Working Whole Systems: Putting Theory into Practice in Organisations

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Please accept our apologies for any inconvenience this may cause. Add to Wish List. Toggle navigation Additional Book Information. Description Table of Contents. Summary Working Whole Systems offers a radical way of thinking about organisations as living systems.

It provides practical methods for engaging with complex social and organisational issues that are applicable to any group wanting a new way to work. The book draws directly on the authors' experience in health agencies, housing, transport, local government, police and voluntary agencies. This second edition contains new research on the criminal justice system, services for children and young people and services for people with mental health problems.

Leaders, managers and human resources professionals in all organisations will find the approach of this book fundamental to the way their systems function. It provides practical methods for engaging with complex social and organisational issues that are applicable to any group wanting a new way to work.

The book draws directly on the authors' experience in health agencies, housing, transport, local government, police and voluntary agencies. This second edition contains new research on the criminal justice system, services for children and young people and services for people with mental health problems. Leaders, managers and human resources professionals in all organisations will find the approach of this book fundamental to the way their systems function.

It also offers vital information for policy makers and shapers. Working whole systems - a brief summary. Metaphors - whole system approach using the metaphor of a living system to understand organisations.

Working Whole Systems: Putting Theory Into Practice in Organisations

Data were collected from multiple sources using the fourth generation stakeholder evaluation approach [ 28 ]. Multiple sources of evidence are highly complementary to cross case synthesis to triangulate information from each data source [ 25 , 29 ]. Data collection was also guided by collaborative, inclusive, participatory principles of practice development aimed to develop a shared purpose underlined by person-centered values and effective workplace cultures that enable individuals and teams to flourish [ 30 ]. Four methods were used to gather qualitative data to gain clear understanding of issues emerging in urgent and emergency care.

Firstly, a review of evidence relating to urgent and emergency care delivery including care pathways and protocols was undertaken to understand international and national workforce implications. The review was guided by six questions:. Competence was defined as acquiring and using evidence-based scientific and humanistic knowledge and skill in the application of therapeutic interventions in the practice setting [ 31 ].

Secondly data were collected from ten regional stakeholder events held in South East England across one Trust consisting of five hospitals, one community healthcare trust and one ambulance trust. The events were widely publicized using both electronic and paper flyers which included the research questions.

The stakeholder events were facilitated using a claims, concerns, and issues approach [ 28 ] to pave way for insights on:. At each stakeholder event, discussion points and other verbal contributions were noted on separate flipcharts for each question to enable collaborative data analysis.

Some participants gave accounts of their experience with or within the service to demonstrate the gaps and pinch points in the service and or in the workforce. These accounts were themed but also maintained as case examples Additional file 1. Stakeholder events continued to run until no new themes emerged and data appeared to be saturated. Thirdly, a short online survey with open-ended questions focusing on gaps, challenges, innovations and good practice in urgent and emergency care was administered for stakeholder groups that were not adequately represented at the events in order to capture the experiences of all stakeholders Additional files 2 , 3 , 4.

The fourth data source was a process mapping activity in urgent and emergency care contexts that aimed to explore and test the consistency of themes generated from stakeholder events and gain deeper understanding of gaps and pinch points identified. Swim lanes organized activities into groups based on who is responsible for the different steps within the urgent and emergency care delivery system. These provided in-depth perspectives about duplication and waste; what worked well and prompted debate on the structure of an effective urgent and emergency care system Additional file 5.

Participants in the study were urgent and emergency care stakeholders including representatives of service user groups. Forty-eight respondents completed the online survey that targeted underrepresented groups at the stakeholder events.

The process mapping activity involved in-depth interviews with leads in each of the 14 contexts identified namely: The multiple data sources facilitated triangulation, enhanced the validity and reliability of the case study and provided holistic understanding of existing challenges in the urgent and emergency service and workforce. Primary data analysis involved collaborative thematic analysis with participants at each stakeholder event to empower participants to co-create a shared purpose [ 28 ]. Collaborative data analysis is the process in which stakeholders jointly focus and have dialogue among themselves about a shared body of data to produce an agreed interpretation [ 33 ].

During analysis, participants were encouraged to apply an appreciative inquiry approach to gaps and pinch points they identified about the current urgent and emergency care service [ 34 ]. This approach facilitated stakeholders to translate constraints into enabling factors through building on shared understanding of what works well in providing care that is safe, person-centered and effective.

The research team used a similar process to generate themes from the literature review, qualitative online survey and process mapping activity. Themes from each of the four datasets were maintained separately during primary level data analysis to enable cross data consistency checks [ 29 ].

The research team completed secondary level data analysis by triangulating themes from all datasets and synthesizing them in relation to broad system components [ 26 , 27 ]. The data triangulation process focused on examining patterns and variations in themes emerging from all datasets. Each dataset yielded a number of themes, consistent across all sources but overarching themes for system enablers, specific workforce enablers and whole systems outcomes were resolved based on the process mapping gap analysis matrix, which provided a holistic picture of urgent and emergency care delivery covering 14 different settings.

The data analysis process entailed distinguishing characteristics of a whole system approach to urgent and emergency care and developing a representative framework of system and workforce development enablers and outcomes. Data were consciously organized using systems assumptions, into enablers inputs and desired outputs for whole systems urgent and emergency care delivery [ 26 ].

The synthesis for system enablers sought to address the research questions about how we can solve the current workforce crisis in emergency departments creatively to promote sustainable transformational change while specific workforce enablers aimed to respond to what the workforce of the future would look like. Figure S1 illustrates the different levels of data analysis and the influence of themes from datasets on other data collection methods. Themes from the miracle question about an ideal effective integrated urgent and emergency care system yielded the criteria for whole systems urgent and emergency care.

Participants characterized an urgent and emergency care whole system as one that is safe, sustainable and person-centered; based on best evidence and practice standards; integrates health and social care; focuses on quality and safety rather than targets; is tailored to meet needs in the local population; and involves interdependent partners working together towards the same purpose. Figure S2 shows the framework we generated deductively using systems assumptions [ 27 ] to achieve whole systems urgent and emergency care.

Gaps and challenges identified in the current service informed system and specific workforce enablers, building on what works and envisioning what is required for whole systems urgent and emergency care delivery. Three overarching themes prominent in the process mapping gap analysis matrix emerged from all datasets:. We hypothesized that whole system enablers identified across datasets have implications for workforce development at every level ranging from provider-user interfaces; career development across urgent and emergency care; systems leadership; human resource management through to infrastructure development; public information systems, and commissioning.

Participants perceived commissioners to be the gatekeepers for a common strategy that models integrated working at the commissioning level and works to dismantle barriers that drive silos across the system particularly around the use of budgets and information in acute and primary care settings. One urgent care clinician commented:. There is a lack of integrated pathways and too many clinical commissioning groups to work with.

Figure S2 outlines the overarching areas for system and specific workforce enablers and details of system enablers are presented in Additional file 8: Core challenges across the whole health economy were identified as both recruitment and the retention of staff and that these need to be addressed in a joined up way through system and specific workforce enablers. For example, a lead for a community healthcare team stated:.

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Recruitment has been a real problem for our trust. Staff need to have acute experience and know how the systems and processes work in both the community and hospital setting. I often feel that I could facilitate early discharge if a discussion was held between ourselves and the ward staff.

Three specific workforce enablers emerged as most significant not only for achieving a whole system approach to workforce transformation, but also for addressing issues pertaining to staff recruitment and retention. Secondary analysis of data overwhelmingly indicated the need for a much stronger focus on leadership with less emphasis on management.

Themes from all datasets denoted that clinical systems leadership would complement leadership for commissioning urgent and emergency care services. This is reflected in statements made by some of the participants:. Management needs to be much better in an integrated system. At the moment there are many senior managers and I think their role and expectations should be reviewed. Clinical systems leadership is a concept we assigned to the leadership approach that drives integration across boundaries based on specialized clinical credibility working with shared purposes to break down silos and deliver person-centered, safe and effective care with continuity.

Clinical systems leadership was linked to the ability to draw on expertise in a number of different areas to enable contributing partners to work together towards a shared purpose and to create a culture that values and retains staff. The required skill identified in the data encompasses: Cross data analyses suggested that a single integrated career and competence framework would enable staff recruitment and retention and also empower staff to know how the systems and processes work in both the community and hospital settings.

One emergency care doctor emphasized:. There is a need to think productively, are the right resources in place, clear roles and responsibilities.

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Identify what skills and jobs could be done by administrative or healthcare support workers rather than removing a nurse or qualified healthcare professional from hands on care. Themes relating to competences required for current and future integrated urgent and emergency care from each of the datasets were triangulated to identify the key outcome competences.

That is, what staff would be expected to do in the workplace underpinned by essential knowledge and understanding. The key competences were mapped against national competence frameworks identified in the literature for professional groups working across the urgent and emergency care system to validate the themes generated for the single integrated career and competence framework.

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Figure S3 outlines the single integrated career and competence framework for a whole systems urgent and emergency care workforce. A multidisciplinary career and competence framework for urgent and emergency care demonstrates whole systems working in managing the patient pathway and experience in any context - promoting an interdisciplinary team approach underpinned by shared risk and integrated information and finance systems.

Case example 1 illustrates how a learning disabilities consultant undertaking a program to develop expertise in the functions of clinical systems leadership aspiring clinical systems leader works collaboratively across boundaries to ensure that a person with learning disabilities and complex needs receives appropriate care and avoids hospital admission.

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This case example also illustrates effective use of resources in place, and attributes of systems leadership with a focus on person centered, safe and effective care. A nurse working with people with learning disabilities in the community and an aspiring clinical systems leader at the hospital have been corresponding for two weeks about a person with a learning disability and an autistic spectrum condition. The person had recently been discharged from hospital to a residential care home having had a fall and a fractured ankle. A closer review of the records indicated that the individual had experienced two admissions and three visits to the emergency department not quite triggering the learning disability repeated admission pathway people with learning disabilities admitted through the accident and emergency department three times or more.

Diagnostics also suggested a possible malignancy. The aspiring clinical systems leader linked the community nurse with an orthopedic consultant and the general practitioner via email, encouraging coordinated discussion about the individual, which led to swift conclusion regarding the possible diagnosis of cancer and further discussions about interventions for behavior problems and loss of skills.

Case example 2 illustrates how the single career and competence framework can be used in everyday practice for diverse contexts and roles to facilitate work based learning and career development. Case example 2 was developed by the research team to illustrate how the Assess, Treat and SORT can be used to support career development.

Working Whole Systems: Putting Theory into Practice in Organisations, Second Edition

A community nurse working part of an integrated discharge team plays a vital role in preventing unnecessary hospital admissions by liaising with others to make sure that older frail people receive the care and treatment they require in a home setting. For example, pain management, treatment for urinary tract infections and end of life care planning, taking into account the individuals wish about their preferred place of death. Formerly an emergency care nurse, the community nurse in question uses the integrated career and competence framework to undertake a self-assessment and submit a portfolio of evidence to a local university in order to gain academic accreditation for prior learning and development in the workplace.

The community nurse is able to pursue a blended Master of Science advanced practice program at the university tailored to development needs identified. By demonstrating advanced skills in clinical assessment, history taking and decision making in addition to a prescribing qualification, the community nurse gains 60 academic credits towards accreditation for prior experiential learning at advanced practitioner level.

Facilitators of work based learning emerged as an essential enabler for supporting the urgent and emergency care workforce competence and career development while using the workplace as the main resource for learning and development. Evidence from the data suggested that facilitating learning in the workplace would enable role clarity and a team approach to the competences needed for urgent and emergency care demands across the various contexts. A community matron working with people with long term conditions observed:.

Teams from the different organizations involved are often very tribal in their behaviors, with a low level of trust. This is counterproductive and negatively impacts on team working. The patient experiences disjointed care.

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