Pragmatic ProblemPragmatic Problem--Solving for Solving for Healthcare: Principles, Tools, Healthcare: Principles, Tools,
and Applicationand Application
ManimayManimay GhoshGhoshDr. Dr. DurwardDurward K. K. SobekSobek, II, II
Mechanical and Industrial Engineering Dept, Mechanical and Industrial Engineering Dept, Montana State University, Bozeman, MTMontana State University, Bozeman, MT
AcknowledgementAcknowledgement
Funding for this project is provided by Funding for this project is provided by National Science Foundation (Grant # National Science Foundation (Grant # 0115352)0115352)
Healthcare in CrisisHealthcare in Crisis
Huge wastes (35% employeesHuge wastes (35% employees’’ time spent time spent on wasteful work)on wasteful work)
High errors (nearly 100,000 Americans die High errors (nearly 100,000 Americans die each year)each year)
High costs (in 2002, healthcare cost per High costs (in 2002, healthcare cost per person person -- $5267, increasing @ 8$5267, increasing @ 8--9% per 9% per year)year)
Healthcare in CrisisHealthcare in Crisis
Broken work systemsBroken work systems
Experts suggest operational failuresExperts suggest operational failures
Problem Solving Technique in Problem Solving Technique in HealthcareHealthcare
Total Quality Management (TQM)Total Quality Management (TQM)
–– PDCA approach PDCA approach
–– Applied mid1980sApplied mid1980s
–– Limited successLimited success
Problem Solving Technique in Problem Solving Technique in HealthcareHealthcare
Six SigmaSix Sigma
–– DMAIC approachDMAIC approach
–– Applied late 1990sApplied late 1990s
–– Some success, not widely usedSome success, not widely used
Toyota Production System Toyota Production System (TPS)(TPS)
Very successful in the industrial worldVery successful in the industrial world
Mostly applied in manufacturingMostly applied in manufacturing
Applied in healthcare Applied in healthcare –– early 2000early 2000
ReasonReason’’s for Success of TPSs for Success of TPS
Old Explanations:Old Explanations:
–– Elimination of waste in any formElimination of waste in any form
–– Use of specific tools in productionUse of specific tools in production
ReasonReason’’s for Success of TPSs for Success of TPS
New explanation (by Spear and Bowen, New explanation (by Spear and Bowen, 1999)1999)
–– RulesRules--inin--UseUse
Three design rules to construct work processesThree design rules to construct work processes
One rule for systematic problem solvingOne rule for systematic problem solving
Goal of this PresentationGoal of this Presentation
The goal is to demonstrate the efficacy of The goal is to demonstrate the efficacy of TPS design rules to improve process TPS design rules to improve process performance in a nonperformance in a non--manufacturing manufacturing environmentenvironment
Our AgendaOur Agenda
Present the 4 RulesPresent the 4 Rules--inin--Use of ToyotaUse of Toyota
Present a case examplePresent a case example
Discuss the case in light of the RulesDiscuss the case in light of the Rules--inin--UseUse
Concluding remarksConcluding remarks
3 Design Rules of TPS3 Design Rules of TPS
Three Building blocks of Production Three Building blocks of Production SystemSystem
–– ActivityActivity
–– ConnectionConnection
–– PathwayPathway
Design Rule 1 of TPSDesign Rule 1 of TPS(Activity)(Activity)
All work shall be highly specified as toAll work shall be highly specified as to
–– ContentContent
–– SequenceSequence
–– TimingTiming
–– OutcomeOutcome
Design Rule 2 of TPSDesign Rule 2 of TPS(Connection)(Connection)
Every customerEvery customer--supplier connection must supplier connection must be direct and there must be an be direct and there must be an unambiguous yesunambiguous yes--oror--no way to send no way to send requests and receive responsesrequests and receive responses
Design Rule 3 of TPSDesign Rule 3 of TPS(Pathway)(Pathway)
The pathway for every product and service The pathway for every product and service must be simple and directmust be simple and direct
Rule 4 of TPSRule 4 of TPS(Problem(Problem--Solving)Solving)
Any improvement must be made in Any improvement must be made in accordance with the scientific method accordance with the scientific method under the guidance of a teacher, at the under the guidance of a teacher, at the lowest possible level in the organizationlowest possible level in the organization
TPSTPS’’ss Notion of Ideal Notion of Ideal
The RulesThe Rules--inin--Use move the organization Use move the organization toward ideal:toward ideal:
–– Defect freeDefect free
–– Delivered one at a timeDelivered one at a time
–– On demandOn demand
–– ImmediatelyImmediately
TPSTPS’’ss Notion of IdealNotion of Ideal
No waste of resourcesNo waste of resources
In an environment physically, emotionally, In an environment physically, emotionally, and professionally safe for employeesand professionally safe for employees
Problem Solving ToolProblem Solving Tool
Toyota has several kinds of A3 reportsToyota has several kinds of A3 reports
We adapted an A3 report (metric We adapted an A3 report (metric equivalent of 11equivalent of 11””××1717””) from Toyota) from Toyota
The A3 report guides in systematic The A3 report guides in systematic problem solving (Rule 4)problem solving (Rule 4)
Our AgendaOur Agenda
Present the 4 RulesPresent the 4 Rules--inin--Use of ToyotaUse of Toyota
Present a case examplePresent a case example
Discuss the case in light of the RulesDiscuss the case in light of the Rules--inin--UseUse
Concluding remarksConcluding remarks
Case ExampleCase Example
Group meal therapy (2Group meal therapy (2--3 patients) in 3 patients) in Rehabilitation Nursing Unit (R.N.U)Rehabilitation Nursing Unit (R.N.U)
45 minute duration45 minute duration
Location: Common AreaLocation: Common Area
Statement of the ProblemStatement of the Problem
The therapist in R.N.U. during group meal The therapist in R.N.U. during group meal therapy were involved more in nontherapy were involved more in non--value value added activities leading to inconsistent added activities leading to inconsistent and ineffective patient careand ineffective patient care
Problem Solving TeamProblem Solving Team
Initiator (Speech Language Therapist)Initiator (Speech Language Therapist)
–– A front line staffA front line staff
# of participants # of participants –– 50 50
Other participants (mostly front line)Other participants (mostly front line)
–– Occupational and Speech TherapistsOccupational and Speech Therapists
–– Secretary and DietitianSecretary and Dietitian
–– RNs and techsRNs and techs
Outline of the CaseOutline of the Case
Observed the problem firstObserved the problem first--handhand
Drew the current state Drew the current state
Conducted root cause analysis (5 Whys)Conducted root cause analysis (5 Whys)
Developed countermeasuresDeveloped countermeasures
Drew the target state Drew the target state
Developed implementation planDeveloped implementation plan
Collected resultsCollected results
Observed the Problem at SiteObserved the Problem at Site
Observed the problem firstObserved the problem first--hand at sitehand at site
–– The therapist collected schedule from schedulerThe therapist collected schedule from scheduler
–– S/he brought patients (no fixed rule on who will bring S/he brought patients (no fixed rule on who will bring patients)patients)
–– S/he collected supplies from different places (no S/he collected supplies from different places (no designated place)designated place)
–– S/he conducted therapy (unclear on goals to achieve, S/he conducted therapy (unclear on goals to achieve, inconsistencies)inconsistencies)
–– S/he returned patients (unclear on who will return S/he returned patients (unclear on who will return patients) and cleaned common areapatients) and cleaned common area
Current State DrawingCurrent State Drawing
Root Cause AnalysisRoot Cause Analysis
Absence of therapy goals led to Absence of therapy goals led to inconsistency in treatmentinconsistency in treatment
Absence of REHAB protocol led to Absence of REHAB protocol led to confusion at every step in the processconfusion at every step in the process
–– Who is responsible for whatWho is responsible for what
CountermeasuresCountermeasures
Developed goal page for therapyDeveloped goal page for therapy
–– Feeding goalsFeeding goals
–– Positioning goalsPositioning goals
–– Swallowing goalsSwallowing goals
–– Cognition goalsCognition goals
–– Communication goalsCommunication goals
Developed protocol for group meal therapyDeveloped protocol for group meal therapy
–– Responsibilities of each caregiver and how s/he will Responsibilities of each caregiver and how s/he will connect with others in the process chain connect with others in the process chain
Target State DrawingTarget State Drawing
Consensus BuildingConsensus Building
The initiator collected input from all The initiator collected input from all caregiverscaregivers–– TherapistsTherapists
–– RNsRNs
–– TechsTechs
–– SecretarySecretary
–– DietitianDietitian
She drew the target state drawing and She drew the target state drawing and asked others for confirmationasked others for confirmation
Implementation PlanImplementation Plan
Developed implementation plan in terms Developed implementation plan in terms of:of:
–– What actions to be takenWhat actions to be taken
–– Who is responsible for that actionWho is responsible for that action
–– When that action will be completedWhen that action will be completed
–– Outcome of such actionOutcome of such action
ResultsResults
Our AgendaOur Agenda
Present the 4 RulesPresent the 4 Rules--inin--Use of ToyotaUse of Toyota
Present a case examplePresent a case example
Discuss the case in light of the RulesDiscuss the case in light of the Rules--inin--UseUse
Concluding remarksConcluding remarks
Case in Light of TPS RulesCase in Light of TPS Rules(Activity: Rule 1)(Activity: Rule 1)
Before A3Before A3
–– Unclear therapy goals Unclear therapy goals during therapy during therapy (unspecified activities)(unspecified activities)
–– Medical supplies not Medical supplies not arranged before arranged before therapy (unspecified therapy (unspecified activity)activity)
After A3After A3
–– Clear therapy goalsClear therapy goalsDeveloped goal page Developed goal page (specifying activities) (specifying activities)
–– Medical supplies Medical supplies arranged in advance arranged in advance (specified activity)(specified activity)
Case in Light of TPS RulesCase in Light of TPS Rules(Connection: Rule 2)(Connection: Rule 2)
Before A3Before A3
–– Unclear on who will Unclear on who will bring patients to the bring patients to the common area and common area and return return
Unclear connectionsUnclear connections
After A3After A3
–– Techs will bring Techs will bring patients to the patients to the common area and common area and return return
Clear connectionsClear connections
Case in Light of TPS RulesCase in Light of TPS Rules(Pathway: Rule 3)(Pathway: Rule 3)
Before A3Before A3
–– Process path complexProcess path complex
–– Unfolded differently Unfolded differently
–– Confusing at every Confusing at every stepstep
After A3After A3
–– Process path Process path simplifiedsimplified
–– Clear and directClear and direct
Case in Light of TPS RulesCase in Light of TPS Rules(Rule 1,2,3)(Rule 1,2,3)
Specifying activitiesSpecifying activities Defining clear Defining clear connectionsconnections
Simplified PathwaysSimplified Pathways
Case in Light of TPS RulesCase in Light of TPS Rules(Problem Solving: Rule 4)(Problem Solving: Rule 4)
Before A3Before A3
–– Problem solving Problem solving initiated by senior levelinitiated by senior level
employeesemployees
After A3After A3
–– Problem solving Problem solving initiated by front line initiated by front line employeesemployees
–– Situated at problem Situated at problem sitesite
–– Scientific approachScientific approach
–– Collaborative effortCollaborative effort
Our AgendaOur Agenda
Present the 4 RulesPresent the 4 Rules--inin--Use of ToyotaUse of Toyota
Present a case examplePresent a case example
Discuss the case in light of the RulesDiscuss the case in light of the Rules--inin--UseUse
Concluding remarksConcluding remarks
Few Examples of Similar Few Examples of Similar ApplicationApplication
Labeling of specimens from OR to LabLabeling of specimens from OR to Lab
Ordering of specimens from OR to LabOrdering of specimens from OR to Lab
Transporting specimens from OR to LabTransporting specimens from OR to Lab
Transporting patients from the floors to the Transporting patients from the floors to the clinical departmentsclinical departments
ConclusionsConclusions
We studied numerous work processesWe studied numerous work processes
Applied TPS design rules to improveApplied TPS design rules to improve
Results were very satisfactory in all casesResults were very satisfactory in all cases
Gave us confidence that the rules does Gave us confidence that the rules does apply in the nonapply in the non--manufacturing sector as manufacturing sector as wellwell
Systemic changeSystemic change
ConclusionsConclusions
The collaborative problem solving took The collaborative problem solving took place at the front lineplace at the front line
–– Speech Language Therapists, RNsSpeech Language Therapists, RNs
–– Dietitian, Secretary, Occupational therapistsDietitian, Secretary, Occupational therapists
They took ownership for the success of They took ownership for the success of the processthe process
They ensured its sustenanceThey ensured its sustenance