If nothing changes, one in four employees must work in the healthcare sector in 2040, according to the Scientific Council for Government Policy (WRR, 2021). Therefore, acute care must undergo a fundamental system transformation to effectively address the needs of a growing and ageing population, while on the other hand there is a growing scarcity of personnel. Currently, the acute care chain consists of cooperating care providers such as hospitals, ambulances, general practitioners, and nursing homes in each region. A Regionaal Overleg Acute Zorgketen (ROAZ)-agency organizes the collaboration and has been given the responsibility to formulate transformation plans for the acute care chain. While a ROAZ-agency excels in optimising current collaborations between chain partners, it faces at least three knowledge gaps when it comes to designing a fundamental transformation. Overall, 1) the actors of the acute care lack a holistic view on the problem situation, 2) are predominantly inward-looking, and 3) lack a desirable vision of how the acute care could change as a whole. Therefore, this graduation project used a systemic design approach to facilitate the transformation towards a more resilient system. Resilience theory was consulted in this project, because of the prevalent framing of the growing older population, as a pressure on acute services (Adema, 2019). To produce transformation plans, the design process consisted of three phases. The first was mapping the current state of the system, the second was proposing a resilient state, and the third was exploring strategic responses aimed at achieving that state. Central to a transformation from one system state to another is a shift in paradigm (Meadows, 2008). A paradigm shift radically changes the way we see the world and with that it changes the way we give purpose to our systems. Four paradigm shifts are derived from interviews with experts and stakeholders from the acute care domain:

From viewing care as a business for professionals to approaching care as a social undertaking. From a belief in the makeable human, to live with a view of the end. From perceiving care as a commodity to seeing care as a common good. From the wish to live independently at home to the desire to live old together.

These paradigm shifts are at the foundation to how we can transform our acute care system. However, they still have to be made tangible. The shifts are shaped in four responses addressed at decision-making processes, information flows, spatial concepts, and social network.

We need a management structure which enlarges trust, flexibility, and professional freedom of action. A military mission command structure can be adapted to the context of acute care. Mission-command embraces operationally ambiguity and sees this as advantage, while commanders aim to be as clear as possible in their strategies and their underlying intentions (Braw, 2022).
There is a need for a central information structure to improve decision-making processes in and before acute situations. Information entailing acute care policies based on a patient’s values, wishes, and needs must be made available prior to an acute situation.
There is a need for new (architectural) typologies and processes to address different (sub-)acute care situations. These options lie for instance in communal senior housing, neighbourhood clinics, and geriatric emergency squares in hospitals. Acute process needs to facilitate space for geriatric, and palliative skills of professionals, especially at ambulance organizations and ED’s.
At last, we must create a longing for intergenerational social networks instead of enforcing obligatory social service. We need to foster intergenerational social networks, based on value exchanges between generations. Stronger social networks, when directed at reassurance, are likely to indirectly lower the pressure on the acute care chain.
This thesis concludes with a discussion of each response, highlighting opportunities for further development, and a set of final recommendations for the ROAZ-agency to embrace systemic design practices.