David C. Lane

Looking in the wrong place for healthcare improvements: a system dynamics study of an accident and emergency department

Accident and Emergency (A&E) units provide a route for patients requiring urgent admission to acute hospitals. Public concern over long waiting times for admissions motivated this study, whose aim is to explore the factors which contribute to such delays. The paper discusses the formulation and calibration of a system dynamics model of the interaction of demand pattern, A&E resource deployment, other hospital processes and bed numbers; and the outputs of policy analysis runs of the model which vary a number of the key parameters. Two significant findings have policy implications. One is that while some delays to patients are unavoidable, reductions can be achieved by selective augmentation of resources within, and relating to, the A&E unit. The second is that reductions in bed numbers do not increase waiting times for emergency admissions, their effect instead being to increase sharply the number of cancellations of admissions for elective surgery. This suggests that basing A&E policy solely on any single criterion will merely succeed in transferring the effects of a resource deficit to a different patient group.

Modelling as learning: A consultancy methodology for enhancing learning in management teams

This article reviews the experiences of a practising business consultancy division. It discusses the reasons for the failure of the traditional, expert consultancy approach and states the requirements for a more suitable consultancy methodology. An approach called ‘Modelling as Learning’ is introduced, its three defining aspects being: client ownership of all analytical work performed, consultant acting as facilitator and sensitivity to soft issues within and surrounding a problem. The goal of such an approach is set as the acceleration of the clients learning about the business. The tools that are used within this methodological framework are discussed and some case studies of the methodology are presented. It is argued that a learning experience was necessary before arriving at the new methodology but that it is now a valuable and significant component of the divisions work.

Should system dynamics be described as a 'hard' or 'deterministic' systems approach?

This paper explores the criticism that system dynamics is a ‘hard’ or ‘deterministic’ systems approach. This criticism is seen to have four interpretations and each is addressed from the perspectives of social theory and systems science. Firstly, system dynamics is shown to offer not prophecies but Popperian predictions. Secondly, it is shown to involve the view that system structure only partially, not fully, determines human behaviour. Thirdly, the fields assumptions are shown not to constitute a grand content theory—though its structural theory and its attachment to the notion of causality in social systems are acknowledged. Finally, system dynamics is shown to be significantly different from systems engineering. The paper concludes that such confusions have arisen partially because of limited communication at the theoretical level from within the system dynamics community but also because of imperfect command of the available literature on the part of external commentators. Improved communication on theoretical issues is encouraged, though it is observed that system dynamics will continue to justify its assumptions primarily from the point of view of practical problem solving. The answer to the question in the papers title is therefore: on balance, no.

Expression of the second lysine decarboxylase gene of Escherichia coli

Certain amino acids are substrates for two decarboxylase enzymes in Escherichia coli, one inducible by anaerobic growth at low pH and the other constitutive. In the case of lysine, an inducible decarboxylase (CadA) has been extensively characterized, but evidence for the existence of a second lysine decarboxylase is fragmentary and uncertain. This paper confirms that a second lysine decarboxylase is encoded by a locus (ldc) previously suggested to be a lysine decarboxylase gene on the basis of sequence comparisons. Overexpression of the cloned gene provided sufficient quantities of enzyme in cell-free extracts for preliminary examination of the properties of the ldc gene product, Ldc. The enzyme is active over a broad range of pH with an optimum at 7.6, much higher than that of CadA, about 5.5. The temperature optimum for both enzymes is similar, at about 52 degrees C, but Ldc is more readily inactivated by heat than CadA. Expression of ldc from its own promoter was very weak for cells growing in a variety of media, although a low level of lysine decarboxylase was present in cells that carried the ldc region on an oligo-copy plasmid when these were grown in minimal-glucose medium. Northern analysis of RNA extracted from such cells revealed a transcript whose length corresponded to that of the ldc gene, suggesting that ldc is normally transcribed from a promoter immediately upstream. However, most of the ldc mRNA was shorter, indicating degradation or premature termination. The ldc upstream sequence promoted transcription of a lacZ gene to which it was fused. Introduction of the upstream sequence as an insert in a multicopy vector increased transcription of the resident lacZ fusion. The low level of expression in single copy, the emergence of expression when the gene is present at moderate copy number, and the derepression by the upstream sequence in trans imply that this second lysine decarboxylase gene may not be constitutive but subject to specific repression by a factor which remains to be identified.

System Dynamics Mapping of Acute Patient Flows

Department of Health staff wished to use systems modelling to discuss acute patient flows with groups of NHS staff. The aim was to assess the usefulness of system dynamics (SD) in a healthcare context and to elicit proposals concerning ways of improving patient experience. Since time restrictions excluded simulation modelling, a hybrid approach using stock/flow symbols from SD was created. Initial interviews and hospital site visits generated a series of stock/flow maps. A ‘Conceptual Framework’ was then created to introduce the mapping symbols and to generate a series of questions about different patient paths and what might speed or slow patient flows. These materials formed the centre of three workshops for NHS staff. The participants were able to propose ideas for improving patient flows and the elicited data was subsequently employed to create a finalized suite of maps of a general acute hospital. The maps and ideas were communicated back to the Department of Health and subsequently assisted the work of the Modernization Agency.

Reinterpreting 'generic structure': evolution, application and limitations of a concept

This paper traces the evolution of the generic structure concept in system dynamics and discusses the different practical uses to which they have been put. A review of previous work leads to the identification of three different views of what a generic structure is and, hence, what transferability means. These different views are distinguishable in application as well as in theory. Examination of these interpretations shows that the assumptions behind them are quite distinct. From this analysis it is argued that it is no longer useful to treat generic structure as a single concept since the unity it implies is only superficial. The conclusion is that the concept needs unbundling so that different assumptions about transferability of structure can be made explicit, and the role of generic structures as generalisable theories of dynamic behaviour in system dynamics theory and practice can be debated and clarified more effectively.

Client Involvement in Simulation Model Building: Hints and Insights from a Case Study in a London Hospital

This paper describes the collaborative process of building a simulation model in order to understand patient waiting times in an accident and emergency department. The purpose is to explore the issues that arise when involving clients, in this case health care professionals, in the process of model building. The study background and a detailed account of the modelling process are presented. The focus of the paper is on some general themes that can be discovered running through the process. These offer some tentative insights into client involvement in system dynamics modelling, in particular its application in health care. Given this studys first promising results, further collaborative studies are encouraged.

Simulation applied to health services: Opportunities for applying the system dynamics approach

The aim of this essay is to raise awareness and broaden understanding within the health services community of the system dynamics (SD) simulation approach to policy analysis. The application of simulation in health services is reviewed. A comparison is made between the SD and traditional simulation approaches and is illustrated by considering reductions in waiting times for coronary heart disease treatment. Traditionally, simulation studies have tended to focus on the analysis of localized decisions and therefore on problems orientated towards individual patients. Although these methods are extremely powerful and effective, there is scope for an alternative modelling approach which is based on a more holistic perspective; SD is one such approach. It can assist in the design of robust policies by supporting debate on how the underlying structure might influence the evolutionary behaviour of a system. Using this method we can consider the time variation both of tangibles, such as waiting times and health care costs, and intangibles, such as patient anxiety and the effects of various pressures on purchasing decisions. We propose that SD holds great potential in assisting policy formation in health care.

Friendly amendment: A commentary on Doyle and Ford's proposed re-definition of 'mental model'

Some amendments are proposed to a recent redefinition of the mental model concept in system dynamics. First, externalised, or articulated mental models should not be called cognitive maps; this term has a well established, alternative meaning. Second, there can be mental models of entities not yet existing beyond an individuals mind; the modelling of planned or desired systems is possible and recommended. Third, saying that mental models maintain social systems connects with some exciting research opportunities for system dynamics; however, it is probably an accidental distraction from the intended meaning of the redefinition. These minor criticisms apart, the new definition of mental model of a dynamic system is welcomed as a useful contribution to both research and practice.

Blending systems thinking approaches for organisational analysis: Reviewing child protection in England

This paper concerns the innovative use of a blend of systems thinking ideas in the ‘Munro Review of Child Protection’, a high-profile examination of child protection activities in England, conducted for the Department for Education. We go ‘behind the scenes’ to describe the OR methodologies and processes employed. The circumstances that led to the Review are outlined. Three specific contributions that systems thinking made to the Review are then described. First, the systems-based analysis and visualisation of how a ‘compliance culture’ had grown up. Second the creation of a large, complex systems map of current operations and the effects of past policies on them. Third, how the map gave shape to the range of issues the Review addressed and acted as an organising framework for the systemically coherent set of recommendations made. The paper closes with an outline of the main implementation steps taken so far to create a child protection system with the critically reflective properties of a learning organisation, and methodological reflections on the benefits of systems thinking to support organisational analysis.