Application of systems dynamics and group model building to identify barriers and facilitators to acute care delivery in a resource limited setting

Fiona Muttalib,Peter Hovmand,Ellis Ballard,Kenneth Remy,Andreas Hansmann,Yudy Fonseca,Allan Doctor,Josephine Langton,Sara Malone

doi:10.1186/s12913-020-06014-7

Abstract

BackgroundGroup model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi.MethodsOver 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed.ResultsCausal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias.ConclusionsGMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.

Highlights

Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors
Facilitators were introduced to the hospital environment and staff and toured the Paediatric special care ward (PSCW) High dependency unit (HDU) and paediatric accident and emergency (pA&E) to understand the basic processes of care
Severe illness and high volume of patients stress the system in three interconnected domains: (1) physical space, (2) resource utilization and needs and (3) provider capacity

Summary

Introduction

Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resourcelimited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. The vast majority of deaths occur in resource-limited settings (RLS) in low- and middleincome countries where delayed illness recognition and care-seeking are common. Severe illness at presentation is exacerbated by barriers to delivery of optimal acute care, together increasing early hospital mortality [2,3,4]. Barriers to optimal acute care delivery in RLS have been identified. A complex interplay of these factors and barriers exogenous to the healthcare system limit ability to identify the issues meriting attention that, if addressed, would lead to systems improvement

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