Critical Systems Thinking

The report analyses the value stream map of the emergency department of a public hospital. The main drawback of the current value stream map is that the patients are waiting for a long time for emergency medication. Limits to growth, shifting the burden, eroding goals, escalation, success to the successful, tragedy of commons, fixing the fails and growth and underinvestment models are utilised to establish the argument. A new value stream map has also been discussed which can be used to solve the performance issues of the staff.

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Critical System Thinking

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Executive summary
The report analyses the value stream map of the emergency department of a public hospital.
The main drawback of the current value stream map is that the patients are waiting for a long
time for emergency medication. Limits to growth, shifting the burden, eroding goals,
escalation, success to the successful, tragedy of commons, fixing the fails and growth and
underinvestment models are utilised to establish the argument. A new value stream map has
also been discussed which can be used to solve the performance issues of the staff.

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Table of Contents
Executive summary....................................................................................................................2
Table of Contents.......................................................................................................................3
Introduction................................................................................................................................4
Analysis......................................................................................................................................5
Impact of different systems of archetypes on different systems of hospital and emergency
department..............................................................................................................................5
Identification and analysis of the different kinds of system archetypes which impede
performance standard.............................................................................................................5
Limits to growth.................................................................................................................6
Eroding goals.....................................................................................................................7
Escalation...........................................................................................................................7
Success to the successful....................................................................................................8
Tragedy of commons..........................................................................................................8
Fixes and fails....................................................................................................................9
Growth and underinvestment.............................................................................................9
Recommended new state value stream map reducing the turnaround time...........................9
Intended and unintended consequences of the system.........................................................12
Recommendations....................................................................................................................13
Conclusion................................................................................................................................14
References................................................................................................................................15
Appendices...............................................................................................................................17

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Introduction
The emergency department of a hospital is driven to fulfil the primary goal of serving quality
services to its customers. To enforce this objective the hospital management has to engage
the staff in effective operations management to produce the desired outcomes. Operations
management uses certain tools such as the service package, the service process, management
tools, and quality management tools. The report deals with the case study of an emergency
room which has a primary drawback of keeping the patients waiting for a longer time span.
The hospital follows a particular value stream map to manage the operations of the
emergency department. The report aims to analyse various models which can be implemented
in the workings of the emergency department to decrease the waiting time of the patient
without degrading the quality of services provided by them.The report will include some
recommendations to improve the value stream mapping to speed up the operations of the
staff.

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Analysis
Impact of different systems of archetypes on different systems of hospital and
emergency department
System archetypes are utilised to analyse the organisational structure and its link with
organisational behaviour. Different kinds of archetype system can be utilised and
implemented in hospital and emergency departments to provide more patient centric care.
Archetypes develop a systematic way to strategies and develop a plethora of problems in the
hospital. For example- lack of proper infrastructure, inadequate space for patients movement
or lack of quality care. Different kinds of archetypes address the issues and resolve stresses.
The problems of emergency department are identified initially. Then, solutions are developed
founded on it. For example- if the communication system in emergency department is not
properly developed, system archetype first analyse all potential barriers of communication
and resolve accordingly.
Identification and analysis of the different kinds of system archetypes which impede
performance standard
The system archetypes are effective tools to evaluate the behavioural pattern and reflective
structure of the organisational infrastructure. Archetype systems can be applied in two
separate aspects which include diagnostic application and prospective application. Both types
of application are utilised to measure the performance standard of the staff and their
departments. Archetypes systems can be utilised to improve the existing system of the
emergency room, performance standard and information flow of hospital. The efficiency of
archetypes lays in a basic remedial structure which is utilised to develop emergency
department of hospital. The role of emergency department of a hospital is to provide
diagnosis to patients referred from primary healthcare with some serious issue where one has

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to make a decision for patient admission and enquire safety measures of all departments of
hospital. Archetypes generally find a common way to look into the behavioural outcome of
organisations. There are eight types of archetypes which can be effective to impede the
performance standard (Winkel et al., 2015). The types are Limits to growth, shifting the
burden, eroding goals, escalation, success to the successful, tragedy of commons, fixing the
fails and growth and underinvestment. Archetypes can be implemented to develop diagnostic
prospectively. The principles can be used to examine problems and ways to deal with it.
Moreover, the principles of prospective archetypes can be used for the betterment of the
treatment process.
Limits to growth
Limits to growth evaluate that several factors always try to limit the growth of positive
reinforcing behaviour. For example- limiting growth is capable to evaluate operational
limitations of performance growth of the emergency department of a hospital.
Dynamic theory
In the dynamic theory, archetypes determine the reinforcement of accelerating growth. It
determines the growth of external factors which increases the limitations of the behavioural
process. The continual efforts of growth acceleration diminish return as a limiting approach.
Identified limitations of handling healthcare emergency can be successfully achieved by
 Focusing on the fundamental situations: The focus on fundamental situations can be
monitored by providing a symptomatic solution. In this case, the situation of the
emergency room and the patient’s waiting time can be provided with an indirect or
indicative solution for emergency handling through briefing the staff regarding the
average time a patient has to wait at the emergency room and also by explaining them
the importance of reducing the time span of the wait.

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 Eliciting multiple viewpoints: eliciting multiple viewpoints differentiates
fundamental symptoms and symptomatic solutions. In the scenario, the undeveloped
situation of the emergency room including patients’ waiting time can be observed by
depicting the fundamental symptoms responsible for the delay.
 Using advanced archetypes: The use of advance archetype can be utilised to address
the side effects. As per the given scenario, the possible impact of improving the
process for patient waiting in the emergency room can be evaluated by this process
such as lack of staff in other departments, poor performance outcome etc.(Henrique et
al., 2016).
However, the ‘limits to growth’ model is a time-consuming improvement process. This
aspect of archetype cannot be adopted for quick improvement.
Eroding goals
Eroding goals is a shift of burden and tension between the symptomatic solutions. In this
case, managers force their employees to develop their performance which ultimately fails. A
rational change in the objectives is the ultimate goal of this archetype aspect. Linking with
the scenario, it can be stated that the emergency department of the hospital cannot be
improved forcefully as it may not maintain the required quality. A steady and effective step
can be beneficial to improve existing situations of eroding goals (Bal et al., 2017).
Escalation
Escalation archetype is irony management which escalates harmful behaviour and reduce
consumer satisfaction. As per the given scenario, the patient waiting time in the emergency
department must be improved along with fulfilling all other requirements such as,
development of hospital records, attending nurses and attending physicians. Thus, the
escalation process cannot be utilised to improve standing situations of the emergency
departments.

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Success to the successful
Success to the successful archetype depicts the common practices which can be utilised to
develop performance level through the reward and recognition process. Moreover, this
archetype requires sufficient resources o improve its existing performance level.
Improvement of existing performance depends on the capabilities of organisational staffs to
utilise resources. The value of success to successful archetype is to raise questions regarding
previous performance gaps. The questions on previous performance gap help to reduce the
performance hazards which can be beneficial for overall performance development
(Kingsnorth et al., 2015). Hence, in the emergency department of the hospital, the patient
waiting time should be improved by evaluating previous performance gaps of the emergency
department and its staff. This archetype can be utilised to improve the waiting time in the
emergency department. However, this archetype is time-consuming and requires a detailed
analysis of the previous performance records (Nallusamy, 2016).
Tragedy of commons
A tragedy of commons is a set of organisational resources which includes human resources,
materialistic resources and tools resources. This archetype focuses on team sharing to satisfy
the goals and objectives set for each team. Expectations and demands for common
departments increase with the expansion of the team and its individuals. Teams do not have
sufficient awareness regarding the increase of demand from the consumers (De Steur et al.,
2016). Thus, the sharing of information among common departments and resources is
essential to improve the situation of the emergency department of the hospital. Moreover, the
Tragedy of Commons is helpful in evaluating reduction is thinking. It determines the adverse
impact of unawareness about the information among the team members. Information can be
shared by evaluating quality care in the emergency department, recording improvement levels
of each patient, number of times nurses attend patients, the capability of nurses in providing

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medical supplies and ways through which doctors take care of patients. The tragedy of
common archetypes can be adapted to impede the performance (Provost et al., 2015).
Fixes and fails
Fixes and fails can be stated as an updated version of the shifting of the burden. This type of
archetype evaluates that managerial symptoms and should be primarily evaluated to identify
issues rather than finding difficulties in all the problems associated with the system. The
consequences of fix and fails are an unintended quick fix all functions of problem
symptoms(Chandler et al., 2016). This model also evaluates the adverse situations created
after the application of the fixing strategy. The current scenario of emergency department
cannot be improved by fix and fails as this archetype does not provide any solution to issues
which can develop existing issues of the emergency department.
Growth and underinvestment
Growth and underinvestment archetype limits growth by evaluating the need for investments
in resources. It follows a process of growing action, current demand, current performance
evaluation, and requirement of investment, the capacity of investment capacity to grow.
Apart from that, a performance standard can also be included in the stage requirement of
investment. Growth and underinvestment focus on the long-term requirement and core
competency for competitive development. This archetype cannot be adopted to improve the
patient waiting time as this focuses on the external development instead of internal
infrastructure development (Rani et al., 2018).
Recommended new state value stream map reducing the turnaround time
The value stream model is a flow chart which evaluatesthe flow of inventory and information
system of an organisation.The current steam value mapping of the hospital did not have an
effective design to communicate with the referred patients and was incapable to deliver quick
information. Patients need to wait long in queues which results in poor consumer experience.

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Moreover, the Existing value chain map of the hospital was hazardous as there was no
equivalent spreading of information amongst the teams (Dako et al., 2018). This was the
ultimate reason for the improvement of patient wait times.
Steps to improve value chain mapping areCurrent state, future state and next future
state
The required principles to improve value stream mapping is as follows:
 Specification of the value from consumer’s end
 Identification of value stream for each emergency medical service
 Making of service flow
 Pulling the flow from consumers’ end
 Perfection management
Figure: Value stream map
Source: Created by Researcher
The value stream map focuses on the value expectations which include price determination,
quality determination, and determination of reliability and response to change. Symbols play
effective roles in developing value streaming map. For example- some symbol indicates the

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consumer or supplier, some symbol indicates process flow and some symbol indicates work
cell icon.
Figure: Value stream mapping symbol
The future value stream mapping for developing the emergency department and for
improving information flow should be free from operational hazards. Moreover, it must
improve the existing situation of the emergency room. The proposed value stream map
should be as below:
Figure: Proposed value stream map
Source: Matharu, 2012

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The value stream map for emergency room of the hospital is helpful in allowing ‘‘ITEMS''
flow. It defines:
 Development and designing of proposed value stream map
 Understanding of internal consumers’ need
 Understanding of external consumers’ need
Hence, development of a value stream map is capable to provide a proper infrastructure for
the patients' wait time. The development of infrastructure can improve existing situations of
an emergency room to manage and handle inpatient admissions and reduce long waiting time.
The improvements must be localised to analyse strengths, visions and plans of improvement
activities. A value stream mapping can be considered as an effective tool to address the
operational issues and propose changes for issues (Wysocki, 2004).
Intended and unintended consequences of the system
As per the given scenario, unintended consequences evaluate the efficiency of the archetype
system to develop emergency room. The unintended consequences of the various type of
archetype system are as follows:
 Fixes that fail is quickly fixed into motion and ends up adding some more issues and
symptoms
 Shifting the burden has developed side effects by harming the initial system solution
 Limits to success slow the growth of performance standard
 Eroding goals decline the system performance
 Growth and under investment slows the demand validating
 Success to successful allocates resources disproportionately
 Escalation archetype escalates retaliation
 Tragedy of commons shuts down the activities of all parties

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Recommendations
The holistic solution of issues of emergency department depends on developing loopholes of
different system archetypes. The required changes in system archetypes are potential limits
and balancing scoops that should be identified to develop limits to growth. As well as, all the
quick fixes should be mapped properly to keep issues under control and a clear transition plan
should be developed to influence performance in eroding goals. Escalation trap must be
avoided by building a collaborative competition. Moreover, the performance gaps must be
scanned at a regular interval. All the central focal points must be determined by sharing
visions, measuring systems and allocating resource base needs in the case of the tragedy of
commons. As well as, a diversified investment input must be searched to seek new
perspectives of products and services. These changes can bring potential growth to system
archetypes which can develop emergency department of hospital.

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Conclusion
The public hospital is dealing with the main issue of longer waiting time in the emergency
department. This issue is hampering the image of the hospital. So, the hospital authorities are
willing to bring in some reforms to reduce the waiting time without bringing down the
quality. The report analysis various models such as the dynamic theory, fixes and fails and so
on to understand their suitability to solve the issues of the hospital. A critical analysis of the
current value stream map has also been provided along with some recommendations to deal
with the issues.

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References
Bal, A., Ceylan, C., and Taçoğlu, C. (2017) Using value stream mapping and discrete event
simulation to improve efficiency of emergency departments, International Journal of
Healthcare Management, 10(3), pp.196-206.
Chandler, J., Rycroft‐Malone, J., Hawkes, C., and Noyes, J. (2016) Application of simplified
Complexity Theory concepts for healthcare social systems to explain the implementation of
evidence into practice, Journal of advanced nursing, 72(2), pp.461-480.
Dako, F., Cobb, R., Verdi, S., Grygorenko, M., Patel, T., Zink, R., and Belden, C. (2018) Use
of value stream mapping to reduce outpatient CT scan wait times, Journal of the American
College of Radiology, 15(1), pp.82-85.
De Steur, H., Wesana, J., Dora, M. K., Pearce, D., and Gellynck, X. (2016) Applying value
stream mapping to reduce food losses and wastes in supply chains: A systematic
review, Waste management, 58, pp.359-368.
Henrique, D. B., Rentes, A. F., Godinho Filho, M., and Esposto, K. F. (2016) A new value
stream mapping approach for healthcare environments, Production Planning &
Control, 27(1), pp. 24-48.
Kingsnorth, S., Lacombe‐Duncan, A., Keilty, K., Bruce‐Barrett, C., and Cohen, E. (2015)
Inter‐organizational partnership for children with medical complexity: the integrated complex
care model, Child: Care, Health and Development, 41(1), pp.57-66.
Nallusamy, S. (2016) Lean manufacturing implementation in a gear shaft manufacturing
company using value stream mapping. In International Journal of Engineering Research in
Africa, 21, pp. 231-237.

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Provost, S. M., Lanham, H. J., Leykum, L. K., McDaniel Jr, R. R., and Pugh, J. (2015) Health
care huddles: Managing complexity to achieve high reliability. Health Care Management
Review, 40(1), pp. 2-12.
Rani, S., Ahmed, S. H., and Shah, S. C. (2018) Smart health: a novel paradigm to control the
chickungunya virus, IEEE Internet of Things Journal, 31(2), pp. 41-53.
Winkel, J., Edwards, K., Birgisdóttir, B. D., Jarebrant, C., Hanse, J. J., Gunnarsdóttir, S., and
Ulin, K. (2015) A Nordic evaluation of a work environment complement to Value Stream
Mapping for increased sustainability of patient flows at hospitals-The NOVO Multicentre
Study I, In 9th Novo symposium. Sør-Trøndelag University College, 22(3), pp. 77-91.
Wysocki, B. (2004) To fix health care, hospitals take tips from factory floor, Wall Street
Journal, 4(2), pp. 89-99.

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Appendices

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