Systems Thinking in Healthcare — The Hogeweyk case
During my last academic years, I came across the idea of “Systems Thinking” in the context of social sciences. The first time I heard about this concept, I was very confused, relieved, and astonished: how can such an influential and essential idea is not widely expressed in every corner of society? Why do we do the same things over and over but end up very frustrated when we get the same results?
During my research through educational videos and articles, I’ve started to understand this idea a bit more and, as time goes by, I get even more confused, relieved and astonished by the way we, as a human species, work. And I think these feelings are never going to change the more I dig deeper into this issue.
A good way to understand things, I believe, is through examples and that’s exactly what this article is about: how can we understand systems thinking in the context of health care?
Topics:
- What is Sytems Thinking? And why is it relevant?
- Systems Thinking in Healthcare
- What is dementia — in a nutshell?
- What is The Hogeweyk?
- Why is it innovative?
- Important concepts about this structure
Have fun!
1. What is Sytems Thinking? And why is it relevant?
Systems thinking is a way of looking at the world. Let’s understand that on a practical level: fix your gaze on this red ‘dots’ below and, without moving your eyes, try to explore the environment you are in — your room, for example. Do that for 5 seconds.
It seems a bit blurred, doesn’t it…
Now, explore the same environment moving your eyes, your head, and even your whole body (take 10 more seconds to do that).
How different does it feel to move your eyes, adjust the focus while you are looking at objects around you, and explore different colors, textures and distances? It even seems like you are in a completely different environment, much bigger and with way more possibilities compared to the first part of this exercise. Well, that’s the power of systems thinking.
“I still don’t get what you mean…”
In a nutshell, systems thinking is a new way of looking at the world, it is a new paradigm. It is a comprehensive way of observing situations and events, putting them in perspective, and understanding the relationship between the elements and the whole structure they are an inherent part of. While in the first part of the activity our grasp of the details in the room as a whole was very low, in the second, the explosion of information, details and, ultimately, opportunities to explore around was way greater than before .
We can think of the first part of this activity as the exploration of the “linear” way of thinking while the second part is the representation of the potential of “systems thinking”.
Michael Goldman summarizes well this idea when he states that Systems Thinking is “an awareness of the role of structure in creating the conditions we face; a recognition that there are powerful laws of systems operating that we are unaware of; a realization that there are consequences to our actions that we are oblivious to” [1].
When faced with a problem, we can use systems thinking to question not just the observable phenomena and events we are confronted with but to go deeper and question the whole structures of the problems in itself: rather than just asking ‘how’, we start asking ‘why’. The well-known “iceberg” model is a great tool and representation of the potential the “systems thinking” approach can offer when we are confronted with problems that seem to repeat themselves or seem to have no solution at all.
This is important because it widens our perception and, with that, gives us more possibilities to understand the current situation, opening up a range of opportunities to tackle the problem in completely new ways.
2. Systems Thinking in Healthcare
The Hogeweyk case is a great way to understand the difference between linear thinking and systems thinking in practice. But first, to understand more about the whole idea behind this initiative, we should define what is dementia.
What is dementia — in a nutshell?
Dementia can be defined as “a syndrome associated with an ongoing decline of brain functioning” [2] and the most apparent symptom of this syndrome is memory loss. Some people may lose interests in activities they once enjoyed doing and may not recall a familiar face.
This is a challenging situation not only for the people that acquire this condition but also for the close ones — family, friends, and caregivers. Dementia as well as other mental health conditions are what we call “complex” challenges. As the syndrome progresses, the person will need full-time assistance and care, meaning that home care may not be enough for the majority of situations. Therefore, for several reasons, institutionalization may seem the only way forward for the majority of cases.
However, the conditions of mental health institutions are, in general, not ideal since the treatment can be very standardized and impersonal, which imposes big challenges for the person’s quality of life and, consequently, becomes very detrimental to their own health.
What are the alternatives to this scenario? Is it possible to use systems thinking principles to rethink the quality of care for the ones who experience dementia?
Here is the innovative approach found in The Hogeweyk.
What is The Hogeweyk?
The Hogeweyk [3] is a facility for people with severe dementia located in the Netherlands, popularly known as “dementia village” [4]. Rather than being limited by 4-colorless walls, the institution was designed to resemble a small village, with shops such as barber shops, restaurants, and supermarkets and with people walking around these areas.
The fundamental principle taken into account was the “humanizing care for the growing numbers diagnosed with dementia”, meaning that instead of looking at dementia with the same perspective as other institutions, The Hogeweyk started to understand the problem differently — in a systemic way.
Using a traditional approach to tackling this issue is to see the person as a problem to be cured and to be isolated in order to be analysed. This dehumanization of the person suffering a severe condition doesn’t help to understand the problem and, even worse, adds detrimental elements to the issue, such as isolation and a lack of sense of belonging. In the words of Ely van Hal, one of the founders of “The Hogeweyk”, [in the traditional nursing health care institutions] there’s not much attention to who you really are. What’s my life’s story, who am I, what do I prefer to do during the day” [5] are questions completely disregarded. In an attempt to try to help the person, the traditional institutions miss the very fundamental point they started with.
Why is it innovative?
The Hogeweyk changes the whole way they understand the issue in the first place: they don’t start with the ‘illness’, they start with the person who is in front of them. On their website, it states [they] ‘strongly believe in the deinstitutionalization of care and the need to emancipate people living with dementia and include them in society.’ ‘Living in The Hogeweyk' puts boredom, loneliness and hopelessness in another perspective. It focuses on possibilities, not on disabilities”
There is no cure for dementia and as the disease progresses, the best thing any institution/professional/person can do is to ensure a good quality of life for the elderly rather than pathologizing the situation and adding labels to the condition as it moves forward. And that’s where “The Hogeweyk” got it right: shifting the mindset around this issue requires seeing the whole context in which the person is involved — from each one’s private room to the public outdoor space they are involved in. It requires observing how to merge healthcare and community lifestyle, balancing public and private spaces as well as an attentive and close look without constraining their sense of freedom.
And the idea of restructuring the whole design of the institution to resemble a village is a brilliant idea.
Important concepts about this strucure:
- Family-feel: Separating the “all in one space” mindset, found in traditional institutions, to one that separates people into smaller groups, resembling the number of people you normally find in a household, giving more privacy for the residents.
- Identification of groups with similar interests: On top of creating environments where people live with 5 or 6 other members, house colleagues are selected by their worldviews, lifestyle, likes and needs. Yvonne van Amerongen, a dementia care advocate and healthcare advisor who helped develop the program, mentions that this type of selection helped bring together people with similar perspectives so they could have a good and real possibility of becoming friends when living together [6].
- Adaptation of rooms: each room is redesigned to fit the needs of their residents — light that mimics natural light regulates residents’ circadian rhythm and acoustic ceilings and rugs absorb noises that trigger disorientation, for example.
- The facility looks like the outside world: Public spaces were created to give a sense of a community where people actually live. The addition of cinema, pubs, grocery shops and parks gives a sense of freedom that people wouldn’t experience in traditional institutions. The shops are strategically organised in a way that people have the possibility to walk around, see others and have conversations.
- All the facility professionals and volunteers are prepared: Everyone that works in the institution, from the bartenders and gardeners to managers and nurses, is equipped with enough knowledge and training to be able to interact with them in the most natural way possible and, of course, be aware if they need any specific support.
To finish off this article, I believe the power of thinking differently about this pressing and chronic issue of dementia healthcare is a very good example of not just the application of systems thinking in reality but that, yes, it is possible to improve people’s quality of life if we just look at things in another way.
As Yvonne van Amerongen says “It has to do with thinking differently, looking at that person in front of you and looking at what this person needs, now” [7]. This is the essential idea about systems thinking: reframing the way you look at the challenge in front of you will open possibilities to new ways of perceiving a possible alternative to it. Once we think differently, we can act differently.
