Systems Thinking for Healthcare

1. Systems Thinking for Healthcare Diana M. Luan, PhD Uniformed Services University of the Health Sciences & Center for Disaster Assistance & Humanitarian Medicine

2. 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

3. 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.

4. Allows for the iterative unfolding of the interrelationships and processes within a system • Understanding the drivers of behavior

5. Systems • Network of interdependent components that work together to accomplish the aim of the system

6. Systems are Embedded within Systems

7. 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

8. 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

9. Microsystems are Embedded within Larger Systems of Care Vanderbilt Healthcare System DoD Military Health System

10. 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

11. The Current State

12. Staff Response to Quality & Safety Initiatives It is a Burden The Solution

13. Microsystem Definition 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, 472-497. “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

14. The FocusSmallest 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. 1992. Free Press, NY, pg 103.

15. Clinical Microsystems • Processes are organized around the needs of the patient • Enhances every interface with the patient

16. Reverses the Organizational Traditional Pyramid VANDY

17. Acute care Chronic care Preventive care Palliative care Functional Biological Expectations Functional Costs Biological Satisfaction Costs Microsystem Improvement Model Initial Work-up, Plan for care Entry, Assignment Orientation Disenrollment

18. 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

19. It involves… Analysis Planning Context Execution Evaluating

20. Microsystem Framework is a Process

21. 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

22. Microsystem Process

23. Assessment Involves • Understand the system's elements and behaviors • Reflect and use the tension for change to develop a deeper understanding of the system

24. 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

25. W. Edwards Deming • “The aim precedes the organizational system and those that work in it.”

26. 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

27. 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.

28. 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

29. 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

30. Clinic Patients • # Patients seen each day 330 • # Patients seen each week 1649 • # Patients seen each month 7102 * Based on data for May & June 2007

31. Clinic Age Distribution • Birth – 4 years 11% • 5 – 17 years 18% • 18 – 24 years 25% • 25 – 34 years 26% • 35 – 44 years 16% • 45 – 64 years 3% • Age 65+ 0.01% *** Females 42%

32. 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

33. 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

34. 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

35. Ward Nursing Staff

36. 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

37. Patterns • Cycle time • Key supporting processes • Indirect patient pulls • The things that pull/distract from direct patient care • Communication • Culture • Outcomes • Satisfaction • Mortality • Morbidity • Biological markers • Costs • Productivity

38. 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

39. 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

40. 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

41. One Day He Followed the Specimen Plume, SK. (2004). Dartmouth Medical School

42. L&D Clinic Process (Outpatient)

43. 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

44. Improved Process Plume, SK. (2004). Dartmouth Medical School

45. 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

46. Improved Turnaround Time Process Change Plume, SK. (2004), Dartmouth Medical School

47. 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

48. Implications • Decreased risk for the patient • Infection • Time on pump • Morbidity and mortality • Increased OR efficiencies • Improved surgical team satisfaction • Improved OR turnaround times • Improved relationship with the lab microsystem

49. Identify Unintended Consequences • Think about evidence-based solutions • Try to anticipate unintended consequences

50. 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