Systems thinking — improving quality and patient safety

Jennifer Hamlin
Tuesday, March 2, 2021



The concept of being good at what we do might seem like an obvious outcome for our profession, after all, we are here to do the best for our patients, but is it inherent that our intentions ensure that we are doing a good job? Not necessarily. Consider the well-known example of airline pilots — is their belief that they want to keep passengers safe going to prevent a crash from occurring? No. Airline travel is safe because of the standardised systems and processes that are embedded in integrated systems frameworks.

In clinical practice, ensuring patient safety is directly related to quality and clinical effectiveness, ‘…doing the right thing, in the right way, for the right patient, at the right time’ (Royal College of Nursing). The World Health Organization defines patient safety as ‘the prevention of errors and adverse effects to patients associated with health care.’ Ensuring quality and patient safety in veterinary practice is more than checklists, audits, and evidence-based practice, it requires systems thinking.

Systems thinking is a three-dimensional mindset that expands understanding of problems in the context of a wider system. It helps us to change our mindset to match the dynamic interconnected complexity of the communities and environments we live and work in. It establishes processes for communication with collaborators and assists with developing shared understanding. It also helps us to initiate behavioural change to address complex problems, anticipating a wide variety of possible outcomes, expanding our choices, and leveraging them toward a common goal. A systems thinking approach can help us to overcome barriers to success even before they become a problem. We are already familiar with concepts of evidence-based practice and clinical audits, but what happens when we hit barriers that limit our ability to utilise those practices in our workplace? Processes like evidence-based practice need to be integrated into a system-wide framework that is designed to support and integrate transparent and reflective quality improvement processes. Clinical governance is an example of a systems framework, and a well-implemented clinical governance framework should ensure a comprehensive and integrated approach to evaluate safety and quality for every patient.

Clinical governance should represent the comprehensive application of systems thinking to interconnect clinical practitioners, management, and consumers who work together to ensure clinical effectiveness, quality improvement, patient safety, engaged workforces, multidisciplinary collaboration, consumer co-design, and shared decision-making. All parts of the puzzle are necessary to ensure quality governance of clinical care. No single aspect can run in isolation. Achieving effective implementation of a systems framework requires a circular approach to problem solving, breaking down silos of isolation, bringing people together, and developing processes to support new ideas and relationships.

The tools of systems thinking require cognitive and metacognitive attributes including a growth mindset, as well as skills in clinical reasoning, reflective practice, and developing followership toward a culture of continuous improvement. It also requires system-wide organisational support that facilitates integration of reflective practice, quality improvement, and measurement and transparency of clinical outcomes.

Veterinary nurses are often the drivers of change in a veterinary clinic and often contribute to clinical governance frameworks. Developing skills and attributes of systems thinking is a powerful tool that veterinary nurses can use to help facilitate improvements across a team or organisation.

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