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Systems-Based Practice: Improving the Safety
and Quality of Patient Care by Recognizing
and Improving the Systems in Which We Work
Julie K. Johnson, MSPH, PhD; Stephen H. Miller, MD, MPH; Sheldon D. Horowitz, MD
As the complexity of health care delivery has increased, it has become essential for physicians to
understand how individual practices relate to the larger system of care.1 It is within this context
that the Accreditation Council for Graduate Medical Education (ACGME) and the American
Board of Medical Specialties (ABMS) identified systems-based practice (SBP) as one of the six
core competencies in which physicians must be proficient to deliver patient care that is safe and
high in quality. SBP is challenging to define, incorporate into training and practice, and evaluate.
Competency in SBP requires that physicians understand how patient care relates to the health
care system as a whole and how to use the system to improve the quality and safety of patient
care. Systems thinking is the cornerstone of SBP. Fostering the ability to recognize the
contribution of the system is important for medical students, residents, and practicing physicians.
However, current efforts in medical education focus on mastering knowledge of disease,
diagnostic skills, and treatment at the level of the physician-patient interaction. As a result, there
is a preoccupation with system components, while the system as a whole and its effect on the
quality and safety of care remain invisible. To clarify the definition of SBP and to develop
effective strategies for teaching and assessing SBP, it is necessary to provide a broad awareness
of systems within a context of systems thinking. Patient safety is a good entry point into SBP
because the concepts of safety, errors, and harm all place the individual, whether patient or
provider, within the framework of a system.
Background and Rationale
The Accreditation Council for Graduate Medical Education (ACGME) and the American Board
of Medical Specialties (ABMS) identified six core competencies required of residents and
physicians to deliver high quality medical care--patient care, medical knowledge, practice-based
learning and improvement, interpersonal and communication skills, professionalism, and
systems-based practice. Of these six, systems-based practice is one of the most challenging to
define, incorporate into training and practice, and evaluate.
Systems-based practice can be thought of as an analytic tool, as well as a way of viewing the
world, both of which can make caregiving and change efforts more successful. The focus is on
understanding the interdependencies of a system or series of systems and the changes identified
to improve care that can be made and measured in the system. The metaphors "a village" and "a
mirror" have been used to illustrate and differentiate the concepts of systems-based practice
(SBP) and practice-based learning and improvement (PBLI). "SBP is like a village. A physician
must work with a community of providers to deliver optimal patient care."2 This is contrasted
with the core competency of PBLI, where the metaphor is "a mirror." "PBLI is like holding up a
mirror to ourselves to document, assess, and improve our practice."2
In clinical settings, we can operationalize these concepts by asking two separate but related
1. The PBLI question: "How can I improve the care for my patients?"
2. The SBP question: "How can I improve the system of care?"
Since the landmark Institute of Medicine (IOM) report focused national attention on patient
safety, it has been generally agreed that the systems we work within are at the root of many of
our patient safety problems.3 Safety is a property of systems. Many of our patient safety
initiatives belong to the system. Furthermore, certain patient safety issues are especially relevant
to system solutions. These include the World Health Organization's list of "High 5" patient
safety initiatives--managing concentrated injectable medicines, assuring medication accuracy at
transitions in care, communicating during patient handovers, improving hand hygiene to prevent
infections associated with health care, and performing correct procedures at correct body sites4--
and The Joint Commission's patient safety goals, which are updated yearly.5
Although an understanding of systems is essential to improve the quality and safety of patient
care, training in SBP falls outside the scope of traditional training. As result, undergraduate
medical institutions, residency programs, specialty boards, and societies may have difficulty
effectively teaching and evaluating SBP. In addition, although SBP is required by the ACGME
as one of the core competencies that residents must demonstrate, there is a lack of literature
about how to integrate the theory of systems and systems thinking into medical education.
The common program requirements for SBP, as approved by the ACGME in February 2007,6
are outlined as follows: Residents must demonstrate an awareness of and responsiveness to the
larger context and system of health care, as well as the ability to call effectively on other
resources in the system to provide optimal health care. Residents are expected to:
? Work effectively in various health care delivery settings and systems relevant to their clinical
? Coordinate patient care within the health care system relevant to their clinical specialty.
? Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or
population-based care as appropriate.
? Advocate for quality patient care and optimal patient care systems.
? Work in interprofessional teams to enhance patient safety and improve patient care quality.
? Participate in identifying system errors and implementing potential systems solutions.
The aim of this paper is to further refine the definition of SBP by providing a broad awareness of
systems within a context of systems thinking and to highlight the importance of teaching SBP as
part of any program focused on improving the quality and safety of care.
Definition of a System
Implementing and evaluating SBP in a medical context requires a broader understanding of what
constitutes a "system," coupled with an understanding of systems thinking. Bertalanffy, the
founder of the scientific, mathematical "Theory of Systems," defined a system as a set of
interacting, interrelated, or interdependent elements that work together in a particular
environment to perform the functions that are required to achieve the system's aim.7 The
importance of understanding systems as interrelated parts of a whole cannot be overstated.
Systems can be continually improved, but one must consider how its products are created, why
they are created, and how they can be improved. Comprehending the assembly of the system as a
whole can inform the work of those who are trying to create successful, interdependent systems.8
Learning to see interrelationships, rather than linear cause-and-effect chains, and grasping the
phenomenon of change as a process, rather than as a snapshot, are essential for understanding
Systems have certain rules (or principles) that help us predict how they will behave:10, 11
? The whole has one or more defining functions.
? Each part can affect the behavior or properties of the whole.
? Each part is necessary but alone is insufficient to carry out the defining function
of the whole.
? Behavior and properties of one part of the system depend on the behavior and properties
of at least one other part of the system.
Systems thinking is the cornerstone of how "learning organizations" think about their world.9
Learning organizations are those that measure outcomes and strive for improvement. Many fields
outside health care--including education, telecommunications, and aviation--use systems theory
to better serve their clients, understand applicable research, improve outcomes, and ensure
quality and safety. Recognizing feedback from the system and using that feedback for design and
redesign of services is an inherent element of systems thinking.
Competence in SBP necessitates that physicians understand how patient care and other practices
relate to the health care system as a whole and how to use the system to improve patient
outcomes, safety, and quality. SBP is care that is sensitive to the context in which it is delivered.
Fostering the ability to recognize the contribution of the system is important for medical
students, residents, and practicing physicians because care is never delivered in a vacuum--there
is always a powerful context.
However, current efforts in medical education focus on mastering knowledge of disease,
diagnostic skills, and treatment at the level of the physician-patient interaction, resulting in
preoccupation with system elements, while the system as a whole and its effect on patients
remains invisible. The context is what has been minimized as educators try to standardize the
experience for trainees. Systems thinking and the application of systems thinking through SBP
provide an opportunity to look at the context.
Title: Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work
Author: Agency for Healthcare Research and Quality
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