We presented at earlier version of this paper at the INCOSE UK Meeting in November 2017 (see here). This was subsequently updated by ourselves and our co-authors into a 15 page paper and was presented at the INCOSE International Symposim (IS) in July 2018 in Washington DC.
We were proud to find out just ahead of the Symposium that the paper won a Best Paper on Biomed / Healthcare / Social Services award. Thanks to Holistem co-authors Alan Harding (BAE Systems), Gary Smith (Airbus) and Fran Beck (NHS) for their contributions. Special thanks to Fran for hosting the workshops, bringing together a great community of healthcare professionals, and providing an opportunity to apply systems engineering and systems thinking approaches within a healthcare context.
Holistem has facilitated during 2016-2017 a successful series of workshops applying systems thinking and systems engineering techniques to the healthcare domain. This facilitation was done with with other systems engineering colleagues from INCOSE UK. A summary of the approach and the outcomes of this engagement, presented at the INCOSE UK ASEC (Autumn Systems Engineering Conference) in November 2017, can be found here.
If you are interested in more information, please contact us.
This page summarises a successful engagement with over 20 healthcare organisations during the second half of 2016.
The engagement with this healthcare community was driven by a conviction that application of systems engineering and system thinking approaches could provide real insight into the challenges of achieving improvement in the ‘wicked’ problem area that is healthcare. During 2016, Holistem had the opportunity (with two other INCOSE colleagues) to work with a multi-disciplinary group of healthcare representatives from over 20 organisations to assist their journey of improving using a number of systems approaches. Organisations include many departments within the UK NHS, but also included other groups (social services, ambulance service, voluntary service…).
A reference that provides useful context to the engagement is the NHS Five Year Forward View  available here.
Workshop objectives and rationale
The workshops were aimed to get overy one across a range of organisations ‘on the same page’, to understand their role on ‘the bigger picture’, and potentially help break down ‘silo working’.
The use of the techniques generically served multiple purposes:
Supported dialogue across stakeholders and disciplines, enabling all stakeholders to see the wider perspective;
Ensured each contributor’s voice is heard, avoiding certain personalities being dominant;
Brought in valuable visualisations that stakeholders may not previously have been aware of, and that provided new insights into the improvement domain.
The techniques are complementary to others traditionally used in healthcare improvement:
Lean (elimination of waste in repetitive processes)
PDSA – Plan, Do, Study, Act – improvement cycles
…in particular bringing a systemic perspective.
Some techniques were applied before or after the workshops (causal loop modelling, concept modelling, topic clustering…), while others where applied within the workshops, as part of facilitation (round tables, prioritisation…). Where a technique was used prior to a workshop, the output of that technique (for instance a causal loop diagram, or systemigram) acted as focus for part of the discussion in a subsequent workshop. (The diagram below only shows the three online workshops. and does not show offline activities, before or after the workshops).
The healthcare workshops
The engagement used a sequence of workshops (see figure below), each making use of a number of techniques. Some techniques were used within the workshops, while other techniques were used offline of the workshops, before or after. The techniques themselves are described here.
The pre-workshop meeting agreed to focus on the topic are of healthcare supporting ‘frail and elderly’ patients, or more succinctly ‘frailty’. This enabled some initial preparation for Workshop 1, using Causal Loop Modelling and Concept Modelling (see Techniques for examples).
Workshop 1 primarily used a Round Table approach, to collect both Issues and Opportunities. These were subsequently organised, using Clustering and Thematic Analysis. In addition, an N-Squared approach was used to visualise inter-organisation interactions. (why? makes it easier to see systemic issues with inter-organisation interactions). Offline, the techniques thematic analysis and clustering were used to organise Issues and Opportunities. In preparation for workshop 2 concept modelling was used to draw up a structured view of all the organisations represented at the workshops – not ‘rocket science’ but useful to the subsequent attendees. Systemigrams diagrams and causal loop models were also produced, inspired by “Mrs Andrews Story”, an animation available here.
At workshop 2 the issues and opportunties from Workshop 1 were refined and validated. The workshop also made use of the Systemigrams diagrams and causal loop models to stimulate further input, and to ensure everone was ‘on the same page’. Power-workshop 2, issues and proposals for improvement were further analysed (~60 issues, ~100 proposals), to prepare for Workshop 3. Clustering into different categories helped to organise proposals into categories: Person focus, Organisation Integration, Information Sharing, Decision Making and Techn ology Exploitation.
Workshop 3 built on the outcomes from the previous workshops, by using a prioritisation approach, to focus on a subset of proposals, and to organise them into a proposal architecture: short term with substantial early benefits, medium term tackling more complicated topics, and longer term addressing complex topics.
The engagement achieved for the participants:
an understanding of the bigger cross-organisational picture;
concrete improvement proposals traceability back to the issues raised;
mutual benefit to both healthcare organisations (proposed improvements) and INCOSE (systems techniques applied in healthcare).
During the last year Holistem engaged in the UK, via INCOSE, the International Council on Systems Engineering (website), to apply systems approaches to organisational improvement in the healthcare domain. Applying systems approaches in healthcare is not a ‘new thing’ but there is certainly a growing momentum to apply such approaches and the value of such approaches is recognized both within and outside the NHS. The results of a joint activity between healthcare professional and the Royal Academy of Engineering is reported in the publication “Engineering Better Care”, available here; INCOSE was also involved.
Holistem’s engagement to apply systems approaches successfully with a number of healthcare organisations is being reported in a presentation and paper at this year’s INCOSE UK Annual Systems Engineering Conference (ASEC), details of the conference and programme available here. Our approach and outcomes are reported in Session 1.2. If you are interested in the topic, hopefully we’ll see you there – at the time of writing, registration is currently open.
To find out more about our approaches and success in any of these areas, contact us.
Success through Systems thinking in healthcare
Holistem has facilitated during 2016-2017, with other systems engineering colleagues from INCOSE, a successful series of workshops applying systems thinking and systems engineering techniques to the healthcare domain. Healthcare in the UK faces many challenges from multiple sources: changing demographics – people living longer with multiple long term conditions; increased sophistication and potential to diagnose and treat conditions; increased pressure on budgets; a healthcare ‘organisation’ (which is much much more than just the NHS) that has evolved from the the original vision in the 1940’s to a large, diverse, set of organisations that, at times, perhaps are not well-connected or coordinated. Techniques used have included: round tables, concept models, cluster topic mapping, causal loop models, N-squared tables, architecting. A summary of the challenges, approach and outcomes to date has been presented at the INCOSE Annual Systems Engineering Conference, ASEC 2017, in Warwick, UK, 21-22 November 2017, conference details here.
A more extensive explanation of this successful engagement is available here.
Avionics development process improvement
We worked with a major defense contractor aircraft project in systematically looking at how to identify issues with their avionics development process, and come up with traceable recommendations for improvement. Over a 6 month period, this project worked from senior management brief to scope the work, through to identification of stakeholders and the target community, to development of data collection techniques, and subsequently data analysis, and recommendation development. Data collection techniques involved a combination of online survey to community (~400 engineers and engineering managers), a representative set of structured interviews, and ‘data forensics’, collection of actual process meta-data (data about data). Root cause analysis techniques, such as the “five-why’s”, were used to get beyond symptoms to root causes. The outcomes of the project were a set of ~70 recommendations, structured into ~6 topic areas, fully traceable to the source data and briefings to both management and the engineering community. Roll-out of the recommendations is ongoing within the company.
Technical proposal development and management of low-TRL projects
We’ve extensive experience developing technical proposals and associated Statements of Work for internal, national level and international level agencies, and of technical management of such projects. We’ve focussed on primarily tackling low Technology Readiness Level (TRL) challenges. An example Technical Proposal led to the European Framework 4 and 5 SEDRES and SEDRES-2 projects (1996-2002), which themselves produced the work that formed the basis of the ISO 10303-233 systems engineering data exchange standard. The SEDRES/ISO 10303-233 team also subsequently contributed to and worked with the team that developed the OMG Systems Modelling standard, SysML (latest version of the standard available here).
Standards development and assessment
Our experience in standards work ranges from development of systems engineering data exchange standards, to involvement in process standards, to application of modelling to existing document-represented standards. We have operated at national and international level on various standards bodies (BSI, ISO SC4). Our Director led the team that developed ISO 10303-233, the part of the STEP standard that supports Systems Engineering data exchange, and subsequently involved in influencing the evolution of the OMG SySML standard. An example of application of modelling applied to existing standards involved modelling applied to Tactical Data Links (TDLs), in particular Link-16 (Mil Std 6016C, NATO STANAG 5516), where one Holistem employee co-authored multiple patents arising from the modelling work.
Domain modelling success
We’ve extensive experience in data and information modelling, and more recently partitioning of such models along ‘domain’ (subject matter) lines, also recognised as domain modelling. A success story was the modelling for the domains underlying the development of a tool to support ship complement design, which included Royal Navy personnel organisation, ship physical and functional, and mission and manning aspects. Such models provided the basis for tool implementation.
One of the best explanations of domain modelling we are aware of is in Model Driven Architecture with Executable UML, by Chris Raistrick et al (Amazon link here); don’t be put off by the reference to UML, nor criticisms in the Amazon reviews of iUML/xUML – domain modelling is not just a ‘software thingy’!
Techniques used to drive this success
The techniques we’ve used to achieve these successes are described here.