Combining soft systems methodology, ethnographic observation and discrete-event simulation: A case study in cancer care

Why it matters

Understanding complex problems in healthcare and finding solutions often requires using several different approaches. But we don’t always know how these approaches fit together.

Take the case of the outpatient oncology department at a large French hospital. Demand for services was growing, efficiency was low, and patients were experiencing long wait times. Looking for ways to improve patient flows, researchers combined three approaches: discrete-event simulation (DES), soft systems methodology (SSM), and ethnographic observation.

DES is an approach from operational research that uses computer simulation to model complex systems as series of events. SSM is a structured way of thinking about problems and finding solutions that is also common in operational research. And ethnography is an approach from the social sciences that involves closely observing participants to understand why things happen the way they do.

Though operational researchers have combined DES and SSM before, they have rarely been used together throughout an entire project. Adding ethnography further distinguishes the project, and using these methods across multiple departments – the outpatient unit where chemotherapies are delivered and the pharmaceutical unit that prepares the drugs – makes it especially unique.

By describing a mixed-method case study aimed at improving patient flows, this paper looks at how SSM and DES can be combined in practice, and how ethnographic observation can complement these approaches.

What we found

• The project showed the promise of combining different approaches from operational research (DES and SSM) and from social sciences (ethnography).
• Each of the three methods showed specific benefits for the project.
  • SSM provided a flexible and useful framework to integrate other methods.
  • Ethnographic observation revealed aspects of the care process that were taken for granted by practitioners, and may not have surfaced in interviews. It also helped the analyst build rapport with staff at the hospital.
  • DES provided quantitative scenarios to support decisions, without having to make any changes to actual processes.
• Working across two departments brought forward solutions that would not have been possible by looking only at one department.
• This kind of mixed methods approach requires a long involvement in the field, and further evaluation on costs and benefits is required to understand in which cases it would be most useful.

Related content from our open-access series, Elements of Improving Quality and Safety in Healthcare