UNSW ZEIT8305 KPH Case Study - Essay Writing Expert

King Phillips Hospital:

A Systems Thinking Case Study

UNSW ZEIT8305 KPH Case Study 2

Table of Contents

Summary…………………………………………………………………………………………………………..4

1 KPH management briefing……………………………………………………………………………..6

1.1 Symptoms of the issues at KPH (Assignment 1) ……………………………………………………..6

1.2 Addressing the issues (Assignment 2)…………………………………………………………………..8

2 High-level policy and process descriptions…………………………………………………………9

2.1 KPH Capacity…………………………………………………………………………………………………..9

2.2 KPH Desired Emergency Department Flow …………………………………………………………. 11

2.3 KPH Emergency Department……………………………………………………………………………. 13

2.3.1 KPH Emergency Department Patient Presentations……………………………………………………………..13

2.3.2 KPH Emergency Department Wait Times ……………………………………………………………………………13

2.4 KPH Emergency Department Waiting Points and Blockages …………………………………… 15

2.5 COVID-19 Response Measures at KPH ……………………………………………………………….. 17

2.5.1 Cancer Screenings Delayed……………………………………………………………………………………………….17

2.5.2 Elective Surgery Postponed ………………………………………………………………………………………………18

2.6 Nurse to Patient Ratio ……………………………………………………………………………………. 21

2.7 Government and State Funding To KPH……………………………………………………………… 22

3 Interviews ………………………………………………………………………………………………… 24

3.1 Issue 1: KPH Capacity……………………………………………………………………………………… 24

3.2 Issue 2: KPH Processes……………………………………………………………………………………. 26

3.3 Issue 3: KPH Culture ………………………………………………………………………………………. 29

4 Assignment 1…………………………………………………………………………………………….. 31

4.1 Introduction…………………………………………………………………………………………………. 31

4.2 Learning objectives ……………………………………………………………………………………….. 31

4.3 Guidance through the assessment ……………………………………………………………………. 31

4.4 Resources ……………………………………………………………………………………………………. 31

4.5 Tasks description…………………………………………………………………………………………… 31

4.5.1 Explore the system ………………………………………………………………………………………………………….32

4.5.2 Highlight the current reality ……………………………………………………………………………………………..32

4.5.3 Identify key issues and formulate focusing questions …………………………………………………………..33

4.5.4 Surface mental models about the selected issues………………………………………………………………..33

4.5.5 Map issues using causal loop diagrams ………………………………………………………………………………34

4.5.6 Use the issues maps to explore connections……………………………………………………………………….34

4.5.7 Apply the systems archetype as a thinking tool to diagnose the selected issues ……………………..34

4.5.8 Reflect on the assessment ………………………………………………………………………………………………..34

4.6 Assessment checklist and marking guideline ………………………………………………………. 35

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5 Assignment 2…………………………………………………………………………………………….. 36

5.1 Introduction…………………………………………………………………………………………………. 36

5.2 Learning objectives ……………………………………………………………………………………….. 36

5.3 Guidance through the assessment ……………………………………………………………………. 36

5.4 Resources ……………………………………………………………………………………………………. 36

5.5 Tasks description…………………………………………………………………………………………… 36

5.5.1 Identify key goals and formulate focusing questions ……………………………………………………………36

5.5.2 Map out systemic change required to achieve goals ……………………………………………………………37

5.5.3 Use the future roadmap to explore connections and identify leverage points…………………………37

5.5.4 Surface mental models about the proposed systemic change ……………………………………………….38

5.5.5 Visualise the physics of the proposed change and leverage points ………………………………………..38

5.5.6 Reflect on the assessment ………………………………………………………………………………………………..39

5.6 Assessment checklist and marking guideline ………………………………………………………. 39

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Summary

This document will be referred to as the case study description document. You need to use this case study description document while preparing Assignment 1 and Assignment 2.

Assignment 1 and Assignment 2 are based on a fictional hospital, King Phillips Hospital (KPH). To build the details of this fictional hospital, various articles regarding other real hospitals within Australia have been used.

While there is sufficient information in this case study description document to complete the two assignments without additional research, if you would like to make additional statements regarding KPH, please support your statements with studies or articles on public Australian hospitals – with the assumption that the same event or characteristic is found at KPH.

The assignments use a hypothetical situation to put you in the position of a systems analyst trying to help stakeholders solve a real-world management problem. In this hypothetical situation KPH management has commissioned you as a ‘systems analyst’ to apply a systems thinking problemsolving approach to better communicate the issues at KPH to KPH stakeholders. To achieve this, you will have to apply a suite of systems thinking methods to help KPH management articulate and analyse the issues that the hospital is facing.

Subsequent to this issue analysis (Assignment 1), KPH would then expect a plan to be developed to address these issues by understanding the gap between the current state and a desirable future state which then sets the basis for associated management actions (Assignment 2).

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This case study description document is organised into five sections. Use the following table to guide you through the document and make use of the provided information to prepare your assignments.

Section	Description	How to make use of this information in preparing your Assignment 1	How to make use of this information in preparing your Assignment 2
1	A briefing from KPH management providing a description of the situation that assignments 1 and 2 will need to specifically address.	Use section 1.1 to discuss complexity factors, start the iceberg analysis and use the defined topics for the basis of your causal loop diagrams in Assignment 1.	Use section 1.2 to define the topics for Assignment 2.
2	High-level KPH policy and process descriptions. This also includes investigation notes against these policies and processes, based on discussions with clinical staff. These notes document apparent shortfalls/issues with the processes and their potential effects.	Use the description of the processes to complete the “structure level” of the iceberg analysis in Assignment 1.Where an action or response is described, consider adding it to the loops in your causal loop diagrams in Assignment 1	Similarly, the processes and responses should also be considered for the causal loop diagrams in Assignment 2.In particular, consider the information in section 2.1 – 2.7 for loops in the addressing section 5.5.2 (Map out systemic change required to achieve goals) of Assignment 2.
3	An interview with some KPH staff with regards to the consolidated issues – providing additional information to be considered when preparing your response to Assignment 1 and 2	Use the attitudes, expectation and concerns expressed through the interviews to populate the “mental model level” of the iceberg analysis in Assignment 1.Where an action or response is described, consider adding it to the loops in your causal loop diagrams in Assignment 1.	Any systemic change needs to consider the existing mental models, behaviours, and power structure. Use the interview to explain any barriers and opportunities to obstruct or enable your suggested changes.
4	Assignment 1 description	Follow the step-by-step description for completing your assignment.Check your efforts against the marking criteria.
5	Assignment 2 description	Follow the step-by-step description for completing your assignment.Check your efforts against the marking criteria.

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1 KPH management briefing

1.1 Symptoms of the issues at KPH (Assignment 1)

The objective of this section is to provide you with information for the commencement of Assignment 1. The information below should be: 1. Discussed as part of the complexity factors (some reading of the linked articles will help these discussions); 2. Re-presented in the iceberg analysis at the “event level” and “pattern level”; and 3. Considered for the causal loop diagrams based on the three key issues which have been identified in the last section of 1.1, students are required to select one of these key issues.

King Phillips Hospital (KPH) is a hypothetical large regional public hospital in Australia. The hospital consists of over 30 departments which have defined roles in providing various hospital services to the city in which it is located and the surrounding regions. Problems that have existed for years at KPH have been amplified by COVID-19. Over the last 5 years, KPH management has had increasing demand for services and adverse trends, ranked in order of significance, including:

o Increasing strain on hospital capacity and hospital staff.

o Increasing shortage of hospital beds available.

o Increasing number of patients and their acuity1.

o Increasing elective surgery waiting and treatment times.

o Increasing emergency department waiting and treatment times.

o Increasing medical outliers.

o Increasing frustrations in the community resulting in spilling over into abuse of staff

from patients.

o Difficulty recruiting and retaining health professionals.

o Increasing workload of staff resulting in staff fatigue.

o Decreasing patient quality of care2.

Specific examples of incidents which have occurred at KPH over the same period are:

• 30% of patients were waiting too long for emergency treatment before the pandemic; patients waited for longer than an hour when treatment should have occurred within ten minutes3. During the pandemic the emergency department wait time was 36 hours4. • Frequently occurring ‘bed blocks’ where no beds are available, with carry on effects resulting in the emergency department becoming fully clogged5; overcrowding in the emergency department has resulted in patients who are classified as non-urgent not being prioritised, leaving, and returning when their condition worsens6.

2 The Sydney Morning Herald, NSW public hospitals record rise in medication errors, surgical errors, inpatient suicides, <http://www.smh.com.au/national/health/nsw-public-hospitals-record-rise-in-medication-errors-surgical-errors-inpatient-suicides- 20160203-gmksyi.html> 3 https://www.smh.com.au/national/nsw/emergency-wait-times-increase-across-nsw-hospitals-20190910-p52prs.html 4 https://www.smh.com.au/politics/nsw/ambulance-patients-waiting-up-to-36-hours-to-be-admitted-at-hospitals-inquiry-hears- 20221005-p5bnam.html 5 https://www.theguardian.com/australia-news/2022/jun/01/australians-in-hospital-emergency-departments-waiting-days-for-wardbeds-as-health-system-overwhelmed 6 https://www.abc.net.au/news/2022-06-01/victorian-hospitals-emergency-department-crisis/101111452

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• Frequently occurring ‘ambulance ramping’ where patients are unable to be transferred from the ambulance to the emergency department; only 62% of patients were transferred within 30 minutes of arrival7, ballooning ambulance response times for the next patients8. • During the height of the pandemic defence personnel were deployed to drive ambulances; a single paramedic joined by either a defence personnel driver, an emergency service driver or a student paramedic driver were deployed to improve response times9.

• Staff shortages10 have witnessed junior doctors resigning11, with 60% of the remaining junior

doctors stating that they were concerned about making clinical errors due to fatigue, an

increase in 51% from the previous year12.

• Overall wellbeing and workplace culture ratings for 2022 returned a D+13.

• When surveyed in 2022, 28% of trainee doctors have reported that they felt unsafe at work,

and 31% experience bullying and harassment14 .

• COVID-19 response witnessed delaying cancer screening test; in 2018 there were more than 74,000 mammograms performed, whereas in 2020 there were approximately 1,10015. • Within KPH, in 2018 the rate of hospitalisations in the emergency department that had an adverse event was above 10%, and this percentage has remained constant for several years16.

In face of these incidents and trends, it can be easy for management to dismiss incidents as just oneoff events and interpret trends as being driven by uncontrollable drivers (i.e. open-loop mentality). Such problem framing can only lead to simplistic solutions that cannot only fail, but also exacerbate the situation by triggering unintended consequences. The KPH management problems is a mess, and needs to be treated as such. This is where systems thinking comes to the story.

Need for systems thinking approach

While KPH management understands the relationship between trends and incidents, KPH management requires assistance in analysing this information in a manner which can help guide any adjustments to hospital policy, procedures or culture. To provide a basis for this, you have committed to KPH management to analyse KPH as a system through the lens of complexity features. The complexity features will need to consider the trends and incidents listed above. These trends and incidents will also need to be considered in the thinking iceberg framework so that the Structure and Mental Models driving the issues are articulated to KPH management. KPH management has provided additional details in Part 2 and 3 of this document which should also be considered in your analysis.

7 https://www.ama.com.au/articles/ama-ambulance-ramping-report-card 8 https://www.theguardian.com/australia-news/2022/may/07/health-system-in-distress-how-ambulance-ramping-became-a-majorproblem 9 https://www.theage.com.au/national/victoria/ambulance-boss-calls-in-adf-to-ease-health-crisis-20211007-p58y5i.html 10 https://www.youtube.com/watch?v=qM-qtRDKWEM 11 https://twitter.com/10NewsFirst/status/1574224988332523520 12 https://todaygladstone.com.au/news/2022/10/04/fatigued-system-causes-fears/ 13 https://www.ama.com.au/qld/campaigns/resident-hospital-health-check

14 https://www.ama.com.au/qld/campaigns/resident-hospital-health-check 15 https://www.aihw.gov.au/reports/cancer-screening/cancer-screening-and-covid-19-in-australia-inbrief/contents/what-was-the-impactof-covid-19-in-australia 16 https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/table-of-contents

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You have completed an initial workshop with KPH management. An outcome of that initial workshop is that it has been found appropriate to consolidate the analysis of these trends and incidents into three key issues:

1. Insufficient capacity at KPH;

2. Inefficient processes17 at KPH;

3. Undesirable workplace culture.

1.2 Addressing the issues (Assignment 2)

This section defines the three key objectives required to structure your response to Assignment 2. Students should select one of the key objectives that aligns with their Assignment 1 key issue.

Following the analysis of the current situation, a subsequent workshop was held with KPH where you have committed to providing an analysis of factors that will help KPH management with achieving the three primary objectives of:

• Improving KPH capacity;

• Improving KPH processes;

• Changing KPH’s workplace culture.

To articulate these change factors, you are required to:

• Map out systemic change required to achieve the goals;

• Explore the connections and leverage points from the mapping exercise;

• Describe the mental models from the point of view of various stakeholders;

• Create stock and flow diagrams to visualise the influence that these factors can have on the

issues.

The achievement of one of the three objectives should address the selected issue identified by Assignment 1 and your document should reflect this relationship.

17 https://bmjopen.bmj.com/content/7/5/e015676

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2 High-level policy and process descriptions

After reading through the information in this section to gather a basic understanding of the hospital system:

• Use the description of the processes to complete the “structure level” of the iceberg analysis

in Assignment 1.

• Where an action or response is described, consider adding it to the loops in your causal loop

diagrams in Assignment 1.

• Similarly, the processes and responses should also be considered for the causal loop

diagrams in Assignment 2.

2.1 KPH Capacity

General Population

• An indication of whether a person will receive timely admission into a hospital is the number

of available beds per population size. Available hospital beds at KPH per 1,000 people have

been declining since 1980, with 12.3 beds available per 1,000 to 3.8 in 2016, marking a 69.1%

decrease18 – view Graph 1. The 2019-2020 figure was 2.47 beds available per 1,000 people.

• Graph 219 shows Australia’s projected population, with the addition of Australia easing visa

rules20, with 623,000 temporary and permanent visa applications processed21 in 2022.

Aging Population

• Australia will have an aging population, with predictions of Australians aged 85 years and older doubling by 204222; as of June 2020, 16% of Australia’s total population is aged 65 and over23, resulting in a predicted 32% of the total population being aged 65 and over by 2042. • Despite the aged 65 years and older accounting for 16% of Australia’s population, they utilise 39.9% of KPH beds available and stay 32.4% longer than the other aged cohorts24. • 6 hospital beds for every 1,000 people over 65 years have been lost at KPH since 2008; in 1990 there were 30 hospital beds for every 1,000 people over 65 years whereas currently there are less than 15. Graph 3 shows the decline in beds for aged 65 and over.

18 https://data.worldbank.org/indicator/SH.MED.BEDS.ZS?end=2016&locations=AU&start=1960&view=chart

19 https://www.abs.gov.au/statistics/people/population/population-projections-australia/2017-base-2066

20 https://www.businesstoday.in/latest/world/story/australia-relaxes-visa-rules-to-address-labour-shortage-increases-skilled-workersquota-346033-2022-08-31

21 https://playfair.com.au/2022/07/27/urgent-fix-to-counteract-skills-crisis/

22 https://www.abs.gov.au/articles/population-aged-over-85-double-next-25-years

23 https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/summary

24 https://www.ama.com.au/sites/default/files/2022-03/ama-phrc-2022_0.pdf

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Graph 1 – Available Hospital Beds at KPH from 1960-2015 (World Bank, 2022)

Graph 2 – Australia Projected Population 2017-2066 (ABS, 2022)

Graph 3 – KPH Hospital Beds 1991-2020 for Aged 65 and over per 1,000 People (AMA, 2022)

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

3 4 5 6 7 8 9 10 11 12 13

KPH

KPH bed ratio for > 65 years

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2.2 KPH Desired Emergency Department Flow

The desired patient journey through KPH’s emergency department (ED) is shown in Figure 425. The main stages that occur are:

o Triage assessment: < 5 minutes to establish patient level of emergency.

o Early assessment: < 10 minutes to stream patients to appropriate areas. Senior ED physicians

determine streaming of patients within or outside of ED.

o Early Treatment Zone: < 2 hours to either move the patient to another area or discharge the

patient. The early treatment zone is a multi-functional and flexible clinical area where an ED

assessment plan is completed, and the commencement of a clinical management plan is

undertaken.

o Designated Model of Care (MOC): < 1 hour for speciality treatment team to review patient

management and/or inpatient bed allocation

o Acute – inclusive of: higher level of care, more comprehensive management plan,

specialised interventions, frequent observations, cardiac monitoring

o Sub-acute – inclusive of: low acuity, high-complex with multiple co-morbidities and

resource intensive, non-ambulant

o Fast track – dedicated area to treat ambulant, non-complex patients.

o Patient transfer: < 1 hour for patient transfer to inpatient unit, another hospital or community

service or discharge patient

From patient presenting at the emergency department till transference of healthcare (inpatient, other hospital/community, or discharge) the desired maximum timeframe should not be greater than 4 hours. For more information visit: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0005/273794/emergency-departmentmodels-of-care-july-2012.pdf

25 https://aci.health.nsw.gov.au/__data/assets/pdf_file/0005/273794/emergency-department-models-of-care-july-2012.pdf

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Figure 4 – Desired KPH Patient Journey Map (NSW Health, 2012)

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2.3 KPH Emergency Department

2.3.1 KPH Emergency Department Patient Presentations

KPH ED patient presentations (Figure 526) from 2016-2019 increased from 311 presentations per 1,000 people in 2016 to 329 presentations per 1,000 people in 2019 (3.2% increase on average). From 2019- 2020 there was a 1.4% decrease to 319 presentations per 1,000 people, with the 2020-2021 rate registering 342.5 presentations per 1,000 people, marking a 6.3% increase on 2019-2020 figures. The 2019-2020 figures were at the start of COVID-19 when KPH implemented its emergency response measures, with the 2020-2021 figures also under the emergency response measures. Patients aged under 4 years and over 65 years accounted for 31% of 2020-2021 figures: 10% and 21% respectively. Figure 5 – 2016-2021 KPH ED Patient Presentation per 1,000 People (Adapted from AIHW, 2022)

2.3.2 KPH Emergency Department Wait Times

The desired 4-hour timeframe is an important indication for KPH that patients are receiving appropriate high-quality care. In 2020-2021, KPH recorded 67% of all emergency department presentations (total across all ED categories) being completed within 4 hours. Figure 627 shows KPH in comparison to aggregated state hospital averages. 90% of patients presenting to KPH ED left after 8 hours. KPH 2020-2021 figure was proportionally influenced by the COVID-19 pandemic, however, Figure 728 shows KPH’s trend from 2011-2012 to 2020-2021.

26 https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care 27 https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care 28 https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care

290

300

310

320

330

340

350

2016-2017 2017-2018 2018-2019 2019-2020 2020-2021

KPH Emergency Department Patient Presentation

per 1,000 People

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Figure 6 – Comparison of KPH to State Hospitals 2020-2021 Emergency Department Visits Completed within 4 Hours (AIHW, 2022)

Figure 7 – KPH Percentage of Emergency Department Visits Completed within 4 Hours 2011-2021 (Adapted from AIHW, 2022)

2011-2012

2012-2013

2013-2014

2014-2015

2015-2016

2016-2017

2017-2018

2018-2019

2019-2020

2020-2021

% of Emergency Department Visists Completed <4 Hours

NSW VIC QLD WA SA TAS ACT NT KPH

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2.4 KPH Emergency Department Waiting Points and Blockages

Patient overcrowding at KPH presents patient waiting points and key blockages, which are described in Table 1, with Figure 829 displaying these. KPH was not starting from a point of strength and could not scale up its capacity to meet COVID-19 demand. Issues that had already existed such as ambulance ramping, bed blocks, exit blocks and wait times were further compounded.

Table 1 – Description of Figure 8 (Adapted from AMA, 202230)

Figure 8 Numbering	Figure 8 Description
1	Ambulances delayed at ED result in patients waiting longer for ambulances to arrive at the next medical emergency.
2	No hospital bed capacity or ED capacity result in nurses and doctors seeing patients that are still on ambulance stretchers. Ambulance cannot offload the patient into ED.
3	The emergency waiting room is overcrowded. ED waiting delays are long. Patients who are waiting are in pain, hurt, scared, frustrated and angry.
4	Transferring patients from ED to MOC/elsewhere in the hospital is a long waiting delay. Results in patient not receiving specialist care and proper monitoring.
5	Exit block. Patients waiting to be transferred to a nursing home, another hospital or community service have waiting delays.
6	‘Elective’ but urgent surgeries are cancelled at short notice to prioritise emergency surgeries coming through ED.
7	Delays in waiting for outpatient appointments to get on surgery lists and delays in waiting for surgery appointments cause patients to present at ED hoping to get their surgery sooner.

29 https://www.ama.com.au/sites/default/files/2022-10/Public%20hospitals%20-%20cycle%20of%20crisis.pdf

30 https://www.ama.com.au/sites/default/files/2022-10/Public%20hospitals%20-%20cycle%20of%20crisis.pdf

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Figure 8 – KPH Emergency Department Patients Waiting Points and Blockages (AMA, 2022)

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2.5 COVID-19 Response Measures at KPH

KPH was not starting from a point of strength and could not scale up its capacity to meet COVID-19 demand. To function within this constrained system, KPH has had to re-purpose its resources and stop other types of healthcare. To increase bed availability across KPH and preserve protective equipment for staff handling COVID-19 patients during the height of COVID-19, KPH emergency response measures included delaying cancer screenings and elective surgeries.

2.5.1 Cancer Screenings Delayed

Mammograms, cervical cancer screenings, and bowl cancer screenings were some of the cancer screenings delayed at KPH. o Breast cancer services were suspended from March 2020, with younger women (aged 50-54 years) slower to return to pre-COVID screening levels, however, older women (aged 70-74 years) returned to pre-COVID screening levels (Figure 9)31. o The number of cervical cancer screenings was expected to be lower, irrespective of COVID- 19, given the change from screenings being 2-yearly to 5-yearly, however trends can be seen showing younger people (aged 25-39 years) returning to ‘normal’ screening levels, however people aged 60-79 years had proportionally fewer screenings compared to 2019 levels across all months (Figure 10)32. o The relatively slow development of bowl cancer allows for early-stage cancers to be screened for and treated. The effect of COVID-19 response measures at KPH witnessed fewer bowl cancer test kits being returned (Figure 11)33.

Figure 9 – Percentage Difference in Number of Screening Mammograms in 2020 compared to 2018 by Age Cohort (AIHW, 2021)

31 https://www.aihw.gov.au/reports/cancer-screening/cancer-screening-and-covid-19-in-australia-inbrief/contents/what-was-the-impactof-covid-19-in-australia 32 https://www.aihw.gov.au/reports/cancer-screening/cancer-screening-and-covid-19-in-australia-inbrief/contents/what-was-the-impactof-covid-19-in-australia 33 https://www.aihw.gov.au/reports/cancer-screening/cancer-screening-and-covid-19-in-australia-inbrief/contents/what-was-the-impactof-covid-19-in-australia

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Figure 10 – Percentage Difference in Number of Cervical Cancer Screening in 2020 compared to 2019 by Age Cohort (AIHW, 2021)

Figure 11 – Percentage Difference in Number of Bowl Screening Kits Returned in 2020 compared to 2019 by Age Cohort (AIHW, 2021)

2.5.2 Elective Surgery Postponed

2.5.2.1 Official Elective Surgery Wait Times

From April 1, 2020 all elective surgeries except for Category 1 and high level Category 2 were paused at KPH. KPH defines elective surgery as any medically necessary surgery that can be delayed for at least 24 hours. Table 2 shows the elective surgery categories. Measurement indicators for timely elective surgery at KPH include: (a) the median waiting time for elective surgery and (b) percentage of patients treated within the clinically recommended times.

Table 2 – KPH Elective Surgery Categorisation

KPH Category	Level of Urgency	Procedure Indicated Time
Category 1	Urgent	Specialist Consultation Within 30 days
Category 2	Semi-Urgent	Specialist Consultation Within 90 days
Category 3	Non-Urgent	Specialist Consultation Within 365 days

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Using pre-2019 data, category 1 patients at KPH account for 27.8% of total elective admissions, category 2 account for 38.2% and category 3 account for 34%34.

The median wait time indicates the number of days within which 50% of patients were admitted for their elective surgery procedure. Figure 1235. shows that the median wait time at KPH has been increasing since 2014. Figure 12 – Median Elective Surgery Wait Time at KPH (AMA, 2022)

The percentage of category 2 surgeries patients admitted within the 90 days can be viewed in Figure 1336. COVID-19 did impact on KPH’s elective surgery wait time; however, the overall trend shows widening discrepancies from the target and the actual numbers.

Figure 13 – Percentage of Category 2 Elective Surgeries 2002-2021 Completed Within Recommended Time (AMA, 2022)

34 https://www.ama.com.au/sites/default/files/2022-10/Public%20hospitals%20-%20cycle%20of%20crisis.pdf 35 https://www.ama.com.au/sites/default/files/2022-10/Public%20hospitals%20-%20cycle%20of%20crisis.pdf 36 https://www.ama.com.au/sites/default/files/2022-10/Public%20hospitals%20-%20cycle%20of%20crisis.pdf

KPH

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2.5.2.2 Unofficial Elective Surgery Wait Times

When looking outside of the official elective surgery wait times, there is also a ‘hidden’ wait time. The process of receiving elective surgery at KPH is shown in Figure 1437. KPH refuses to release how large their hidden wait time is, however, Figure 1538 and Figure 1639 can provide an indication.

Figure 14 – KPH Patient Journey to Receive Elective Surgery (Adapted from AMA, 2022)

Figure 16 – 90th percentile Wait Time for Urgent Initial Patient Appointment with KPH Specialists (AMA, 2022)

37 https://www.ama.com.au/elective-surgery-hidden-waiting-list

38 https://www.ama.com.au/elective-surgery-hidden-waiting-list

39 https://www.ama.com.au/elective-surgery-hidden-waiting-list

Patient is injured

Patient sees GP and is

referred to a specialist

at the outpatient clinic

Patient sees specialist at the

outpatient clinic and is added

to the elective surgery

waiting list

Patient received surgery

Patient waits for

GP appointment

Patient waits for

specialist appointment

Patient waits for

elective surgery on

elective surgery wait list

‘Hidden’ waiting

list

Official elective

surgery waiting

list

KPH State

Average

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Figure 17 – 90th percentile Wait Time for Non-Urgent Initial Patient Appointment with KPH Specialists (AMA, 2022)

2.6 Nurse to Patient Ratio

The resourcing for nurses is planned for (at most) 6 nursing hours for each patient per day. That is equivalent to ratios of 1:4 on morning shifts, 1:4 on afternoon, shift and 1:7 on night shifts, with some shifts including an ‘in charge’ nurse without a patient allocation. However, these ratios (based on the NSW award40) are only applicable to specific hospital departments and do not include:

1) All Types of Critical Care Units: a. Intensive Care Units b. High Dependency Units c. Coronary Care Units d. Burns Units e. Neo-natal Intensive Care Units 2) Day Only Wards 3) Day of Surgery Wards 4) Procedural Units (Haemodialysis, Endoscopy, Cardiac Catheter, etc) 5) Paediatrics 6) Drug & Alcohol 7) All Midwifery Services: a. Antenatal

40 Industrial Relation Commission of New South Wales 2017, Public Health System Nurses’ And Midwives’ (State) Award 2017, p65, <http://www.health.nsw.gov.au/careers/conditions/Awards/nurses.pdf>

KPH State

Average

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b. Post Natal, Nurseries c. Delivery & Birthing Suites 8) 23 Hour Wards 9) Fast track wards 10) Transition Wards (slow stream) 11) Medical Assessment Units 12) Medical/Surgical Acute Care Units (MACU & SACU) 13) Wards/Units attached to Emergency Departments: a. Psychiatric Emergency Care Centres (PECC) b. Observation wards c. Emergency Medical Units (EMUs)

Note: Nurses are generally feeling that their concerns regarding inadequate nurse to patient ratios are not being understood or that inadequate action has been undertaken to enforce these ratios at the departments which need them most (e.g. emergency and critical care) 41.

2.7 Government and State Funding To KPH

The flow of funds into public hospitals and other competing areas in 2019-2020 is shown in Figure 1842. Figure 1943 shows the federal government and state governments combined public hospital funding from 1966 – 2020. Breaking it down into per person funding, Figure 20 shows how much funding is allocated per person. KPH funding is in-line with NSW trends for both Figure 19 and 2044. Figure 18 – Flow of Funds 2019-2020 (AIHW, 2022)

41 NSW Nurses and Midwives Association 2017, It’s time to improve ratios, < https://thelamp.com.au/professional-issues/public-health/itstime-to-improve-ratios/ > 42 https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2019-20/contents/mainvisualisations/overview 43 https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2019-20/contents/mainvisualisations/overview 44 https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2019-20/contents/mainvisualisations/overview

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Figure 19 – Total Federal and State Government Public Hospital Funding (AIHW, 2022)

Figure 20 – Total per Person Funding for Public Hospitals from Federal and State Government (AIHW, 2022)

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3 Interviews

This section describes the attitudes, expectation and concerns (i.e. mental models) for various hospital staff for each issue. Use this information in developing the iceberg analysis (4.5.2) and the stakeholder analysis (4.5.4).

Further, where an action or response is described in this section, think of the feedback loops that can emerge, and use this information to create your causal loop diagrams in Assignment 1 and 2.

3.1 Issue 1: KPH Capacity

Do you think there is a lack of capacity at KPH?

Senior Doctors Response

This is a very difficult and complex question. We do admit very sick patients at KPH, but we also drop our threshold and admit patients with minor problems because they may live far away (> 300/400km), and they may not have a support network (no relatives or friends). Their admissions are also longer than average. I think this is not a capacity question, but an efficiency question – how efficiently we can deal with patients. For example, how well are your doctors trained, how quickly do they work, how well equipped is the hospital? If you have a very well-equipped hospital with all the gadgets, and if you have well trained and driven staff, they can manage a large volume of patients – they can manage a much larger volume of patients than a hospital with lower quality facilities and equipment and lower quality staff. You can’t compare bed capacity from 40 years ago to today, at that time it was very common for patients to be in hospital for extended amounts of time and admitted for things you wouldn’t dream of admitting for today. Germany has a high number of beds, but they also over-investigate and keep patients for a long time, so only looking at the number of beds is not the full picture. If we increase the number of beds, the problems that we have will still be here – more beds are not a silver bullet.

Costs has also driven an outpatient assessment of medicine, and management tries to not bring patients into hospitals and just manages them as outpatients because it’s cheaper. This also factors into how many beds you require, and it’s very complicated.

Junior Doctors Response

The bed availability at KPH is grossly insufficient. There are insufficient hospital beds to cover the patients that are admitted now, let alone thinking about future patient numbers. It doesn’t matter if medicine advances further, we need beds, and we need those beds now. The way medicine also advances allows us to treat more complex cases, but they will require more hospitalisation and the population is living longer, therefore, beds are essential. No matter how you look at this, you can’t get around the issue of KPH not having enough beds. We need to double the current number of beds, and thereafter double that number again. I work emergency shifts, and the number of patients waiting for beds used to make me very anxious. I’ve heard that 10 years ago, there might have been 4 or 5 patients presenting at emergency that we have to help, but now the number is more like 15-20. We just don’t have anywhere to put them.

Ambulance ramping has also become the norm; I see sometimes 15 paramedics waiting with their patients on stretchers, waiting for a nurse to hand the patients over to, so that the paramedics can leave. And this is daily. It’s not shocking to me anymore. What used to be shocking is now everyday business. We are constantly trying to play around with the bed issue. We are opening up a short stay

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area in ED now to try and help alleviate the bed issue, it won’t work, because we are not addressing the real issue, that we need more beds.

Nurses Response

There is always a push for beds and a focus on discharge date, and sometimes the pressure is so great that things start to fall apart – we focus on the discharge date and not the needs of the patient. The problem with beds is that when you create more capacity, more patients will fill those beds. Instead, we should be asking “where is the care best placed?”. There is a big movement recently to have more rapid access to outpatient specialty care, especially people with complex chronic disease, including the elderly. When these people come into hospitals, it causes more problems. Elderly people are often over-investigated and take up bed availability for extended periods. I don’t understand why we over-investigate elderly people, given that they will not benefit from intervention. There should be a rapid response to elderly people at nursing homes. Instead, say if an elderly person falls at a nursing home, the nursing home brings them into the emergency department and we run all the tests: we take their blood, we scan their heads… and then it’s like to what end? We found a tumour in their head, but no neurosurgeon is going to touch any person with dementia, because there is nothing that can be done to reverse dementia. And sometime elderly people are dying, we can’t stop them from dying. So, nursing homes should be making a care plan, where the families are onboard, as to what should occur if a fall takes place for instance. There is a whole misperception about aging and healthcare, and the amount of damage we do to elderly people when they come to hospitals is extreme.

The Australian population believes that hospitals are the pinnacle of care, that you should always go to hospitals, and you have to die in hospitals. This is the story now of hospitals and aging, while really, less hospital visits are good. Priorities of the industry is workforce recruitment and retention, and the other priority is prenatal care and birth outcomes for aboriginals. There is no priority for an aging population. I’ve asked head nurses and other professions, “what about the aging population?”, and the responses I’ve received is always very similar “we look at things from a broader perspective, if we focus on birthing outcomes, then the aging trajectories will differ, and quality of life will differ”.

Covid also didn’t affect us nearly as badly as other parts of the world, and I am proud of how KPH’s put in response measures like cutting the elective surgeries and cutting all non-essential meetings and redistributed staff. For example, because day surgeries have been cancelled, we repurposed that into a covid ward. There were some overtimes for staff, but we go through it quite smoothly. At the moment, we see covid all the time, and we don’t have to isolate these patients anymore, and special areas of ED for covid aren’t there anymore.

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3.2 Issue 2: KPH Processes

Do you think there are inefficiencies at KPH, particular in KPH processes?

Senior Doctors Response

The inefficiency at KPH is the biggest problem. I can see it in my private practise, that the amount of work that gets done is so much more. You work harder in private for the same amount of money or for less. Public systems in principle are much less efficient. I don’t know exactly what the reasons are, but one is union related. Staff are entitled to this and that. For example, the nurse’s tea break. The tea break is so holy and enshrined in law that it can determine whether the operations start or not, because if an operation goes into the tea break it may not take place. Also, when the day comes to an end. In a private hospital the day does not end at 4:30pm, we just work. At KPH the day ends at 4:30pm, regardless.

Another problem are the nurses. KPH is better staffed with nurses than in private, so a lot of the cost comes from the nurses and the nursing ratios. Some of the nursing ratios are good, there is normally a good reason for having these ratios, but it is always a big fight between nurses and governance. I have become very critical of nurses.

Another big problem are nurses reporting on doctors and bullying doctors, in a healthy environment it’s good that we all keep an eye on each other, but the extent to which nurses report on doctors at KPH has now become unpleasant and unreasonable. It causes major disruptions as certain doctors don’t want to work with certain nurses, and vice versa, and to have governance constantly breathing down your neck because you know at any moment you can be reported causes unnecessary stress on an already stressful job. The younger doctors don’t cope well with this additional stressor.

Doctor’s contracts also create inefficiencies. When you sign the contract, you can determine if you want to be Option A or Option B. One option is you get a salary, and you get some other payments on top of the salary. Everything that happens at KPH is coded as a service and carries a number. This number generate the amount of money that is paid for the service delivered, now some of the patients are not public patients but are private patients, so that bill is sent to the private insurance, then there are rules around if a patient is referred to you directly or through the institution, which also determines how much you get paid. At the end of the month, doctors’ salaries are made up of many bits and pieces. Some of it is a base salary and the other is payments that are received. Effectively, the more you do, the more you earn. This results in doctors doing work unnecessarily – doctors are over-servicing to be paid more. This works in the interest of doctors, so no one will complain about it, but it causes inefficiencies.

Junior doctors are also more likely to over-service because they are inexperienced. There has been a decrease in the quality of training of junior doctors. This is particularly the case for the university level. We try and correct the gaps in knowledge of the junior doctors, but it’s very difficult and time consuming. We always compare the way that we were trained, and we think the young ones are not trained properly. The ratio of senior to junior doctors are appalling – you find more inexperienced doctors at KPH than experienced.

Huge disruptions to the flow of ED are complex cases and medical outliers. For the complex cases in the geriatric population, I think it would be better if the 4-hour rule did not apply, because it is not useful. All the medical outliers seem to end up at one ward, my ward. If all the complex and medical outlier cases go to one ward, this ward will get clogged up quicker, because these cases take

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longer to diagnose. The issues associated with medical outliers are normally not related to what I specialise in, but I am required to solve them. I’ve spoken to a colleague of mine, and at his hospital he also receives all the medical outliers. It becomes standard practise that if the junior or senior doctors, or nurses, don’t know what to do with a medical outlier then they send them to me. I have to deal with medical outliers on top of my normal working load, which is already complex given my specialty. And what makes me annoyed, is that now KPH is giving me more beds for my ward because of all the medical outliers I receive and how long it takes to diagnose and treat them.

Junior Doctors Response

The cornerstone of medicine is learning and improving on past performance – you are continually trying to improve and through this improvement, things should get better. The issue is that most doctors want to continually improve and help their patients, but other staff are more interested in their own self-interest. They put themselves before the wellbeing of the patient.

Processes at KPH are inefficient, but I think the outpatient management is much more inefficient. Outpatient management has a low acuity response unit, and they should be preventing patients from going to hospitals unnecessarily. For example, outpatient management should identify patients that require antibiotics, these patients don’t need to go to hospital. People who are very sick will get seen to relatively soon while low acuity will have longer wait times, that’s just the process. Take an example that occurred recently, there was a woman who came into emergency because a spider bit her, this bite occurred 6 weeks ago. She should have gone to outpatient management. This example also illustrates another inefficiency at KPH, which is that sometimes patients who do not require a bed are given a bed. The nurses at KPH processed this woman, and she was given a bed. She should not have ended up getting a bed and I don’t understand how she was given a bed.

Everyone thinks that for any minor complaint they have, that they have to go to the emergency department, where in actual fact a GP appointment will be sufficient. GPs also tell patients to come into the emergency department when they should be taking them. So, given that people come to the emergency department for all sorts of non-emergencies, it is the nurse’s responsibility to make sure that they filter these patients out of the system, and they don’t get a bed. The process at KPH should be only admitting critical patients who need a bed. Another example is patients that require rehabilitation. Rehabilitation is not a medical emergency; however, they are given a bed, and this impacts on ED flow.

Bed block in wards is the biggest issue, given that patients are also not discharged on-time. We used to have some wards close at night, but because of covid, these have now stayed open during the night, and they are filled up by morning. Whereas previously, a process to close the ward at night allowed for more bed capacity in the morning.

Nurses Response

The biggest inefficiency at KPH is that we are not on the electronic medical record system (eMRs). There are numerous hospitals now on the eMRs, where everything is electronically recorded and documented, and everything is automatically available on any computer. KPH is paper based. Paper based means that everything is a lot slower, and say you want to pull up some histories, you have to go and find the chart, and sometimes people carry around the charts, so they could be anywhere in the hospital, so you have to find where this chart is. This also means that there is a lack of visibility. Anything that happens at KPH, stays at KPH, except if it is documented in the discharge summary or specialist’s letter. KPH is lucky to have access to eMRs from other hospitals if one of their

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patients come into KPH, it makes our jobs a lot easier. Because each hospital is not adopting the same technology, it causes a lot of inefficiencies.

Another inefficiency is that I see a difference in the quality of younger nurses coming into the hospitals. From personal experience, when I was doing my nursing degree, I had to have 4 years and had to have a broad range of subjects – some from psychology, philosophy, etc. The nursing degree now is only 3 years and focuses solely on nursing. The nurses coming out are not as well rounded – they are tasked based and need checklists of what they should do. I think we should go back to the older days, when nurses were less ‘qualified’ but there is a head registered nurse overseeing everything. An example of this, is that we work on weighted activity units (WAO), so it’s a chart that goes to the coders, who code different diagnoses, and there is a certain amount of money that comes from each of these diagnoses, and all these different conditions, and if the nurses and doctors don’t carefully write these diagnoses, then they don’t get coded properly, and patients will get charged incorrectly and have an incorrect patient history. Younger nurses often make mistakes and don’t write things down properly, but doctors also make mistakes.

The staffing issues for nurses are particularly bad because sometimes there are no workarounds. For example, because of the mandatory ratios (4:1 ratio), whole wards sometimes can’t be open because we can’t meet the staffing ratio. We will get in trouble from the union if we move outside the mandatory nursing ratios, and the unions are the only ones protecting us, so we don’t want to go against them.

I think another big inefficiency is not related to KPH, rather that GP’s are not bulk billing as much anymore, and they have raised their prices. People at the moment can’t really afford to go to the GP and spend $60 out of pocket, so they come to emergency instead. Medicare rebates to the doctors are not sustainable, they require an overhaul, but this is another problem in itself. At the moment, we are dealing with more minor cases at the emergency department because people can’t afford a GP.

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3.3 Issue 3: KPH Culture

Do you think KPH has a good workplace culture?

Senior Doctors Response

KPH work culture is toxic. The dominance of nursing and the way that nursing has taken over control of medicine is appalling; doctors don’t like working with nurses and they don’t like getting ordered around by them – there’s a lot of resentment. I think we have to educate the doctors and the nurses to communicate. Also, the people who run the hospitals. At the moment, governance gives nurses instructions to convey to the doctors. Why don’t they just tell the doctors? What right do the nurses have to boss the doctors around – why does governance allow this and why is this the communication channel? Why are nurses in the middle of the communication channel between governance management and the doctors? It makes no sense. Doctors who are very driven don’t last long at KPH – they leave, they can’t stand working with the nurses and they can’t handle the inefficiencies. I train junior doctors and once they are more experienced, they leave, and I start over again with a new junior doctor.

I don’t think doctors and nurses are overworked, but again like the previous questions I can only answer for myself and KPH. You know, if you go and look at the way surgeons work, they work extremely long hours. Some doctors, for example, interventionalist cardiologists work late nights and get called out for their patients. So, it does vary quite a lot, but on the whole, doctors and nurses get paid too much for the quality of work they deliver.

Patients have also become more aggressive, demanding, and entitled. Patients demand more interaction, demand more investigations, demand more information. A story I have is a patient came in and said that his brother recently had a medical emergency and he wanted tests done, I told him that I would not perform these tests because they were not necessary, and you could see the aggression start to come out.

There is also more demand from governance to do things and quality control- they always want more and more from you, but you only have so much time.

Junior Doctors Response

A big problem is the nurses. The nurses make the work harder, more unpleasant, and more draining than it really should be. Historically, nurses are female, and they are bullying, sexually harassing, and displaying sexism to male doctors and surprisingly to female doctors too. The doctors and nurses at KPH don’t like each other and the nurses have too much power. I think because we have had and do have nursing shortages, that governance management has given them more power than they should have (to keep them) and it’s gone to their head. A nurse doesn’t have my skillset, so why should the nurse tell me that I’m not doing something right or have the power to report on me.

The senior doctors protect the junior doctors from the nurses most of the time, but you also have to be careful with the senior doctors. They will drag you through a furnace if you make a small mistake like a test that you thought the patient required… and they make us work long hours.

Many good senior doctors have resigned or entered retirement early because they don’t want to have to deal with the nurses anymore, which disrupts the process at KPH, because good doctors who could handle many patients at a time aren’t there anymore. I can’t handle as many patients as a senior doctor. It’s just not possible.

I really don’t like the working culture at KPH, and I’m trying to leave to rather work for another hospital.

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Nurses Response

Nurses are overworked at KPH. We are constantly pushing ourselves to the maximum, and there is no wriggle room. It is constant churn all day. We are at the max. There is a constant push to do more, and to justify what you are doing, but we are beyond maximum. We are tired. Nurses just want to help, but the conditions we are forced to work in is very unhealthy, just look at how unhealthy night shift is… I mean at KPH there is a culture of sneaky around to have a small nap on your night shift, and you feel bad if you sleep for 30 minutes. KPH discourages doctors from having a snooze on nightshifts as well.

Communication between doctors and nurses depends on the culture that you find yourself working in, and at KPH it is not a good culture. KPH does not have very clear communication plans. One tool that nurses have to work with is escalation. Management has taught us how to engage in escalation. We use a tool called SBAR (Situation-Background-Assessment-Recommendations) frequently. An example is, say a young nurse on the ward at night and they call the doctor, and they are nervous, they can use SBAR as a framework. If they are not being answered or if they are not getting the outcome that they want, they can then escalate to their manager or a senior clinician or management. This framework was brought in after the 2005 Bundaberg Hospital incident. The nurses should feel comfortable escalating and complaining. It is scary. Some specialists are big egos on legs, but they are only people, and you should feel fine to escalate. Sometimes younger nurses do escalate more than they should, but I would rather have them feeling comfortable to escalate then not to escalate. Especially given that KPH doesn’t have a good communication plan, the one tool that we do have is escalation. I feel more comfortable talking with some doctors in comparison to others. Some doctors live in la-la land. They give their orders and walk away and leave us to pick up everything. If you want to understand how the hospital really runs, talk to a nurse, not a doctor.

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4 Assignment 1

Weight: 45%

4.1 Introduction

Refer to section 1.1 of this document and complete the following sections.

4.2 Learning objectives

This assessment allows you to demonstrate your ability to:

1. Recognize the key features of complex problems that warrants employing the systems

thinking approach (4.5.1)

2. Recognize the four levels operating simultaneously in the problem (4.5.2)

3. Understand the system boundary (4.5.3)

4. Identify multiple perspectives and possible hidden priorities (4.5.4)

5. Create and use Causal Loop Diagrams (4.5.5)

6. Create and use Systems Archetypes (4.5.6)

4.3 Guidance through the assessment

To complete the assignment successfully:

1. Follow the step-by-step analysis process described in section 4.5.

2. Use the tips provided in each step to guide you in addressing the assessment requirements.

3. Remember that the systems thinking approach is an iterative and non-linear process. This

means that you will need to revisit steps and refine your answers as you progress through the

assignment.

4. Ensure that the report presents as a cohesive document. This includes, using the findings from

the iceberg and mental models to inform the causal loop diagrams.

5. Use the Assessment Rubric for Assignment 1 and 2 Document (available on Moodle) to

ensure that you have addressed all the assessment requirements.

6. Through the assessment, you are encouraged to seek early and frequent guidance from your

lecturer regarding the development of your assignments. You can find information on the

availability of the course lecturer at the course Moodle website.

7. Clearly organise your response around the tasks described in section 4.5.

8. Your response should be approximately 20 pages long, but this will vary depending on writing

style and formatting details. Responses which are unnecessarily long and vague will be scored

lower than clear and concise responses.

4.4 Resources

1. Case study description (Summary and sections 1 to 3 of this document including references).

2. Course slides and recorded modules (available on Moodle).

3. Recommended course textbooks, course readings, and course articles (available on Moodle).

4. Anylogic Software (Personal Education License), Vensim PLE, or any other mapping software.

4.5 Tasks description

Tip: Structure your response in the same order as the following tasks for a clear response to the marking criteria. Marking criteria references (OBJ-01, OBJ-02, etc.) are included in the following task descriptions for transparency and traceability.

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4.5.1 Explore the system

[OBJ-01] Explain how each of the following complexity features are applicable to KPH:

a. Many elements and interconnectedness

b. History dependence

c. Dynamic (i.e., non-linear and governed by feedback)

d. Counterintuitive

e. Policy resistant

[OBJ-02] Based on these complexity features and their applicability to KPH, address the question, “Why is a systems approach useful for analysing this System of Interest?”

Tip: Describe clearly using specific examples how you think these features manifest themselves in the KPH case study.

Tip: Read and understand the following resource prior to completing your response for this task: Sterman, J. D. (2006). Learning from evidence in a complex world. American journal of public health, 96(3), 505-514 (Available on Moodle – Week 2).

Tip: Refer to the slide pack (Week 1) on Moodle to consider the advantages of applying a systems approach in this scenario – i.e., how do the principles of systems thinking combat the complexity features?

4.5.2 Highlight the current reality

[OBJ-03] Apply the iceberg analysis to this System of Interest (select one issue stated in Section 1.1) by creating four lists, for elements at each level of the iceberg. A minimum number is specified for the structure and mental model levels in the table below.

Tip: Use the table below to present your results in the report.

[OBJ-04] In addition to the table, analyse (describe in a few paragraphs) what the iceberg is showing and give one example of how the elements are interlinked.

Tip: Consider how the policy or procedures relate to the patterns. Consider how the culture or expectation is contributing to the issue. These relationships should be further explored in the causal loop diagrams. This analysis should be consistent with the mental models described in your response to section 4.5.4.

Levels of analysis	Findings
Event level (what happened?)
Pattern level (what has been happening?)
Structure level (why?)
Mental model level (why?)

• List the key events that are caused by the issues – at a minimum, list those already provided in section 1.1. Add any additional identified by descriptions Section 3 or through your own research.

• List the issues which are causing the incidents. Describe these as relative changes in key indicators over time – at a minimum, list the those already provided in section 1.1. Add any additional identified by descriptions Section 2 and 3 or through your own research.

• List at least 5 critical pressures, such as policies, power dynamics that affect the issues – specifically, consider the policies and processes described in Section 2.

• List at least 3 underlying assumptions that influence the issues – consider the interviews responses in Section 3.

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4.5.3 Identify key issues and formulate focusing questions

[OBJ-4a] Select one issue from the below three issues identified and state the focusing question to define the analysis tasks.

Tip: Use the focusing question to bound the analysis task (i.e., the answers to these questions should be coherent between each of the sections in your response)

Tip: Frame the focusing question as a ‘why’ question.

Tip: Use the table below to present your results in the report.

Issues included in the analysis	Focusing question to be addressed through the analysis
1	Insufficient capacity at KPH
2	Inefficient processes at KPH
3	Undesirable workplace culture at KPH

4.5.4 Surface mental models about the selected issues

[OBJ-05] For the selected issue, analyse each of the stakeholders (listed in the following table) in order to describe their respective mental models that they may have about addressing the issue selected in 4.5.3. Use the theory of espoused purpose versus hidden priorities (Stroh, 2015: Chapter 6 – Available on Moodle (Week 3)) to distinguish between the public objectives stakeholders may state and the private agenda they may have to optimize their part in the system. Materials from Week 2 “Problem Actors” (Available on Moodle) will also assist you.

Tip: Use the table below to present your results in the report.

Stakeholder	Espoused purpose	Possible hidden priorities
KPH Management
Senior Doctors
Junior Doctors
Nurses
Paramedics
Patients
State Government Departments
Other ()

Tip: In the “Other” row, add any stakeholder group that you think is relevant to the issue that is not already included.

Tip: If you think a particular stakeholder group is irrelevant to the issue, highlight it as irrelevant and explain why you think so.

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4.5.5 Map issues using causal loop diagrams

For your selected issue:

1. [OBJ-06] Identify the key variables or factors that make up the selected issue by interpreting

the relationships described by Sections 1 to 3, the iceberg analysis, and mental models. For each

variable, identify which factors are internal for KPH, and which are external;

2. [OBJ-07] Apply the causal loop diagram structure to develop an issue map for the selected issue

by mapping out interdependencies among variables;

3. [OBJ-08] Identify (by labelling in accordance with good causal loop diagram mapping practices)

and explain (by way of an accompanying text description) the feedback loops depicted in the

causal loop diagram, the minimum number of feedbacks required are five.

Tip: When listing the key variables, provide this in a table and provide a definition for each variable. Tip: Use the ‘Good practices for developing CLD’ document (available on Moodle – Week 6) to reflect on the causal loop diagrams. In particular, avoid the use of vague factors (e.g., strategy) and instead, think of variables that are traceable over time. Also, name factors unambiguously; do not use unexplained acronyms.

Tip: Use the focusing question to determine if a factor is included or excluded. Remember that iteration across the CLD variables, CLD diagram, and CLD feedbacks will be necessary to achieve an appropriate and useful CLD representing your selected issue.

4.5.6 Use the issues maps to explore connections

[OBJ-09] Reflect on your selected issue map and explore possible interconnections where the additional two issues (that were not mapped) would impact upon your selected issue. Explain these connections.

Tip: You may need to add more variables/factors to see connections. In this case, justify the additions. Tip: Connections between your selected issue map and the remaining issues that appear to be unlikely, unnatural, or illogical or are not properly justified will be scored lower than those that appear to be plausible. The remaining two issues might be represented as external factors or internal factors.

4.5.7 Apply the systems archetype as a thinking tool to diagnose the selected issues

For the issue map you have developed, use two (or more) of the systems archetypes presented in the course to generate insights about the issue.

1. [OBJ-10] Identify the systems archetype(s) that can be useful for analysing the selected issue

and use that systems archetype template/structure to map the issues.

2. [OBJ-11] Analyse the archetype to infer lessons about the problem (i.e., identify logical lessons

based on these archetypes – consider the 7 steps thinking process from the Slide packs (Week

7 and 8) available on Moodle.

Tip: To identify insights, investigate feedback loops and delays. For example, the actions (in an effort to address each issue) by the individuals responding to the interview questions in section 3 will have unintended consequences.

Tip: Check the Slide packs (Week 7 and 8) available on Moodle on ways to overcome archetype dynamics and 7-step plans to use archetypes as diagnostic tools.

4.5.8 Reflect on the assessment

[OBJ-15] Analyse your experience in completing this assessment by addressing the following questions:

1. Which part(s) of this assessment you find the most difficult? Why?

2. Which part(s) of this assessment you find the least difficult? Why?

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3. Which part(s) of this assessment you find the most interesting? Why?

4. Which part(s) of this assessment you find the least interesting? Why?

5. What parts of this assessment do you think will be most useful to use outside the course?

6. How do you think your systems thinking skills (See the learning objectives in Section 4.2) have

improved after undertaking this assessment part (Yes/No)? Please support your answer with

explanation.

7. Describe any iterations on your assessment response. i.e., did you revisit any sections based on

a change or multiple changes in thinking?

Tip: Avoid using general statements about the strengths/weakness of methods (e.g., the thinking iceberg method is useful for multi-level analysis). Focus your answers on articulating your own personal experience through the analysis process.

4.6 Assessment checklist and marking guideline

Refer to Assessment Rubric for Assignment 1 and 2 Document (available on Moodle)

UNSW ZEIT8305 KPH Case Study 36

5 Assignment 2

Weight: 45%

5.1 Introduction

Refer to section 1.2 of this document.

5.2 Learning objectives

This assessment allows you to demonstrate your ability to:

1. Understand the system boundary (5.5.1)

2. Create and use Causal Loop Diagrams (5.5.2 and 5.5.3)

3. Identify multiple perspectives and possible hidden priorities (5.5.4)

4. Create and use Stock and Flow Diagrams (5.5.5)

5.3 Guidance through the assessment

To complete the assignment successfully:

1. Follow the step-by-step analysis process described in section 5.5.

2. Use the tips provided in each step to guide you in addressing the assessment requirements.

3. Remember that the systems thinking approach is an iterative and non-linear process. This

means that you will need to revisit steps and refine your answers as you progress through the

assignment.

4. Use the checklist within the Assessment Rubric for Assignment 1 and 2 Document (available

on Moodle) to ensure that you have addressed all the assessment requirements.

5. Through the assessment, you are encouraged to seek early and frequent guidance from your

lecturer regarding the development of your assignments. You can find information on the

availability of the course lecturer at the course Moodle website.

6. Clearly organise your response around the tasks described in section 5.5.

7. Your response should be approximately 20 pages long but this will vary depending on writing

style and formatting details. Responses which are unnecessarily long and vague will be scored

lower than clear and concise responses.

5.4 Resources

1. Case study description (introduction and sections 1 to 3 of this document including

references).

2. Course slides and recorded modules (available on Moodle).

5. Recommended course textbooks, course readings and course articles (available on Moodle).

3. Anylogic Software (Personal Education License), Vensim PLE, or any other mapping software.

5.5 Tasks description

5.5.1 Identify key goals and formulate focusing questions

[OBJ-04a] Select one goal from the listed three goals, and state a focusing question to guide the subsequent analysis tasks.

UNSW ZEIT8305 KPH Case Study 37

Tip: Use the focusing question to bound the analysis task (i.e., the answers to these questions should be coherent between each of the sections in your response)

Tip: Frame the focusing question as a ‘how’ question.

Tip: Use the following table to present your results in your report.

No.	Goals included in the analysis	Focusing question to be addressed through the analysis
1	Improving the capacity at KPH
2	Improving the processes at KPH
3	Changing the workplace culture at KPH

5.5.2 Map out systemic change required to achieve goals

For the goal selected:

1. [OBJ-06] Identify the key variables or factors that make up the goal issue by considering the two

systemic theories of change (success amplification theory and correct an existing situation;

Stroh, 2015: Chapter 11 – Available on Moodle (Week 12)) to introduce the dynamics of

reinforcing and balancing loops. For each variable, identify which factors are internal for KPH,

and which are external.

2. [OBJ-07] Apply the causal loop diagram structure to develop a roadmap for the selected goal

issue by mapping out interdependencies among the variables/factors.

3. [OBJ-08] Identify (by labelling in accordance with good causal loop diagram mapping practices)

and explain (by way of an accompanying text description) the feedback loops depicted in the

causal loop diagrams, as a minimum five feedbacks should be identified. The causal loop

diagram represents a roadmap for the future.

Tip: When listing the key variables, provide this in a table with a definition of each variable

Tip: Use the ‘Good practices for developing CLD’ document (available on Moodle – Week 6) to reflect on the causal loop diagrams. In particular, avoid the use of vague factors (e.g., strategy) and instead, think of variables that are traceable over time. Also, name factors unambiguously; do not use unexplained acronyms.

Tip: Use the focusing question to determine if a factor is included or excluded.

Tip: Take time delay into account.

Tip: Think of how to use the systems archetypes to predict the KPH system behaviour.

5.5.3 Use the future roadmap to explore connections and identify leverage points

[OBJ-09] Analyse one roadmap to explore possible interconnections among the selected goal map, and the remaining goals that have not been mapped. For example, identify where the remaining goals might impact upon the selected goal map you have developed.

Explain the connections between roadmap and the remaining goals. Investigate the roadmap to identify leverage points to achieve goals.

Tip: You may need to add more variables/factors to see connections. Justify your additions.

Tip: Connections between maps that appear to be unlikely, unnatural, or illogical will be scored lower than those that appear to be plausible.

UNSW ZEIT8305 KPH Case Study 38

5.5.4 Surface mental models about the proposed systemic change

[OBJ-05] For the selected goal, analyse each of the stakeholders (listed in the following table) in order to describe their respective mental models about the proposed change which may inhibit or promote the proposed change and unanticipated effects. For those perceptions which may inhibit the change, propose possible actions that KPH can take for the stakeholder group to be promoting the change instead (i.e., aligned with the proposed change).

Tip: Use the following table to present your results in the report.

Tip: In the “Other” row, add any stakeholder group that you think relevant to the goal issue that may not be already included.

Tip: If you think a particular stakeholder group is irrelevant to the systemic change, highlight as irrelevant and explain why you think so.

Stakeholder	Mental models	Will these perceptions inhibit or promote change? How?	Possible actions that KPH can take to align mental models with the proposed change
KPH Management
Senior Doctors
Junior Doctors
Nurses
Paramedics
Patients
State Government Departments
Other ()

5.5.5 Visualise the physics of the proposed change and leverage points

1. [OBJ-12] In preparation of creating a stock and flow diagram for the selected goal, identify,

define, and classify variables according to their function in the system (i.e., stocks, flows), and

their unit of measurement. Present this in a table format. Consider the results from tasks

described by section 5.5.3 and 5.5.4 above.

2. [OBJ-13] Using the Systems Dynamics library in the Anylogic Software (Personal Education

License), or Vensim create a stock and flow diagram for the selected goal to visualise the

mechanics of achieving the stated goal. Identify clearly on the diagrams flows what will be

targeted to achieve the desirable change.

3. [OBJ-14] Analyse the stock and flow diagrams to describe (in 1 to 2 paragraphs) the flows and

variables to be targeted to achieve the selected goal.

Tip: Remember that stocks and connected flows MUST have the same units.

UNSW ZEIT8305 KPH Case Study 39

5.5.6 Reflect on the assessment

[OBJ-15] Analyse your experience in completing this assessment by addressing the following questions:

1. Which part(s) of this assessment you find the most difficult? Why?

2. Which part(s) of this assessment you find the least difficult? Why?

3. Which part(s) of this assessment you find the most interesting? Why?

4. Which part(s) of this assessment you find the least interesting? Why?

5. What parts of this assessment do you think will be most useful to use outside the course?

6. How do you think your systems thinking skills (See the learning objectives in Section 5.2) have

improved after undertaking this assessment part (Yes/No)? Please support your answer with

explanation.

7. Describe any iterations on your assessment response. i.e. did you revisit any sections based on

a change or multiple changes in thinking?

Tip: Avoid using general statements about the strengths/weakness of methods (e.g. the thinking iceberg method is useful for multi-level analysis). Focus your answers on articulating your own personal experience through the analysis process.

5.6 Assessment checklist and marking guideline

Refer to Assessment Rubric for Assignment 1 and 2 Document (available on Moodle)

I always seek to improve the course content and methods. To achieve this, I conduct research with the aim of understanding what worked, what did not work, and why. I use the course assessment to understand how students receive the course, and if (and how) the course achieves its intended outcome. Part of the research process is publishing peer-reviewed research articles making use of the collected data through the course assessment. No individuals will be identified, and data is only being shared with my research team. If you wish to know more details about this, please send me an email. If you don’t wish your assessment be used part of the research dataset, please explicitly state this at the end of your assessment, or simply send me an email to express your preference.