Learning from 30 years of systems thinking in healthcare.

Systems thinking is a foundational discipline for the quality improvement practitioner. A 1997 publication on building knowledge of healthcare as a system created a bridge between system thinking and quality management, summarized the thinking about systems thinking and quality improvement at that time, and created a 10-step exercise to guide participants in applying systems thinking in their own healthcare settings. During the past 30 years, our understanding of how systems thinking can be applied in healthcare has evolved. We now recognize several limitations to our previous thinking, in particular, the need to distinguish between product logic and service logic. Products are particularly well-suited for quality improvement initiatives that address standardization of linear processes while services are not. Further, we need to consider the role of coproduction for the person seeking care and the relationship and communication with the clinical team. Finally, we must design the system to include care that transcends organizational boundaries. In essence, we need to apply systems thinking to care that is non-linear, involves multiple organizations, and importantly, is coproduced with the patient. We propose a revised and updated systems thinking exercise to help healthcare leaders and patients to apply this discipline in their daily practice.