Introduction
Medical care is the product of a complex system consisting of people, equipment, processes, and institutions. In light of this, a systems approach to perioperative healthcare improvement is advocated by both the Royal College of Anaesthetists and the National Institute of Academic Anaesthesia Health Services Research Centre. More widely, a systems approach to improvement underpins the guidance of the World Health Organisation and the Institute for Healthcare Improvement, among others.
Figure 1. A systems approach as a series of ordered questions addressing general improvement (grey), people (purple), systems (green), design (pink), and risk (orange).
The Engineering community have developed a wide variety of tools and techniques for understanding and managing large, complex, safety-critical organisations. The value of applying these to healthcare has been endorsed by the 2017 joint publication by the Royal Academy of Engineering, Academy of Medical Sciences, and Royal College of Physicians: Engineering better care: a systems approach to health and care design and continuous improvement. The systems approach advocated by this report involves focus on four key areas in the improvement of healthcare – people, systems, design, and risk – and defines a systems approach as a iterative stepwise series of questions addressing these areas (Figure 1, reproduced with permission from Engineering better care, Royal Academy of Engineering, Royal College of Physicians and Academy of Medical Sciences 2017).
While multiple methodologies already exist to help improve clinical care, many of these do not cover all of the elements identified by the Royal Academy working group. Engineering approaches may be useful in providing an alternative perspective (Figure 2, reproduced with permission from Engineering better care, Royal Academy of Engineering, Royal College of Physicians and Academy of Medical Sciences 2017).
The clinical data generated through the electronic patient records systems (EPIC) used by Cambridge University Hospitals NHS Foundation Trust (CUH) allow for a systems approach which combines analysis of large datasets along with qualitative, ‘soft-systems’, methodologies to research the design of novel improvement to perioperative patient care. The UDA works in partnership with the Healthcare Design Group in the Engineering Design Centre (EDC), University of Cambridge, to research the application of a systems approach into both Global Health and Perioperative Medicine, and alongside the Department of Anaesthesia within Cambridge University Hospitals NHS Trust to bring this academic experiments to bear on practical improvement projects.
Figure 2. A comparison of improvement methodologies in taking a systems approach.
Research Projects
A Systems Improvement Approach to Traumatic Brain Injury (ASIA-TBI):
Developing a participatory approach to the systems improvement of traumatic brain injury care in Yangon, Myanmar
This project is a collaboration between the UDA, the Engineering Design Centre (EDC), and the NIHR Global Health Research Group on Neurotrauma. It seeks to use a Soft Systems Methodology within a wider engineering systems approach to understand and model the care of TBI patients in Yangon, with a view to developing improvement projects.
Funded by the NIHR Global Health Research Group on Neurotrauma
Prof DK Menon
Prof PJ Clarkson
Dr Tom Bashford
Designing Improved Care for Older Surgical Patients
This is an upcoming project being organised jointly between the Division of Anaesthesia, and the Healthcare Design Group. It aims to inform the design of surgical care systems through the analysis of perioperative data pertaining to the care of older people undergoing surgery.
Funded by the Wellcome Trust PhD for Clinicians Programme in Cambridge
Prof DK Menon
Prof PJ Clarkson
Dr A Ercole
Dr F Gilder
Dr Daniel Stubbs
Determining the optimum composition of a critical care outreach/’rapid response’ service
This work is exploring the optimum composition of critical care outreach teams as well as determining the best way to assess the impact and performance of such a service. This is a collaborative program between the University Division of Anaesthesia, Critical Care services, and the Healthcare Design Group.
Funded by an NIHR Academic Clinical Fellowship
Dr Dr Dhupal Patel
Dr C Summers
Prof DK Menon
Prof PJ Clarkson
Perioperative Network Analysis
This work is looking at exploring patient flow in individuals presenting for emergency surgery and developing mathematical and computational techniques for the handling of this information.
Funded by an NIHR Academic Clinical Fellowship
Dr Katharina Kohler
Dr A Ercole
Prof PJ Clarkson
Publications
Stubbs DJ, Davies BM, Bashford T, et al Identification of factors associated with morbidity and postoperative length of stay in surgically managed chronic subdural haematoma using electronic health records: a retrospective cohort study BMJ Open 2020;10:e037385.http://dx.doi.org/10.1136/bmjopen-2020-037385
Clarkson J, Dean J, Ward J, Komashie A, Bashford T. A systems approach to healthcare: from thinking to practice. Future Healthcare Journal. 2018. 5(3). p151-155 doi: 10.7861/futurehosp.5-3-151.
Bashford T, Nwe Myint PP, Win S, Thu M, Naing MM, Burnstein RM, Hlaing TT, Brealey E, Hutchinson PJA, Clarkson PJ. A systems approach to trauma care in Myanmar: from health partnership to academic collaboration. Future Healthcare Journal. 2018. 5(3). p171-175. doi: 10.7861/futurehosp.5-3-171.
Key Partners
Key References & Links
CCT in Anaesthetics Annex G. Royal College of Anaesthetists (2010).
PRISM: Perioperative Improvement Science & Management
National Institute of Academic Anaesthesia (NIAA) Health Services Research Centre