Systems theories have been used to describe and help predict how systems behave. It has been used for space projects, financial systems and can also be applied to the healthcare system. Key system concepts are that actors within systems are interdependent but may be disparate. There may be a time lag between actions and effects within systems, so that the effect of an action is not immediately felt and thus the root cause of a problem often goes unrecognised. This can be especially so when actors, actions and effects are in different parts of the system. Systems have feedback processes that can be accelerate growth/decline or rebalance. We see pathology tests as key decision points in a networked system of decision making with the aim of supporting patients, and those helping patients, to make good and timely decisions about their care.
Key decision points trigger actions within the system which can help patients on a path to better health, or in some cases lead them off this path! Tests are placed at key decision points. In primary care, within a clinical consultation there are four key decision points/ actions: these are whether or not to
- Support the patient
- Test
- Prescribe or
- Refer.
Systems can have patterns of behaviour. To help identify root causes of problems- these patterns of behaviour- system archetypes- have been identified. Our work on wound swabs in lower leg wound care demonstrates one of these archetypes and shows how primary care pathology can identify the root causes of health system failures, as pathology tests/ actions are placed at key decision points in care. Pathology can deliver value here and better health for patients by reducing system failures, through testing decision support and the optimisation of testing.
Lower leg wounds are common. They can become chronic in patients with underlying diseases such as venous or arterial insufficiency, diabetes and anaemia. The majority, approximately 80%, are due to venous insufficiency and require compression dressings to heal in optimal time. The remainder are made up of arterial and mixed arterial/ venous ulcers. It is important to perform a doppler ABPI (ankle brachial pressure index) test on all leg wounds to help decide the likely aetiology of an ulcer and subsequent dressing/ treatment. This is a key decision point. A venous ulcer treated with compression dressings should heal within 3 months. An arterial ulcer would deteriorate with compression dressings which constrict the circulation further. A doppler test can help differentiate between venous and arterial ulcers- and places a patient on the right path to quick healing.
What we did:
1) Identification of high volume/ low value test requesting= Lower leg wound swabs from primary care to the lab. Why was this? A clinical conversation between microbiology and tissue viability suggested that wound care in primary care was not optimal- as suggested by inappropriate tissue viability referrals for patients who hadn't received good primary treatment.
2) Go See: What was happening in primary care: The lab led a collaborative multidisciplinary meeting with microbiology/ vascular surgeon/ tissue viability/ practice nurse/ podiatrist/ GP. It was important to look jointly at the problems with the views of all healthcare professionals involved in the system.
3) Audit of patients with wound swabs/ lower leg wounds in primary care
4) Mapping of key decision points
5) Audit of patients vs mapped decision points
Findings:
Doppler tests not being done routinely or in a timely fashion- due to the lengthy time taken to do the test (30-40 minutes, not enough time was given in nurse timetables for this) This led to patients with venous ulcers not being put into compression dressings for a long time and consequently very very long heal times, and patients with arterial ulcers being referred very late to vascular surgeons for healing interventions This led to more nurse appointments for lower leg wounds that were not healing....which in turn made it more difficult to offer extended nurse appointments for doppler tests... (the system here was accelerating decline) When wounds were not healing, clinicians would often take a wound swab to look for infection. They would find bacteria colonising the wound, not causing infection, and often give unnecessary antibiotics. This demonstrates the 'Quick fix' systems archetype and often led to 'repeated quick fixes- fixes that fail to treat the underlying cause' It is much easier to take a swab, which takes seconds, and believe that this is the right decision, than to take the time to do a doppler (which the system also makes difficult to do in practice)
Here is a systems diagram showing this 'quick fix'
Pathology identified the route cause: a test which was a quick fix (wound swab) used instead of another test (doppler) at a key decision point- the root cause that would fix the whole system failures. The next step was to support primary care decision making and the optimisation of testing. Less wounds swabs- more doppler tests. We showed the key decision points and audit data. It was important to tell the story of how the system was not working and how this impacted on patients. The story for GP practices was that if they prioritised time for a lengthly doppler test, they would actually free up more time later through reduced nurse appointments and quicker heal rates. Addressing the root cause here would also reduce whole system failures- which is the patients story.... which was also important to tell. And the story for pathology? How many other times are tests used as quick fixes that lead to systems failures? Lets Go See!
