Introduction to System Redesign (SR) and Operational Systems Engineering (OSE)

1. Introduction to System Redesign (SR) and Operational Systems Engineering (OSE) Heather Woodward-Hagg, MS, CQE, CSSBB Isa Bar-On, PhD Peter Woodbridge, MD, MBA Diana Ordin, MD Lean

2. Step 3 Materials System Redesign Methods Identifying and Eliminating Operational Barriers within Patient Treatment Processes

3. 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.

4. VA-TAMMCS Framework

5. What is Systems Redesign? Industry vs. Craft Paradox Systems Redesign/Engineering Professionalism Adapted from Peter Woodbridge, Brenda Zimmerman, 2002

6. 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

7. Rubenstein, Pugh Model for TRIP Rubenstein & Pugh, JGIM 2006; 21:S58-64

8. 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

9. VAP Bundle Implementation What does this process look like at week 15?

10. Sustainability What happened? 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.

11. Average Daily % of ED stat orders (Order to Verify) returned within 60 minutes through April, 2006

12. 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

13. Repenning QI Model * delay * 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

14. The “Work Harder” Loop delay

15. The “Work Smarter” Loop delay

16. Systems Redesign Applications delay 16

17. Systems Redesign Applications Reducing Reliability Erosion Improving Reliability Identification of Performance Gaps Effectiveness/Timeliness of “Work Smarter” Loop delay • - Intrinsic pressure • - Extrinsic pressure • Organizational • Microsystem 17

18. Isolation Sign By permission: LSSHC

19. Complexity in Healthcare Social Adapted from Ralph Stacey “Complexity and Creativity in Organizations” Technical

20. 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 20

21. 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 21

22. 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” 22

23. 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 23

24. 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 24

25. Introduction to Operational Systems Engineering (OSE)

26. 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

27. 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 Increasing Level Of Complexity 80% of issues can be resolved with lower complexity tools

28. Why Systems Engineering?Healthcare has people from different disciplines interact with each other and with Technology

29. 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

30. 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

31. 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

32. BCMA Medication Pass Supply Area Supply Area Pyxis Steps per patient: 181 steps Attempts: 3.3 Total time per patient: 18 mins Supply time per patient: 9 mins Med administration time: 9 mins

33. Med/Isolation Carts – Current State

34. 14 minutes in the life of a Pharmacy Tech 34

35. VAMC EMR Implementation 8 feet of paper per week

36. Incoming Documentation by type/unit

37. SDS Paper Generation

38. Conversion to e-documentation

39. 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

40. ‘Side Effects’ = Limitations of Mental Models “ 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” “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

41. Current VHA Systems Engineering Applications

42. 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

43. 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

44. Supply Organization

45. 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

46. 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

47. Health Systems Engineering in the VHA – next steps

48. 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

49. 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

50. 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