From systems thinking to systems change: The power of quality improvement

In the past few months, we’ve spent considerable time exploring systems thinking, from reviewing why systems matter in college health in last month’s newsletter, to reading Donella Meadows’ Thinking in Systems in the Campus Health 360 Book Club. By now, we know about the value of stepping back and seeing college health and well-being as a system, rather than as a collection of individual programs, services, and departments.

That shift in perspective is important, but raises a practical question:

Once we see the system, how do we actually change it to make it better?

One answer is quality improvement.

Quality improvement (QI) provides something that systems thinking alone does not: a disciplined way to move from understanding a system to testing changes within it.

Donella Meadows offers an important perspective. Systems can behave in surprising ways, and interventions that seem logical in one part of a system can produce unexpected results somewhere else. Meadows’ discussion of leverage points, places where relatively small changes can influence system behavior, provides a useful way to think about where and how we intervene. She also cautions that complex systems are not machines with simple, predictable cause-and-effect relationships.¹

That is one reason QI can be so powerful. QI helps us work through complex problems that have uncertainty, multiple possible solutions, and potential consequences for getting it wrong.

Small tests can create big learning

One of the most appealing aspects of QI is the idea that we don’t have to get everything right before we begin, nor do we have to find the perfect solution right away. We can start small.

What happens if we test a new referral process with one population? What if we try a different approach to appointment access for one clinic? What if we change one part of a communication process and see what happens before redesigning the entire system?

The goal isn’t simply to prove that our idea works, but to learn. That distinction matters enormously in complex systems, and it connects directly to Meadows’ thinking. Her work on leverage points reminds us that meaningful change often comes from altering the structures, rules, information flows, feedback mechanisms, or goals that shape system behavior — not simply from trying harder within the existing system.¹

QI gives us a practical mechanism for testing whether those changes actually produce better outcomes.

What are the mechanisms for testing change?

The quality improvement model most familiar to many of us is the Model for Improvement, developed by Associates in Process Improvement and widely used by the Institute for Healthcare Improvement (IHI).²

At its heart are three questions:

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?

Those questions force us to define the problem, establish a measurable aim, determine how we will recognize improvement, and identify potential changes before jumping immediately to implementation.

What makes QI particularly useful in complex environments is Plan-Do-Study-Act (PDSA) cycles.

Rather than assuming we know exactly what will work, we can use PDSA cycles to test a change on a small scale, study what happens, learn from the results, and adapt. The process is iterative; what we learn from one test can change our understanding of the problem, our measures, or our next proposed change.²

Quality improvement in action

Quality improvement (QI) initiatives in college health have successfully driven measurable gains in clinical process metrics, preventive care delivery, and operational efficiency.

One example of QI in action can be seen in a multi-site learning collaborative across 45 student health centers (SHC) looking to increase influenza (flu), human papillomavirus (HPV), and meningococcal serogroup B (MenB) vaccinations to students on campus. The project was designed to address a common challenge in higher ed: improving vaccination rates among students. Rather than implementing a single standardized intervention, participating institutions used quality improvement methods to examine their existing immunization systems, identify barriers, and test change within their own campuses.

This QI learning collaborative adapted the IHI’s Breakthrough Series Model over an eight-month period to guide the cohort of SHC teams in transforming their vaccination practices. The facilitators established a framework of tailored performance measures and a set of evidence-based change concepts across five healthcare domains (organization, delivery system design, provider decision support, clinical information systems, and patient self-management) for the cohort to use.

The teams then applied core QI science by formulating aim statements, tracking progress with run charts, and conducting rapid-cycle PDSA tests based on selected change concepts. Through monthly remote learning sessions, asynchronous online modules, targeted electronic medical record optimization, and a secure online portal, teams shared their work, progress, data, and implementation resources with the entire cohort — driving their efforts through a collaborative process.^8-10

Quality improvement can be used to drive meaningful change in college health settings. This study offers a practical example of how a collaborative, structured process for testing ideas, measuring outcomes, and adapting based on evidence can lead to better outcomes. Instead of searching for a sole solution, continuous learning leads to sustainable improvements.

From seeing systems to improving them

Systems thinking helps us ask better questions:

What is really driving this problem?
How are different parts of the system connected?
Where might there be feedback loops or unintended consequences?
Where might we have leverage?

Quality improvement helps us take the next step:

What specifically are we trying to change?
How will we know whether it worked?
What is the smallest test we can run?
What did we learn — and what should we change next?

For Campus Health 360, I see these approaches as complementary.

Systems thinking helps us understand the system. QI helps us change it.

Not every change requires a QI framework. But when we are trying to change something complex, uncertain, or consequential, using one can help us make our assumptions explicit, test changes before scaling them, recognize unintended consequences, and learn our way toward better results.

References:

1. Meadows, D. (2008). Thinking in Systems: A Primer. Chelsea Green Publishing. Accessed on September 21, 2026.  https://www.chelseagreen.com/product/thinking-in-systems/
2. Institute for Healthcare Improvement. (n.d.) Model for Improvement. IHI. Accessed on September 21, 2026. https://www.ihi.org/library/model-for-improvement
3. Shah, A., & Course, S. (2018). Building the business case for quality improvement: a framework for evaluating return on investment. Future healthcare journal, 5(2), 132–137. https://doi.org/10.7861/futurehosp.5-2-132. Accessed on September 21, 2026.
4. Thusini, S., Soukup, T., Chua, KC. et al. How is return on investment from quality improvement programmes conceptualised by mental healthcare leaders and why: a qualitative study. BMC Health Serv Res 23, 1009 (2023). https://doi.org/10.1186/s12913-023-09911-9. Accessed on September 21, 2026.
5. Thusini, S., Soukup, T., Chua, K., & Henderson, C. (2023). How is return on investment from quality improvement programmes conceptualised by mental healthcare leaders and why: a qualitative study. BMC Health Services Research, 23. Accessed on September 21, 2026.
6. S’thembile Thusini, Tayana Soukup, Claire Henderson, The four main domains of the concept of return-on-investment from healthcare quality improvement programmes, International Journal for Quality in Health Care, Volume 38, Issue 3, July 2026, mzag089, https://doi.org/10.1093/intqhc/mzag089. Accessed on September 21, 2026.
7. Ciotoli C, Smith AJ, Keeling RP. Call to Action: Better Care, Better Health, and Greater Value in College Health. Journal of American College Health. 2018;66(7):625-639. doi:10.1080/07448481.2018.1431908
8. Fu LY, Smith A, Ciotoli C, Dannenbaum M, Jacobs M. An Immunization Quality Improvement Learning Collaborative in the College Health Setting. Journal of American College Health. 2023;71(8):2612-2621. doi:10.1080/07448481.2021.1979560
9. Hoskins EJ, Sayger SA, Westman JS. Quality Improvement in Patient Distribution at a Major University Student Health Center. Journal of American College Health. 2002;50(6):303-308. doi:10.1080/07448480209603449

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