1 introduction to system redesign (sr) and operational systems engineering (ose) lean heather...
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Introduction to System Redesign (SR) and Operational Systems Engineering (OSE)
Lean
Heather Woodward-Hagg, MS, CQE, CSSBB
Isa Bar-On, PhD
Peter Woodbridge, MD, MBA
Diana Ordin, MD
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System Redesign MethodsIdentifying and Eliminating Operational Barriers within Patient Treatment ProcessesMaterials
Step 3
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Reducing sources of variation…Every step in the patient treatment process contributes to the:
•Patient Outcome•Patient Satisfaction•Cost of Treatment
Every caregiver and staff member must be active in reducing variation.
VA-TAMMCS Framework
What is Systems Redesign?Industry vs. Craft Paradox
Adapted from Peter Woodbridge, Brenda Zimmerman, 2002
Systems Engineering Professionalism
Simple
“Follow a Recipe”
Patient Check-in
LinearDefined
Few Steps
Standardized
Complicated
“Flying an Airplane”
Scheduling a Consult
Non-linearDefinable
Many Steps
Rigid Adherence to
Protocols
Complex
“Raising a Child”
Patient Care
Uniqueness
Experience Helps
Chaotic
“Emergency”
Emergency
Unpredictable
SpeedImprovisation
ProfessionalismSystems Redesign/Engineering
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Evidence Based Practice
Clinical Practice Bundles
“a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices - generally three to five - that, when performed collectively and reliably, have been proven to improve patient outcomes.”
IHI – Institute for Healthcare Improvement IHI.org 100,000 lives campaign 5 million lives campaign
Rubenstein, Pugh Model for TRIP
Rubenstein & Pugh, JGIM 2006; 21:S58-64
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Ventilator Associated Pneumonia (VAP bundle) Ventilator Associate Pneumonia Bundle
Head of bed elevation 30-45o
Daily assessment for weaning Peptic Ulcer Disease (PUD) Prophylaxis Deep Vein Thrombosis (DVT) Prophylaxis
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VAP Bundle Implementation
What does this process look like at week 15?
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What happened?
Sustainability
Woodward-Hagg, H., El-Harit, J., Vanni, C., Scott, P., (2007). Application of Lean Six Sigma Techniques to Reduce Workload Impact During Implementation of Patient Care Bundles within Critical Care – A Case Study. Proceedings of the 2007 American Society for Engineering Education Indiana/Illinois Section Conference, Indianapolis, IN, March 2007.
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Average Daily % of ED stat orders (Order to Verify) returned within 60 minutes through April, 2006
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Repenning QI Model *
* Repenning, N. and J. Sterman (2001). Nobody Ever Gets Credit for Fixing Defects that Didn't Happen: Creating and Sustaining Process Improvement, California Management Review, 43, 4: 64-88
ProcessReliability
Errosion inReliability
Investment inReliability
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Repenning QI Model *
* Repenning, N. and J. Sterman (2001). Nobody Ever Gets Credit for Fixing Defects that Didn't Happen: Creating and Sustaining Process Improvement, California Management Review, 43, 4: 64-88
ProcessReliability
Errosion inReliability
Investment inReliability
ActualPerformance
PerformanceGap
DesiredPerformance
Time Spent onImprovement
+
+
-
+
Time SpentWorking
+delay
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The “Work Harder” Loop
ProcessReliability
Errosion inReliability
Investment inReliability
ActualPerformance
PerformanceGap
DesiredPerformance
Time Spent onImprovement
+
+
-
+
Time SpentWorking
+
Pressure todo work
+
+
Work Harder
delay
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The “Work Smarter” Loop
ProcessReliability
Errosion inReliability
Investment inReliability
ActualPerformance
PerformanceGap
DesiredPerformance
Time Spent onImprovement
+
+
-
+
Time SpentWorking
+
Pressure todo work
+
+
Work Harder
Pressure toImprove
Capability+
+
Work Smarter
delay
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Systems Redesign Applications
ProcessReliability
Errosion inReliability
Investment inReliability
ActualPerformance
PerformanceGap
DesiredPerformance
Time Spent onImprovement
+
+
-
+
Time SpentWorking
+
Pressure todo work
+
+
Work Harder
Pressure toImprove
Capability+
+
Work Smarter
delay
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Systems Redesign Applications
ProcessReliability
Errosion inReliability
Investment inReliability
ActualPerformance
PerformanceGap
DesiredPerformance
Time Spent onImprovement
+
+
-
+
Time SpentWorking
+
Pressure todo work
+
+
Work Harder
Pressure toImprove
Capability+
+
Work Smarter
Improving Reliability
Effectiveness/Timelinessof “Work Smarter” Loop
Identification of Performance
Gaps
Reducing ReliabilityErosion
delay
- Intrinsic pressure- Extrinsic pressure• Organizational• Microsystem
Isolation Sign
By permission: LSSHC
Complexity in Healthcare
Anarchy(Random Chaos)
Far fromAgreement
Close toAgreement
Close toCertainty
Far fromCertainty
Complexity
(Dynamic System
s;
Deterministic Chaos)
Rational (Linear) Systems
Adapted from Ralph Stacey “Complexity and Creativity in
Organizations”
Soc
ial
Technical
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Approaches to Improvement
RCC PDSA Within a clinical
microsystem Microsystem is capable
Deep Dive Defined charter Little analysis required Motivated team
Rapid Process Improvement Workshop (RPIW) Defined charter Many RCC PDSA A lot of progress likely in
one week
100 Day Project Analysis required Ambiguous charter Follows DMAIC
5 RCC PDSA
Fast Start RPIW100 Day Project
Increasing Complexity
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RCC PDSA
RCC PDSA Use small tests of change Test each idea for
quantifiable impact No charter
“Improvement” is charter Success depends on
Motivated team Capable team
Use when there is good “agreement” but weak evidence as to best practice
Anarchy(Random Chaos)
Far fromAgreement
Close toAgreement
Close toCertainty
Far fromCertainty
Rational (Linear) Systems
Negotiated Systems
Evolving Systems
(RCC PDSA)
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Deep Dive Project
One day “mini-blitz” followed by weekly meetings First day:
Process map Isolate problems Identify RCC PDSA
Up to 6 weeks Analyze results RCC PDSA Additional RCC PDSA
Has charter Progress tracked at monthly
milestone meetings
Best used for “simple” problems that may require a structured environment for “negotiation”
Anarchy(Random Chaos)
Far fromAgreement
Close toAgreement
Close toCertainty
Far fromCertainty
Rational (Linear) Systems
Negotiated Systems
Evolving Systems
(RCC PDSA)
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Rapid Process Improvement Workshop (RPIW)
Weeklong (40 hour) event + 90 day weekly follow-up Combine education and
improvement Highly structured Day 1-2 analysis
VOC & PD Process map Isolate problems
Day 3-5 RCC PDSA 20-30 small tests of
change in one week
Best used for “complicated” but well defined problems
Anarchy(Random Chaos)
Far fromAgreement
Close toAgreement
Close toCertainty
Far fromCertainty
Rational (Linear) Systems
Negotiated Systems
Evolving Systems
(RCC PDSA)
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100 Day Project
Advanced SR Tools Based on TAMMCS cycle
Define Measure Analyze Implement Control
2-3 hour meetings weekly for 8 weeks followed by 1 hour meetings for 4-6 weeks
Just in time training of team
Formal “go / no-go” milestones
Often requires value stream mapping
Use for “complex” problems May spin off other project
teams
Anarchy(Random Chaos)
Far fromAgreement
Close toAgreement
Close toCertainty
Far fromCertainty
Rational (Linear) Systems
Negotiated Systems
Evolving Systems
(RCC PDSA)
Introduction to Operational Systems Engineering (OSE)
Operational Systems Engineering* Academic discipline where researchers and practitioners
treat health care industry as complex systems, and further identify and apply engineering applications in health care systems.
Professionals in this field are often called hospital engineers, management engineers, industrial engineers, or health systems engineers.
Incorporates many engineering applications, such as Industrial engineering, human factors engineering, quality engineering, informatics and implementation research
* http://en.wikipedia.org/wiki/Health_systems_engineering
OSE Tools/Methods*
Discrete Event Models Stochastic Models Lean Six Sigma Measurement System Analysis (MSA) Value Stream Mapping Time and Motion Studies Process Observation Process Mapping PDSA Cycles
IncreasingLevel
OfComplexity
80% of issues can be resolved with lower complexity tools
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Why Systems Engineering?
Healthcare has people from different disciplines interact with each other and with Technology
Origins of Systems Thinking…
“A fault in the interpretation of observations, seen everywhere, is to suppose that every event is attributable to someone (usually the one closest at hand), or is related to some special event. The fact is that most troubles… lie in the system and not the people”.
- Deming, The New Economics
“A fault in the interpretation of observations, seen everywhere, is to suppose that every event is attributable to someone (usually the one closest at hand), or is related to some
special event. The fact is that most troubles…
lie in the system and not the people”.
- Deming, The New Economics
Medication Delivery
Estimated 30% of all medical errors occur during medication delivery processes
Average litigation expense = $680,000
Technology available to prevent errors: BCMA – Bar Code Medication Administration Pyxis – Automated Medication Delivery Infusion (Alaris) pumps – regulates IV flow
BCMA Background
BCMA introduced to reduce medication errors in 1999
Bypassing / workarounds persist 94 incidents since 10/2002 10/13 aggregate RCA related to BCMA
BCMA Medication Pass
AM med pass (current state)
PM med pass (modified cart)
Steps per patient: 181 stepsAttempts: 3.3Total time per patient: 18 minsSupply time per patient: 9 minsMed administration time: 9 mins
PyxisSupplyArea
SupplyArea
Med/Isolation Carts – Current State
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14 minutes in the life of a Pharmacy Tech
VAMC EMR Implementation
8 feet of paperper week
Incoming Documentation by type/unit
SDS Paper Generation
Conversion to e-documentation
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Other Challenges to Technology Implementation
Technology is not effectively integrated in clinical workflow.
Healthcare professionals (clinicians, administrators) lack the tools for assessing and addressing potential ‘side effects’
Result more workarounds and ambiguity
‘Side Effects’ = Limitations of Mental Models
“A fault in the interpretation of observations, seen everywhere, is to suppose that every event is attributable to someone (usually the one closest at hand), or is related to some special event. The fact is that most troubles… lie in the system and not the people”.
- Deming, The New Economics
“ There are no ‘side effects’…only ‘effects’ ….those that we thought of in advance we call the ‘main effects’ and take
credit for...the ones that came around and bit us the in the rear….those are the ‘side effects’…
…in effect we are highlighting the limitations of our mental models.”
- J. Sterman, “All models are wrong…(some are useful)….reflections on becoming a systems scientist”
Current VHA Systems Engineering Applications
Examples of Systems Engineering Projects in the VHA Discrete Event Simulation Models created by
Health Systems Engineers to optimize patient throughput:
Outpatient Clinic Patient Flow Models Radiology Capacity Models ER Throughput Models Surgical Flow Models
Highest Level of Technical Complexity
Examples of Systems Engineering Projects in the VHA Health System Engineers incorporate HSE
tools/methods (process mapping, process observation, visual controls) w/in Systems Redesign Projects
Optimize Medication Administration Processes Discharge Process Optimization Clinical Practice Guideline Implementation
Dysphagia, Post-op Glycemic Control, VAP Bundle, MRSA Bundle
Moderate/Low Level of Technical Complexity
Supply Organization
How does HSE contribute to effective systems redesign? Improving Reliability/Reducing Reliability
Erosion: Discrete Event Simulation Models Stochastic Models Value Stream Analysis Lean Tools – 5S, Visual Controls
Identifying the Performance Gap Measurement System Analysis (MSA) Dashboards Predictive Analytics
How does HSE contribute to effective systems redesign? Improving Effectiveness of “Work Smarter”
Loop
Training/Facilitation to enable front line staff and clinicians to apply HSE tools to improve processes:
Lean Six Sigma Value Stream Mapping Process Mapping Process Observation
Health Systems Engineering in the VHA –
next steps
Health Systems Engineering in the VHA Systems Engineering solutions must have
IMPACT in improving patient care:
Integration with current system redesign programs
Integration with Health Services Researchers to create level of generalizable knowledge: Implementation Research Evidence Based Management
Design/creation of support infrastructure for HSE application in VAMCs
VHA Engineering Resource Centers (VERCs)
Primary Mission: Development, testing, and deployment of innovative methods of operational systems engineering (OSE) to transform VA healthcare delivery system
VERCs Funded: VISN1 VERC: New England Healthcare Engineering
Partnership (NEHCEP) VISN11 VERC: VA Center for Applied Systems
Engineering (VA-CASE) VAPHS VERC Mid-West Mountain Region VERC (MWM VERC)
VISN12,18,19,23
Conclusions
Health Systems Engineering (HSE) provides systematic, multi-disciplinary approaches to optimization of healthcare systems
Health Systems Engineering methods are tools within systems redesign to enable:
Improved Process Reliability/Reduced Erosion Improve Identification of Performance Gaps Improved Effectiveness of Systems Redesign
efforts
Questions?