Academic Division: Mechanics, Materials and Design
Research group: Engineering Design
Telephone: +44 1223 (7)48577
- Health systems design
- Global Health
- Systems modelling
- Participatory diagramming and Graphical elicitation
- Narrative as a tool for deriving system requirements
A Systems Improvement Approach to Traumatic Brain Injury (ASIA-TBI): Developing a participatory approach to the systems improvement of traumatic brain injury care in Yangon, Myanmar.
Trauma accounts for nearly 10% of global deaths, of which 90% occur in low and middle income countries (LMICs). Traumatic brain injury (TBI) is one of the most devastating, both in terms of mortality, but also in terms of the long-term implications to both the patient and their family.1,2
Caring for the TBI patient is a complex task, involving a number of different heath system elements: pre-hospital care, emergency medicine, anaesthesia, surgery, intensive care, physiotherapy, and rehabilitation. These elements are inter-dependent, and improving one area may not show a measurable benefit without concomitant improvement in the others. Furthermore, TBI care is context-specific with lessons from one setting not easily translating to a new environment. This variation does not simply apply to the technical expertise required but to the fundamental questions if what constitutes an acceptable final outcome.3
Healthcare is the emergent property of a sociotechnical system consisting of people, processes, information, equipment, consumables, infrastructure, culture, finance, and governance. To improve the overall care of TBI patients, we need to understand how these come together how these deliver the existing system of care, and how specific interventions might work to reengineer them to provide the desired system of care. This requires a health systems approach.
Systems thinking is championed in healthcare by the World Health Organisation (WHO), the Institute for Healthcare Improvement (IHI), and many others. The WHO specifically recommend its place in LMIC healthcare improvement given the complexity of this undertaking.4–6 In considering TBI, the need for a systems approach is also advocated by both the Lancet Commission for Global Surgery and the Lancet Neurology Commission on TBI.7,8 However, there are few examples of a systems approach being applied to TBI care in LMICs.
A new position document published by the UK Royal Academy of Engineering in partnership with the Royal College of Physicians and the Academy of Medical Sciences has demonstrated the value that the Engineering community can add to the understanding and improvement of complex healthcare systems.9 (Fig 1). We have established a partnership between clinical academics in the UK and Myanmar with an interest in Neurotrauma, alongside the Healthcare Design Group, based in the Engineering Design Centre, Cambridge. This partnership is seeking to use tools from the engineering community to understand the current service around TBI care in Myanmar, and to understand how interventions may be designed to improve this service.
The project is beginning with a qualitative exploration of the current experiences of TBI in Myanmar through a variety of stakeholders. This will be performed through facilitated interviews conducted by our partner researchers in Myanmar, and seek to explore some core questions relating to the provision of TBI care (Fig 2):
- Who are the stakeholders?
- Where is the system of TBI care situated?
- What are its elements?
- How does the system perform?
Using this data we will then seek to develop consensus models which can help describe the current system of TBI care in Myanmar and inform the design of a series of interventions to improve TBI care which are context-dependent, and consistent both with each other and with the wider heath system.
Fundamental to this approach is that it is context-specific: carried out by Myanmar researchers and seeking to explore the perspectives of not only clinicians but also clinical managers, patients and the public.
Lozano, R. et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2095–2128 (2012).
Murray, C. J. L. et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2197–2223 (2012).
Rubiano, A. M., Carney, N., Chesnut, R. & Puyana, J. C. Global neurotrauma research challenges and opportunities. Nature 527,S193–S197 (2015).
Adam, T. & De Savigny, D. Systems thinking for strengthening health systems in LMICs: Need for a paradigm shift. Health Policy Plan. 27, 2006–2008 (2012).
Rwashana, A. S., Nakubulwa, S., Nakakeeto-Kijjambu, M. & Adam, T. Advancing the application of systems thinking in health: understanding the dynamics of neonatal mortality in Uganda. Heal. Res. Policy Syst. 12, 36 (2014).
Adam, T. et al. Evaluating health systems strengthening interventions in low-income and middle-income countries: Are we asking the right questions? Health Policy Plan. 27, (2012).
Meara, J. G. et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet 386, (2015).
Maas, A. I. R. et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol.4422, (2017).
Engineering better care: a systems approach to health and care design and continuous improvement. Royal Academy of Engineering, Academy of Medical Sciences, and Royal College of Physicians. (2017).
Fig. 1 Engineering approaches to healthcare improvement alongside traditional tools.
Fig. 2 A systems approach as an ordered series of questions.
Reproduced with permission from Engineering better care. Royal Academy of Engineering, Academy of Medical Sciences and Royal College of Physicians. 2017
Previously an NIHR Academic Clinical Fellow in the UDA, Tom is a Clinical Research Fellow funded by the NIHR Global Health Research Group on Neurotrauma, and a Specialist Registrar in Anaesthesia at Addenbrooke’sHospital. His academic interest is in developing a systems understanding of interventions to improve anaesthetic care in low income settings, and he is currently registered as a PhD student working within the UDA Health Systems Engineering Group and the Healthcare Design Group in the Department of Engineering. This is supported by a WD Armstrong Studentship from the University of Cambridge School of Technology, and involves systems mapping of traumatic brain injury care in Myanmar.
Tom’s introduction to global health came working with VSO in Ethiopia between 2011-2012, for which he was awarded the AAGBI/MPS Patient Safety Prize in 2012. He sits on the Education Board of Lifebox Foundation, and leads their current anaesthesia workstream in Ethiopia. In addition, he is co-director of the THET-funded Cambridge-Yangon Trauma Intervention Project ICU Partnership and senior lecturer on the systems-based Delivering Trauma Intensive Care Course developed as part of this partnership, supported by Cambridge Global Health Partnerships. He teaches on the MSc in Global Health with Surgery & Anaesthesia at King’s College London, and the NIAA Introduction to Academic Anaesthesia. Tom is the current President of the World Anaesthesia Society, the Specialist Society for UK anaesthetists interested in global health.
- FRCA Fellow of the Royal College of Anaesthetists, 2014
- MRCP Member of the Royal College of Physicians, 2010
- MBBS Clinical Medicine. St George’s Hospital Medical School, University of London, 2007
- MBiochem (Hons) Molecular and Cellular Biochemistry. University of Oxford, 2002
BashfordT, VercueilA. Anaestheticresearch in low- and middle-income countries. Anaesthesia. 2018. doi:10.1111/anae.14518
MoonesingheSR, BashfordT, WagstaffD. Implementing risk calculators – time for a Trojan horse?. British Journal of Anaesthesia. 2018. 121(6): 1192e1195 doi:10.1016/j.bja.2018.09.025
Clarkson J, Dean J, Ward J, KomashieA, BashfordT. A systems approach to healthcare: from thinking to practice. Future Healthcare Journal. 2018. 5(3). 151-155 doi: 10.7861/futurehosp.5-3-151.
BashfordT, Nwe MyintPP, Win S, Thu M, NaingMM, BurnsteinRM, HlaingTT, BrealeyE, Hutchinson PJA, Clarkson PJ. A systems approach to trauma care in Myanmar: from health partnership to academic collaboration. Future Healthcare Journal. 2018. 5(3). 171-175. doi: 10.7861/futurehosp.5-3-171.
AbouEl Ela BourquinB, GnanakumarS, Bath MF, BashfordT, MenonDK, Hutchinson PJA. The international health elective: a stepping stone for tomorrow's global surgeons and anaesthetists. PerspectMed Educ. 2018. https://doi.org/10.1007/s40037-018-0439-4
Bashford T, Clarkson PJ, Menon DK, Hutchinson PJA. Unpicking the Gordian knot: a systems approach to traumatic brain injury care in low and middle income countries. BMJ Global Health 2018;3:e000768. http://dx.doi.org/10.1136/bmjgh-2018-000768
Gibbs A, Bashford T, Wilson IA. Pulse oximetry in a high income setting: how big is the gap? Anaesthesia. 2017. 72(12): 1565–1567. https://doi.org/10.1111/anae.14146
Bashford T, Howell V. Anaesthesia a Tropical Disease 2. BJA Education. 2017. Mar 18(30), p75-81 https://doi.org/10.1016/j.bjae.2017.11.009
Bashford T, Howell V. Anaesthesia a Tropical Disease 1. BJA Education. 2017. Feb 18(2) , p35 – 40 https://doi.org/10.1016/j.bjae.2017.10.004
Bashford T, Reshamwalla S, McAuley J, Allen NH, McNatt Z, Gebremedhen Y. Implementation of the WHO Safe Surgery Checklist in an Ethiopian Referral Hospital. Patient Safety in Surgery. 2014 Mar 8(16). https://dx.doi.org/10.1186%2F1754-9493-8-16
Walker IA, Bashford T, Fitzgerald E, Wilson IH. Improving Anesthesia Safety in Low-Income Regions of the World. Current Anesthesiology Reports. 2014. https://doi.org/10.1007/s40140-014-0056-7
Bashford T. Anaesthesia in Ethiopia: providers’ perspectives on the current state of the service. Tropical Doctor. 2014 Jan 4(1) p6-13. https://doi.org/10.1177/0049475513512642
Bashford T. Quality Improvement in Low Resource Settings: An Ethiopian Experience. British Journal of Hospital Medicine. 2013 May 79(5) p.286-288. https://doi.org/10.12968/hmed.2013.74.5.286
2016 ‘The Checklist Effect’
Interviewed for Lifebox film detailing international efforts to implement the WHO Surgical Safety Checklist
2012 ‘Into Thin Air’
BMJ Blog in support of Lifebox BMJ Christmas Appeal 2012
2012 ‘Road to Safer Surgery’, Yekatit 12 Hospital, Addis Ababa
Produced in association with the Clinton Health Access Initiative, Ethiopia
2012 ‘How to Implement the Safe Surgery Checklist’, Yekatit 12 Hospital, Addis Ababa
Produced in association with the Clinton Health Access Initiative, Ethiopia
2012 Voluntary Service Overseas: Anaesthesia in Ethiopia
A video detailing some of the work of this placement can be found at: