pragmatic problem-solving for healthcare: principles ...€¦ · case in light of tps rulescase in...

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

THANK YOU!

OUR E-MAIL ADDRESS:

manimayghosh@hotmail.com

dsobek@ie.montana.edu