Systems thinking methods: A worked example of supporting Emergency Medical Services decision-makers to prioritize and contextually analyze potential interventions and their implementation

Cassandra Rehbock, Thomas Krafft, Anja Sommer, Carijn Beumer, Stefan K. Beckers, Stefan Thate, Joern Kaminski, Alexandra Ziemann

Research output: Contribution to journalArticlepeer-review


Systems thinking can be used as a participatory data collection and analysis tool to understand complex implementation contexts and their dynamics with interventions, and it can support the selection of tailored and effective implementation actions. A few previous studies have applied systems thinking methods, mainly causal loop diagrams, to prioritize interventions and to illustrate the respective implementation context. The present study aimed to explore how systems thinking methods can help decision-makers (1) understand locally specific causes and effects of a key issue and how they are interlinked, (2) identify the most relevant interventions and best fit in the system, and (3) prioritize potential interventions and contextually analyse the system and potential interventions.

A case study approach was adopted in a regional emergency medical services (EMS) system in Germany. We applied systems thinking methods following three steps: (1) a causal loop diagram (CLD) with causes and effects (variables) of the key issue “rising EMS demand” was developed together with local decision-makers; (2) targeted interventions addressing the key issue were determined, and impacts and delays were used to identify best intervention variables to determine the system’s best fit for implementation; (3) based on steps 1 and 2, interventions were prioritized and, based on a pathway analysis related to a sample intervention, contextually analysed.

Thirty-seven variables were identified in the CLD. All of them, except for the key issue, relate to one of five interlinked subsystems. Five variables were identified as best fit for implementing three potential interventions. Based on predicted implementation difficulty and effect, as well as delays and best intervention variables, interventions were prioritized. The pathway analysis on the example of implementing a standardized structured triage tool highlighted certain contextual factors (e.g. relevant stakeholders, organizations), delays and related feedback loops (e.g. staff resource finiteness) that help decision-makers to tailor the implementation.
Original languageEnglish
Article number42
Number of pages13
JournalHealth Research Policy and Systems
Issue number1
Publication statusPublished - 5 Jun 2023

Bibliographical note

Funding Information:
We would like to thank the members of the EMS Oldenburg project consortium for their steady input throughout the conduct of this study. Furthermore, we thank Kim Worseling for her support in the early stages of the study.

Data Availability Statement

All data generated or analysed during this study are included in this published article and its additional files.


  • Complexity
  • Decision support
  • Implementation

ASJC Scopus subject areas

  • Health Policy


Dive into the research topics of 'Systems thinking methods: A worked example of supporting Emergency Medical Services decision-makers to prioritize and contextually analyze potential interventions and their implementation'. Together they form a unique fingerprint.

Cite this