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Open Access Highly Accessed Research article

An effectiveness analysis of healthcare systems using a systems theoretic approach

Sheuwen Chuang1* and Kerry Inder2

Author Affiliations

1 Health Services Research Group, University of Newcastle, 3rd floor, David Maddison Building, Cnr King and Watt St, Newcastle, NSW, 2300, Australia

2 Centre for Clinical Epidemiology & Biostatistics, University of Newcastle, 3rd floor, David Maddison Building, Cnr King and Watt St, Newcastle, NSW, 2300, Australia

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BMC Health Services Research 2009, 9:195  doi:10.1186/1472-6963-9-195

Published: 24 October 2009



The use of accreditation and quality measurement and reporting to improve healthcare quality and patient safety has been widespread across many countries. A review of the literature reveals no association between the accreditation system and the quality measurement and reporting systems, even when hospital compliance with these systems is satisfactory. Improvement of health care outcomes needs to be based on an appreciation of the whole system that contributes to those outcomes. The research literature currently lacks an appropriate analysis and is fragmented among activities. This paper aims to propose an integrated research model of these two systems and to demonstrate the usefulness of the resulting model for strategic research planning.


To achieve these aims, a systematic integration of the healthcare accreditation and quality measurement/reporting systems is structured hierarchically. A holistic systems relationship model of the administration segment is developed to act as an investigation framework. A literature-based empirical study is used to validate the proposed relationships derived from the model. Australian experiences are used as evidence for the system effectiveness analysis and design base for an adaptive-control study proposal to show the usefulness of the system model for guiding strategic research.


Three basic relationships were revealed and validated from the research literature. The systemic weaknesses of the accreditation system and quality measurement/reporting system from a system flow perspective were examined. The approach provides a system thinking structure to assist the design of quality improvement strategies. The proposed model discovers a fourth implicit relationship, a feedback between quality performance reporting components and choice of accreditation components that is likely to play an important role in health care outcomes. An example involving accreditation surveyors is developed that provides a systematic search for improving the impact of accreditation on quality of care and hence on the accreditation/performance correlation.


There is clear value in developing a theoretical systems approach to achieving quality in health care. The introduction of the systematic surveyor-based search for improvements creates an adaptive-control system to optimize health care quality. It is hoped that these outcomes will stimulate further research in the development of strategic planning using systems theoretic approach for the improvement of quality in health care.