objectively describing the specific
situation or behavior that is causing the conflict. Stick to the facts and
avoid personal judgments.
• Evidence or Data: Provide concrete evidence or data related to the
issue.
• Express Your Feelings: Share how the situation makes you feel. Be
honest but respectful. Use “I” statements to avoid sounding accusatory.
• State Concerns: Clearly express your concerns about the impact of
the conflict. Consider team dynamics, patient safety, or any other
relevant factors.
 THE DESC SCRIPT

• Alternative Solutions: Suggest alternative approaches or solutions.

Encourage brainstorming and collaboration to find a resolution.
• Seek Agreement: Engage in open dialogue with the other party. Seek
their input and try to find common ground. The goal is consensus.
• Consequences: Discuss the potential consequences of not resolving
the conflict. Frame these consequences in terms of their effect on
established team goals or patient safety.
EXERCISE
 CASE SCENARIO-1
PATIENTS INJECTED WITH WRONG SOLUTION

Jacqui had an exploratory procedure called an endoscopic

retrograde cholangio pancreatography (ERCP) at a large teaching
hospital for a suspected disorder of her gall bladder. Under general
anesthetic, an endoscope was inserted into her mouth and guided
through the esophagus to the duodenum. Cannulas were inserted
through the endoscope into the common bile duct and a contrast
medium injected so an X-ray could be taken.
 CASE SCENARIO 1- CONTINUED

Two months later, Jacqui was told that she was one of 28 patients who had been
injected with contrast medium containing a corrosive substance, phenol. The
pharmacy department normally ordered 20 ml vials of Conray 280. However, for
a period of approximately five months they incorrectly ordered and supplied to
theatre 5 ml vials of 60% Conray 280 with 10% phenol with the label clearly
stating, “use under strict supervision–caustic substance” and “single dose vial”.
A nurse finally picked up the mistake, which had been missed by the pharmacy
department and many teams of theatre staff.
 CASE SCENARIO 2

• An underweight, young, non-English-speaking refugee who also

had a low haemoglobin count was booked for midwifery-led care.
Her husband, who had very poor English himself, acted as
interpreter. She was admitted to the hospital late in pregnancy with
bleeding and abdominal pain. Constipation was diagnosed,
despite abnormal liver function tests, and she was sent home under
midwifery-led care.
 CASE SCENARIO 2- CONTINUE

• She was readmitted some weeks later, late in pregnancy with abdominal pain
and, despite a further abnormal blood assay, no senior medical opinion was
sought and she was again discharged. Some days later, she was admitted in
extremis, with liver and multi-organ failure, her unborn baby having died in
the meantime. Despite the severity of her condition, her care was still
uncoordinated and, although she was visited by a critical care senior house
officer, she remained in the delivery suite. The woman died two days later of
disseminated intravascular coagulation related to fatty liver of pregnancy
Using a systems approach, describe
the factors that may be associated with
this catastrophic outcome and how
similar adverse events might be
prevented in the future.
 CASE SCENARIO-3
An oral surgeon was performing a surgical removal of lower third molar, which was
completely impacted. None of the third molars (on either side) were visible. According to
the clinical record, the right third molar was to be extracted. However, the X-ray on the
view box appeared to show that it was the right third lower molar that was impacted and
that the left third lower molar was absent. The oral surgeon made the incision, raised the
flap and started the osteotomy. The impacted molar did not appear, so the surgeon
enlarged the osteotomy. The surgeon finally realized that the right third molar was not
there and that he had made a mistake when he had reviewed the clinical notes earlier and
planned the operation. Furthermore, the dental assistant had displayed the X-ray in the
wrong position, reversing the left and right sides of the mouth.
• What factors may have existed that caused
the surgeon to select the wrong tooth?
• What may have caused the assistant to put
the X-ray in the wrong position?