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?