Abstract
Health systems worldwide have struggled for decades to provide efficient, effective, safe, high-quality, consistent, and equitable health services. Structural reforms have failed to achieve these aims, with a major contributor being the disconnect between governance, management, and operations in health services. Quality improvement (QI) and clinical governance efforts have also failed to address these disconnects as they have been ad hoc, project-oriented, and fragmented. Systems thinking has the potential to answer the problem of disconnects and to strengthen QI and clinical governance work but has not become ubiquitous, partly due to a lack of clarity about how to go about it.
This research answers calls for systems thinkers to ‘get their hands dirty’ and show what systems approaches have to offer health system research and practice. Specifically, it seeks to understand how system theory and model-based management, utilising cybernetic insights from the Viable System Model (VSM), can help us to conceptualise and address the disconnects between governance, management, and operations in the publicly funded health system in New Zealand to improve system functioning and viability at the clinical services delivery level. It also seeks to show how this approach supports clinical governance and QI efforts to achieve their aims.
This research is a case study of a public ophthalmology service with an action research component. Through semi-structured interviews and workshops, the views of clinicians, managers, an academic, and health system reform designers and advisors are sought on the health system’s issues and the reforms’ aims. The disconnects apparent in the issues and aims are then conceptualised using the VSM. Participants’ views are sought on a proposed, new, VSM-inspired framework for use throughout the system as a way of functioning that addresses system disconnects and supports those working in the system to deliver services that meet the reforms’ aims. The new framework provides a mechanism for introducing cybernetic insights into a health service by improving the accessibility of the VSM. This approach enables services to identify, disentangle, and reassemble their critical functional elements, and to establish those that are missing — the result of which is the integration of QI and clinical governance objectives and the mechanisms to support dissolution of the disconnects.
The study’s findings are useful for those working in or on the health system and introduce three new organisational pathologies to the VSM literature, which are useful for anyone implementing the VSM when articulating the management / coordination / operations functions and inter-relationships.