The Netherlands faces significant capacity challenges in healthcare due to staff shortages. Many healthcare positions remain unfilled, despite rising demand for medical services. This also impacts the Emergency Department (ED), as higher patient volumes lead to longer wait times and increased responsibilities for emergency physicians. The combination of these variables leads to an increase in personnel turnover, putting additional strain on capacity. These capacity difficulties may also be seen in Deventer Hospital's ED, highlighting the significance of effectively organising patient flows and addressing system dynamics.

Although Deventer Hospital has conducted analyses to improve capacity management, current approaches, both locally and in the broader literature, primarily focus on technical aspects, such as staffing planning within the ED. However, by focusing solely on technical factors, such analyses may fail to account for social factors that influence system performance, such as human behaviour, communication patterns, decision-making processes, and institutional constraints. To bridge this gap, this study adopts a socio-technical systems approach that incorporates both technical and social factors of capacity management in the ED.

The main question is:
How can Emergency Department capacity challenges be improved using a social-technical approach?

To answer this question, the current system at Deventer Hospital's ED was examined through a socio-technical systems framework. The IDEF0 model was used to map both the technical and social factors influencing capacity management. This model systematically represents workflow processes, resource dependencies, regulatory constraints, and the stakeholders involved. The system mapping was informed by multi-day observations, open interviews with ED physicians, document analysis, and a stakeholder analysis. The stakeholder analysis provided deeper insights into communication patterns, knowledge distribution, and power-interest relationships among the actors. Together, these methods resulted in a comprehensive and structured representation of the ED.

The system analysis revealed that ED capacity challenges involve both technical and social dynamics. These were categorized across three phases: inflow, throughput, and outflow. Specific issues included variability in triage processes, workforce shortages, delays in diagnostics, and asymmetric information exchange between departments. Furthermore, ED physicians noted that a proportion of patients could potentially have been treated elsewhere, affecting resource allocation and patient flow.

Based on these insights, potential interventions were developed to optimize patient redirection within the socio-technical landscape. A snapshot analysis estimated the proportion of patients who, according to ED physicians, could have been treated in alternative settings, such as by general practitioners or outpatient clinics. This analysis was complemented by interviews with ambulance personnel, GPs, and medical specialists, which provided deeper insight into barriers and opportunities for patient redistribution.

The findings indicate that while technical opportunities exist, particularly in redirecting patients to urgent outpatient clinics, success is dependent on effective capacity planning and accessibility in alternative care settings. Social factors play an equally critical role. Efficient patient diversion requires a robust communication framework among general practitioners, ambulance services, and specialists. In practice, however, such communication is not always optimal.

Additionally, a growing claims culture increasingly influences referral behavior. Concerns regarding legal liability and potential complaints compel healthcare providers to refer patients to the ED more frequently as a precaution, even when alternative care options could be more appropriate. This defensive referral behavior exacerbates ED workload and reflects a broader trend of risk aversion in healthcare decision-making.

To address these issues, both technical and social interventions are proposed. Technically, expanding urgent outpatient clinic capacity could offer potential, provided that accessibility and appointment scheduling are carefully managed. Socially, interventions such as structured feedback systems between EDs and referring providers, enhanced real-time communication channels, and targeted legal literacy training for healthcare professionals could reduce unnecessary referrals.

In conclusion, the socio-technical system analysis provided a more comprehensive understanding of ED capacity management by considering both technical and social dimensions. This approach revealed important dynamics that a purely technical analysis might have overlooked, such as communication gaps, coordination barriers, and organizational constraints. It led to the development of potential interventions that not only address logistical aspects of patient redirection but also promote social structural improvements within the healthcare system. By targeting both technical workflows and social coordination mechanisms, this socio-technical approach offers a more realistic pathway to optimizing Emergency Department capacity.

The water and sanitation sector faces well-documented issues that are challenging to address, leading to the establishment of the Platform of Vocational Excellence (PoVE) Water. This platform brings together five regional Centers of Vocational Excellence (CoVE) Water in Europe and South Africa to ensure high-quality skills and competencies in the water sector. These CoVEs facilitate collaboration among stakeholders, enabling the development of vocational education and training programs to increase awareness, responsiveness to industry needs, and address sector challenges. A few months ago, CoVE Water SA was established in South Africa to achieve the previously mentioned goals. Therefore, it is important that the following research question is answered in this initial set-up phase: What actions need to be taken to enhance the effectiveness of the CoVE Water SA?
To answer this research question, several important stakeholders were interviewed. Subsequently, the interviews were analysed thematically in order to extract the most important themes and quotes, PI grids were created to assess power and interest dynamics among stakeholders, and a Social Network Analysis was conducted to understand the CoVE Water SA network and potential clusters.

The research findings have unveiled key aspects for enhancing the effectiveness of CoVE Water SA. The current network in the water sector has a low density, implying that many collaborations are lacking. This leads to a high degree of interdependence within the network, resulting in a non dynamic system. The lack of collaborations, such as connections with TVET colleges, schools, farmers and local communities, results in a lack of knowledge, funding and connection to the labour market. Governmental stakeholders, like DWS, EWSeta, and BGCMA, have been identified as influential players with extensive networks and important resources, Local Authorities and Research Organizations also play important roles. Universities exhibit substantial international links, making them crucial contributors. These stakeholders have the potential to provide knowledge, collaboration, and power. These are valuable insights for CoVE Water SA, fostering network growth and effectiveness in the water sector.

Furthermore, six key themes have been derived from the conducted interviews, addressing the needs of stakeholders and where CoVE can make a valuable contribution.
These themes include raising awareness, reducing the skills gap in the water sector, fostering international collaborations, mitigating the labour shortage in the water sector, improving education material and establishing desired collaborations. For each theme, the interviewed stakeholders have presented their views and numerous suggestions on how CoVE Water SA can assist in addressing these issues. Additionally, stakeholders have also mentioned possible failures of CoVE Water SA, which can aid in preventing any shortcomings of the platform. Furthermore, stakeholders mentioned ongoing initiatives related to the six themes, through which they can contribute to the platform.

From the Thematic Analysis, PI Grids and the SNA, a set of actions have emerged that are essential for enhancing the effectiveness of CoVE Water SA. These actions revolve around expanding and enhancing the network, organising activities and contributing to educational improvement. In terms of broadening and strengthening the network, the platform should focus on enhancing the collaborations among educational groups, building stronger relations with international institutions in Europe and Africa, involving TVETs and schools within the water network, improving stakeholder involvement and encouraging the involvement of Local Communities to increase awareness and knowledge about water issues. Furthermore, CoVE Water SA should play a role in organising activities to raise awareness of Water Resource Management. Additionally, it should assist in improving curricula, supporting students’ preparation for the workforce and making the education more practical instead of only theoretical. CoVE Water SA should also provide training and learning resources as well as comprehensive courses.

However, this study recognizes several limitations that should be considered in future research and when implementing recommendations for CoVE Water SA. These limitations encompass factors like a limited scope due to resource and time constraints, minimal varied interviewee responses, and potential biases in responses. Addressing these limitations will be crucial in guiding future research and actions for CoVE Water SA.