A participatory systems approach to design for safer integrated medicine management.

It is recognised that whole systems approaches are required in the design and development of complex health care services. Application of a systems approach benefits from the involvement of key stakeholders. However, participation in the context of community based health care is particularly challenging due to busy and geographically distributed stakeholders. This study used action research to investigate what processes and methods were needed to successfully employ a participatory systems approach. Three participatory workshops planned and facilitated by method experts were held with 30 representative stakeholders. Various methods were used with them and evaluated through an audit of workshop outputs and a qualitative questionnaire. Findings on the method application and participation are presented and methodological challenges are discussed with reference to further research. Practitioner Summary: This study provides practical insights on how to apply a participatory systems approach to complex health care service design. Various template-based methods for systems thinking and risk-based thinking were efficiently and effectively applied with stakeholders.

Critical Hazards Identification and Prevention of Cascading Escalator Accidents at Metro Rail Transit Stations.

Escalator accidents not only happen frequently but also have cascading effects. The purpose of this study is to block the formation of cascading accident networks by identifying and preventing critical hazards. A modified five-step task-driven method (FTDM) is proposed to break down passenger-related cascading escalator accidents. Three complex network parameters in complex network theory are utilized to identify critical and non-critical Risk Passenger Behavior (RPB) hazards and Other Hazards related with Risk Passenger Behavior (OH-RPB) in accident chains. A total of 327 accidents that occurred in the Beijing metro rail transit (MRT) stations were used for case studies. The results are consistent in critical and non-critical RPB and OH-RPB and prove that through combination of FTDM accident investigation model and complex network analysis method, critical and non-critical RPB and OH-RPB in a complicated cascading hazards network can be identified. Prevention of critical RPB can block the formation of cascading accident networks. The method not only can be used by safety manager to make the corresponding preventive measures according to the results in daily management but also the findings can guide the allocation of limited preventive resources to critical hazards rather than non-critical hazards. Moreover, the defects of management plan and product design can be re-examined according to the research results.

Understanding variation in unplanned admissions of people aged 85 and over: a systems-based approach.

AIM: To examine system characteristics associated with variations in unplanned admission rates in those aged 85+. DESIGN: Mixed methods. SETTING: Primary care trusts in England were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three 'improving' sites where rates had declined by more than 4% and three 'deteriorating' sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services and adult social care. PARTICIPANTS: A total of 142 representatives from these organisations were interviewed to understand how policies had been developed and implemented. McKinsey's 7S framework was used as a structure for investigation and analysis. RESULTS: In general, improving sites provided more evidence of comprehensive system focused strategies backed by strong leadership, enabling the development and implementation of policies and procedures to avoid unnecessary admissions of older people. In these sites, primary and intermediate care services appeared more comprehensive and better integrated with other parts of the system, and policies in emergency departments were more focused on providing alternatives to admission. CONCLUSIONS: Health and social care communities which have attenuated admissions of people aged 85+ prioritised developing a shared vision and strategy, with sustained implementation of a suite of interventions.