Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis

Published in


Komashie A., Ward J., Bashford T., et al. Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis. BMJ Open. 2021;11:e037667.


  • 21 June 2023


Why it matters

In engineering and design, taking a systems approach to improvement has been shown to be successful. Over the past two decades, there has been a growing recognition of the potential value of a systems approach to healthcare improvement. However, the evidence for this type of approach in healthcare improvement has not previously been systematically reviewed.

It is difficult to define what is meant by a systems approach. For our study, we used the working definition informed by Clarkson et al, “A systems approach to healthcare improvement is a way of addressing health delivery challenges that recognises the multiplicity of elements interacting to impact an outcome of interest and implements processes or tools in a holistic way.”

This definition includes perspectives on people, systems, design and risk in a way that is applicable to healthcare systems across all scales, from local services to organisational and national policy levels.

Our approach

We systematically reviewed the evidence base for a systems approach to healthcare design, delivery or improvement.

For our review, we searched databases of academic research for relevant research papers. We included published studies involving any patients in any healthcare setting where a systems approach was compared with usual care or a non-systems approach, and which reported numerical results for both groups for any outcomes relevant to the study being conducted. The analysis and results are based studies up to May 2019.

Project findings

We initially identified 11,405 records and following a careful selection process, 35 studies were included in the review.

The interventions being studied were diverse and there was a lot of variation in the types of outcomes they reported. There was also considerable diversity in how a systems approach was conceptualised and implemented. The quality of the studies also varied widely. However, almost all results showed a benefit for using a systems approach.

Most of the factors reported as contributing to success were related to people, such as engaging with stakeholders, enhancing communication, adopting a collaborative approach, or patient-centredness.

Our study suggests that a systems approach to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. Existing systematic reviews have not been comprehensive enough and have lacked focus on patient and service outcomes.

As this is the first review to combine the published evidence base for a systems approach, and to support further research and increased practice of a systems approach in health and care, policy-makers need to understand the evidence base. Our review may be helpful to policy-makers who have found the argument for a systems approach appealing but want to see the evidence of what difference such an approach can make to patient and service outcomes. Individually, the research papers we review are also examples of the real-world application of a systems approach to healthcare improvement.

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