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R E S E A R C H A R T I C L E Open Access
Change and improvement 50 years in the
making: a scoping review of the use of soft
systems methodology in healthcare
Hanna Augustsson
1,2*
, Kate Churruca
1
and Jeffrey Braithwaite
1
Abstract
Introduction: Improving the quality of healthcare has proven to be a challenging task despite longstanding efforts.
Approaches to improvements that consider the strong influence of local context as well as stakeholders’differing
views on the situation are warranted. Soft systems methodology (SSM) includes contextual and multi-perspectival
features. However, the way SSM has been applied and the outcomes of using SSM to stimulate productive change
in healthcare have not been sufficiently investigated.
Aim: This scoping review aimed to examine and map the use and outcomes of SSM in healthcare settings.
Method: The review was based on Arksey and O’Malley’s framework. We searched six academic databases to
January 2019 for peer-reviewed journal articles in English. We also reviewed reference lists of included citations.
Articles were included if they were empirical studies focused on the application of SSM in a healthcare setting. Two
reviewers conducted the abstract review and one reviewer conducted the full-text review and extracted data on
study characteristics, ways of applying SSM and the outcomes of SSM initiatives. Study quality was assessed using
Hawker’s Quality Assessment Tool.
Result: A total of 49 studies were included in the final review. SSM had been used in a range of healthcare settings
and for a variety of problem situations. The results revealed an inconsistent use of SSM including departing from
Checkland’s original vision, applying different tools and involving stakeholders idiosyncratically. The quality of
included studies varied and reporting of how SSM had been applied was sometimes inadequate. SSM had most
often been used to understand a problem situation and to suggest potential improvements to the situation but to
a lesser extent to implement and evaluate these improvements.
Conclusion: SSM is flexible and applicable to a range of problem situations in healthcare settings. However, better
reporting of how SSM has been applied as well as evaluation of different types of outcomes, including
implementation and intervention outcomes, is needed in order to appreciate more fully the utility and contribution
of SSM in healthcare.
Keywords: Soft systems methodology, Healthcare, Change management, Participation, Collaboration, Stakeholders
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* Correspondence: hanna.augustsson@mq.edu.au
1
Centre for Healthcare Resilience and Implementation Science, Australian
Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd,
North Ryde, Sydney, NSW 2109, Australia
2
Procome research group, Medical Management Centre, Department of
Learning, Informatics, Management and Ethics, Karolinska Institutet,
Stockholm, Sweden
Augustsson et al. BMC Health Services Research (2020) 20:1063
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Strengths and limitations of this study
The review was conducted in accordance with
Arksey and O’Malley’s framework for scoping
reviews and the Preferred Reporting Items for
Systematic reviews and Meta-Analyses extension for
Scoping Reviews (PRISMA-ScR) guidelines.
The scoping methodology allowed information from
a broad range of studies, using different designs and
methods, to be included and synthesised.
The findings highlight gaps and future directions for
research on the use of soft systems methodology in
healthcare.
The review was limited to peer-reviewed articles and
English-speaking literature.
Although it provides insights into use, the review
does not provide a definitive account of the
effectiveness of soft systems methodology.
Background
Despite longstanding efforts to improve the quality of
healthcare, increasingly there is a recognition of dimin-
ishing returns despite the considerable investments
made [1]. This is because many of the most pressing is-
sues in healthcare improvement—including integration
of services [2,3], culture change [4], and treating pa-
tients with chronic diseases [5]—resist easy solutions.
These are all examples of messy, multi-faceted “wicked”
problems in that they “have incomplete, contradictory,
and changing requirements and complex interdependen-
cies that are often unique to the local setting of the
problem”[6]. Multiple stakeholders are involved in
wicked problems and typically have very different under-
standings of the situation as well as its solution.
It is not just the problems that are complex; healthcare
systems are also increasingly understood as complex
adaptive systems in that they are comprised of diverse,
interconnected agents (e.g., patients, clinicians, hospital
managers, government policymakers) whose localised in-
teractions over time give rise to emergent, system-level
behaviours [7,8]. Such systems are considered to be
more than the sum of their parts; although we may be
able to discern patterns in the behaviour and perform-
ance of the healthcare system as a whole, the agents that
comprise it always inevitably act locally, and are inter-
dependent with those around them. Trying to change or
improve some aspect of the system, then, must begin
with consideration of this local context [9].
In complexity thinking, many of the traditional, step-
wise, scientific approaches to problem solving and en-
gendering change, which focus on breaking problems
into discrete parts, implementing standardised solutions,
and controlling for “confounding”(i.e., contextual) vari-
ables [10,11], are not effective. Now more than ever,
approaches to healthcare improvement are needed that
recognise the complexity of context, as well as the vary-
ing interests and understandings of a problem held by
different stakeholders.
Soft systems methodology (SSM) [12,13] is an ap-
proach to tackling wicked problems and developing ac-
tion to improve a challenging situation. It relies on
system thinking and recognises different perspectives of
actors involved in change. The development of SSM
began 50 years ago in the 1970s, and an early version of
the methodology included the following seven stages: (1)
Problem situation considered problematic; (2) Problem
situation expressed; (3) Root definitions of relevant pur-
poseful activity system; (4) Conceptual models of the
systems named in the root definitions; (5) Comparison
of models and real world; (6) Changes: systematically de-
sirable and culturally feasible; (7) Action to improve the
problem situation [14]. The seven stage model developed
into a two stream model which emphasised that SSM
needed to account for both a logic based analysis, i.e,.
analysing the tasks included in the situation and a cul-
tural analysis, i.e., assessing the social and political cul-
ture influencing the situation [13]. The methodology
was later further refined into a less prescriptive four-
activity process. The first activity, (1) Finding out about
the problematic situation, including cultural and polit-
ical dimensions, aims to gain an overview and insight of
the situation in which the problem exists. To facilitate
this the methodology involves the development of a rich
picture of the situation, which outlines the interconnec-
tions between actors, structures and processes involved.
The second activity, (2) Formulating relevant purposeful
activity models, involves the development of conceptual
models structuring how activities in the situation could
look. This is not intended to be a perfect model to im-
plement but rather function as an aid in structuring the
discussion about feasible and desirable changes that
could be made to the problematic situation. The third
activity, (3) Debating the situation using the models, aims
to find feasible and desirable changes to implement. In
the fourth activity, (4) Taking action to bring about im-
provement, the results from the three previous activities,
i.e., the changes decided on, are tested and implemented
as a basis for further learning.
The methodology has several tools to aid the improve-
ment process and involves its own language and terms,
which are outlined in Table 1.
Explanations are based on Checkland and Poulter [12]
but interpreted by us and adapted to a language more
often used in relation to implementation and improve-
ment science.
Although SSM has been around since the 1970s with
modifications through the 1980s and 1990s [15], and
there is evidence of its adoption in healthcare research
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[16], the extent and nature of its use in care settings has
not been sufficiently studied. Two previous reviews
showed that SSM had been applied in many different
areas, including healthcare [17,18]. One of these reviews
focused on the methodological aspects of using SSM in
healthcare and found that SSM had been used in differ-
ent ways including in combination with other methods
and modified [17]. The review included both empirical
and theoretical papers and provided a brief overview of
how SSM has been used in healthcare but limited its
search to one data base and did not go into detail about
how SSM has been applied [17]. The other review fo-
cused on providing a categorisation of fields of applica-
tion of SSM publications, i.e., categorising papers into
empirical and theoretical papers and thereafter a subdiv-
ision into type of organisations and type of organisation
processes in which SSM has been used [18]. However,
these previous reviews have not investigated how SSM
has been applied, including the extent of stakeholder in-
volvement in the SSM process, the reasons for using
SSM and what outcomes there are in using SSM in
healthcare. The aim of this scoping review was to exam-
ine and map the use and outcomes of SSM in the con-
text of healthcare and provide an up to date account of
the use of SSM in healthcare, focusing on empirical
studies. Specific research questions addressed by this re-
view were:
1 In which countries and healthcare settings has SSM
been embraced?
2 How has SSM been applied, for example, for
problem structuring, or for proposing or
implementing interventions?
3 For what type of problem situations, i.e., the area in
need of improvement, has SSM been used?
4 To what extent have stakeholders, i.e., the
individuals that are affected by or involved in the
problem situation and/or improvements that are
the focus of the study, been involved and consulted
in the SSM process? This includes the number of
stakeholder groups that have been involved and the
nature of stakeholder involvement, e.g., have
stakeholders been actively involved in the SSM
process, for instance in creating rich pictures of the
problem situation and developing root definitions
and PAMs, have stakeholders informed the SSM
process by acting as informants in a researcher led
study or have stakeholders not been involved at all?
5 What kinds of interventions have been
implemented using SSM?
6 What kinds of outcomes have been reported
following the use of SSM?
Method
A scoping review methodology was chosen because it
lends itself to mapping relevant literature in a field of
interest rather than focusing on a narrow research ques-
tion [19]. It also allows for studies using different designs
and methods to be included and synthesised, which was
considered necessary for this review. We followed the
methodological stages outlined by Arksey and O’Malley
[19] to conduct the review. These are: 1. Identifying the
research question, 2. Identifying relevant studies, 3.
Study selection, 4. Charting the data, and 5. Collating,
summarizing and reporting the results. A protocol for
the scoping review has been published [20]. The report-
ing of the review follows the PRISMA-ScR Checklist
[21] (Additional file 1.).
Eligibility criteria
Citations were assessed against the following inclusion
criteria: English-language, peer-reviewed, empirical
Table 1 Glossary of tools, terms and acronyms used in SSM
Rich picture –An illustrative picture of the structures, processes and
actors involved in the problem situation and the interdependencies
between these.
Purposeful activity model (PAM) –A conceptual model for one or
more aspects of the problematical situation outlining a set of purposeful
activities relevant to the situation. The model is a set of linked activities
that together makes up a purposeful whole.
Root definition –A statement describing the human activity system to
be modelled.
CATWOE –A mnemonic reminder to consider the following information
about the human activity system:
Customers –The beneficiaries or victims affected by the problematical
situation and the improvement intervention.
Actors –The individuals involved in the situation and in performing the
improvement intervention.
Transformation –The change process.
Worldview –Underlying assumptions that makes the improvement
intervention worthwhile and important.
Owners –The actors that are responsible for the improvement
intervention and who decide whether it will be implemented or not.
Environmental constraints and enablers –The contextual factors that
may influence the problematical situation and the improvement
intervention.
The PQR-formula –A formula useful for defining the root definition. It
is applied by answering the questions: what should be done (P), how it
should be done (Q) and why it should be done (R).
Five E’s–Criteria for assessing the outcomes of the improvement
intervention, including:
Efficacy –does the intervention produce the intended outcomes?
Efficiency –is the improvement being achieved with minimum use of
resources?
Effectiveness –does the intervention help achieve some higher-level or
longer-term aim?
Ethicality –is the intervention morally appropriate?
Elegance –is it an aesthetically pleasing intervention?
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research articles published in scholarly journals where
the full text was available. Using the PCC mnemonic
(Population/problem, Concept, Context), recommended
for scoping reviews [22], we specified that the content of
the citations had to be focused on the application of
SSM (concept) in a healthcare setting (context), includ-
ing policy, primary care, mental health, hospital care,
residential aged care, rehabilitation and community
health facilities. We did not specify a population since
we were interested in the broad application of SSM in
healthcare. Studies claiming to apply one or several ele-
ments from SSM were included even if SSM had not
been applied in its entirety, as were studies using SSM,
or aspects of SSM, in combination with other methods.
Citations focusing on the use of SSM in settings other
than healthcare, e.g., educational settings (including
healthcare education) were excluded. Citations without a
description of the type of data that was collected and
how this data was accessed/collected were excluded.
This helped enable us to answer questions about the ap-
plication of SSM in healthcare. No date limit was
applied.
Information sources
The focus of the review was on peer-reviewed literature
and electronic databases from different disciplines such
as biomedicine, psychology, health services research, and
nursing were searched to identify relevant studies. The
databases searched were: Scopus, MEDLINE, Web of
Science, CINAHL, EMBASE and PsycINFO.
The search strategy (Table 2) used the term “soft sys-
tems method*”to identify citations referring to SSM.
Search terms were used to limit the search to the health-
care context, e.g., health* and “acute care”. The wildcard
character represents one or more other characters which
allows variable endings of keywords, e.g., healthcare,
health system, healthcare organisation. In addition to the
database search the reference lists from the included ci-
tations were snowball-searched to identify additional ci-
tations. To reduce the likelihood that relevant articles
were overlooked we also hand searched reference lists of
key review papers [17,18]. Search terms were discussed
by the three authors and the database searches were
then conducted by one researcher (HA) and included all
citations published before January 24, 2019. An example
of a search strategy is presented in Table 2.
Selection of sources of evidence
After duplicates had been removed, all references were
imported into Rayyan, a web-based and mobile app that
organises and facilitates the initial screening of titles and
abstracts [23]. Two reviewers (HA, KC) applied the in-
clusion and exclusion criteria to a random sample of 20
citations to test the criteria, i.e., piloting the criteria, and
to ensure consensus on included citations. Interrater-
agreement between the two reviewers was calculated
using Cohen’s kappa [24] and yielded an excellent agree-
ment rate (0.88). The two reviewers then, in parallel, ap-
plied the inclusion and exclusion criteria on all
remaining citations. The citations where the reviewers
did not agree on inclusion (n= 31) were discussed until
consensus was reached. In the next step, one of the re-
viewers (HA) assessed the full-texts of the included cita-
tions for final inclusion. All citations that were given an
exclusion decision were also assessed by the second re-
viewer in order to confirm the decision to exclude the
citation.
Data charting process and data items
An electronic data charting form was developed in excel
to guide data charting from included citations. Data con-
cerning study characteristics, e.g., authors, year of publi-
cation, and the methodology, e.g., design and data
collection as well as information related to the objectives
of the review, i.e., how SSM had been applied in health-
care and the outcomes of using SSM were charted
(Table 3). The data charting form was piloted by the two
reviewers on a selection of the citations to test if the
data charting form covered all study objectives and was
specific enough to ensure that the reviewers extracted
the same data. The pilot test resulted in minor changes
Table 2 Search strategy used in Web of Science
TOPIC: ((“soft systems method*”) and (health* or hospital or “acute care”
or “primary care”or “general practice”or “aged care”or “nurs* home”or
medic* or clinic* or nurs*))
Refined by: LANGUAGES: (ENGLISH)
Timespan: All years. Indexes: SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-
SSH, ESCI.
Table 3 Overview of data items
Charted data items
a. Author(s)
b. Publication year
c. Title
d. Aim
e. Country of origin
f. Type of healthcare setting(s)
g. Methods (design, data collection methods, number and type of
participants)
h. Way of using SSM (for problem structuring, for proposing
interventions, for implementing and/or evaluating interventions)
i Type of problem that SSM has been applied to
j. Degree of stakeholder participation (i.e., number of stakeholder
groups that have been consulted in the different SSM activities and
how stakeholders were involved)
k. Type of intervention implemented (if applicable)
l. Type of outcomes reported (if applicable)
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to the form. One of the reviewers (HA) then independ-
ently charted the data from the remaining citations. Un-
certainties were discussed by the two reviewers.
Critical appraisal of individual sources of evidence
A critical appraisal of the studies was conducted using
the Hawker tool [25]. This tool was developed to sys-
tematically review research from different paradigms,
i.e., both qualitative and quantitative studies and provide
an assessment ranging from very poor to good for a
range of domains: abstract and title; introduction and
aims; method and data; sampling; data analysis; ethics
and bias; results; transferability; and implications and
practice. Based on the ratings an overall quality rating of
low, medium or high was assigned to each study based
on Lorenc et al. [26]. The appraisal was not used to ex-
clude studies from the review but instead added to the
information about the quality of reporting of studies
using SSM in healthcare. The quality appraisal was con-
ducted by one reviewer (HA) and when questions oc-
curred, these were discussed between the two reviewers.
Synthesis of results
Results were synthesised and presented using frequency
counting as well as summarised in text. The data were
compared and synthesised to summarise study charac-
teristics, use of SSM, type of problems that SSM was ap-
plied to, stakeholder participation, types of improvement
interventions implemented, and outcomes of these im-
provements if applicable.
Patient and public involvement
The study involved no patient or public involvement.
Results
The search resulted in 228 unique citations of which 49
were included in the review. Figure 1demonstrates the
inclusion and exclusion of citations at each stage of the
screening process, using the PRISMA flow diagram [27].
Characteristics of studies using SSM in healthcare and
quality assessment
The included studies were published between 1986 and
2019, without any clear time trend. A majority of studies
originated from the United Kingdom (n= 28, 57.1%).
Five studies (10.2%) were conducted in the USA, four
(8.2%) in Australia and two (4.1%) in Norway. The re-
mainder were single studies conducted in Belgium,
Canada, the European union member states, Finland,
Greece, Ireland, Portugal, Scotland, South Africa and
Turkey.
The included studies were conducted in a wide range
of healthcare settings with hospitals (n= 15, 30.6%) the
most common. Nine studies (18.4%) were conducted in
policy settings, five studies (10.2%) in mental health set-
tings and four studies (8.2%) each were held in commu-
nity settings and multiple types of setting. Other
represented settings were aged care (n= 2, 4.1%), ambu-
latory care (n= 1, 2%), primary care (n= 2, 4.1%), public
health (n= 2, 4.1%), health informatics management or-
ganisations (n= 2, 4.1%), ambulance service (n= 1, 2%),
end-of-life care (n= 1, 2%) and blood collection estab-
lishments (n= 1, 2%).
Two thirds of the studies had a qualitative design (n=
34, 69.4%), 14 studies (28.6%) a mixed methods design
and one study (2%) was purely quantitative. The major-
ity of studies employed a case study design (n= 43,
87.8%). The remaining studies had cross sectional design
(n= 2, 4.1%), longitudinal design (n= 2, 4.1%), or experi-
mental design (n= 2, 4.1%).
Interviews were the most commonly used method for
collecting data (n= 38, 77.6%) followed by observations
(n= 17, 34.7%), focus group interviews (n= 14, 28.6%),
and workshops/group discussions (n= 14, 28.6%) not
characterised as focus groups. The difference between
focus groups and other group discussions was not always
clear due to a lack of information about their conduct.
Other sources of data were surveys (n= 8, 16.3%), litera-
ture reviews (n= 7, 14.3%), document analysis (n=5,
10.2%) and administrative data (n= 4, 8.2%).
The studies displayed a wide variety of numbers of
data collection methods, ranging between 1 and 6
methods/data sources. Most studies applied one (n= 17,
34.7%), two (n= 12, 24.5%) or three (n= 17, 34.7%)
methods. The remaining studies used five (n= 2, 4.1%)
and six (n= 1, 2%) methods.
The quality assessment revealed that 22 studies
(44.9%) were of high quality, 21 studies (42.9%) were
medium quality and six studies (12.2%) had a low quality
when it came to reporting. Table 4provides an overview
of the characteristics of the studies and descriptions of
each included study can be found in Additional file 2.
Stakeholder involvement
SSM is a participative approach emphasising the import-
ance of considering all relevant stakeholders’views and
opinions about a situation. The extent of stakeholder in-
volvement differed in the included studies. The number
of consulted stakeholder groups varied from none in a
study based on existing population data [28]to20[29].
A categorisation of the different stakeholders involved
showed that the majority of studies (n= 35, 71.4%) in-
volved healthcare professionals such as nurses, physi-
cians, pharmacists and dieticians. Healthcare managers,
e.g., department managers, were also often involved in
the SSM process (n= 21, 42.9%). Fourteen studies each
(28.6%) included service users or representatives, i.e., pa-
tients, family members and patient representatives, and
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policy makers or administrators. Eleven studies involved
staff with an administrative role or support function,
e.g., knowledge and information management. Six stud-
ies (12.2%) included research and development staff
(Table 5).
The studies also illustrate different ways of involving
stakeholders in the SSM process. We allocated types of
stakeholder involvement into four categories (Table 5):
Category 1. 21 studies (42.9%) involved stakeholders dir-
ectly in the SSM process. This category included studies
where stakeholders were active in at least parts of the
SSM process, such as creating rich pictures or develop-
ing PAMs. Category 2. 22 studies (44.9%) involved stake-
holders as informants/sources of data. This category,
which included studies where stakeholders participated
as informants, e.g., in interviews, and researchers used
the information to inform the researcher led SSM
process. Category 3. Included five studies (10.2%) where
stakeholder involvement was not clear or not stated.
This pertained to studies where the reporting of the data
collection process was not described in such a way that
the type of participation could be decided. Category 4.
Included one study (2%) based on pre-existing data,
which therefore did not include any stakeholders.
Ways of using SSM
The purpose of using SSM varied with the majority (n=
20, 40.8%) harnessing SSM both for problem structuring
Fig. 1 Search and review strategy
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Table 4 Study characteristics
Number of studies %
Healthcare setting
Hospital 15 30.6
Policy 9 18.4
Mental health 5 10.2
Community 4 8.2
Multiple settings 4 8.2
Aged care 2 4.1
Primary care 2 4.1
Public health 2 4.1
Health informatics management organisations 2 4.1
Ambulatory care 1 2
Ambulance service 1 2
End-of-life care 1 2
Blood collection establishments 1 2
Method
Qualitative 34 69.4
Mixed methods 14 28.6
Quantitative 1 2
Study design
Case study 43 87.7
Cross-sectional 2 4.1
Longitudinal 2 4.1
Experimental design 2 4.1
Data collection method
a
Interviews 38 77.6
Observations 17 34.7
Focus groups interviews 14 28.6
Workshops/group discussions 14 28.6
Survey 8 16.3
Literature review 7 14.3
Document analysis 5 10.2
Administrative data 4 8.2
Number of data collection methods used
1 17 34.7
2 12 24.5
3 17 34.7
4––
5 2 4.1
612
Quality assessment
High quality 22 44.9
Medium quality 21 42.9
Low quality 6 12.2
a
Percentage exceeds 100 because some studies used multiple data collection methods
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and for proposing interventions or recommendations for
improvements. Eight studies (16.3%) used SSM solely for
problem structuring without proposing any interventions
or recommendations. Five studies (10.2%) used SSM for
implementing interventions or making recommenda-
tions in addition to problem structuring and proposing
interventions or recommendations. The remaining stud-
ies utilised SSM for evaluating interventions (n=6,
12.2%), for determining objectives for simulation studies
(n= 2, 4.1%), to describe or understand models of care
or processes in healthcare (n= 4, 8.2%) or for other pur-
poses (n= 4, 8.2%) (Table 6).
The problem situations to which SSM was applied var-
ied greatly, facilitating a broad categorisation of the dif-
ferent problem situations (Table 6). The most common
reason for using SSM was for health systems improve-
ments (n= 9, 18.4%), for instance to inform the develop-
ment of integrated health and social services in mental
health [31] or to improve inadequate and fragmented
services for children with serious emotional disturbance
[32]. The second most common reason was to improve
care processes (n= 8, 16.2%) such as enhancing continu-
ity of care for palliative patients in a community setting
[33] and reducing long waiting times for patients after
having arrived for their appointments [34]. Seven studies
(14.3%) used SSM for different kinds of policy improve-
ments including contracting in the National Health Ser-
vice (NHS) in England [35,36] and making suggestions
for the development of a policy for the organization of
child and adolescent mental healthcare services in
Belgium [37]. Six studies (12.3%) engaged with SSM for
information system development/improvement. In these
studies, SSM was used to develop information systems
for particular healthcare settings or for improving an
existing information system. One example was the use
of SSM to develop an information system that facilitates
the sharing of information across stakeholders involved
with rehabilitative care for older patients [38]. The
remaining studies had applied SSM to knowledge man-
agement improvements (n= 3, 6.1%), for intervention/
program/care model evaluation (n= 3, 6.1%), to analyse/
improve practice development (n= 3, 6.1%), and to ana-
lyse/improve teamwork (n= 2, 4.1%). Eight studies
(16.2%) took to SSM for other purposes that could not
be sorted into any of the categories, e.g., to explore the
development of specialist staffing [39] and to examine
community partnership, engagement and participation
[40]. All the problem situations to which SSM was ap-
plied are described in Additional file 2.
The included studies used different versions of SSM.
Thirteen studies (26.6%) used the seven-stage version
and the four activity version was use in six studies
(12.3%). A number of studies (11, 22.5%) used SSM in
combination with other methods or used parts of the
methodology, e.g., only the CATWOE, (n= 6, 12.3%).
Three studies (6.1%) used a new adapted version of SSM
and one study each (2%) used the two strands model
and a nine-stage version of SSM. In eight (16.3%) of the
included studies it was not clear what type of SSM was
used or in what way SSM had been used.
There was also wide variation in how many and which
SSM tools were applied in the studies. The most fre-
quently used tools were PAM (n= 33, 67.3%), Root def-
inition (n= 29, 59.2%), CATWOE (n= 28, 57.1%) and
Rich picture (n= 20, 40.1%). Seventeen (34.7%) studies
described having compared the real world and the
PAMs. The three Es (n= 4, 8.2%), the five Es (n= 1, 2%)
and the PQR formula (n= 2, 4.1%) were used to a lesser
extent (Table 6).
Outcomes of implemented improvements
Although 20 studies proposed improvements only five
studies reported that the improvements had been imple-
mented. These studies reported some, often narrative,
information about the outcomes of these improvements.
Kotiadis et al. [41] developed a model for how a multi-
disciplinary team should function. The model was at
least partially implemented 3 years later resulting in a
Table 5 Stakeholder involvement
Number of
studies
%
Number of stakeholder groups involved
0–3 13 26.5
4–7 13 26.5
8–11 10 20.4
12–20 4 8.2
Not clear/not stated 9 18.4
Categories of stakeholders involved
a
Healthcare professionals 35 71.4
Healthcare managers 21 42.9
Service users/representatives 14 28.6
Policy makers/administrators 14 28.6
Administrative/support staff 11 22.4
Research and development staff 6 12.2
Not clear/not reported 6 12.2
Stakeholder involvement category
Category 1: Stakeholders involved in the SSM
process
21 42.9
Category 2: Stakeholders involved as
informants and SSM process conducted by
researchers
22 44.9
Category 3: Not clear/not stated 5 10.2
Category 4: No stakeholder involvement 1 2
a
Percentage exceeds 100 because many studies involved multiple
stakeholder categories
Augustsson et al. BMC Health Services Research (2020) 20:1063 Page 8 of 13
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better functioning team. However, the authors stressed
that it was not possible to determine whether this was
because of the SSM intervention, although they adduced
some evidence to support that. In the study by Hales
and Chakravorty [42] SSM was used together with mind-
fulness to implement high reliability organization (HRO)
principles. SSM facilitated the implementation of HRO,
which ultimately led to improved reliability in a critical
care unit, including an increase in the percentage of pa-
tients discharged alive with stable vital signs. Before
HRO implementation, this measure was 93.8% and after
implementation, it increased to 99.5%, a statistically sig-
nificant increase. In the study by Lehaney et al. [34], a
procedure to reduce unexpected non-attendance of
Table 6 Ways of using SSM
Number of studies %
Purpose of using SSM
Problem structuring and proposing improvements 20 40.8
Problem structuring 8 16.3
Evaluation 6 12.2
Problem structuring, proposing and implementing improvements 5 10.2
Describing or understanding models of care or processes in healthcare 4 8.2
Determine objectives for a simulation study 2 4.1
Other 4 8.2
Problem situation/reason for using SSM
Health system improvement 9 18.4
Care process improvement 8 16.3
Policy improvement 7 14.3
Information system development/improvement 6 12.3
Describe/improve knowledge management system 3 6.1
Intervention/program/care model evaluation 3 6.1
Analyse/improve practice development 3 6.1
Analyse/improve teamwork 2 4.1
Other 8 16.3
Type of SSM used
Seven stage 13 26.5
Four activity 6 12.3
Combined with other method 11 22.5
Part of the method 6 12.3
New adapted version 3 6.1
Two strands 12
Nine stage 12
Not clear/not stated 8 16.3
SSM tools applied
a
PAM 33 67.3
Root definition 29 59.2
CATWOE 28 57.1
Rich picture 20 40.1
Comparison of real world and PAM 17 34.7
Three Es 4
b
8.2
PQR-formula 2 4.1
Five Es 12
a
Percentage exceeds 100 because some studies applied multiple SSM tools
b
One study used an adapted version of the Three Es [30]
Augustsson et al. BMC Health Services Research (2020) 20:1063 Page 9 of 13
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patients by using simple rules for patient scheduling was
implemented. This strategy resulted in reduced clinic
waiting times. Pentland et al. [43] used SSM to design
and implement improvements to a mental health service,
enhancing knowledge acquisition and management ac-
tivities in order to facilitate effective evidence-based
practices. A ten-month change programme resulted in a
number of changes to the knowledge acquisition and
management structures and procedures. Holm et al.
[29], applied SSM to improvements in a central surgery
unit (CSU). Several enhancements that would directly
and indirectly affect surgical activities were suggested,
some of which were implemented. One example was the
implementation of more flexibility to the duration of
shifts, which was accepted and adopted by staff, resulting
in fewer procedures being cancelled due to expected
overtime. The authors also discussed that the manage-
ment and the actors involved in the CSU seemed more
aware of the importance of team behaviour and team
leadership as well as communication and cooperation
between staff groups after the study.
Discussion
This scoping review provides an overview and synthesis
of how SSM has been applied in healthcare. It illustrates
a wide area of application of SSM, and highlights the
way people have embraced it –with flexibility and
adaptability. As a change strategy it has been used across
many kinds of problem situations which might be seen
as a benefit. But critics might say that SSM has been in-
consistently applied –and not routinely in the way that
Checkland and colleagues originally envisaged its use. In
short, researchers and change agents in healthcare have
adapted SSM to suit different contexts, implementation
aims and study designs. This means we have witnessed a
proliferation of different versions of SSM, application of
different tools in divergent studies and involving stake-
holders to dissimilar extents. Overarchingly, most stud-
ies used SSM for problem structuring and for proposing
improvement interventions. However, those who did re-
port SSM use were less likely to report on the imple-
mentation and outcomes of their interventions.
The wide area of application shows that SSM has been
considered applicable to many different settings and
complex problems found in healthcare (e.g., inadequate
and fragmented services for children with serious emo-
tional disturbance [32]; the need to increase safe blood
management in the EU [44]). SSM has been proposed to
be especially suited to these types of wicked problems
which may explain the flexible use of SSM in different
settings and situations in healthcare. Given how hard it
is to make change in an arena that has so many funda-
mentally complex challenges, the SSM methods and ap-
proaches to deal with these complexities are warranted
[10,45]. At the same time, research methods used in
healthcare contexts have traditionally been of a positivist
nature (e.g., randomised controlled trials, formal before
and after or time series studies), yet many researchers
and practitioners now acknowledge the need for less lin-
ear and more context-sensitive methods [46,47].
Stakeholder involvement and co-creation
The review revealed wide variation when it came to in-
volving stakeholders, ranging from no involvement to
full involvement in exploring the problem situation, de-
veloping PAMs and taking action to improve the situ-
ation. Arguments have been made that research and
improvement attempts that build on co-creation and
collaboration have the potential to generate more rele-
vant, applicable and contextually-sensitive knowledge
and thereby deliver enhanced processes and outcomes
[48,49]. With its emphasis on stakeholder involvement
baked into the model, SSM has potential to make far-
reaching changes. Based on the potential of co-creation,
it can be hypothesised that SSM studies that involve
stakeholders to a greater extent are more likely to
achieve effective outcomes.
Inconsistent application of SSM
The inconsistent use of SSM, including different ver-
sions and different tools applied, makes it difficult to
compare the use of SSM across studies. Although the
aim of this review was not to determine the effectiveness
of SSM, this finding indicates that it may be premature
to comment on the effectiveness of SSM for making
widespread improvements in healthcare despite the ex-
istence of the method for some time. The inconsistent
use of SSM across studies also impedes the ability to as-
sess the core components of the methodology, i.e., if cer-
tain tools or components of the methodology are
especially important for bringing about successful im-
provements. The varied use of SSM may be related to
the fact that SSM is indeed intended to be a flexible ap-
proach (originating in the initial work of Peter Check-
land and his colleagues) which is also illustrated by the
development of the more prescriptive seven-stage ver-
sion of SSM to the less prescriptive four-activity process
[13]. However, the seven stage version was the most
commonly applied and newer studies also chose to use
this version [e.g., [50]], possibly suggesting that a more
prescriptive or multi-staged version may be easier to
apply. Yet, use of earlier versions of SSM may contribute
to a continued inconsistent use of SSM. It is possible
that the flexibility in itself is a core component of SSM.
Nevertheless, the way SSM was applied needs to be
clearly described to facilitate understanding of the cir-
cumstances under which SSM may be useful, and in
order to facilitate cross-study comparison.
Augustsson et al. BMC Health Services Research (2020) 20:1063 Page 10 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Evaluating outcomes of using SSM in healthcare
As we have seen, SSM had been put to work for varied
purposes, mostly to understand or structure a problem
situation in combination with coming up with proposals
for improvement. To a much lesser extent, these solu-
tions were implemented and evaluated. This confirms
previous findings from a more selective overview of the
use of SSM in healthcare [16]. Possibly this indicates
that the strength of SSM is in the problem structuring
and modelling phase, including debating a difficult situ-
ation where earlier attempts to improve the situation
have failed, and coming up with improvement sugges-
tions that can be tested, rather than the process of actu-
ally putting these improvements into action, which may
require other approaches [16].
One important issue that arises in relation to evaluat-
ing the effectiveness of SSM is the question of what
types of outcomes to consider. The traditional approach
to the evaluation of effectiveness focuses on intervention
outcomes, i.e., the outcomes of the improvement inter-
vention implemented as a result of SSM. However, these
outcomes will not only depend on the value of SSM but
also on how such an intervention is implemented and
the nature and content of the improvement intervention
itself. This suggests that different types of outcomes
need to be considered when evaluating SSM. We
propose that evaluations of using SSM in healthcare
should include measures of whether the application of
SSM led to an understanding about the problem situ-
ation (evaluation of the complex system in which the
problem exists), whether SSM facilitated the formulation
of suggestions for improvements, whether improvements
were successfully implemented (implementation out-
comes [51]) and whether the improvements led to posi-
tive outcomes (intervention outcomes).
The studies included in this review mainly reported
outcomes related to the understanding about the prob-
lem situations and formulation of potential improve-
ments. Nevertheless, the lack of studies reporting on the
implementation and intervention outcomes of using
SSM limits the potential to assess the capacity of SSM to
evoke change and deliver positive outcomes in
healthcare.
In sum, supporting an earlier review of SSM [17], our
review revealed an insufficient description of how SSM
had been applied and how data had been collected and
analysed in several of the studies. This obviously limits
the potential to make comparisons across studies as well
as reduces the possibility of using previous research suc-
cess to inform future studies.
Implications and future directions
Our results point to the need for better reporting of the
use of SSM in healthcare. Studies should clearly report
on how SSM was used, including which version of SSM
that was used, which tools that were applied, how stake-
holders were involved, and how data was collected and
analysed. The review also revealed a gap in knowledge
regarding the outcomes of using SSM. Future studies
should strive to clearly report different types of out-
comes from using SSM in addition to describing the
context of the study and the application of SSM. This
will facilitate assessment of under what conditions SSM
may be a useful and an effective approach. Furthermore,
the varied involvement of stakeholders in the process
and the fact that participation lies at the core of the
SSM methodology calls for further investigation of how
the level of involvement influences the process and the
outcomes of SSM.
Strengths and limitations
The review followed a comprehensive methodology for
scoping reviews as outlined by Arksey and O’Malley [19]
and the reporting of the study followed the PRSIMA-
ScR [21]. A double blinded review of all abstracts was
applied to ensure consistency of study inclusion. Full-
texts were screened by one reviewer only; however, all
exclusion decisions as well as uncertainties were dis-
cussed with a second reviewer. The review is limited to
studies in English published in the peer review literature,
meaning that studies reported in the grey literature or in
languages other than English are not covered. A diffi-
culty encountered was the sometimes inadequate meth-
odological description of the studies, which limited the
information that could be extracted. As such, important
information about how SSM has been used in healthcare
may have been missed. For instance, assessment of par-
ticipation was made based on the information reported
in the included papers and the true level of participation
may not have been captured in some cases because of
insufficient reporting about how stakeholders were in-
volved. This study does not therefore provide a full ac-
count of the effectiveness of using SSM in healthcare
and it was not possible to assess the impact of level of
involvement of stakeholders on the success of the SSM
process.
Conclusion
SSM is flexible and applicable for a range of settings and
for a wide array of problem situations in healthcare.
SSM has been inconsistently used and the reporting of
how SSM is applied is often insufficient, which limits its
comparability across studies. Better reporting of how
SSM has been applied as well as evaluation of different
types of outcomes, including implementation and inter-
vention outcomes, is needed in order to be able to more
fully appreciate the usefulness of SSM in healthcare.
Augustsson et al. BMC Health Services Research (2020) 20:1063 Page 11 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12913-020-05929-5.
Additional file 1. Preferred Reporting Items for Systematic reviews and
Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.
Additional file 2. Table of all studies included in the review.
Abbreviations
PAM: Purposeful activity model; PRISMA-ScR: Preferred Reporting Items for
Systematic reviews and Meta-Analyses extension for Scoping Reviews;
SSM: Soft systems methodology
Acknowledgements
To Professor Peter Checkland: a visionary, ahead of his time, able to see how
complex systems were in need of a structured methodology decades ago.
To the late Professor Don Hindle: an inspiration to all those he met, and
always striving to harness the power of systems thinking.
Authors’contributions
JB conceptualised the study. HA, JB and KC developed the study design and
methodology. HA and KC conducted the abstract review. HA conducted the
full-text review and data extraction with KC acting as advisor. The quality as-
sessment of included articles was conducted by HA with assistance by KC in
case of uncertainties. HA undertook the synthesis of data. HA and KC drafted
the initial manuscript, reviewed and edited by JB. All authors contributed to
the final manuscript, edited it into its final form and approved the final
submission.
Funding
This work was supported by the NHMRC Partnership Centre in Health
System Sustainability (Grant ID 9100002).
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 12 March 2020 Accepted: 16 November 2020
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