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Systems Thinking for Healthcare
Diana M. Luan, PhD Uniformed Services University of the Health Sciences & Center for Disaster Assistance & Humanitarian Medicine
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The Issue in Healthcare
We understand what we do, but not how we do it Fail to see problems within their context Fail to understand the processes Jump to solutions before understanding the problem
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Sharpens our awareness of whole and of how the parts within the whole interrelate
Provides a vocabulary for discussing the dynamic complexity of our environment.
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Allows for the iterative unfolding of the interrelationships and processes within a system
Understanding the drivers of behavior
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Systems Network of interdependent components that work together to accomplish the aim of the system
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Systems are Embedded within Systems
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Complex Adaptive System
A collection of smaller systems - microsystems Share an environment Microsystems act independently Microsystems are interconnected Action by any part affects the whole Movement between the context and organization occurs freely
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Systems Thinking VUMC is a complex adaptive system
Requires consideration of: Context of the parts Linkages of parts Behaviors Recognizes connections and interrelationship where: Cause and effects are distant in both time and space Feedback may be delayed Solutions may have unintended consequences
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Microsystems are Embedded within Larger Systems of Care
Vanderbilt Healthcare System DoD Military Health System
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The Challenge To operate safely Provide quality, patient-centered care
Measurably improve outcomes & patient satisfaction Continually remove real costs, waste & rework Create an environment that is honest, open, and respectful
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The Current State
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Staff Response to Quality & Safety Initiatives
It is a Burden The Solution
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Microsystem Definition
“A small group of people who work together on a regular basis to provide care to discrete subpopulations of patients.” “It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes.” Day 1 Nelson, EC, Batalden, PB, et al (2002). “Microsystems in Health Care: Learning from High-Performing Front-Line Clinical Units.: J. on Quality Improvement vol. 28, no. 9,
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The Focus Smallest Replicable Unit (SRU)
= Provider SRU SRU Patient The smallest possible unit of interaction that connects the core competencies of the organization to the beneficiaries The interaction between the patient and the health system The quality, safety and value of care for any single patient (or cohort of patients) is a function of the sum of each interaction the patient has with the system Quinn, J.B. Intelligent Enterprise Free Press, NY, pg 103. 14
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Clinical Microsystems
Processes are organized around the needs of the patient Enhances every interface with the patient 15
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Reverses the Organizational Traditional Pyramid
VANDY
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Microsystem Improvement Model
Acute care Chronic care Preventive care Palliative care Initial Work-up, Plan for care Entry, Assignment Orientation Biological Functional Satisfaction Costs Biological Functional Expectations Costs Disenrollment
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Microsystems Thinking
Creates an awareness of the work being done Designed to engage everyone in making improvement part of the daily work It is a culture change Long-term transformation Understanding how care is delivered Reliability of care
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It involves… Analysis Planning Context Execution Evaluating
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Microsystem Framework is a Process
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Change Perspective Look at the your work from a variety of different angles and differing points of view Understand how things are accomplished in a dynamic system
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Microsystem Process
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Assessment Involves Understand the system's elements and behaviors
Reflect and use the tension for change to develop a deeper understanding of the system
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Assessment Knowledge What is your mission? Who do you serve?
Who do you work with? How do you do the work? How do you characterize your work? How do you improve? Clinical Aim/Purpose Pt. Characteristics Professionals Processes Patterns What information do you share? Metrics do you care about? What variation is there? Culture 24
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W. Edwards Deming “The aim precedes the organizational system and those that work in it.”
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What is your mission? (Purpose)
Focuses the team on the patient population Identifies the services necessary to meet the specific needs of that patient population Aligns the clinical aim and organizational mission to meet strategic goals 26
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Vanderbilt University
Vanderbilt University is a center for scholarly research, informed and creative teaching, and service to the community and society at large. Vanderbilt will uphold the highest standards and be a leader in the quest for new knowledge through scholarship, dissemination of knowledge through teaching and outreach, creative experimentation of ideas and concepts.
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Who do you serve? (Patients)
What are the characteristics of your patient population? What are their needs? Characteristics of the Patient Population Age Gender Top 5 Diagnoses Top 5 Consumer of Resources 28
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Understanding the Patient Population
Processes necessary to meet those needs Creates patient-centered care that ensures patients receive Right services When needed In the amount needed At the time needed
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Clinic Patients # Patients seen each day 330
# Patients seen each week # Patients seen each month * Based on data for May & June 2007 30
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Clinic Age Distribution
Birth – 4 years % 5 – 17 years % 18 – 24 years % 25 – 34 years % 35 – 44 years % 45 – 64 years % Age % *** Females % 31
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Clinic Top 10 Diagnoses Well Child Visit Well Woman/GYN Exam
Deployment Physical Exam Acute URI, NOS Administrative visit, unspecified Joint pain – L/leg Acute Pharyngitis Essential HTN, unspecified Need Prophylactic Vaccination Other General Medical Examination 32
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Who do you work with? (Professionals)
Characteristics of Staff Military, Contractor, GS Per Diem Physicians, Nurses, Others Housekeeping What activitites do they engage in? Research Administrative Clinical time
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Understanding the Professionals
Necessary depth and breadth of capabilities Defined roles and responsibilities Accountability Reduces redundancies but allows for back-up Maximizes the talents of the care team Creates shared mental models of the work Shared expectations Shared attitudes Increases collegiality, communication and teamwork 34
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Ward Nursing Staff Military Nurses 19 (Available)
Registered Nurses (RNs) 12.5 Contract Nurses (RNs): 2 LVNs 11 Licensed Vocation Nurses: 3 Nursing assistants Nursing Aides 10 Telemetry 4 Technicians Ward Clerks 2.5 9/17/2018 35
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How do you characterize the work? (Patterns)
Understanding patterns is the key to identifying improvements Understanding the work environment enables identification of areas for improvements Sustainment of change involves making the change part of the daily work 36
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Patterns Outcomes Cycle time Key supporting processes Satisfaction
Indirect patient pulls The things that pull/distract from direct patient care Communication Culture Outcomes Satisfaction Mortality Morbidity Biological markers Costs Productivity
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Outcomes Addresses the issues of:
How are we doing? Are we making an improvement? What do we need to change? We need to be data driven at the local level Using data to focus our efforts Justify what we do Improve the safety and quality of the care 38
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How do you do the work? (Process)
Allows for agreement on the steps involved in the delivery of care Creates standardized, measurable processes Doing the basics reliably and safely each and every time Delineates unexpected complexity, problem areas and redundancies Manage the unexpected Identifies where data can be collected and investigated Reduces variation 39
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Tension for Change Start with the process map
Identify places where the process are unsafe, or need improvement Examined system bottlenecks or failures or gaps Understand how you currently do things and Diagram the current reality Identify the quick, easy fixes Prepare for the larger changes Ask everyone to participate, keep everyone informed. 40
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One Day He Followed the Specimen
So he decided to follow a STAT specimen from the OR. What he discovered was…there were multiple points of delay. Transport being the most variable factor, dependent upon whether or not a volunteer was present and available, and whether the volunteer had other activities such as patient transport to address. Labs being less important to them than patients. Plume, SK. (2004). Dartmouth Medical School 41
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L&D Clinic Process (Outpatient)
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Understanding the processes allows the identification of change points
Leveraging change is "....seeing where actions and changes in (process) structure can lead to significant, enduring improvements.“ (Senge, 1990) Structure, process, interdependencies, and feedback within a system are important to producing outcomes
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Improved Process Plume, SK. (2004). Dartmouth Medical School
By removing the need to have a volunteer transport the specimen, the lag time was removed and the turn around time improved. Plume, SK. (2004). Dartmouth Medical School 44
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Check Results and Changes
Constantly monitor and evaluate the behavior of the system Takes action when needed to assure the system continues to produce the desired results
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Improved Turnaround Time
To being under 20 minutes Process Change Plume, SK. (2004), Dartmouth Medical School 46
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Consider Short and Long Term Consequences of Action
Weigh the possible short and long-term outcomes of change Consider change implications both up stream and down stream from change
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Implications Decreased risk for the patient Increased OR efficiencies
Infection Time on pump Morbidity and mortality Increased OR efficiencies Improved surgical team satisfaction Improved OR turnaround times Improved relationship with the lab microsystem This improved safety and quality significantly. 48
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Identify Unintended Consequences
Think about evidence-based solutions Try to anticipate unintended consequences
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Unexpected Outcomes Others ask to participate in improvement
Physicians became engaged Other departments become engaged “Removal of internally perceived barriers, leading us more towards ‘how can we do this?’ and away from ‘I don’t think we can do this.’” – Team Member 50
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Model for Improvement Act Plan Study Do
Aim: What are we trying to accomplish? Measures: How will we know that a change is an improvement? Changes: What changes can we make that will result in an improvement? What are we trying to accomplish Have a clear vision of your aims, the specific aims statement is a reflection of this Act Plan Study Do After Langley, Nolan, et. al. 51
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Microsystems is a Transformation Process
Create a new culture Become systems thinkers Use data to understand the system Working on the work Understanding how care is delivered Think about the SRU Patient-centered care Outcomes are created by teams Impressions are delivered by the individual Value means that we can justify Per capita costs, measured quality and population health status Systems must absorb the cost for medical errors and mistakes Pressure ulcers, infections and falls Proven Care – Geisinger Health System
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Sharp End Focus Focus must be at the sharp end, the point where the patient interacts with the system Locus of most work & policy Good outcomes are made at the front line not the front office Center for variables relevant to patient Place where “value (quality) is added” and “safe” care is made
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Healthcare Professionals must Recognize
Healthcare today requires a new mental model About the work About process About change “Success in the past has no implication for success in the future….the formulas for yesterday’s success are almost guaranteed to be formulas for failure tomorrow.” Michael Hammer Improvement, safety and quality must continually be re-invented Constantly changes because they are complex adaptive systems, where change is the constant 54
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Healthcare Paradigm Shift
Today Relationship multiple:1 Care based on continuum Alleviate burden of illness Patient centered Anticipation of patient needs Evidence-based decisions Safety is a system issue Transparency Teamwork Yesterday Relationship 1:1 Care based upon a visit Mono-disease Physician autonomy Reaction to patient needs Professional knowledge Do no harm Secrecy Professional individualism 55
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“Every system is perfectly designed to get the results it gets.”
Remember That… “Every system is perfectly designed to get the results it gets.” If we persist in holding the beliefs we have always held, and Insist on taking the action we have always taken, We should expect to continue to get the same results we have always gotten. Paul Batalden, MD Director Health Care Improvement Leadership Development The Dartmouth Institute Co-Founder Institute for Healthcare Improvement 56
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If you are still unsure about improving care…
Consider the Business Case
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Healthcare Driven by volume Reducing “volume” impacts the bottom line
Patients Procedures Reducing “volume” impacts the bottom line Payment changes “Never events” impact volume Volume sustains the bottom-line
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Institute of Medicine (IOM) Building a Better Delivery System (2005)
$ of every dollar spent on healthcare is associated with Overuse Underuse Misuse Duplication System failures Inefficiencies Half the patients seen receive evidence-based care 98,000 patients die 1 million sustain injuries from medical errors
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CMS Billing Data on Hospital Acquired Conditions for 2006
Number Events Average Cost Retained foreign object 764 $61,962/case Air embolism 45 $66,00/case Blood incompatibility 33 $46,492/case UTI, cath assoc 11,780 $40,347/case Pressure ulcer 322,946 $40,381/case IV assoc infection unknown Mediastinitis post-CABG 108 $304,747/case Fall from bed 2,591 $24,962/case UTI - $475,287,660 = 475 million Pressure ulcers 13,040,882,426 = 13Billion Blood incompatibility = 1.5 million Retained foreign obj = 47,338,968 =47 million CABG infection = $32,912,676 = 33 million Falls - $64,676,542 = 65 million
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The Reality is… Hospital-acquired conditions accounted for 12.2% of total legal liability costs (1 in 6 claims) Injuries - falls and fractures Pressure ulcers Foreign objects left in the body Pressure Ulcers - most frequently reported and most expensive $145,000 on average for claims per incident $25,000 cost to the insurance payor
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Now Consider 4% defect rate for the hospital Annual Errors
17,000 annual admissions 16,000 surgical procedures Annual Errors 640 surgical defects 501 transfusion defects 40,000 errors in medication administration
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Expense to the System Quality and safety shortfalls lead to declining profits and decreased health for the patients Increased demand for accountability and public reporting
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Now think about… What could we do with the money we save?
Services Staffing Equipment Facilities What could we do with time we would save? What could we do with the knowledge we would acquire?
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Solution Better systems
Prevent errors Improve quality Systems must ensure the provision of effective care Evidence-based practice Leape, LL, Berwick, DM, Bates, DW. “What practices will most improve safety? Evidence-based medicine meets patient safety.” JAMA, July 24, Vol 288, No. 4
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Questions 66
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Structure Team is skilled, practiced, motivated
Operating within an enabling structure
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Structure What does this structure do to the performance of the same team?
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Elements of Structure that Drive Behavior
Physical layout & environment Information flows Policies, procedures Practices, norms Values Organizational performance metrics Reporting relationships Reward systems Mental models Language
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Force Field Analysis COLLABORATION Shared vision of ideal state
DRIVING RESTRAINING Shared vision of ideal state Desire to satisfy customer Pressure to be a team player Performance measures linked to dept. budgets No feedback re: impact of local decisions on others Culture glorifies the “hero”
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Conclusion “Rational” actions may have unintended (and undesirable) consequences Cause and effect are often distant in time and space Structure drives behavior What were the processes that lead to the results?
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