International Working Group for Health Systems Strengthening

Health system stewards must ultimately attain competence in understanding their own systems, understanding the positive and negative effects of change ideas on systems, grappling with their own local realities, and charting their own paths forward. 

Dr Ng Yeuk Fan and Dr Teo Ken Wah, IWG Guest Contributors

Hey there, fellow health systems enthusiasts! Today, let’s dive deep into an exciting and innovative approach to support you in your health system and healthcare transformation journey —the Health System Transformation Playbook (HSTP). We’re talking about a method that combines design thinking, systems thinking, and complexity thinking that hopes to revolutionize how we tackle the complex puzzle of health systems transformation.

Our Context – Where Most Journeys Necessarily Begin

Picture this: The healthcare landscape is evolving faster than ever before, but traditional strategies for transforming health systems often fall short. Have you witnessed or experienced innovations that fail to scale, or the inability to excite and encourage concurrent necessary developments in manpower development, healthcare financing or informatics and IT systems? When faced with the intricate web of health systems connections and dynamic relationships, it’s time for us to meet such complex and “wicked” challenges head-on with a fresh perspective.

Thinking Outside the Box – Harnessing Implementation Science

Enter the triad of thinking: Imagine blending Design Thinking’s creativity, focus on agency and human-centred solutioning, Systems Thinking’s knack for understanding the whole, for revealing hidden interdependencies and loops between parts of our systems, and Complexity Thinking’s embracing of the known unknowns and unknown unknowns, of the uncertainties that are present in all socially and technologically complex systems. This integrated approach equips us with a powerful methodology to navigate the complexities of health systems and healthcare transformation.

Introducing the Health System Transformation Playbook (HSTP)

In Health System Transformation Playbook and Unified Care Model: an integrated design, systems & complexity thinking approach to health system transformation, Front. Health Serv., Ken Wah Teo and Yeuk Fan Ng argue that HSTP is itself a methodology bringing together diverse implementation science methods and tools, all requiring substantial practice for skilful usage during health system transformation. However, this deep competence in HSTP may paradoxically be simpler to attain than for the entire range of tools and methods potentially required in different situations. 

Through a simple three-step process HSTP aims to enable this: 

1. Step One: Story Telling—Seeing the System: Imagine sitting down with a diverse group of healthcare stakeholders—doctors, nurses, administrators, and more. Together, we facilitate the experiencing and appreciation of each other’s stories — narrative about strengths, opportunities, ideas, change, that uncovers the current state and future ideals of their collective systems. These stories that come to light are woven together to help stakeholders creating a shared view of the expanse of their systems where their current efforts to improve or change are targeting.

2. Step Two: Model Building—Understanding the System: Armed with insights from the storytelling phase, stakeholders embark on a journey of iterative group model building, throughout the system, and through time. HSTP empowers stakeholders to create and evaluate future-state models of their transformed health and healthcare system and/or processes. Such future-state models create a shared understanding of the cascade of possibilities and therefore interventions that are needed to coherently change and transform, to impact shared outcomes. 

3. Step Three: Path Finding—Working with the System: Here’s where the magic happens! Using the cascade of future-state models as a guide, stakeholders then ideate model prescribed interventions and discuss how to prioritize actions using Four Action Classes that are grounded in understanding levels of agreement and certainty. Anchoring path finding on model-prescribed interventions rather than local and situational contexts alone helps sets the stage for accelerating more coherent health systems and services transformation. 

A Real-Life Example: Health System Transformation Journey & the Unified Care Model in Yishun Health, Singapore

Yishun Health is a network of medical institutions and health facilities of the National Healthcare Group in the north of Singapore. It comprises Khoo Teck Puat Hospital, Yishun Community Hospital and community extensions such as Admiralty Medical Centre and Wellness Kampung, working together as a small regional population health system caring for about 320,000 people. 

In our health system transformation experience, we noted that services redesign and transformation projects were initiated continuously through time with transformation actions interacting across all health system sub-systems e.g., governance, manpower, financing, informatics systems, etc. Ensuring synergistic and coherent transformation into a more people-centred, integrated and value-driven health system at scale was extremely challenging. 

Our experience suggested that any health system transformation method with the hope of accelerating whole system change must address the need to train and gather numerous stakeholders as co-designers, it must enable a continual series of innovations that remain synergistic despite their introduction at different time points and into different sub-systems of a complex adaptive system, and it must guard against incremental-only innovations, premature convergence and lock-in into transformation paths that are less transformative or with potential negative effects.

The Unified Care Model (UCM) and its associated cascade of models is the result of our Model Building exercises and are examples of ongoing application of the Health System Transformation Playbook (HSTP) in the Yishun Health Regional Population Health System in Singapore. 

The UCM is a model of care that ensures that all residents have a One Care Plan emphasizing a fit and healthy life, and hassle-free access to dignified, safe, and value-driven care by collaborative teams and networks. The UCM represents Yishun Health’s aspiration to co-create with all staff and our communities, the highest form of integrated care that is person- and community-centred, and built upon collective strengths and shared goals, trust, and relationships.

Design Principles of the UCM include: 

– Biopsychosocial, needs- and assets-based approach to well-being and health throughout a persons’ life-course, for the entire Yishun Zone population

– Residents, caregivers, and communities drive self-care, and participate in care planning and co creation of care delivery with providers that employ strength-based and relationship-based approaches

– Single integrated needs assessment and care plan to meet residents’ needs

– Interactions among providers and care institutions are based on population needs, and are organizational and strategic

– Care episode defined from time-of-identification to time-of-resolution of needs, and system boundaries defined by types of needs

– Coordination achieves efficiency and effectiveness of care systems in discovering and generating health assets while meeting care needs, across all sites and transitions of care

– Carers and institutions form an integrated care organization and jointly optimize resident-centred outcomes and value for populations

A Closing Note: Paving the Way for Healthcare Transformation

Mastering the HSTP does take time and dedication. However, health system stewards must ultimately attain competence in understanding their own systems, understanding the positive and negative effects of change ideas on systems, grappling with their own local realities, and charting their own paths forward. 

The HSTP is a mindset shift that acceleration of whole systems change and strengthening is possible. It’s about embracing change systemic design and working with the complexity of health and healthcare systems, based on reinforcing agency and ensuring collaborations to pave the path toward a brighter future. 

As our health and healthcare landscape faces ever increasing challenges in the post-pandemic world, HSTP stands as a beacon of hope—a method that empowers us to implement better health systems that are truly people-centred, integrated, and value-driven. 

So, are you ready to embark on your own healthcare transformation journey? Let the Health System Transformation Playbook be your guide!