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Systems Thinking:Learning Session #2

David Munch M.D.

Faculty IHI

Chief Clinical Officer

Healthcare Performance Partners

May 14th, 2014

Objectives

Participants will be able to discuss systems thinking.

Participants will be able to relate the lessons learned to

their present methods of improvement.

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Dr. W. Edwards Deming:

System of Profound Knowledge

Appreciation for a

System

Understanding

Variation

Theory of Knowledge

Psychology“The various segments of the system of profound knowledge cannot be separated. They interact with each other.”

Appreciation for a System

A system is an interdependent group of items, people

and processes with a common aim.

All work is done through processes.

Every system is perfectly designed to achieve exactly

the results it gets.

If each part of a system, considered separately is made

to operate as efficiently as possible, then the system as

a whole will not operate as effectively as possible.

People are a key part of systems in organizations: they

want to do a good job and take pride in their work.

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Individual

Individual and System5

• Individual performance is

influenced by the system

• The performance of the

system as a whole is

influenced by the

individuals

• How do you determine:

• Who owns what?

• What is your role?

• How will you know about

system problems?

If We Want a New Level of Performance,

We Must Get a New System

Most problems in organizations do not come from

individual workers.

Most problems come from the structure of the systems

themselves, and people are only parts of those systems.

Changing the people, or pushing them to "try harder" or

"do better" will not result in improved performance.

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Human Error Models

Personal ModelNames, Blames and Shames

Assumptions of negligence, carelessness, lack of skill, knowledge or motivation

Uses fear and discipline as response

Lowers morale, hides problems

Systems ModelPoor system design causes or contributes to error

“Latent Failure Conditions”: culture, interactions, influences

Recognizes that humans have limits and error is inevitable

Design systems to anticipate, prevent and mitigate errors caused by humans

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Example: Inpatient Warfarin Prescribing8

Decision to Prescribe

Earlier in the Day

Need INR Value

Need Blood Draw

Need Lab Results

Results Communicated with Clinician

Change in prescribing to an earlier time of the day

What can go wrong?

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Systems Thinking

What is the problem we actually have (not perceive)?

What are the causes of the problem? – Why is the defect occurring?

– How do the parts relate to the whole?

– How does the system influence the problem?

What are we going to do to fix the problem?– Cycles of PDSA

– Note: Are we fixing the problem or putting a Band-Aid on it?

How will we know our changes are effective?

What systems and structures will be establish to support and sustain?

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Principles of a Safe System

Prevent

– Through standardization, simplification

Detect

– Improve methods to identify errors when they occur

– Should not be the primary strategy

Mitigate

– Prevent error from causing harm

– Mitigate the severity of the harm

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Systems: Processes and Interactions at All

Levels

Governance

Therapies

Leadership

Supply Chain

TransitionEvaluation

Management

FacilitiesHR

Entry

Staff

I.T.Revenue

Cycle

Drivers

Mainstay

Support

The Patient

Scorecard Used in Daily Management

Systems

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Satisfaction Financial Quality Growth

Outcome Metrics

Reason For Miss

A3s

ProcessMetrics

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Visual ManagementWhat the Executive Evaluates What the Manager Evaluates

Are the metrics correct? (strategically aligned)

Last updated? Are there targets or

specifications? Does performance

meet the standard? Are reasons for misses

documented AND driving problem solving activity?

Is the visual mgmtsystem being updated regularly and driving behavior?

Are things getting better?

Does performance meet standard?

Are there standards that need to be tightened?

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Develop “True North” and align the organization to that pursuit

Strategy development and deploymentDevelop systems and structures

Develop and support all staff in continuous improvement

Developing Lean LeadersA3 Deployment

Organizational Development and Learning

Engage staff in surfacing and

solving problemsA3 Problem Solving

Safety Culture

Eliminate waste and make the right work

easier to doLeadership Standard Work

Visual ManagementKaizen

5S

Exercise: Write Your Progress Report

Spend 10 minutes at your table discussing the

possible causes as to why your improvement effort

did not achieve desired results1. What influenced the ability of staff to carry out the steps?

2. What got in their way?

3. What other part of the system did not support the change?

Spend 5 minutes discussing what you will do to

keep that from happening going forward.

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Thank You