1. Complex clinical systems
Factor influencing clinical errors:
• Patient factors
o Condition (complexity, seriousness, agitation)
o Language or communication
o Personality and social issues
• Task Factors
o Availability of guidelines, pathways or protocols
o Availability of test results
o Accuracy of test results
• Provider factors
o Knowledge, skills and competence
o Fatigue
o Motivation and attitude
o Physical and mental health
o Failure to follow established guideline, pathway or protocol
• Team factors
o Verbal or written communication during hand-over
o Communication during care
o Communication during crisis
o Supervision and seeking help or assistance
o Team structure and leadership
• Ward Unit environment
o Staffing levels
o Skills and experience mix
o Workload
o Availability and maintenance of equipment
o Administrative and managerial support
o Physical environment (e.g., space, noise, cleanliness, temperature)
• Institutional environment
o Financial resources
o Time pressures
o Culture
o Policies
o Governance
• Health System environment
o Funding arrangement
o Competition
o Regulation
o Professional self-regulation
o Education
o Media
A ‘system” is “An organised or connected group of objects” and “A set or assemblage of
things connected, associated, or interdependent, so as to form a complex unity; a
whole composed of parts in orderly arrangement according to some scheme or plan”
A system that interacts with its environment is called an ‘open system’, while one that
does not is called a ‘closed system’.
Complex systems have additional features that drive their complexity:
• Emergence – the behaviour of the systems emerges from the interaction of the
patterns of relationship between the parts. Rather than looking at a system’s
configuration at a point in time (a “snap-shot”) we need to look at it as a continuous
process (more like a “movie”).
• Non-linear relationships – cause and effect relationships are not simple and linear.
A stimulus may be amplified or have no effect at all. Interventions in the system often
lead to unintended consequences.
, • Short-range relationships – the parts of the systems are richly connected to near
neighbours.
• Rich feedback loops – negative and positive feedback loops govern the
interrelationship between the parts. The relationship between parts is as, or more,
important than the characteristics of the parts.
• Open boundaries – the boundaries of complex systems may be hard to define
resulting in high levels of interaction with the environment.
• Nesting – complex systems tend to be composed of adaptive sub-systems – referred
to as ‘agents’ – that are nested within the system (for example, the thyroid system is
nested within the endocrine system).
Some suggestions to assist decision-making in the complex clinical situations:
• Use intuition and muddle through—Doctors frequently make what would be the
best but not definitively the “right” decision on the basis of experience, evidence, and
knowledge of the patient's story
• Experiment—Try different management options with patients, using an empirical trial
of treatment or a plan-do-study-act cycle (See Module 10 for further information on this
cycle.)
• Minimum specification—Offer patients general goals, suggestions, and examples
but do not attempt to work everything out for them—your tidy solution is unlikely to be
compatible with all aspects of their lifestyle and values
• Chunking—Instead of trying to sort out every problem, try solving one or two (using
problem solving techniques, for instance); other solutions may follow naturally once a
new pattern has emerged
• Use metaphors—Communication can be difficult when issues are complex. Using
metaphors can often create a shared understanding—for example, “you seem like a
tree bowed over by the wind” or “what does that last hypo remind you of?”
• Provocative questions—Ask questions that might throw light on basic assumptions,
especially when the patient is “stuck”—for example, “if you got better, might this cause
some problems for you?”
2. Coordinating clinical tasks
Division of labour reduces the scope of a job and hence improves productivity by allowing
specialisation. Rather than one person having to know everything about the complete set of
tasks needed to treat a patient, each person can concentrate on, and learn in detail, each
component task. The greater the division of labour, the more staff involved in delivering care
for one patient, the more coordination is required. The greater the level of interdependence
between people doing tasks, the greater the need for coordination.
There are two broad strategies for coordinating care:
Programming – where the need to exchange information is reduced by planning and
implementing ahead of time the design of tasks and the roles people will perform.
1. Standardisation of tasks: In this case work processes are standardized using guidelines
and protcols
2. Standardisation of skills: In this form of coordination the skills and knowledge required to
perform a task, or set of tasks, is determined ahead of time and staff are trained in them in a
standardised way. The medical education you are undergoing is preparing you in a
standardised way to become a doctor – a hospital intern in the first instance.
3. Standardisation of output: In this mechanism the output from work performed is pre-
determined. An example of this is the unit-dose pharmacy system (prepackaged medication
from pharmacy).
, Feedback – where the exchange of information takes place, usually in real time, directly
between interdependent staff.
1. Supervision: where the exchange of information involves staff in a hierarchical
relationship to each other.
2. Mutual adjustment: where the exchange of information takes place between staff who are
not in a hierarchical relationship. When one nurse asks another on the ward how or when to
do something, they are using this mechanism.
3. Group Coordination: where staff exchange information in a group setting. A particular
instance is ward rounds every morning
Feedback strategies, while rich and adaptable are limited by the time available. There is only
so much time that can be spent in a meeting or in discussion with colleagues.
Programming strategies on the other hand are very efficient, if less flexible, although carefully
designed ones can be very sophisticated. The more information that can be exchanged
through programming strategies the higher the complexity and difficulty of issue that can be
dealt with by feedback.
Barriers to seamless coordination
1. Overstressed primary care: increased panel of patient load with insufficient time
2. Dysfunctional financing: pay for service but not for after discharge care
3. Lack of interoperable computerized records: only 25% have interoperable
records, documentation is lost in this way.
4. Lack of integrated systems of care: many private physicians work in practices of 1
or 2 and this leads to care fragmentation
Models for improved hare coordination
1. Coordination between primary care and specialty care:
a. Electronic referral: this may allow for specialists to give advice without
seeing the patient
b. Referral agreements: outline which clinical conditions best managed within
primary care and which are best referred.
2. Care after hospital discharge
a. Hospitalist initiated projects: improve transition care after discharge with
discharge plans geared to the patient’s language and literacy level.
b. Advanced practiced nursing: More specialised nurses to alleviate the
crunch of medical workforce
c. Care transition program: advanced practice nurses are trained as coaches
to assist in self care skills
3. Assisting primary care practices
a. “Teamlet model”: additional nonphysician member who can help with the
coordination of care.
b. Paying for care coordination: paying for the care coordination and for
someone to be willing to do it.
Module 3 – Clinical Guidelines and integrated care
5 different types of guidelines:
• Best Practice guidelines: systematically developed statements to assist practitioner
and consumer decisions about appropriate health or disability care for specific
circumstances
• Protocol: specific guidelines which are expected to be followed in detail with little
scope for variation due to HIGH RISK areas
• Consensus based guideline: most common form of guideline developed is
agreement among a group of experts
• Evidence based guideline: Developed after the systematic retrieval and appraisal of
information from the literature
Factor influencing clinical errors:
• Patient factors
o Condition (complexity, seriousness, agitation)
o Language or communication
o Personality and social issues
• Task Factors
o Availability of guidelines, pathways or protocols
o Availability of test results
o Accuracy of test results
• Provider factors
o Knowledge, skills and competence
o Fatigue
o Motivation and attitude
o Physical and mental health
o Failure to follow established guideline, pathway or protocol
• Team factors
o Verbal or written communication during hand-over
o Communication during care
o Communication during crisis
o Supervision and seeking help or assistance
o Team structure and leadership
• Ward Unit environment
o Staffing levels
o Skills and experience mix
o Workload
o Availability and maintenance of equipment
o Administrative and managerial support
o Physical environment (e.g., space, noise, cleanliness, temperature)
• Institutional environment
o Financial resources
o Time pressures
o Culture
o Policies
o Governance
• Health System environment
o Funding arrangement
o Competition
o Regulation
o Professional self-regulation
o Education
o Media
A ‘system” is “An organised or connected group of objects” and “A set or assemblage of
things connected, associated, or interdependent, so as to form a complex unity; a
whole composed of parts in orderly arrangement according to some scheme or plan”
A system that interacts with its environment is called an ‘open system’, while one that
does not is called a ‘closed system’.
Complex systems have additional features that drive their complexity:
• Emergence – the behaviour of the systems emerges from the interaction of the
patterns of relationship between the parts. Rather than looking at a system’s
configuration at a point in time (a “snap-shot”) we need to look at it as a continuous
process (more like a “movie”).
• Non-linear relationships – cause and effect relationships are not simple and linear.
A stimulus may be amplified or have no effect at all. Interventions in the system often
lead to unintended consequences.
, • Short-range relationships – the parts of the systems are richly connected to near
neighbours.
• Rich feedback loops – negative and positive feedback loops govern the
interrelationship between the parts. The relationship between parts is as, or more,
important than the characteristics of the parts.
• Open boundaries – the boundaries of complex systems may be hard to define
resulting in high levels of interaction with the environment.
• Nesting – complex systems tend to be composed of adaptive sub-systems – referred
to as ‘agents’ – that are nested within the system (for example, the thyroid system is
nested within the endocrine system).
Some suggestions to assist decision-making in the complex clinical situations:
• Use intuition and muddle through—Doctors frequently make what would be the
best but not definitively the “right” decision on the basis of experience, evidence, and
knowledge of the patient's story
• Experiment—Try different management options with patients, using an empirical trial
of treatment or a plan-do-study-act cycle (See Module 10 for further information on this
cycle.)
• Minimum specification—Offer patients general goals, suggestions, and examples
but do not attempt to work everything out for them—your tidy solution is unlikely to be
compatible with all aspects of their lifestyle and values
• Chunking—Instead of trying to sort out every problem, try solving one or two (using
problem solving techniques, for instance); other solutions may follow naturally once a
new pattern has emerged
• Use metaphors—Communication can be difficult when issues are complex. Using
metaphors can often create a shared understanding—for example, “you seem like a
tree bowed over by the wind” or “what does that last hypo remind you of?”
• Provocative questions—Ask questions that might throw light on basic assumptions,
especially when the patient is “stuck”—for example, “if you got better, might this cause
some problems for you?”
2. Coordinating clinical tasks
Division of labour reduces the scope of a job and hence improves productivity by allowing
specialisation. Rather than one person having to know everything about the complete set of
tasks needed to treat a patient, each person can concentrate on, and learn in detail, each
component task. The greater the division of labour, the more staff involved in delivering care
for one patient, the more coordination is required. The greater the level of interdependence
between people doing tasks, the greater the need for coordination.
There are two broad strategies for coordinating care:
Programming – where the need to exchange information is reduced by planning and
implementing ahead of time the design of tasks and the roles people will perform.
1. Standardisation of tasks: In this case work processes are standardized using guidelines
and protcols
2. Standardisation of skills: In this form of coordination the skills and knowledge required to
perform a task, or set of tasks, is determined ahead of time and staff are trained in them in a
standardised way. The medical education you are undergoing is preparing you in a
standardised way to become a doctor – a hospital intern in the first instance.
3. Standardisation of output: In this mechanism the output from work performed is pre-
determined. An example of this is the unit-dose pharmacy system (prepackaged medication
from pharmacy).
, Feedback – where the exchange of information takes place, usually in real time, directly
between interdependent staff.
1. Supervision: where the exchange of information involves staff in a hierarchical
relationship to each other.
2. Mutual adjustment: where the exchange of information takes place between staff who are
not in a hierarchical relationship. When one nurse asks another on the ward how or when to
do something, they are using this mechanism.
3. Group Coordination: where staff exchange information in a group setting. A particular
instance is ward rounds every morning
Feedback strategies, while rich and adaptable are limited by the time available. There is only
so much time that can be spent in a meeting or in discussion with colleagues.
Programming strategies on the other hand are very efficient, if less flexible, although carefully
designed ones can be very sophisticated. The more information that can be exchanged
through programming strategies the higher the complexity and difficulty of issue that can be
dealt with by feedback.
Barriers to seamless coordination
1. Overstressed primary care: increased panel of patient load with insufficient time
2. Dysfunctional financing: pay for service but not for after discharge care
3. Lack of interoperable computerized records: only 25% have interoperable
records, documentation is lost in this way.
4. Lack of integrated systems of care: many private physicians work in practices of 1
or 2 and this leads to care fragmentation
Models for improved hare coordination
1. Coordination between primary care and specialty care:
a. Electronic referral: this may allow for specialists to give advice without
seeing the patient
b. Referral agreements: outline which clinical conditions best managed within
primary care and which are best referred.
2. Care after hospital discharge
a. Hospitalist initiated projects: improve transition care after discharge with
discharge plans geared to the patient’s language and literacy level.
b. Advanced practiced nursing: More specialised nurses to alleviate the
crunch of medical workforce
c. Care transition program: advanced practice nurses are trained as coaches
to assist in self care skills
3. Assisting primary care practices
a. “Teamlet model”: additional nonphysician member who can help with the
coordination of care.
b. Paying for care coordination: paying for the care coordination and for
someone to be willing to do it.
Module 3 – Clinical Guidelines and integrated care
5 different types of guidelines:
• Best Practice guidelines: systematically developed statements to assist practitioner
and consumer decisions about appropriate health or disability care for specific
circumstances
• Protocol: specific guidelines which are expected to be followed in detail with little
scope for variation due to HIGH RISK areas
• Consensus based guideline: most common form of guideline developed is
agreement among a group of experts
• Evidence based guideline: Developed after the systematic retrieval and appraisal of
information from the literature
