Systems thinking studies how parts of a structure interrelate to form an overall system. For example, the human body is a system – and so too are healthcare organizations and the healthcare industry in general. By adopting a systems mindset that supersedes individual functions and departments, practitioners can complete strategic value analysis based on internal and external factors, trends, and causal effects. In turn, this analysis can help deliver broader benefits and move an organization toward a higher level of thinking and performance.

The following case study examines how viewing the patient education and communication functions within the context of the greater hospital system can have a powerful impact. As part of this effort, the improvement team determined the project’s role within the organization’s strategic goals, analyzed value streams and formulated prioritized value statements to develop a project scope.

Selecting a Project

Systems thinking can show the causal effects and relationships between an organization’s marketing, branding, legal matters, cash flow, technology, employee satisfaction, and future forces and trends. Each function within an organization is fertile ground to capitalize on systems thinking opportunities.

To begin, it may help to examine project selection using a systems-thinking approach. The project initiation process involves looking at the strategic context surrounding a project – in this case improvements to patient education and communication (see table below). When applying systems thinking, practitioners might ask: How does patient education affect outcomes, cost structures and physician satisfaction? Or, How can patient education affect brand, payer relationships and competitive standing? Although limiting the scope of the project has advantages, expanding the scope to a systems level – based on external forces, industry influences and strategic initiatives – can drive benefits to a higher level.

Project Relevancy

Structured Patient Education and Communication

External Forces Industry Influences Strategy and Organizational Goals
  • Informed/involved consumers and choice
  • Transparency
  • Quality and cost
  • Pay for performance
  • Perceptions and expectations
  • Legal and regulatory
  • Technology
  • Competition
  • Independent studies
  • National benchmarks
  • Health plan data
  • Federal and state comparison data
  • Quality – Clinical and admin processes and outcomes
  • Service – Patient and family satisfaction
  • Finance – Revenue, market share, capital, cash flow, costs
  • People – Employee satisfaction, staffing
  • Brand and relationships – Consumers, payers, community, suppliers and other

Brainstorming with the team to analyze the value stream of the patient education and communication process helped to visualize touch-points for scope. Indirectly, the activity also identified stakeholders and contributors (see figure below).

Value Stream Analysis and Causal Relationship Mind Map
Value Stream Analysis and Causal Relationship Mind Map

Legend: Arrows represent cause-and-effect relationships; the red arrows are two of several value streams depicted in the diagram. Outlined areas map to strategic/organizational goals.


  1. Examples: National Benchmarks, the California Office of the Patient Advocate, Press Ganey, and various government and health-plan data sources. Also includes Press, Community Relations, Internet presence.
  2. Waste is a primary focus and an area in which to apply Six Sigma tools for analysis and prioritization.
  3. Example: patient adherence to treatment plans.
  4. Cost reductions derived from the improvements on complications and Accounts Receivable.
  5. Example: Benchmark service and patient satisfaction through surveys (e.g., Press Ganey).
  6. Generic benchmarking example involving technology (YouTube, blogs, social networks, and webcasts)

The team determined numerous causal relationships from the analysis; two examples are highlighted in the red dashed arrows in the figure and mapped as follows: 

  • Clinical value: Proper patient education (for example, about prescribed medications) -> Reduction in clinical complications -> Improvements in patient outcome -> Improvements in patient satisfaction -> Enrichment of brand -> Increases in revenue. Variations include improvements in industry standing and payer relationships that affect revenue.
  • Administrative value: Proper patient communication (for example, through clear forms and directions) -> Reduction in administrative complications -> Improvements in staff effectiveness -> Reductions in cost. Variations include improvements in accounts receivable, thereby improving cash flow and avoiding write-offs of patient bills and uncollected insurance payments that affect costs. 

Expressing Project Value

This broader systems thinking can lead to innovative and more comprehensive value statements. Two examples: 

  • Clinical – Establishing physician expectations and educating patients on their treatment plans, medication usage and potential drug side effects can increase adherence, decrease unnecessary follow-up (waste) and improve outcomes. Analyzing and prioritizing current complications using a Pareto chart can help set education priorities. Standardized materials and measurements for prioritized areas can help in the implementation of plans and achievement of desired results. Standardized materials and practices also can improve the brand and reduce legal and regulatory risks.
  • Administrative – Researching insurance coverage and educating patients on their responsibilities and payment options can reduce write-offs and accounts-receivable problems, thus reducing cost and improving cash flow. When done properly, these upfront administrative processes also can prevent patient dissatisfaction. With increases in insurance options, complexity, and reduced or dropped coverage, patient financial responsibility escalates and the resulting effects to accounts receivable and write-offs need to be addressed.

There are approximately 12 value streams and value statements in the figure that can be identified, prioritized and further defined. For example, there is evidence correlating patient dissatisfaction with increased risks of litigation; that is, an irritated patient is more likely to file suit over a complication. Legal aspects also can come into play in the administrative billing and collections processes through disputes between providers, payers and patients, as well as with clinical information disclosure factors and liabilities. A structured systems-thinking approach helps bring these pressures to light and provides compelling evidence for making improvements. 

Involving Stakeholders

The map in the figure above also helps to identify project stakeholders, influencers, decision makers and contributors – such as representatives from finance, market development, payer relationships and the legal department – who might not be considered when using a non-systems-thinking approach. 

Managers, executives and other stakeholders are short on time. Determining and articulating the value and organizational relevancy of a project to management and other stakeholders are important steps in the process. A good way to do this is to develop a summary of value statements. A short value statement should state the current problem, a proposed solution and the expected outcome. 

The following is the summary for this project: “The current approach to patient education misses opportunities to improve patient outcomes, patient satisfaction and other strategic measures. The systems-thinking and value-analysis approach, which addresses clinical and administrative data and processes, can improve outcomes and patient satisfaction. Additionally, it can have a positive impact on cost structure, brand, accounts receivable, payer relationships, industry standing, employee satisfaction and revenue generation. 

The primary difference between a value statement and value proposition is that a value proposition is quantified; for example, a proposition would include return on investment (ROI) information. The DMAIC roadmap can be used to define the value proposition and detailed project plan. 

Identifying, analyzing and engaging stakeholders are important steps in affecting change, both for project acceptance and implementation. Few projects are solely intra-departmental or intra-organizational – hence the need to work across organizational lines, disciplines and focuses. When the team focuses on the customer, the mission of the organization and the value stream, individual or department agendas and preconceived solutions are less likely to be factors, thus keeping the solution lean. The project’s resulting solution should be purposeful, robust and sustainable.

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