OBJECTIVE: This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector.
METHODS: An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors.
RESULTS: High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management\'s commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident.
CONCLUSIONS: This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays.
CONCLUSIONS: This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow.
CONCLUSIONS: This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department\'s value stream maturity.

BACKGROUND: The Aotearoa New Zealand COVID-19 pandemic response has been hailed as a success story, however, there are concerns about how equitable it has been. This study explored the experience of a collective of Māori health and social service providers in the greater Wellington region of Aotearoa New Zeland delivering COVID-19 responses.
METHODS: The study was a collaboration between a large urban Māori health and social service provider, Tākiri Mai Te Ata whānau ora collective, and public health researchers in Aotearoa New Zealand. Two online workshops were held with staff of the Māori service provider, collectively developing a qualitative causal loop diagram and generating systemic insights. The causal loop diagram showed interactions of various factors affecting COVID-19 response for supporting whānau (Māori family/households) at a community level. The iceberg model of systems thinking offered insights for action in understanding causal loop diagrams, emphasizing impactful changes at less visible levels.
RESULTS: Six interacting subsystems were identified within the causal loop diagram that highlighted the systemic barriers and opportunities for effective COVID-19 response to Māori whānau. The medical model of health service produces difficulties for delivering kaupapa Māori services. Along with pre-existing vulnerability and health system gaps, these difficulties increased the risk of negative impacts on Māori whānau as COVID-19 cases increased. The study highlighted a critical need to create equal power in health perspectives, reducing dominance of the individual-focused medical model for better support of whānau during future pandemics.
CONCLUSIONS: The study provided insights on systemic traps, their interactions and delays contributing to a relatively less effective COVID-19 response for Māori whānau and offered insights for improvement. In the light of recent changes in the Aotearoa New Zealand health system, the findings emphasize the urgent need for structural reform to address power imbalances and establish kaupapa Māori approach and equity as a norm in service planning and delivery.

The COVID-19 pandemic caused a surge in the number of unimmunized and under-immunized children in Africa. The majority of unimmunized (or zero-dose) children live in hard-to-reach rural areas, urban slums, and communities affected by conflict where health facilities are usually unavailable or difficult to access. In these settings, people mostly rely on the informal health sector for essential health services. Therefore, to reduce zero-dose children, it is critical to expand immunization services beyond health facilities to the informal health sector to meet the immunization needs of children in underserved places. In this perspective article, we propose a framework for the expansion of immunization services through the informal health sector as one of the pillars for the big catch-up plan to improve coverage and equity. In African countries like Nigeria, Ethiopia, Tanzania, and the Democratic Republic of Congo, patent medicine vendors serve as an important informal health sector provider group, and thus, they can be engaged to provide immunization services. A hub-and-spoke model can be used to integrate patent medicine vendors into the immunization system. A hub-and-spoke model is a framework for organization design where services that are provided by a central facility (hub) are complimented by secondary sites (spokes) to optimize access to care. Systems thinking approach should guide the design, implementation, and evaluation of this model.

Scale-up and sustainability are often studied separately, with few studies examining the interdependencies between these two processes and the implementation contexts of innovations towards malaria prevention and control. Researchers and implementers offer much more attention to the content of innovations, as they focus on the technological dimensions and the conditions for expansion. Researchers have often considered innovation a linear sequence in which scaling up and sustainability represented the last stages. Using systems thinking in this manuscript, we analyze complex scaling and sustainability processes through adopting and implementing seasonal malaria chemoprevention (SMC) in Burkina Faso from 2014 to 2018.
We conducted a qualitative case study involving 141 retrospective secondary data (administrative, press, scientific, tools and registries, and verbatim) spanning from 2012 to 2018. We complemented these data with primary data collected between February and March 2018 in the form of 15 personal semi-structured interviews with SMC stakeholders and non-participant observations. Processual analysis permitted us to conceptualize scale-up and sustainability processes over time according to different vertical and horizontal levels of analysis and their interconnections.
Our results indicated six internal and external determinants of SMC that may negatively or positively influence its scale-up and sustainability. These determinants are effectiveness, monitoring and evaluation systems, resources (financial, material, and human), leadership and governance, adaptation to the local context, and other external elements. Our results revealed that donors and implementing actors prioritized financial resources over other determinants. In contrast, our study clearly showed that the sustainability of the innovation, as well as its scaling up, depends significantly on the consideration of the interconnectedness of the determinants. Each determinant can concurrently constitute an opportunity and a challenge for the success of the innovation.
Our findings highlight the usefulness of the systemic perspective to consider all contexts (international, national, subnational, and local) to achieve large-scale improvements in the quality, equity, and effectiveness of global health interventions. Thus, complex and systems thinking have made it possible to observe emergent and dynamic innovation behaviors and the dynamics particular to sustainability and scaling up processes.

Global food safety and security are key principles to be followed in the context of the implementation of food safety management systems. The objective of this paper is to assess the contemporary developments of Food Safety Management System standards (FSMS) worldwide and to identify the primary constraints and advantages associated with their implementation by small and medium-sized enterprises across different regions. The effectiveness of these systems has also been evaluated. 116 case studies have been employed across developing and developed regions worldwide across 27 primary food sectors. After the implementation of FSMS, there was a significant increase in the percentage of companies that have implemented the international FSMS, both in developed (16.7% to 63.9%) and developing countries (26.6% to 48.1%). Certification has also increased from 34.2% to 59.6% in the total sample, namely from 33.3% to 61.1% in developed countries and from 34.6% to 59.0% in developing countries. There was a significant increase in medium vs. small company size (57.1% to 62.3%, p = 0.046), only in developing countries. Food safety culture and manager leadership implementation were increased to over 80% after FSMS implementation in both developed and developing countries (p < 0.001). Training, resources, and technology adequacy were also increased in all companies (p < 0.001).

Systems Thinking (ST) has become essential for practitioners and experts when dealing with turbulent and complex environments. Twitter medium harbors social capital including systems thinkers, however there are limited studies available in the extant literature that investigate how experts\' systems thinking skills, if possible at all, can be revealed within Twitter analysis. This study aims to reveal systems thinking levels of experts from their Twitter accounts represented as a network. Unraveling of latent Twitter network clusters ensues the centrality analysis of their follower networks inferred in terms of systems thinking dimensions. COVID-19 emerges as a relevant case study to investigate the relationship between COVID-19 experts\' Twitter network and their systems thinking capabilities. A sample of 55 trusted expert Twitter accounts related to COVID-19 has been selected for the current study based on the lists from Forbes, Fortune, and Bustle. The Twitter network has been constructed based on the features extracted from their Twitter accounts. Community detection reveals three distinct groups of experts. In order to relate system thinking qualities to each group, systems thinking dimensions are matched with the follower network characteristics such as node-level metrics and centrality measures including degree, betweenness, closeness and Eigen centrality. Comparison of the 55 expert follower network characteristics elucidates three clusters with significant differences in centrality scores and node-level metrics. The clusters with a higher, medium, lower scores can be classified as Twitter accounts of Holistic thinkers, Middle thinkers, and Reductionist thinkers, respectfully. In conclusion, systems thinking capabilities are traced through unique network patterns in relation to the follower network characteristics associated with systems thinking dimensions.

Significant loss of valuable resources and increasing burdens on landfills are often associated with a lack of proper planning in waste management and resource recovery strategy. A sustainable waste management model is thus urgently needed to improve resource efficiency and divert more waste from landfills. This paper proposes a comprehensive system model using stock-and-flow diagram to examine the current waste management performance and project the future waste generation, treatment and disposal scenarios, using England as a case study. The model comprises three integrated modules to represent household waste generation and collection; waste treatment and disposal; and energy recovery. A detailed mass and energy balance has been established and waste management performance has been evaluated using six upstream and downstream indicators. The base case scenario that assumes constant waste composition shows that waste to landfills can be reduced to less than 10% of the total amount, by 2035. However, it entails greater diversion of waste to energy-from-waste facilities, which is not sustainable and would incur higher capital investment and gate fees. Alternative case scenarios that promote recycling instead of energy recovery result in lower capital investment and gate fees. Complete elimination of the food and organic fraction from the residual waste stream will help meet the 65% recycling target by 2035. In light of the need for achieving a more circular economy in England, enhancing material recovery through reuse and recycling, reducing reliance on energy-from-waste and deploying more advanced waste valorisation technologies should be considered in future policy and planning for waste management.

Wastewater treatment facility location selection and network design issues have become attractive topics in the field of wastewater management due to increasing human population, resource scarcity, environmental concerns, and rise of necessity for sustainable solutions for future policy designs. Especially in areas where the demand for wastewater treatment increases dramatically over the years because of reasons such as high migration levels, rapid industrialization, and tourism activities, the problem turns out to be more critical and dynamic. The existing studies try to deal with the issue through mathematical modeling approaches based on optimization perspectives, which require significant computational effort. In this study, an alternative approach based on system dynamics (SD) method is proposed to examine the complex dynamic and nonlinear structure of wastewater treatment facility location selection and network design problems. The proposed SD simulation model is designed for a densely populated industrial and tourism spot, the city of Antalya, located on the Mediterranean coast of Turkey. The model is capable of determining where and when to build a new wastewater treatment facility as well as generating the generic wastewater network structure to be built for the five districts situated in the city center based on cost issues for 2015-2040 period. In addition, the impacts of demand level changes for wastewater treatment due to population variations are analyzed via several scenarios to help decision makers to develop sustainable and cost-efficient management policies. Although SD is a frequently utilized approach in the water/wastewater management arena, to the best of our knowledge, this study is the first attempt to examine the complex and dynamic nature of wastewater treatment facility location selection and network design problems through SD approach.

Despite policy intentions and many interventions aimed at reducing socioeconomic health inequalities in recent decades in the Netherlands and other affluent countries, these inequalities have not been reduced. Based on a narrative literature review, this paper aims to increase insight into why socioeconomic health inequalities are so persistent and build a way forward for improved approaches from a theoretical perspective. Firstly, we present relevant theories focusing on individual determinants of health-related behaviors. Thereafter, we present theories that take into account determinants of the individual level and the environmental level. Lastly, we show the complexity of the system of individual determinants, environmental determinants and behavior change for low socioeconomic position (SEP) groups and describe the next steps in developing and evaluating future effective approaches. These steps include systems thinking, a complex whole-system approach and participation of all stakeholders in system change.

BACKGROUND: Integrated community case management (iCCM) is a child health program designed to provide integrated community-based care for children with pneumonia, malaria, or diarrhea in hard-to-reach areas of low- and middle-income countries. The foundation of the intervention is service delivery by community health workers (CHWs) who depend on reliable provision of drugs and supplies, consistent supervision, comprehensive training, and community acceptance and participation to perform optimally. The effectiveness of the program may also depend on a number of other elements, including an enabling policy environment, financing mechanisms from the national to the local level, data transmission systems, and appropriate monitoring and evaluation. The extent to which these factors act upon each other to influence the effectiveness and viability of iCCM is both variable and challenging to assess, especially across different implementation contexts.
OBJECTIVE: In this paper, we describe a mixed methods systems-based study protocol to assess the programmatic components of iCCM that are associated with intervention effectiveness and report preliminary results of data collection.
METHODS: This protocol uses a mixed qualitative and quantitative study design based on a systems thinking approach within four iCCM programs in Malawi, Democratic Republic of the Congo, and Niger State and Abia State in Nigeria. Routine monitoring data are collected to determine intervention effectiveness, namely testing, treatment, and referral outcomes. Surveys with CHWs, supervisors, and caregivers are performed to collect quantitative data on their demographics, activities, and experiences within the program and how these relate to the areas of intervention effectiveness. Focus group discussions are conducted with these stakeholders as well as local traditional leaders to contextualize these data. Key informant interviews are undertaken with national- and district-level program stakeholders and officers knowledgeable in critical program processes.
RESULTS: We performed 3836 surveys and 45 focus group discussions of 379 participants with CHWs, supervisors, caregivers, and traditional leaders, as well as 120 key informant interviews with district- and national-level program managers, health officers, and ministry officials. Policy and program documents were additionally collected for review.
CONCLUSIONS: We expect that evidence from this study will inform child health programs and practice in low- and middle-income settings as well as future policy development within the iCCM intervention.
UNASSIGNED: DERR1-10.2196/33076.