Introduction to Systems PDF

Introduction to Systems and Systems Thinking- a prelude to Health Systems Maria Susan T Yanga-Mabunga,DDM,MSD,FDPH La Salle College of Dentistry September 10 ,2024 Lessons from the Covid Pandemic...

Introduction to Systems and Systems Thinking- a prelude to Health Systems Maria Susan T Yanga-Mabunga,DDM,MSD,FDPH La Salle College of Dentistry September 10 ,2024 Lessons from the Covid Pandemic There are multiple complex and interacting systems that affect our health, including our physical bodies, behaviors, workplaces, schools, faith institutions, environment, regulations, policies, socioeconomic conditions, and culture. Need for systems thinking to understand the complexities of the health system and the environment To design and run an effective health system, it is critical to understand the features and characteristics of each system as well as how they interact and fit together. A systems approach begins with understanding the characteristics of complex systems, which often involve multiple stakeholders, multiple perspectives, and multiple objectives and incentives. Balancing conflicts in complex systems like HPE( health professional educatio requires consideration of different perspectives and making trade-offs. Definition of a system a system is a complex whole the functioning of which depends on its parts and the interactions between those parts. The Health System (WHO) The Health System Dynamics Framework: The introduction of an analytical model for health system analysis and its application to two case-studies | Olmen | Health, Culture and Society [WWW Document], n.d. URL https://hcs.pitt.edu/ojs/index.php/hcs/article/view/71/0 (accessed 8.5.24). (Aristotle n.d., 350 bce, VIII: line 1) In the case of all things which have several parts and in which the totality is not, as it were, a mere heap, but the whole is something beside the parts … Session Objectives By the end of this session , the students should be able to discuss a. what are systems and its nature b. Its implication in health care management (dental public health ) What are systems? Definition of a system a system is a complex whole the functioning of which depends on its parts and the interactions between those parts. Verhoeff et al., Theoretical Nature of Systems Thinking (2018)  General Systems Theory Ludwig von Bertalanffy ( Biologist) Argued that organisms should be studied as complex wholes Published an article on the distinction of open and close systems Systems idea developed and influenced four broad disciplinary areas: General Systems Philosophy Theory: Physical sciences Life sciences Transdisciplinary study of systems - Social sciences across many domains An open system, such as an organism, has to interact with its environment to maintain itself in existence An open system, such as an organism, has to interact with its environment to maintain itself in existence. Source: Jackson , M., Systems Thinking: Creative Holism for Managers Source:Draper L. Kauffman, Jr. SystemsOne: An Introduction to SystemsThinking, THE FUTURE SYSTEMS SERIES Systems Approach to Management The systems approach implies that decisions and actions in one organizational area will affect other Foundation of areas. Organizational Development For example, if the purchasing department does not acquire the right quantity and quality of inputs, the production department wont be able to do its job. This approach recognizes that an organization relies on the environment for essential inputs. Further, the environment serves an outlet for its outputs.  Examples 1. 3. 2. Reengineering of the DOH and the abolition of the Bureau of Dental Health and its integration with the maternal and child clusters https://study.com/academy/lesson/systems-thinking-in-management-definition-theory- model.html While we talk about open systems …there are also close systems There are closed system of interactions that occurs in living entities. Maturana and Varela (1980). Definition of close system Kramer and De Smith (1977) define a closed system as a system that has no interaction at all with its environment. A system may also be considered “close” if the relationship that exit between the system and its environment are disregarded for the sake of simplicity in their analysis. Autopoietic Systems THIS DOES NOT MEAN THAT AUTOPOIETIC SYSTEMS AN AUTOPOIETIC SYSTEM IS CANNOT CHANGE THEIR A NETWORK OF INTER- STRUCTURE, BUT IT DOES RELATED COMPONENT- MEAN THAT THEY DO THIS PRODUCING PROCESSES ONLY WITH A VIEW TO THAT GENERATE THE SAME KEEPING THEIR NETWORK THAT PRODUCED FUNDAMENTAL THEM. ORGANIZATIONAL IDENTITY INTACT. The closed system model was universally adopted in management theory development during the early 20th century One possible explanation for the existence of organizations that continuously remain in a steady state condition is that they reside in a relatively static environment (e.g. some not-for-profit organizations). When the environment is relatively static, stable, and predictable, interactions and relationships between the organisation and its environment are trivial and, thus, can be ignored or otherwise managed (Robbins, 1990). The main objective of a bureaucracy is to promote efficiency and control in systems through the following a fixed division of labour; a hierarchy of offices; a set of general rules that govern performance; a separation of personal from official property and rights; selection of personnel on the basis of technical qualifications; and employment viewed as a career by participants However, the environment has changed dramatically over the past century and the direction of change is toward an increase in both complexity and dynamism (Neumann, 1997; Robbins, 1990) B. CYBERNETICS Verhoeff et al., Theoretical Nature of Systems Thinking (2018) B. Cybernetics Cybernetics: the science of control and communication in the animal and the machine In understanding control, the idea of negative feedback is crucial. Concept of purposive behavior It was Wiener’s insight that all such behavior requires negative feedback In this process, information is transmitted about any divergence of behavior from a present goal and corrective action taken, on the basis of this information, to bring the behaviour back towards the goal. Positive Feedback Although it did not impinge much on the consciousness of Wiener, another form of feedback, positive feedback, has become significant for systems thinking. While negative feedback counteracts deviations from a goal, positive feedback amplifies them. Examples: Positive and Negative Feedback Mechanisms DOH Doctors to the Barrio 1. Incentivizing young medical graduates with higher salary and master's program training If they stay in the rural areas. 2. Sugar Tax on sweetened beverage 3. Tobacco Control framework - Higher cost of cigarettes - Iconographs on the danger of tobacco Examples of feedback mechanisms Return to Service Agreement of UP Manila Oral Health Systems Phil Health Benefits-for extraction cases ? But no preventives services How about systems containing humans? Humans are purposeful The parts of social systems however “ human beings “ can generate their own purposes from inside the system, and these might not correspond at all to any purposes prescribed by managers or outsiders. Social and organizational systems, therefore, have multiple purposes: they are purposeful. Verhoeff et al., Theoretical Nature of Systems Thinking (2018) Systems are complex entities that are comprised of multiple working parts that interact with one another to produce behavior (phenomena) that cannot be explained solely by the individual parts alone. Synergism : when the total of many parts is greater than the individual parts (the interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects.) Systems are dynamic… which simply means it can change over time. As scientists, we are interested in the ability to measure and predict the behavior of systems. Dynamical systems theory is an interdisciplinary theory that combines many different theories, including chaos theory and catastrophe theory. Chaos is a seemingly random and completely unpredictable behavior. Statistically, chaos and randomness are not different. Examples of chaotic systems include physical (weather), social, and economic systems (stock market). Forecasting, modeling Verhoeff et al., Theoretical Nature of Systems Thinking (2018) Systems can be complex Complexity Theory A SET OF THEORETICAL IMPORTANT TO FRAMEWORKS UNDERSTAND IN THE CONTEXT OF SYSTEMS THINKING Main types of complexity framework A. Algorithmic complexity 1. Information Theory 2. Mathematic complexity Theory Complexities in the system lies in the difficulty to describe its characteristics. B. Deterministic Complexify 1. Chaos Theory 2. Catastrophe Theory Interaction of two or three key variables can create largely stable systems prone to sudden discontinuity C. Aggregate Complexities 1. How individual components work together to create systems of complex behavior. C. Aggregate complexities 1. Attempts to assess holism and synergy resulting from the interaction of systems components. 2. Key attributes: a. Relationship between entities b. Internal structures and surrounding environment c. Learning and emergent behavior d. Different means by which a complex system can change and grow 1. Relationships Complexities is defined more by the relationship between components rather than the constituent parts. Non linear Extend beyond simple feedback loops used in traditional modeling. Example : The relationship of Health and Development 2. Internal Structures Relationships of different strengths between components defines the internal structure of the system 3. Environment A complex system owe its existence to relationships with its environment Environment : anything outside the system Division may not be sharp and boundaries may be permeable. 4. Learning and Memory A complex system is not beholden to its environment. It actively shapes, reacts and anticipates. 5. Emergence The capacities of a complex system is greater than its constituent parts- synergyism Systemwide characteristics do not result from superposition or additive effect , but instead the interaction among components Emergent phenomenon may be difficult to predict or control. Difficult to anticipate change beyond a short term because other components of the subsystem adjusts to interventions ( applied to the system), in addition to other changes in the environment 6. Change and evolution A complex system constantly changes : Self organization : changes its internal structures to better interact to its environment Dissipative: a system becomes dissipative when the environment or the internal structure drives it into a high state of disorganization… Self organized critically : ability of the system to balance between randomness and stasis…  The use of complexity theory in health care healthcare is in an age of transformation, where the Complexity thinking can provide convergence of multiple guidance to system actors (i.e., system pressures such as people, organizations and other unprecedented life components that comprise the expectancies, increasing incidence and prevalence system) on how to respond to of chronic diseases , and these pressures and to globalization of infectious transform healthcare systems in diseases are testing the innovative, resilience of health collaborative, and action- systems worldwide. oriented ways. Health care as a complex adaptive system Many actors /subsystems/ systems connected to each other A system becomes “complex” because the interdependencies that define the system also render it highly dynamic, oscillating between periods of stability and chaos The healthcare system is hierarchical and comprises multiple (micro, meso and macro) levels that are nested or embedded within one another , which increases dynamism and therefore, complexity. Khan et al Insight 1: A complexity lens helps us better understand the nebulous term “context” Insight 2: Concepts of CAS may be applied differently when actors are cognizant of the system in which they operate Healthcare is a human system, the functionality of which relies on human cognition and sociality. Insight 3: Actor responses to uncertainty within a CAS is a mechanism for emergent and intentional adaptation. As described above, pressures affecting a complex system stem from and result in uncertainty Insight 4: Acknowledging complexity supports patient centered and intersectional approaches to patient care Insight 5: Complexity perspectives can support ways that leaders manage change (and transformation) in healthcare Level of complexities and solutions Bar-Yam recommends classifying problems according to their complexity, and introducing solutions accordingly. For example, in situations where a low level of uncertainty exists about the solution to the problem, more standardization can be introduced, which may enhance the overall efficiency of the system. Where a higher level of uncertainty exists about the solution to a problem, activities that encourage innovation production, relationship building and “trial-and-error” solutions can be introduced. Complexities Simple Complicated Complex Simple problems Simple problems have simple causes. Causality is linear and simple problems have standard solutions. These can be applied without specific expertise; technical skills are sufficient. · Complicated Problems Complicated problems consist of sets of simple problems, but cannot be reduced to them. They are compounded by scale and coordination problems. Solving complicated problems requires expertise and collaboration between experts. Formulae and instructions to solve complicated problems can be developed and are critical to success. If experts apply the formulae correctly, outcomes can be predicted. Complex problems Include sets of simple and complicated problems to which they are not reducible. The interactions between determinants of the sub- problems can lead to nonlinear causal relations between potential causes and outcomes. Also context sensitivity can make a problem complex. As a consequence, outcomes are unpredictable.  To solve complex problems, formulae and standardized solutions that proved effective in the past provide little guidance. Instead, complex problems are solved through safe fail experiments that allow learning by doing or by making sense of events post facto. Complex Adaptive system Morin (2001) defines a system as a unit made up by and organised through relations between elements (or agents), structures and actions (or processes). As with any system, complex systems consist of multiple elements, which interact with their environment, but some factors make them stand out: the nature of the interactions, the feedback loops, and the importance of the initial conditions and of the past. As a result, complex systems will display emergent behaviour and unpredictability. This applies as much to complex biological systems as to human social systems, including health systems (Plsek, and Greenhalgh, 2001, Wilson and Holt, 2001)  To understand complex systems, one needs to understand the nature of the interactions between the elements. Typically, these interactions can be non-linear: small inputs may have large effects and vice versa. The effect of actions also depends on the initial conditions. In complex systems, positive and negative feedback loops contribute to emergent behavior and unpredictability, and this is largely due to the human factor or the way human beings react to change. Example : For instance, a policy that abolishes user fees may lead to higher utilisation of the hospital because it reduces financial barriers to access. This may lead to higher workloads for the health workers, and in response, health workers may impose new barriers to patient access in an effort to reduce stress.  Other unintended effects may occur as overworked health workers become unfriendly to patients, leading to reduced patient satisfaction, which in turn may affect the decision to use the hospital’s services. Such feedback loops can often explain unexpected or perverse results. Time delay Furthermore, feedback loops may display time delays, in which case effects only become apparent after long periods of time If managers or policymakers overreact in response to slow results of an intervention by initiating new interventions, the situation can change wildly (oscillation) Wait and monitor vs Avoid Knee Jerk Reaction Example of Complexity Complex systems are also path dependent outcomes of interventions are sensitive not only to initial (current) conditions, but also to decisions taken in the past. Applied to policymaking, this explains how present policy choices and implementation modes are determined by past choices. The effect of Dengvaccia to Vaccine Hesitancy Complexity of health intervention A first perspective is to consider the degree of complexity of interventions in health. There is not much debate on when an intervention is simple: simple interventions are addressing a clearly defined problem for a clearly defined group of people and work upon a single cause or mechanism of change (Sanderson, 2002). There is far less agreement on what makes interventions complex. Judge and Bauld(2006) propose criteria such as : the need for protracted negotiation on the goals and resource allocation, the length of the implementation chains and the need for integration of lessons learned from previous projects. Complexity of Health Intervention The guidelines of the UK Medical Research Council for research of complex interventions define such interventions on the basis of the following criteria (Craig et al., 2008a): the number of and interactions between components of the intervention , the number of groups or organizational levels targeted by the intervention the degree of flexibility of the intervention that is permitted